Other·February 8, 2018

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 California Department of Public Health during an annual recertification visit. Representing the Department of Public Health: Health Facilities Evaluator Nurse: 05089 Health Facilities Evaluator Nurse: 36862 Health Facilities Evaluator Nurse: 22694 Highest Severity and Scope = G Total Census: 27 Total Sample Size: 19

F557 SS=D Respect, Dignity/Right to have Prsnl Property CFR(s): 483.10(e)(2)

F557 12/26/2017 §483.10(e) Respect and Dignity. The resident has a right to be treated with respect and dignity, including: §483.10(e)(2) The right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to treat a resident with dignity when CNA 1 brushed a resident's hair while in the Activities/Dinning Room for one of 19 sample residents (Resident 4). As a result Resident 4, who has severe 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: WTEI11 Facility ID: CA970000037 If continuation sheet 1 of 53 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 12/23/2017 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 cognitive impairment, had her hair brushed by Certified Nursing Assistant 1 (CNA 1), while among other alert residents and had the potential to cause embarrassment for the resident. Findings: A review of the admission information indicated Resident 4 was readmitted to the facility on June 23, 2014, with diagnoses of schizophrenia (a severe mental illness). A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated November 11, 2017, indicated Resident 4's Brief Interview for Mental Status (BIMS) score was 3. A BIMS score of 3 indicates the resident has severe cognitive impairment. The MDS indicated the resident required limited assistance of one person for hygiene. On December 23, 2017 at 10 a.m. Resident 4 was observed in the Activities Room/Dining Room, among other alert residents, while CNA 1 was brushing the resident's hair. The resident was not interviewable. On December 23, 2017 at 10 a.m. in an interview, CNA 1 stated she normally brushes Resident 4's hair after a shower, and brushing the resident's hair is considered personal care. CNA 1 stated she could take the resident to her room to comb the resident's hair instead, to give privacy to the resident. CNA 1 stated other residents in the Activities Room may also not like CNA 1 brushing the resident's hair in the Activities Room/Dining Room.

F583 SS=D Personal Privacy/Confidentiality of Records CFR(s): 483.10(h)(1)-(3)(i)(ii)

F583 12/23/2017 §483.10(h) Privacy and Confidentiality. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 2 of 53 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 12/23/2017 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 resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law. This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review the facility failed to provide privacy during personal care for one of 19 sample residents (Resident 4). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 3 of 53 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 12/23/2017 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 As a result Resident 4, who has severe cognitive impairment, had her hair brushed by Certified Nursing Assistant 1 (CNA 1), while in the Activities Room/Dining Room among other alert residents and had the potential negatively affect sense of self worth. Findings: A review of the admission information indicated Resident 4 was readmitted to the facility on June 23, 2014, with diagnoses of schizophrenia (a severe mental illness). A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated November 11, 2017, indicated Resident 4's Brief Interview for Mental Status (BIMS) score was 3. A BIMS score of 3 indicates the resident has severe cognitive impairment. The MDS indicated the resident required limited assistance of one person for hygiene. On December 23, 2017 at 10 a.m. Resident 4 was observed in the Activities Room/Dining Room, among other alert residents, while CNA 1 was brushing the resident's hair. The resident was not interviewable. On December 23, 2017 at 10 a.m. in an interview, CNA 1 stated she normally brushes Resident 4's hair after a shower, and brushing the resident's hair is considered personal care. CNA 1 stated she could take the resident to her room to comb the resident's hair instead, to give privacy to the resident. CNA 1 stated other residents in the Activities Room may also not like CNA 1 brushing the resident's hair in the Activities Room/Dining Room.

