Other·January 7, 2017

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the Department of Public Health during a recertification survey. Representing the Department of Public Health: - Health Facilities Evaluator Nurse: 36526 - Health Facilities Evaluator Nurse: 36576 Total Resident Population: 32 Total Resident Sample: 11 Highest Scope and Severity: J On 11/20/16 at 3:18 p.m., the Director of Nursing (DON) and Administrator were verbally informed of an Immediate Jeopardy (IJ) regarding failure to conduct an IDT after a significant change in resident's condition, review/revise the care plans, and monitor for seizure activity for Residents 1, 8, and 9. On 11/21/16 at 1:40 p.m., the DON and the Administrator were notified that the IJ was corrected after facility provided immediate plans of correction for Residents 1, 8, and 9 that included immediate seizure drug lab monitoring, care plan revisions, seizure precautions, implementation and revisions, fall precautions, implementations and revisions and were fully implemented.

F253 SS=B HOUSEKEEPING & MAINTENANCE SERVICES CFR(s): 483.15(h)(2)

F253 01/08/2017 The facility must provide housekeeping and LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 1 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain three residents' bathrooms that were shared among six residents and two of the two shower rooms in good repair, and the outside patio free from clutter. This deficient practice had the potential to affect resident quality of life and sense of home and potentially cause psycho- social harm. Findings: Upon entry to the facility on 11/18/16 at 7:09 p.m., observed the outside patio being used as an open air storage with four gray trashcans with lids, 4 yellow trashcans with lids, 1 pallet with office supplies on it, 1 gray trashcan with a rake inside of it, broom and dustpan leaning against the wall, one clean looking bedside commode, and two wheelchairs, all obstructing twenty percent of the encircling, cemented walkway of the outside patio. During an observation of the facility in the presence of the Director of Nursing (DON) on 11/18/16 at 7: 30 p.m. the following was observed: 1. Shared resident bathroom for Rooms 1 and 3 affecting residents in 1-A, 1-B, 3-A, and 3-B with broken tile on the window pane. 2. Shared resident bathroom for Rooms 2 and 4 affecting residents in 2-A, 2-B, 4-A, and 4-B with broken tile on the window pane. 3. Tub Room 1, also known as Shower Room 1, with no window screen on the window, easily FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 2 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE accessible to the street, broken tile where the open tub meets the tiled wall, door frame with inches of rotten wood at the base of the door frame, two used wet towels in the tub, cracked grout in the shower, sharps dispenser with three disposable razors stuck in the sharps container lid popping out, and tile grout cracked on the shower floor. 4. Shared resident bathroom for Rooms 5 and 7 affecting residents in 5-A, 5-B, 7-A, and 7-B with broken tile on the window pane. During multiple observations of the patio on 11/19/16, 11/20/16, and 11/21/16, the patio clutter was observed ongoing throughout the day. During an interview with the Maintenance Supervisor (MS) on 11/21/16 at 11:42 a.m., he stated the patio is always filled with that stuff, referring to the clutter. The MS stated that he does not visit the facility daily, has no documentation for the visits he makes to the facility when he does visit, or the environmental rounds he makes when he is in the facility, and was not aware of any ongoing housekeeping or maintenance issues at the facility at that present time. A review of the facility policy on Maintenance Service, revised December 2009 indicated maintenance supervisor is responsible for maintaining the buildings, grounds, and equipment in a safe operable manner at all times and maintain the building in compliance with current federal, state, and local laws, regulations, and guidelines.

