Flower Villa, Inc
FLOWER VILLA, INC in LOS ANGELES, CA — inspection on March 9, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During a review of Resident 27's Admission Record dated 11/13/2024 indicated the resident was admitted to the facility on [DATE] with diagnoses including: dementia (a progressive state of decline in mental abilities), Vitamin D deficiency (condition where the body does not have enough Vitamin D, paranoid schizophrenia (a mental illness that is characterized by disturbances in thought, where there is distrust and suspicion), anxiety disorder (excessive fear or worry), encephalopathy (broad term for any brain disease that alters brain function or structure), and hypotension (low blood pressure).
During a review of Resident 27's Minimum Data Set (MDS, resident assessment tool), dated 2/13/2025 indicated the resident had severe cognitive (the ability to think, learn, and remember clearly) impairment.
The MDS further indicated Resident 27 was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene, bed mobility and transferring.
During a concurrent interview and record review on 3/9/2025 at 4:22 PM with the Director of Nursing (DON) Resident 27's POLST (Physician Orders for Life-Sustaining Treatment) form dated 5/26/2022 and Advance Directive / Medical Treatment and Decisions form dated 5/26/2022 were reviewed.
The POLST indicated Brother written in the Relationship (write self if patient) box of the form.
The DON verified the entry and stated it should be entered self.
The Advance Directive form indicated no date entered the physician's signature and an error with the resident's name.
The DON verified there was not date by the physician's signature and that the resident's surrogate decisions maker's name had been entered in error instead of the resident's.
The DON stated there should be a date and the resident's name entered is a mistake.
056438
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056438 B.
Wing 03/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035
During a review of Resident 27's Minimum Data Set (MDS, resident assessment tool), dated 2/13/2025 indicated the resident had severe cognitive (the ability to think, learn, and remember clearly) impairment.
The MDS further indicated Resident 27 was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene, bed mobility and transferring.
During a review of Resident 27's Order Summary Report dated 3/1/2025 indicated orders for ProAmatine (medication for low blood pressure) oral tablet 5 mg give one tablet by mouth one time a day for blood pressure hold if above 130, Risperdal (medication to [NAME] mental health condition such as schizophrenia) oral tablet (Risperidone) give 1mg by mouth three times a day for paranoid schizophrenia, Vitamin D3 (supplement) oral tablet (Cholecalciferol) give 5000 unit by mouth one time a day for Vitamin D deficiency.
The same report further indicated an order of may crush all crushable meds then mix with apple sauce or food.
During an observation with concurrent interview on 3/8/2025 at 9:05 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed passing medications for Resident 27. LVN 2 removed ProAmatine 5 mg tablet, Risperdal 1 mg tablet and Vitamin D 5000 - unit tablet from their bubble packs, put them all together in one plastic pouch and proceeded to crush all three medications together. LVN 2 stated the medications can be crushed together good and put in applesauce for the resident.
During an interview with the Director of Nursing (DON) on 3/9/2025 at 4:59 PM, the DON stated the medications should not be crushed all together and administered to the resident, the nurse should have known not to do that.
056438
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056438 B.
Wing 03/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035
During a review of Resident 27's Minimum Data Set (MDS, resident assessment tool), dated 2/13/2025 indicated the resident had severe cognitive (the ability to think, learn, and remember clearly) impairment.
The MDS further indicated Resident 27 was dependent on staff for eating, oral hygiene, toileting, dressing, personal hygiene, bed mobility and transferring.
During a review of Resident 27's Order Summary Report, dated 3/1/2025, indicated orders for ProAmatine (medication for low blood pressure) oral tablet 5 mg give one tablet by mouth one time a day for blood pressure hold if above 130, Risperdal (medication to [NAME] mental health condition such as schizophrenia) oral tablet (Risperidone) give 1mg by mouth three times a day for paranoid schizophrenia, Vitamin D3 (supplement) oral tablet (Cholecalciferol) give 5000 unit by mouth one time a day for Vitamin D deficiency.
The same report further indicated an order of may crush all crushable meds then mix with apple sauce or food.
During an observation with concurrent interview on 3/8/2025 at 9:05 AM with Licensed Vocational Nurse (LVN) 2, LVN 2 was observed passing medications for Resident 27. LVN 2 removed ProAmatine 5 mg tablet, Risperdal 1 mg tablet and Vitamin D 5000 - unit tablet from their bubble packs, put them all together in one plastic pouch and proceeded to crush all three medications together. LVN 2 stated the medications can be crushed together good and put in applesauce for the resident.
During an interview with the Director of Nursing (DON) on 3/9/2025 at 4:59 PM, the DON stated the medications should not be crushed all together and administered to the resident, the nurse should have known not to do that.
056438
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056438 B.
Wing 03/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035
During a review of the facility's [NAME] Staffing Nursing Record dated 12/1/2023 to 12/31/2024, indicated
During an interview with Director of Staff and Development (DSD) on 3/9/2025 at 2:22 PM, DSD stated and confirmed, there were no RN coverage for the following days: 12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023.
During an interview with Director of Nursing (DON) on 3/9/2025 at 5:03 PM, DON stated, the facility did not have any RN coverage for the following days: 12/02/20230, 12/03/2023; 12/09/2023; 12/10/2023, 12/16/2023, 12/17/2023; 12/23/2023; 12/24/2023; 12/25/2023, 12/29/2023, 12/30/2023; 12/31/2023. DON stated an RN coverage is required for safety of the all the residents.
During a review of the facility policy and procedures (P&P) titled, Staffing, revised on 1/2025, the P&P indicated, Our facility provides adequate staffing to meet needed care and services of our resident population .
Our facility maintains adequate staffing on each shift to ensure that our resident's needs and services are met.
Licensed registered nursing and licensed nursing staff are available to provide and monitor the delivery of resident care services.
056438
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 056438 B.
Wing 03/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Flower Villa, Inc 1480 S. LA Cienega Bl Los Angeles, CA 90035