F584 SS=E Safe/Clean/Comfortable/Homelike Environment F584 CFR(s): 483.10(i)(1)-(7) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 01/12/2018 Facility ID: CA970000037 If continuation sheet 4 of 53 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 12/23/2017 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 §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide§483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2) (iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81°F; and §483.10(i)(7) For the maintenance of comfortable sound levels. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 5 of 53 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 12/23/2017 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 by: Based on observation and interview, the facility maintenance and housekeeping failed to provide a clean, free of odor, safe and home like environment for 30 of 30 residents residing in the facility. These deficient practices placed the residents at risk of cross contamination, spread of disease-causing organism, and accident/incidents. Findings: On December 23, 2017, from 8 a.m. to 10:15 a.m., the following was observed: 1. During initial tour of the facility, the facility had a strong distinct odor. The housekeeping was observed mopping the residents' room. During closer inspection of each resident's room, an imbedded black substance was observed in the floor baseboard. The floor linoleum had scratches, stained and old. 2. The entrance double door, the double door by Room 12 going to the patio and the double door by the Rehabilitation room had one to two inches gap, missing, and wore weather strips. That rodents or any insects can enter the facility. 3. The pavement in the smoking patio was three to four inches cement crack. 4. The medical record room had boxes directly placed on the floor. The residents' clinical record were disarrayed. 5. The Rehab room had boxes of soda, food, and copy machine and boxes on top of treatment bed. Licensed Vocational Nurse FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 6 of 53 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 12/23/2017 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 (LVN 2) stated that the facility had a recent holiday party. On December 23, 2017, at 3:25 p.m., during an observation and interview with the Assistant Maintenance Supervisor he stated that the linoleums are old and it is hard to clean and remove the imbedded dirt and odor. On December 23, 2017, at 6:00 p.m., during an interview with the Administrator, he stated that the facility's environment are not identify as a concern on the quality assurance meeting.

F640 SS=C Encoding/Transmitting Resident Assessments CFR(s): 483.20(f)(1)-(4)

F640 01/12/2018 §483.20(f) Automated data processing requirement§483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 7 of 53 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 12/23/2017 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 assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure 26 of 30 residents' Minimum Data Set (MDS - a comprehensive assessment and care-screening tool) were timely transmitted to the Centers for Medicare and Medicaid Services (CMS) system. This deficient practice had a potential for delayed services. Findings: On December 23, 2017, at 10:00 a.m., during an interview with Licensed Vocational Nurse 2 (LVN 2) also an MDS nurse assigned to transmit residents' MDS to CMS system, stated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 8 of 53 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 12/23/2017 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 that she was not aware that she was not transmitting the MDS correctly. LVN 2 stated that after she was informed by the State, she noticed that the facility CASPER (MDS Report) only showed four residents' MDS was transmitted to CMS system. LVN 2 stated that she called the facility IT (information technology) and able to transmit the rest of residents' MDS. LVN 2 stated that prior to this identified concern the facility has no system in placed to ensure that the residents' MDS are being transmitted.

F641 SS=D Accuracy of Assessments CFR(s): 483.20(g)