F309 SS=J PROVIDE CARE/SERVICES FOR HIGHEST WELL BEING CFR(s): 483.25

F309 01/09/2017 Each resident must receive and the facility FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 3 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE must provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to conduct an interdisciplinary team (IDT, a group consisting of the head of the different departments who work together to discuss a resident's care) care conference after a significant change in resident's condition wherein the resident had fallen secondary to seizure (Resident 1), review and revise the care plan pertaining to fall and seizure (Resident 1 and 8) and failed to monitor the resident for seizure activity (Resident 9) for three out of nine residents with seizure disorder [a neurological condition where the brain electrical nerve activity is disturbed causing a person to have uncontrollable body movement and loss of consciousness, also known as convulsions, or can present unnoticed with the person looking as though they are staring into space and falls]). These deficient practices had the potential to predispose Residents 1, 8, and 9 to seizure/fall incidents. Resident 1 sustained a head injury from a fall due to seizure and was transferred to the hospital. Upon return to the facility, Resident 1 had abnormally low lab level of Dilantin (medication to treat seizure), placing Resident 1 at risk to have another fall. (Cross Refer F-323, F-507) The facility also failed to adequately assess pain for one of 10 sampled residents (Resident 8). This deficient practice had the potential to FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 4 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE affect Resident 8's quality of life and cause further pain and suffering. On 11/20/16 at 3:18 p.m., the Director of Nursing (DON) and Administrator were verbally informed of an Immediate Jeopardy (IJ) regarding failure to conduct an IDT after a significant change in resident's condition, review/revise the care plans, and monitor for seizure activity for Residents 1, 8, and 9. On 11/21/16 at 1:40 p.m., the DON and the Administrator were notified that the IJ was corrected after facility provided immediate plans of correction for Residents 1, 8, and 9 that included immediate seizure drug lab monitoring, care plan revisions, seizure precautions, implementation and revisions, fall precautions, implementations and revisions and were fully implemented. Findings: 1. A review of Resident 1's Minimum Data Set, ([MDS], a resident assessment and care screening tool), dated on 10/4/16, indicated Resident 1 was admitted to the facility on 10/4/16, with a history of Seizure Disorder. Resident 1's MDS identified her as having no hearing, speech, or vision problems, had moderate cognitive impairment (moderate amount of difficult remembering, focusing, and concentrating), no mood problems, and required limited assistance (staff provided guided maneuvering of limbs or other nonweight bearing assistance) with one staff physical assist with transferring, walking, getting around the facility, toilet use, and personal hygiene. A review of Resident 1's physician's orders on 10/4/16 indicated to give Dilantin (a medication used to treat seizure), also known as FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 5 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Phenytoin, in liquid form 250 milligrams (mg) orally twice a day. According to Pfizer (2016) pharmaceutical company the manufacturer of Dilantin, indicated Dilantin is a prescription medicine used to treat seizures and prevent seizures that happen during or after brain surgery and careful monitoring of phenytoin serum levels should be carried out by your doctor to determine optimal dosage adjustments. Phenytoin doses are usually selected to attain therapeutic plasma total phenytoin concentrations of 10 to 20 micrograms per milliliters (mcg/mL). Dilantin blood drug level results are used to individualize the Dilantin drug amount to be given in order to be within a safe level, or therapeutic range, to maintain the person's risk for seizing as low as possible. A therapeutic drug blood level has a Narrow Therapeutic Index ([NTI], in which the therapeutic dose is very close to the toxic dose). Dilantin therapeutic normal range level is 10.0 mcg/mL to 20.0 mcg/mL. Dilantin Toxicity is when the Dilantin blood drug level is above the normal range of 20 mcg/mL and symptoms lead to dizziness, drowsiness, confusion, lack of coordination, and coma. A review of Resident 1's physician's order, dated 10/25/16, indicated to draw serum (blood) Dilantin every month on the 4th Wednesday starting 10/26/16. Resident 1's laboratory test results on 10/26/16, indicated Resident 1's Dilantin level was 9.6 mcg/mL (normal range is 10.0 mcg/mL to 20.0 mcg/mL), placing Resident 1 at risk for seizures/fall. The laboratory report indicated the physician was notified and without new orders. During an interview with LVN 2 on 11/20/16 at 6:15 a.m., LVN 2 stated she was unaware of Resident 1's low lab Dilantin level of 10/26/16. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 6 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with LVN 3 on 11/20/16 at 3:10 p.m., LVN 3 stated she was unaware of Resident 1's low lab Dilantin level of 10/26/16. A review of Resident 1's nurses' progress notes indicated Resident 1 fell on 11/9/16 at 4:50 a.m. Resident 1 was found in the hallway, unwitnessed, with a bleeding cut to the forehead, agitated, anxious, and was unable to verbalize the account of what happened to her and how she got hurt. Resident 1 was sent to the hospital and was admitted. A review of Resident 1's hospital record indicated Resident 1 arrived to the hospital emergency department on 11/9/16 and was found to have a six centimeter (cm) forehead laceration after a fall related to a seizure. Upon arrival to the emergency department, Resident 1 had repair to her forehead laceration, was given intravenous (IV, given directly into a vein) fluids, provided anti-seizure medication, medication for nausea, given oxygen, and she had a computerized axial tomography scan, also known as a CAT scan, of the head and spine (a type of x-ray imaging that views the area in slices and is able to see inside the body's bone, organs, arteries and is used in diagnosing patients). Resident 1 was admitted to the hospital from 11/9/16 to 11/16/16 and was diagnosed with a traumatic head injury and forehead injury after a fall related to a seizure. A review of Resident 1's physician's orders indicated Resident 1 was readmitted to the facility on 11/16/16 from the hospital with a diagnosis of Seizures with recent fall. A review of Resident 1's clinical record indicated there was no documented evidence the facility conducted an IDT care conference upon the resident's return to the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 7 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1's care plans dated 10/5/16 and 10/10/16 respectively for high risk for fall and high risk for injury due to seizure activity were not reviewed and revised to reflect the Resident 1's change of condition (fall due to seizure sustaining head injury). During an interview and review of Resident 1's clinical record on 11/18/16 at 9:35 p.m. with the licensed vocational nurse (LVN 1), LVN 1 stated there was no revision of care plan for seizure in Resident 1's clinical record. During an interview and review of Resident 1's clinical record on 11/18/16 at 9:40 p.m. with the DON, she stated there was no IDT care conference conducted to address Resident 1's change of condition, there was no fall risk assessment completed and revision of care plans for seizure or care plan for fall after Resident 1's readmission to the facility after being recently admitted to the hospital for a fall related to a seizure. On 11/20/16 at 3:18 p.m., both the DON and the Administrator were notified of an Immediate Jeopardy for failing to conduct an IDT care conference for a change of condition and failure to review and revise care plans for residents with seizures. A review of Resident 1's Dilantin level laboratory result on 11/20/16 at 11:09 p.m. indicated 3.2 mcg/ml (normal range is 10.0 mcg/mL to 20.0 mcg/mL). 2. A review of Resident 8's MDS, dated on 10/11/2016, indicated she was admitted to the facility on 10/11/16, with a history of Seizures. Resident 8 was identified having no speech, hearing, vision, or cognitive impairment, had minimal mood behavior symptoms, and was unable to walk on her own and required FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 8 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE extensive assistance (weight bearing support) with one to two staff with bed mobility, transferring, getting around in her wheelchair in the facility, dressing, and was identified totally dependent on staff for toilet use and bathing. A review of Resident 8's November 2016 medication administration record indicated she was ordered Depakote (a medication used to treat seizure) for seizures on 10/11/16. According to AbbVie, Inc. (2016), the pharmaceutical manufacturer of Depakote, Depakote is anti-epileptic drug is used to treat a variety of epilepsy seizure types. It requires blood drug concentration lab monitoring of Valproic Acid (active chemical in Depakote medication). Depakote normal therapeutic range is 50- 100 mcg/mL. A review of Resident 8's Valproic Acid blood level performed on 10/31/16 indicated her Valproic Acid blood level was 20.0 mcg/mL. During an interview with LVN 2 on 11/20/16 at 6:15 a.m., LVN 2 stated she was unaware of Resident 8's 10/31/16 low Valproic Acid level. During an interview with LVN 3 on 11/20/16 at 3:10 p.m., LVN 3 stated she was unaware of Resident 8's 10/31/16 low Valproic Acid level. A review of Resident 8's care plan for seizure dated 10/24/16, there was no care plan revisions reflecting the 10/31/16 low Valproic Acid level of 20.0 mcg/mL (normal therapeutic range is 50- 100 mcg/mL), placing Resident 8 at high risk for seizure. A review of the facility's revised December 2009 policy on care plans indicated each resident care plan is designed to incorporate risk factors associated with identified problems FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 9 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE and aid in preventing or reducing declines in the resident's functional status and/or functional levels. The policy indicated care plan revisions are to be made when there is significant change in the resident's condition, a desired outcome is not met, and the resident has been readmitted to the facility from the hospital. 3. A review of Resident 8's Minimum Data Set, ([MDS], a resident assessment and care screening tool), dated 10/11/2016, indicated Resident 8 was admitted to the facility on 10/11/16, with a history of Urine Retention (inability to completely empty the urinary bladder and cause accumulation of urine in the bladder which can cause urinary infections) and Acute Kidney Failure (condition where the kidneys suddenly do not work properly to filter the body's waste from the blood thereby affecting urine production and urine characteristics and can lead to death if not identified or treated promptly). The MDS assessment identified Resident 8 having no speech, hearing, vision, or cognitive impairment, minimal mood behavior symptoms, and was unable to walk on her own and required extensive assistance (weight bearing support and at times requires full staff performance) with one to two staff physical assist with bed mobility, transferring, getting around in her wheelchair in the facility, dressing, and was identified totally dependent on staff for toilet use and bathing. A review of Resident 8's urine analysis with culture and sensitivity test (urine test to check for urinary tract infections [UTI]), dated 10/20/16, indicated Resident 