F641 12/23/2017 §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS - an assessment and carescreening tool) was accurately reflected the dental status of one of 19 sampled residents (Resident 20). This deficient practice resulted to resident not receiving dental care as soon as needed. Findings: On December 23, 2017, at 9 a.m., Resident 20 was observed inside his room alert and oriented and able to carry conversation. The resident was observed with broken, and decayed front teeth. According to the admission record, Resident 20 was originally admitted to the facility on February 27, 2017 and readmitted on FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 9 of 53 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 12/23/2017 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 November 17, 2017 with diagnoses that included major depression and schizophrenia (a severe mental disorder in which people interpret reality abnormally). A review of Resident 20's Minimum Data Set (MDS - an assessment and care-screening tool dated October 26, 2017 indicated the resident was cognitively intact and independent with activities of daily living. The MDS indicated that the resident had no dental problems. A review of the Dental Notes dated November 7, 2017 indicated fourth molar broken tooth with mobility and broken front teeth. On December 23, 2017, at 3:00 p.m., during an interview and review of Resident 20's MDS with Licensed Vocational Nurse 2 (LVN 2), an MDS Nurse she was unable to explain the discrepancy.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 01/12/2018 §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 10 of 53 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 12/23/2017 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 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)(A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for one of 19 sample residents (Resident 35). As a result, Resident 35's care plan did not address how to ensure the resident followed physician's orders in concern for healing a foot/ankle fracture. Findings: A review of the admission information indicated Resident 35 was admitted to the facility on September 20, 2017, with diagnoses of fracture FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 11 of 53 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 12/23/2017 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 (broken bone) of the right foot. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated October 2, 2017, indicated Resident 35's Brief Interview for Mental Status (BIMS) score was 15. A BIMS score of 15 indicates the resident has intact cognitive skills. The MDS indicated the resident had a fracture. On December 23, 2017 at 12 p.m., Resident 35 was sitting in a wheelchair with a ankle/foot immobilizer in place. The resident was alert and interviewable. When the resident was asked how she was doing she stated she fell at home and fractured her foot and now it is healing. The resident stated she was receiving physical therapy and was going home soon. A review of Resident 35's care plan dated September 21, 2017, for right foot/ankle fracture did not indicate and address specific care necessary to promote healing of the resident's fracture such as immobilization and weight bearing status. A review of Resident 35's care plan dated September 21, 2017, for at risk of fall, indicated the resident was non-compliant with safety needs. The care plan did not specify what the resident was non-compliant with. The care plan did not indicate devices necessary to immobilize the foot and ankle such as a controlled ankle movement boot (CAM- a brace in the form of a boot) and or other restrictions such as weight bearing status-weight allowed on leg, to the right lower extremity to prevent further injury to the resident's foot/ankle. A review of Resident 35's orthopedic (a medical field that focuses primarily on muscles, spine, bones, and joints) consult dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 12 of 53 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 12/23/2017 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 September 22, 2017 at 3 p.m., indicated the resident had a right distal fibula fracture (a fracture ankle) and a right 2nd, 3rd, and 4th metatarsal fracture (long thin bones are located between the toes and the ankle) / Lisfranc fracture (a dislocation of the midfoot). The consult indicated to continue with the Controlled Ankle Movement boot and non weight bearing (NWB-leg must not touch the floor and is not permitted to support any weight at all), to the right lower extremity. The consult indicated a discussion with patient to be compliant with the CAM boot and NWB, otherwise fracture can move and will require surgery to repair. A review of Resident 35's Licensed Nurses Progress Notes dated October 3, 2017 at 12 p.m., indicated the resident complained of right knee and foot pain. The notes indicated at 8 p.m. the resident was picked up by 2 Emergency Medical Technicians (EMT's) by gurney. The Licensed Nurses Progress Notes did not indicate the reason for the transport. A review of Resident 35's General Acute Care Hospital (GACH) history and physical (H and P) dated October 4, 2017 at 6:05 p.m. indicated the resident was advised to not do weight bearing on the right foot, was non-compliant and is now readmitted for worsening right foot fracture. The resident was scheduled for surgery ORIF of the and was placed on bed rest and pain management.

F692 SS=G Nutrition/Hydration Status Maintenance CFR(s): 483.25(g)(1)-(3)