8 had a urine test that resulted with abnormal findings blood and bacteria in the urine, that correlated with symptoms typically found in urinary tract infections. Normal urine does but no new FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 10 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE orders were not carry blood or bacteria identiifed in this test. Her doctor was notified but no new orders were received. During an observation of the licensed vocational nurse (LVN 2) during a medication administration for Resident 8 on 11/19/16 at 12:55 p.m., Resident 8 was observed complaining of lower back pain to LVN 2. While LVN 2 went to check Resident 8's medication administration record (log of physician's orders for residents' medications; its due times they need to be administered to keep residents' medication times organized for nursing staff), Resident 8 was observed rubbing her right lower back near her hip and stated while grimacing, "It hurts right here," pointing on her right lower back. A few minutes later at 1:55 p.m., LVN 2 was observed calling Resident 8's physician's answering service and leaving a message regarding Resident 8. At 2:10 p.m., LVN 2 returned back and asked Resident 8 if she continued to have pain and Resident 8 said yes. LVN 2 asked Resident 8 what her pain level was according to a numeric pain scale (zero [0] being no pain and 10 being the worst pain) then gave Resident 8 her pain medication. LVN 2 failed to fully assess Resident 8's lower back pain who had a significant history of kidney problems. During an interview with LVN 2 on 11/20/16 at 6:55 a.m., LVN 2 stated when giving pain medication, a pain assessment is performed that includes assessing the type of pain, such as pinching, throbbing, stabbing, or burning, the frequency of the pain such as is it constant or intermittent (off and on), location and does it travel to another area of the body, other measures besides medication that may work to ease the pain, duration of pain, and the residents behavioral symptoms like facial expressions or rubbing a body part. LVN 2 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 11 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated she did not fully assess Resident 8's pain to lower back despite having multiple opportunities to do so. Urinary Tract Infection, also known as UTI, is a detectable condition associated with a disease caused by microorganisms in the urinary system. UTIs can lead to sepsis (severe infection that affects multiple organs and can lead to death), and kidney failure. Common signs and symptoms of UTIs that indicate need for treatment include pain to the sides of the lower back also known as flank pain, urine characteristics, changes in color, clarity, smell, sediment, and amount, fever, and mental changes like confusion. A review of Resident 8's care plan for "Alteration in comfort: potential for pain," initiated on 10/12/16, indicated staff were to determine location of pain and assess type of pain, quality, such as sharp, pounding, pressing, or radiating, and assess non-verbal signs and symptoms of pain such as grimaces. A review of the facility's revised October 2010 "Pain Assessment and Management," characteristics of pain include intensity measured on a standardized scale, such as numeric scale, descriptors of pain, pattern of pain, location of pain, radiation of pain, frequency of pain, timing of pain, and duration of pain. The policy identified behavioral characteristics of pain as verbal expressions like crying, screaming, and groaning, facial expressions such as grimacing and frowning, and guarding and or rubbing a particular part of the body. The policy indicated staff are to review the resident's clinical record to identify conditions or situations that predispose the resident to pain and identified infections and specifically urinary tract infection as one FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 12 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE condition or situation where staff are to identify the cause if pain. 4. A review of Resident 9's Admission Record indicated the resident was admitted to the facility on 8/29/16. Resident 9 was admitted with diagnoses that included convulsions (body muscles contract and relax rapidly and repeatedly, resulting in an uncontrolled shaking of the body), diabetes (high concentrations of sugar in the blood). A review of the Minimum Data Set (MDS), a resident assessment and care screening tool, dated 8/29/16, indicated Resident 9 had problems making himself-understood, but was able to understand others and was severely impaired of cognition. Resident 9 required limited assistance (staff provided guided maneuvering of limbs or other non-weight bearing assistance) with transfers, ambulation and hygiene. A review of Resident 9's physician orders, dated 8/29/16, indicated an order for Lamictal (medication used to treat convulsion) 25 milligrams (mg) by mouth every day and to monitor for seizure (abnormal excessive or synchronous neuronal activity in the brain) activity every shift. A review of Resident 9's care plan titled, "High risk for injury due to seizure activity," dated 9/2016, indicated for the staff to monitor drug levels. A review of Resident 9's assessment flow sheet for the month of 9/2016, there was no seizure monitoring. Seizure monitoring was initiated on 10/26/16, eight weeks after it was ordered. On 11/20/16, at 6:05 p.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 13 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the director of nursing (DON) stated Resident 9 did not need initial laboratory test since it was not necessary for Lamictal medication. A review of Resident 9's laboratory results for lamotrigine (generic name for Lamictal) received on 11/28/16, indicated that Resident 9's lamotrigine level was below 0.5 micrograms (mcg)/milliliters (ml); normal range for Lamictal to be therapeutic is 4.0-18.0 mcg/ml.

F323 SS=G FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES CFR(s): 483.25(h)

F323 12/08/2016 The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents. This REQUIREMENT is not met as evidenced by: Based on interview and record review the facility failed to provide adequate supervision for one of ten sampled residents (Resident 1). Resident 1 had a low or sub-therapeutic (not producing a therapeutic effect) Dilantin blood level on 10/26/16 that was not communicated to the licensed nurses so that the licensed nurses could be diligent in providing frequent visual checks in accordance with the seizure precaution and resident ' s plan of care. As a result Resident 1 experienced an unwitnessed fall and sustained a head injury that required a general acute care hospital (GACH) admission and treatment of the a six FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 14 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE centimeter (cm) forehead laceration (a deep cut or tear in the skin), and pain. Cross refer to F309. Findings: A review of Resident 1 ' s face sheet (admission record) indicate the resident was admitted to the facility on 10/4/16 with diagnoses that included seizure disorder (a neurological condition where the brain electrical nerve activity is disturbed causing a person's to have uncontrollable body movement and loss of consciousness, also known as convulsions). The resident was hospitalized prior to the facility ' s admission, from 9/30/16 to 10/4/16 and was found to have Dilantin toxicity (a high level of Dilantin, a medication used to treat seizures, in the blood). A review of Resident 1's Minimum Data Set, (MDS, a comprehensive medical, mental, and psychosocial standardized assessment and care planning tool), dated 10/4/16, indicated that the resident had no hearing, speech, or vision problems, but had moderate cognitive impairment (moderate amount of difficult remembering, focusing, and concentrating). The resident had no mood problems but required limited assistance (resident highly involved in activity; staff provide guided maneuvering of limbs) with one staff for physical assist with transferring, walking, getting around the facility, toilet use, and personal hygiene. A review of Resident 1's admission physician ' s order dated 10/4/16, indicated to administer to the resident Dilantin in liquid form, 250 milligrams (mg) orally twice a day. A review of Resident 1's fall risk assessment FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 15 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE dated 10/4/16 indicated, that the resident was at high risk for falls. A review of Resident 1 ' s fall care plan initiated on 10/5/16 indicated that the staff will implement fall precautions and monitor for the side effects of the medication laboratory (lab) levels. A review of Resident 1's seizure precaution care plan initiated on 10/10/16, indicated the resident was a high risk for injury due to seizure activity and use of the medication, Dilantin. The resident goals included not having a fall or injury in the next three months and the Dilantin level would be within normal limits from 10 micrograms (mcg)/milliliters (mL) (the therapeutic normal range level is 10.0 mcg/mL to 20.0 mcg/ml). The intervention included but not limited to implementing the fall and seizure precautions, such as providing frequent monitoring and monitoring for the side effects of the medication lab levels. A review of Resident 1's lab results, dated 10/26/16, indicated the resident ' s Dilantin blood level was low or sub-therapeutic, at 9.6 micrograms (mcg)/milliliter (mL), placing the resident at risk for seizures. The physician did not give new orders after being informed of the resident ' s low Dilantin blood level. Resident 1 ' s medical record did not have documented evidence the plan of care was revised to implement measures to prevent falls and injuries from a seizure activity due to a sub-therapeutic Dilantin blood level obtained on 10/26/16 (prior to the fall on 11/9/16). According to the article titled " How to assess phenytoin (generic name for Dilantin) levels, " published by Nursing 2005, page 19, Volume 35, Number 11, indicated " The goal for any FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 16 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE patient is to be free of seizures with minimal adverse reactions. Your patient can best achieve this goal by following an individualized plan of care that focuses on her needs. " A review of Resident 1's nurse progress notes indicated that on 11/9/16 at 4:50 a.m., the resident was found in the hallway of the facility with a bleeding cut to the forehead, agitated, anxious, and unable to verbalize the account of what happened to her and how she got hurt. The resident was transferred to a GACH that day. A review of Resident 1's GACH physician notes indicated the resident arrived at the emergency department on 11/9/16 and was found to have a six centimeter (cm) forehead laceration (deep cut or tear of the skin) after a fall related to a seizure. Resident 1 required the emergency department physician to a repair her forehead laceration, a hospital staff to insert an intravenous (IV, within a vein) catheter for fluids infusion, receive an anti-seizure medication and medication for nausea, receive oxygen, and to have a computerized axial tomography scan, (CAT scan, a type of x-ray imaging of that views the area in slices and is able to see inside the body's bone, organs, arteries, etc. and is used in diagnosing patients) of the head and spine. Resident 1 was discharged from the GACH on 11/16/16 with a diagnosis of traumatic head injury and forehead laceration after a fall related to a seizure. During an interview on 11/20/16 at 6:15 a.m., a licensed vocational nurse (LVN 2), on 11/20/16 at 