F692 01/12/2018 §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 13 of 53 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 12/23/2017 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 comprehensive assessment, the facility must ensure that a resident§483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure one of 19 sampled residents (Resident 19) maintains acceptable parameters of nutritional status, including: 1. Failure to identify the cause of resident slow progressive unplanned weight loss. 2. Failure to monitor and address resident low Pre albumin level (a laboratory test used to identify nutritional status, lower than normal, it may be a sign of a poor diet [malnutrition] of 8 milligrams/dL (Reference range 17 - 31 mg/dL) dated August 10, 2017 and to obtain Pre albumin level as recommended by facility registered dietitian on November 16, 2017. 3. Failure to follow nutritional plan of care for resident to have dental evaluation as needed related to chewing problem. 4. Failure to have multidisciplinary team FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 14 of 53 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 12/23/2017 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 meeting to strive to prevent, monitor, and intervene Resident 23's undesirable weight loss as indicated in the facility's policy and procedure on Weight Assessment and Intervention revised on April 2012. As a result, Resident 23 had undesirable unplanned weight loss of 8.6 % in six months, low Pre-albumin and below his target weight goal range of 139 - 169 pounds. Findings: On December 23, 2017 at 12:15 p.m., during medication pass observation, Resident 23 was observed eating puree diet (consists of common foods, prepared for meals, which are blended until the texture becomes smooth and drinkable) his lunch in his room. Resident 23 was observed with no teeth, tall, thin, with grey face and the shape of his rib bones are sticking out of his shirt. According to the admission record Resident 23 was originally admitted to the facility on March 17, 2013 and readmitted on July 30, 2017 with diagnoses that included infectious gastroenteritis (an infection of the gut (intestines) with causes diarrhea and vomiting), and chronic obstructive pulmonary disease (COPD - a chronic inflammatory lung disease that cause airflow blockage and breathingrelated problems). A review of Resident 23's Minimum Data Set (MDS - a comprehensive assessment and care screening tool), dated July 5, 2016 indicated the resident's cognitive skills for daily decisionmaking were intact and required supervision with activities of daily living. The MDS indicated the resident was 68 inches tall and weighed 158 pounds (lbs). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 15 of 53 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 12/23/2017 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 MDS dated August 11, 2017 indicated Resident 23 was moderately impaired with cognitive skills for daily decision-making and limited to extensive assistance from staff with activities of daily living. The MDS indicated the resident was 68 inches tall and weight 137 lbs. A review of Resident 23's nutritional problem dated July 31, 2017 and updated on August 23, 2017, indicated that the resident needs pureed diet secondary to chewing problem/no teeth. The care plan indicated potential for significant weight changes. The goal indicated that the resident will have no significant weight changes. The interventions included weight per medical doctor (MD) order and notify MD of any significant weight changes, monitor tolerance to current diet - notify MD if texture of food is not tolerated, and dental evaluation as needed (PRN). A review of Resident 23's Monthly Weight Record indicated the following: January 3, 2017 - 142 pounds February 1, 2017 - 142 pounds March 2, 2017 - 142 pounds April 3, 2017 - 142 pounds May 2, 2017 - 141 pounds June 2, 2017 - 139 pounds July 3, 2017 - 139 pounds August 2, 2017 - 137 pounds September 2017 - 133 pounds October 2, 2017 - 131 pounds November 2, 2017 - 129 pounds December 4, 2017 - 127 pounds The resident had a slow progressive unplanned weight loss of 15 pounds in 12 months and 8.6 % in six months. A review of Resident 23's laboratory result dated August 10, 2017, indicated the resident's FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 16 of 53 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 12/23/2017 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 Pre-Albumin level (assess nutritional status and evaluate liver function toward diagnosing disorders such as malnutrition and chronic renal [kidney] failure) was 8 milligrams per deciliter (mg/dL) low in a (Reference range 17 31 mg/dL). A review of Resident 23's physician's order dated February 16, 2017, indicated Mechanical Soft diet, no added salt, large portion. On August 23, 2017, the diet order was changed to puree large portion diet and ready care shake four (4) ounces three times a day with meals. A review of Resident 23's Nutritional Screening and Assessment dated August 24, 2017 completed by the facility's Registered Dietitian (RD) indicated that the resident target weight goal range was 139 - 169 pounds. The estimated daily nutritional requirements indicated the calories 1868 - 2170/day, protein 50-62/day and fluid 1860/day. A review of Resident 23's Dietary Progress Notes dated August 24, 2017 completed by facility's RD indicated diet changed to puree large portion diet. Resident tolerating and accepting diet consistency well. Another Dietary Progress Notes dated November 16, 2017 indicated resident weight was 129 pounds, below weight range of 138 - 169 pounds. Puree large portion with ready shake nourishment four ounces three times a day, meal intake 70-100 percent (%). The plan indicated obtain laboratory for Pre-albumin level and follow per protocol. A review of Resident 23's Nursing Assistant Daily Flow Sheet - Meal intake indicated for month of October, November and December 2017, resident breakfast and lunch meal consumption was less than 70 percent, and dinner 70 - 100 %. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 17 of 53 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 12/23/2017 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 On December 23, 2017 at 2:15 p.m., during an interview and review of Resident 23's clinical record with the Director of Nurses (DON) he was unable to provide documented evidence that an multidisciplinary team (MDT - a group of health care professionals from diverse fields who work in a coordinated fashion to achieve specific objectives for the resident) discuss the resident slow progressive weight loss, and updated the nutritional care plan. The DON stated that he received the RD recommendation dated November 16, 2017 to obtain Pre-albumin level but unable to explain why the Pre-albumin level was done. On December 23, 2017 at 6:05 p.m., during dinner observation, Resident 23 was unable to answer inquiry regarding his food and his weight loss. A review of facility's policy and procedure on Weight Assessment and Intervention revised on April 2012 indicated the multidisciplinary team will strive to prevent, monitor, and intervene for undesirable weight loss.