6:15 a.m., stated that she was unaware of Resident 1's sub-therapeutic Dilantin blood level that measured 9.6 mcg/mL on 10/26/16. During an interview on 11/20/16 at 3:10 p.m., LVN 3 stated that she was unaware of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 17 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Resident 1's sub-therapeutic Dilantin blood level that measured 9.6 mcg/mL on 10/26/16. During an interview on 11/20/16 at 9:35 p. m., Resident 1 stated that she fell hard at the facility while having a seizure which gave her a forehead wound and head pain. Resident 1 stated she had recently returned to the facility and had not had an interdisciplinary care plan meeting to discuss her new plan of care since her 11/9/16 fall related to seizure with the facility. During a concurrent observation, Resident 1 had a six-centimeter linear forehead laceration with a scab which was covered with steri-strips (rectangle bandages used to join a wound for healing) and noted with mild swelling to the area under her eyes. During an interview on 11/20/16 at 10:30 p.m., the director of nursing (DON) stated she forgot to add a copy of the Resident 1 ' s subtherapeutic Dilantin blood level of 9.6 micrograms (mcg)/milliliter (mL) report, dated 10/26/16, to the resident ' s medical chart. The DON stated the resident ' s blood level report should have been in the medical chart for staff to see. The DON stated there was no immediate interdisciplinary care plan meetings, care plan revisions (for fall and seizure precautions due to the sub-therapeutic Dilantin blood level), fall risk and/or re-assessments completed for Resident 1 after the facility received Resident 1's sub-therapeutic Dilantin blood level laboratory report on 10/26/16. A review of the facility's policy and procedure, revised on October 2010, and titled, "Lab and Diagnostic Test Results- Clinical Protocol," indicated the reason for monitoring a drug level is because it affects the urgency of acting upon the result. The policy indicated if the staff that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 18 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE first receive or review lab test results cannot follow the remainder of this procedure for reporting and documenting the results then, another nurse in the facility should.

F371 SS=E FOOD PROCURE, STORE/PREPARE/SERVE F371 - SANITARY CFR(s): 483.35(i) 02/13/2017 The facility must (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain sanitary food refrigeration storage conditions and protect food from contamination in the facility kitchen. This deficient practice had the potential to cause food borne illness and had the potential to affect all residents who could have eaten the contaminated food. Findings: During an observation of the facility kitchen on 11/18/16 at 8:05 p.m., in the presence of the licensed vocational nurse (LVN 1), the refrigerator was observed with a large two feet long white package, soft and squishy to touch, with stapled ends, overhanging from a shallow pan which was on a serving tray on the second FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 19 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE shelf of the refrigerator dripping red, thick liquid on to a lid of a container filled with chicken broth. During an interview with LVN 1 at the time, LVN 1 verified the package was ground meat and the red thick liquid substance was blood. During an observation of the kitchen in the presence of LVN 1 on 11/18/16 at 8:05 p.m. a package was found in the refrigerator inside and overhanging from a shallow pan on the second shelf defrosting and dripping red thick liquid ontop the bottom shelf where a container of chicken broth was. During an observation of the facility kitchen on 11/20/16 at 12:25 p.m., in the presence of the Dietary Supervisor, the refrigerator was observed with a large two feet long package, soft and squishy to touch, with stapled ends, overhanging from a shallow pan which was on a serving tray on the bottom shelf of the refrigerator touching a plastic wrapped watermelon. During an interview with the Dietary Supervisor (DS) at the time, the DS verified the package was a ten pound bag of ground turkey meat defrosting in the refrigerator. The DS immediately threw away the watermelon and adjusted the ten pound bag of defrosting turkey meat into the shallow pan. According to the U.S. Food & Drug Administration (FDA) Potentially Hazardous Food (PHF) is a food that is natural or synthetic and that requires temperature control for safety because it is in a form capable of supporting microorganisms. It includes a food of animal origin that is raw or heat-treated. When temperature control safety is not met the food releases bacteria and or microorganisms that can cause foodborne illnesses and can transfer through cross contamination. Cross FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 20 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE contamination is when one bacteria or microorganism is unintentionally transferred from one substance or object to another, with a harmful effect, such as a food borne illness. Symptoms range from relatively mild discomfort to very serious, life-threatening illnesses. The elderly, young, and persons with weakened immune systems are at greatest risk of serious consequences from foodborne illnesses. A review of the facility's undated policy on "Food Preparation," indicated the facility is to follow when thawing meat: a. Use a drip pan under food being thawed so drippings do not contaminate other food. b. Thaw meat on the bottom shelf below prepared, ready to eat foods. c. Store raw meat separately from cooked ready to eat food to prevent cross contamination. d. Prevent raw-product juices from dripping onto the prepared food and causing food borne illness.

F441 SS=E INFECTION CONTROL, PREVENT SPREAD, F441 LINENS CFR(s): 483.65 02/13/2017 The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 21 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to prevent the development of disease and infection by not implementing their Influenza Vaccination policy and procedure. This deficient practice had the potential for spread of infection to visitor, staff, and residents. Findings: On 11/18/16, at 7:15 p.m., during the initial tour of the facility, no staff members providing direct patient care were observed wearing face mask or having a vaccine visual identifier on their badge. On 11/18/16, at 8:46 p.m., during an interview, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 22 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE the certified nurse assistant (CNA 1) stated she has not gotten the flu vaccine. CNA 1 stated she was not aware of having to wear a mask when providing direct care to the residents. On 11/19/16, at 7:00 p.m., during an observation, direct care staff members were not observed wearing a mask. On 11/19/16, at 8:30p.m., during an interview, the director of staff development (DSD) stated she was aware the staff members were to wear masks if not vaccinated and stated she did not know why the staff were not wearing the masks. On 11/19/16, at 8:35 p.m., during an observation, four (4) direct care staff were observed not wearing a mask while interacting with the residents. No masks were observed by the Nurses' Station or in the medication cart. On 11/19/16, at 8:40 p.m., during an interview, the director of nurses (DON) stated the masks were located in the nurses' lounge. Upon observation at 8:42 p.m., masks were observed in a box in the the nurses' lounge. A review of the facility's policy and procedure titled, "Influenza Vaccine," dated 12/2012, indicated any employee that refuses the flu vaccine and also refuses to wear a mask will be removed from direct patient care until the flu season is over.

F469 SS=F MAINTAINS EFFECTIVE PEST CONTROL PROGRAM CFR(s): 483.70(h)(4)

F469 12/01/2016 The facility must maintain an effective pest control program so that the facility is free of pests and rodents. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 23 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to maintain the facility free of pests. This deficient practice had the potential for the flies to spread infection and potentially affect thirty-two of the thirty two residents. Findings: During the following dates and times, gnats were observed flying around in the facility: 1. On 11/18/16 at 7:08 p.m., two gnats were observed flying around in the hallway. 2. On 11/18/16 at 7:30 p.m., in the presence of the Director of Nursing (DON), Tub Room 1, also known as Shower Room 1, with no window screen on the window with access to pests entry. 3. On 11/18/16 at 7:51 p.m., in presence of the Director of Nursing (DON), gnats were observed flying around the window of Tub Room 1, and flying around the hallway in front of Rooms 1-7 in the presence of the Director of Nursing (DON). 4. On 11/18/16 at 9:00 p.m., gnats were observed flying around the outside patio area near the palms trees. 5. On 11/19/16 at 10:00 a.m., one resident during the quality of life group interview stated he gets gnats in his bathroom which was shared by three other residents because the window screen was always broken and the trees nearby attract gnats. 6. On 11/19/16 at 11:15 a.m., gnats were observed flying around the Rehab Therapy Room. 7. On 11/19/16 at 12:00 p.m., gnats were observed flying around the Dining/Activity Room during lunch landing on a resident's tuna FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 24 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE sandwich. This resident stated that the gnats were always flying around the facility. 8. On 11/19/16 at 4:45 p.m., two gnats were observed flying around the Rehab Therapy Room. 9. On 11/19/16 at 8:40 p.m., in the presence of the facility Administrator, two gnats were observed flying around the Rehab Therapy Room and the Administrator was observed trying to swat them. 10. On 11/20/16 at 6:05 a.m., two gnats were observed flying around the Rehab Therapy Room 11. On 11/20/16 at 10:30 a.m., gnats were observed flying around the Rehab Therapy Room During an interview with the maintenance supervisor (MS) on 11/20/16 at 11:42 a.m., MS stated he does not visit the facility daily, has no documentation for the visits he makes to the facility when he does visit, or the environmental rounds he makes when he is in the facility, and was not aware of any ongoing pest control or gnats issues presently at the facility. A review of the facility policy on "Pest Control," revised August 2008 indicated the facility shall maintain an effective pest control program and maintenance services that would assist when appropriate and necessary, in providing pest control services.