F711 SS=E Physician Visits - Review Care/Notes/Order CFR(s): 483.30(b)(1)-(3)

F711 01/12/2018 §483.30(b) Physician Visits The physician must§483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 18 of 53 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 12/23/2017 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 §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure the residents' physician write the progress notes at each visits for two of 19 sampled residents (Residents 14 and 20). The physician had no documented written progress notes of his/her eight months visits from April 2017 to December 2017 regarding the residents' status/condition. This deficient practice placed the residents at risk of poor continuity of care, poor follow up and unidentified resident's status for each physician visits. Findings: a. According to the admission record, Resident 14 was readmitted to the facility on April 16, 2017 with diagnoses that included diabetes mellitus (high blood sugar) and hypertension (high blood pressure). A review of Resident 14's Minimum Data Set (MDS - an assessment and care-screening tool), dated October 26, 2017 indicated the resident cognitive skills for daily decisionmaking were intact and required supervision from staff with activities of daily living. A review of Resident 14's one sheet Doctors' Progress Notes reflected different dates with initial and fading stamp of "Internal Medicine." There were no documented written progress notes regarding Resident 14's condition at the time of the physician visits. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 19 of 53 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 12/23/2017 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 On December 23, 2017, at 11:00 a.m., during an interview and review of Resident 14's Doctor's Progress Notes," with the Medical Record Director (MRD) she stated that the physician dictates his progress notes but had no record of it in the resident's clinical record. MRD stated that when she asked the physician's office for a copy of dictated progress notes she will received a copy of physician orders. b. According to the admission record, Resident 20 was originally admitted to the facility on February 27, 2017 and readmitted on November 17, 2017 with diagnoses that included major depression and schizophrenia (a severe mental disorder in which people interpret reality abnormally). A review of Resident 20's Minimum Data Set (MDS - an assessment and care-screening tool dated October 26, 2017 indicated the resident was cognitively intact and independent with activities of daily living. A review of Resident 20's one sheet Doctors' Progress Notes reflected different dates with initial and fading stamp of "Internal Medicine." There were no documented written progress notes regarding Resident 20's condition at the time of the physician visits. On December 23, 2017, at 11:10 a.m., during an interview with the MRD she stated that the physician dictates his progress notes but had no record of it in the resident's clinical record. MRD stated that when she asked the physician's office for a copy of dictated progress notes she will received a copy of physician orders. According to undated facility's policy and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 20 of 53 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 12/23/2017 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 procedures titled "Physician Services," indicated the resident's physician participates in the resident's assessment and care planning, monitoring changes in resident's medical status ... the attending physician is responsible for prescribing new therapy, ordering a transfer to the hospital, required routine visits ...physician orders and progress notes shall be maintained in accordance with current OBRA (Omnibus Budget Reconciliation Act of 1987) regulations and facility policy. The policy did not indicate the specific OBRA regulations

F757 SS=E Drug Regimen is Free from Unnecessary Drugs CFR(s): 483.45(d)(1)-(6)