F507 SS=D LAB REPORTS IN RECORD - LAB NAME/ADDRESS CFR(s): 483.75(j)(2)(iv)

F507 01/09/2017 The facility must file in the resident's clinical record laboratory reports that are dated and contain the name and address of the testing laboratory. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 25 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to have a laboratory test result in the clinical record for one of ten sampled residents (Resident 1). This deficient practice had the potential to affect Resident 1's quality of care and ongoing medical diagnosis treatment and plan of care. (Cross Refer F- 309) Findings: A review of Resident 1's Minimum Data Set, ([MDS], a resident assessment and care screening tool), dated on 10/4/16, indicated Resident 1 was admitted to the facility on 10/4/16, with a history of Seizure Disorder [a neurological condition where the brain electrical nerve activity is disturbed causing a person to have uncontrollable body movement and loss of consciousness, also known as convulsions, or can present unnoticed with the person looking as though they are staring into space and falls]). According to the manufacturer of Dilantin, Pfizer (2016), Dilantin is an anti-convulsant medication that helps to reduce seizures. Administration of Dilantin requires the person to have a specific therapeutic drug blood level, which involves measuring the person's blood drug concentration in micrograms per milliliters (mcg/mL). Dilantin blood drug level results are used to individualize the Dilantin drug amount to be given in order to be within a safe level, or therapeutic range, to maintain the person's risk for seizing as low as possible. A therapeutic drug blood level has a Narrow Therapeutic Index ([NTI], in which the therapeutic dose is very close to the toxic dose). Dilantin therapeutic normal range level is 10.0 mcg/mL FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 26 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE to 20.0 mcg/ml. Dilantin Toxicity is when the Dilantin blood drug level is above the normal range of 20 mcg/ml and symptoms lead to dizziness, drowsiness, confusion, lack of coordination, and coma. A review of Resident 1's physician's orders on 10/4/16 indicated to give Dilantin in liquid form 250 milligrams (mg) orally twice a day. A review of Resident 1's physician's order, dated 10/25/16, indicated to draw serum (blood) Dilantin every month on the 4th Wednesday starting 10/26/16. On 11/20/16, review of Resident 1's clinical record indicated there was no Dilantin level result found in Resident 1's clinical record. During an interview with LVN 2 on 11/20/16 at 6:15 a.m., LVN 2 stated she was unaware of Resident 1's 10/26/16 Dilantin level. During an interview with LVN 3 on 11/20/16 at 3:10 p.m., LVN 3 stated she was unaware of Resident 1's 10/26/16 Dilantin level. During an interview with the Director of Nursing (DON) on 11/20/16 at 10:30 p.m., the DON stated she forgot to add the print out copy of the 10/26/16 Dilantin level result in Resident 1's clinical record. A review of Resident 1's laboratory test results dated 10/26/16, indicated Resident 1's Dilantin level was 9.6 mcg/mL (normal range is 10.0 mcg/mL to 20.0 mcg/mL), placing Resident 1 at risk for seizures/fall. A review of the facility's revised October 2010 policy titled, "Lab and Diagnostic Test ResultsClinical Protocol," indicated the reason for monitoring a drug level is because it affects the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 27 of 28 PRINTED: 05/14/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056438 (X3) DATE SURVEY COMPLETED 11/21/2016 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE urgency of acting upon the result. Second, immediate notification of the monitoring of a drug level laboratory result found the resident's clinical status is unclear or worsening, and high or toxic drug levels require prompt notification to the physician. The policy indicated if the staff who first receive or review lab test results cannot follow the remainder of this procedure for reporting and documenting the results than another nurse in the facility should. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: JYRG11 Facility ID: CA970000037 If continuation sheet 28 of 28