F757 01/31/2018 §483.45(d) Unnecessary Drugs-General. Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used§483.45(d)(1) In excessive dose (including duplicate drug therapy); or §483.45(d)(2) For excessive duration; or §483.45(d)(3) Without adequate monitoring; or §483.45(d)(4) Without adequate indications for its use; or §483.45(d)(5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or §483.45(d)(6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 21 of 53 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 12/23/2017 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 Based on observation, interview and record review, the facility failed to ensure residents were free from unnecessary drugs for five of 19 sampled residents (Residents 9, 20, 21, 29, and 34) by: 1. Failing to identify the presence of adverse side effects such as tardive dyskinesia (facial and tongue movements) for Resident 29. This deficient practice placed at risk of falls, and injuries. 2. Failing to monitor specific behavior for Resident 34 who had a severe mental illness. This deficient practice had the potential for the resident not to be monitored for the effectiveness and/or ineffective of medication. 3. Failing to adequate monitor a continuing need for Celexa (an antidepressant medication) for Resident 34. This deficient practice had the potential to result in over use of medication. 4. Failing to adequate monitoring the side effects of Quetiapine (an antipsychotic medication-used to treat severe mental illness) for Resident 9. 5. Failing to monitor specific behavior for Resident 20 and Resident 21 who received antipsychotic medication. This deficient practice had the potential for the resident not to be monitored for the effectiveness and/or ineffective of medication and adjust the medication as necessary. Findings: a. A review of the admission information indicated Resident 29 was admitted to the facility on November 23, 2017, with diagnoses FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 22 of 53 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 12/23/2017 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 of arteriosclerotic heart disease (ASHD- a thickening and hardening of the walls of the coronary arteries), diabetes mellitus (high blood sugar), and major depressive disorder. A review of Resident 29's Minimum Data Set (MDS- a standardized assessment and care screening tool), December 5, 2017, indicated the resident's Brief Interview for Mental Status (BIMS) score indicated the resident's score was 12. A BIMS score of 12 indicates the resident is moderately impaired in cognitive skills. The MDS indicates the resident used antipsychotic (used to treat severe mental illness) medication 7 of the last 7 days. On December 23, 2017 at 12 p.m., 12:30 p.m., 3 p.m. and 5:45 p.m. Resident 29 was observed with obvious tongue thrusting and oral movements. A review of the physician's order dated November 23, 2017, indicated the following medication orders: 1. Seroquel 100 milligrams (mg) by mouth twice a day for schizophrenia manifested by people are trying to hurt her. 2. Lexapro 20 mg by mouth every day for depression manifested by social isolation. 3. Desyrel 50 mg by mouth every night for depression manifested by verbalization of fear. 4. Monitor every shift for Tardive Dyskinesia. A review of the physicians order dated December 2, 2017, indicated the following: 1. Discontinue Seroquel 2. Start Seroquel 50 mg by mouth twice a day 3. Discontinue Trazadone 4. Decrease Trazadone to 25 mg by mouth every day. A review of Resident 29's care plan dated November 24, 2017, indicated the resident was FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 23 of 53 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 12/23/2017 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 at fall risk due to the use of antipsychotic drugs (Seroquel-used to treat severe mental illness) and antidepressant drug use (Lexapro, Trazadone). The care plan did not address how the facility would monitor the resident for side effects of the antipsychotic and antidepressant drugs and how to intervene in the event of adverse drug reactions or side effects. A review of the facility's undated Multi Use Drug Information Reference Form indicated Resident 29 was taking Seroquel an antipsychotic medication, and Lexapro a antidepressant medication. The Reference Form indicated the possible adverse drug reactions for Seroquel included Tardive Dyskinesia and dizziness. On December 23, 2017 at 3:20 p.m., in an interview Resident 29 she stated she had mouth movements since she came to the facility, and she thought medication she takes caused her to have mouth movements. Resident 29 stated she had the mouth movements for a few months now. Resident 29 stated she fell a few weeks ago because she felt dizzy, but she did not hurt herself. On December 23, 2017 at 6 p.m. in an interview Family Member 1 (FM 1) stated Resident 29's mouth movements increased in the last two months, but did not mention the mouth movements to the nurses. On December 23, 2017 at 05:47 p.m. the Director of Nurses (DON) stated he did not see Resident 29 when she first came into facility to know if the resident had side effects of her medication on admission. The DON stated he did not notify the MD, but should if there are side effects, to obtain an order to either decrease the dose or discontinue the medication. The DON stated he did not know FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 24 of 53 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 12/23/2017 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 resident had side effects of the psychoactive medications (Seroquel). The DON stated the resident had a recent decrease in Trazadone. (Not usual to cause Tardive Dyskinesia). A review of Resident 29's Medication Administration Record (MAR) dated December 23, 2017, at 7:30 p.m. indicated the resident was administered Seroquel, Lexapro and Trazadone as the physician ordered. The MAR indicated the Licensed Nurses monitored Resident 29 for Tardive Dyskinesia, however, the MAR indicated the resident had no Tardive Dyskinesia on December 23, 2017 on the 7 a.m. to 3 p.m. shift. On December 23, 2017 at 7:45 p.m. LVN 1 stated he was trained regarding the side effects of psychoactive medications one year ago. LVN 1 who was assigned as the medication nurse for Resident 29, on December 23, 2017, for the 7 a.m. to 3 p.m. shift, stated he was assigned to care for Resident 29 on the 3 p.m. to 11 p.m. shift on December 2, 2017 through December 9, 2017, and on December 16, 2017. LVN 1 stated he usually sees Resident 29 six to seven times during each shift. LVN 1 was unaware the resident had mouth or tongue movements. According to Davis's Drug Guide (2015) some adverse reactions associated with Seroquel include (but are not limited to) dizziness, and tremor, and tardive dyskinesia. b. 1. A review of the admission information indicated Resident 34 was admitted to the facility on June 17, 2017, with diagnosis of schizophrenia and major depressive disorder. A review of the Minimum Data Set (MDS- a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 25 of 53 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 12/23/2017 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 standardized assessment and care screening tool), dated September 28, 2017, indicated Resident 34 used antidepressant and antipsychotic medication. The resident's Brief Interview for Mental Status (BIMS) score indicated Resident 34's score was 15. A BIMS score of 15 indicates the resident has intact cognitive skills. On December 23, 2017 at 8:30 a.m. Resident 34 was observed in her room and was alert. During a concurrent interview, the resident was communicative and stated she liked going to play Bingo in the facility. A review of the December 2017, physician's orders indicated Resident 34 was to be given Celexa 20 milligrams by mouth every day for depression manifested by hopelessness. A review of Resident 34's care plan dated June 19, 2017 for at risk for complications related to the use of Celexa indicated to evaluate the effectiveness of the medication. The care plan did not specify the method for evaluating the effectiveness of the medication or a specific behavior displayed when the resident experienced hopelessness. A review of Resident 34's November 2017 and December 2017, Medication Administration Record (MAR) indicated the resident received Celexa 20 mg every day as the physician ordered. The MAR indicated to monitor Resident 34's behavior for depression manifested by hopelessness every shift and to tally by hashmarks. There was no indication on the MAR to describe the specific behavior the resident displayed when she was experiencing hopelessness, in order to quantify the resident's specific behavior. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 26 of 53 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 12/23/2017 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 b.2. A review of the admission information indicated Resident 34 was admitted to the facility on June 17, 2017, with diagnosis of schizophrenia and major depressive disorder. A review of the Minimum Data Set (MDS- a standardized assessment and care screening tool), dated September 28, 2017, indicated Resident 34 used antidepressant and antipsychotic medication. The resident's Brief Interview for Mental Status (BIMS) score indicated Resident 34's score was 15. A BIMS score of 15 indicates the resident has intact cognitive skills. On December 23, 2017 at 8:30 a.m., Resident 34 was observed in her room and was alert. During a concurrent interview, the resident was communicative and stated she liked going to play Bingo in the facility. A review of the November 2017, physician's orders indicated Resident 34 was to be given Risperidone 2 milligrams (mg) by mouth every night for schizophrenia manifested by fearful thoughts and paranoia. There was no specific behavior identified to describe the resident's displayed behavior when the resident had paranoia, in order to quantify the resident's behavior. A review of Resident 34's care plan dated June 19, 2017, for at risk for complications related to the use of Risperidone indicated to evaluate the effectiveness of the medication. The care plan did not specify the method for evaluating the effectiveness of the medication. A review of the November 2017, Medication Administration Record (MAR) indicated Resident 34 received Risperidone every night as the physician ordered until the Risperidone was discontinued on November 1, 2017. The FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 27 of 53 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 12/23/2017 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 MAR indicated to monitor Resident 34's behavior for schizophrenia manifested by paranoia every shift and tally by hashmarks. There was no indication on the MAR indicating the specific behavior the resident displayed when the resident had paranoia, in order to quantify the resident's specific behavior. d. On December 23, 2017, at 9 a.m., Resident 20 was observed inside his room alert and oriented and able to carry conversation. According to the admission record, Resident 20 was originally admitted to the facility on February 27, 2017 and readmitted on November 17, 2017 with diagnoses that included major depression and schizophrenia (a severe mental disorder in which people interpret reality abnormally). A review of Resident 20's Minimum Data Set (MDS - an assessment and care-screening tool dated October 26, 2017 indicated the resident was cognitively intact and independent with activities of daily living. The MDS indicated that the resident was feeling down, depressed, or hopeless and the symptoms are present 2 - 6 days for the last two weeks. A review of Resident 20's care plan for alteration in thought process as evidenced by delusional (a mistaken belief that is held with strong conviction even when presented with superior evidence to the contrary) thinking and disorganized behavior manifested by sudden outburst of anger. The approach plan included monitor and document behaviors in the medication sheet and notify medical doctor of any uncontrollable behavior. However, the care plan did not address what specific delusional thoughts the resident was manifesting that need to be monitor. A review of the physician's order dated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 28 of 53 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 12/23/2017 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 November 17, 2017 indicated Clozapine (antipsychotic medication) 25 milligrams (mg) by mouth twice a day and Clozapine 300 mg at bedtime for schizophrenia manifested by paranoid delusional thoughts. Another physician's order dated November 17, 2017 indicated Seroquel (antipsychotic medication) 150 mg every noon for schizophrenia manifested by paranoid delusional thoughts. The physician's order did not indicate what specific behavior of paranoid delusional thoughts the resident was manifesting to be monitored to ensure the effectiveness of the medication. A review of the Medication Administration Record for November to December 23, 2017 indicated the resident was being monitored for paranoid delusional thoughts and the resident had zero hash marks (indicating no manifestation of paranoid delusional thoughts) On December 23, 2017 at 5:45 p.m., during an interview and review of Resident 20's medical record with the Director of Nurses (DON) and Licensed Vocational Nurse 2 (LVN 2) both was unable to provide the specific behavior the resident was manifesting for the use of Clozapine and Seroquel. e. On December 23, 2017 at 8:45 a.m., Resident 21 was observed inside his room sitting in a wheelchair. The resident was alert and oriented and speak on his native language. According to the admission record, Resident 21 was admitted to the facility on September 27, 2017 with diagnoses that included psychosis (a severe mental disorder in which thought and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 29 of 53 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 12/23/2017 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 emotions are so impaired that contact is lost with external reality). A review of Resident 21's Minimum Data Set (MDS - an assessment and care-screening tool), dated October 9, 2017 indicated the resident cognitive skills for daily decisionmaking were severely impaired and required supervision to limited assistance from staff with activities of daily living. The MDS indicated the resident has little interest or pleasure in doing things and moving or speaking so slowly that other people could have noticed and the symptoms was present 2 - 6 days for two weeks. A review of Resident 21's care plan for history of behavior problem - responding to internal stimuli potential for harm to self, harming others and recurrence of behavior. The approaches included monitor and document behavior in the medication book, notify medical doctor if any recurrence of behavior is noted and review behavior and medication every three months and as needed. The care plan did not specify the specific internal stimuli behavior the resident was manifesting and to be monitored. A review of Resident 21's physician's order dated September 27, 2017 indicated Zyprexa 15 milligrams by mouth twice a day for psychosis manifested responding to internal stimuli. On December 23, 2017 at 5:55 p.m., during an interview and review of Resident 21's medical record with the Director of Nurses (DON) and Licensed Vocational Nurse 2 (LVN 2) both was unable to provide the specific behavior the resident was manifesting for the use of Zyprexa. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 30 of 53 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 12/23/2017 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 According to the facility's policy and procedure titled "Antipsychotic Medication Use," revised April 2007 indicated residents will only receive antipsychotic medications when necessary to treat specific conditions for which they are indicated and effective. The attending physician and other staff will gather and document information to clarify a resident's behavior, mood, functions, medical condition, symptoms, and risks. Nursing staff shall monitor and report any of the following side effects to the attending physician including extrapyramidal symptoms, akathisia, dystonia, tremor, rigidity, akinesia; or tardive dyskinesia. c. According to the admission record, Resident 9 was originally admitted to the facility on July 10, 2017, and was readmitted on November 28, 2017, with diagnoses that included Schizophrenia (a mental disorder) and Chronic Obstructive Pulmonary Disease [COPD- a lung disease characterized by long term poor airflow]. A review of the Minimum Data Set [MDS- a standardized assessment and care planning tool], dated July 20, 2017, indicated Resident 9 had severe cognitive impairment and required limited assistance for dressing, toilet, and bathing. A record review of Resident 9's physician's order dated November 28, 2017, indicated to give the resident Quetiapine 400 milligrams (mg) twice a day for Schizophrenia manifested by anger outburst and striking out. Monitor side effects of the antispychotic medication: tardive dyskinesia (facial tongue movement), cognitive impairment, akathisia (inability to sit still), and Parkinsonism (tremors & rigidity). On December 23, 2017 at 10:11 a.m., during an observation, Resident 9 was observed sitting in the bed, swaying his body forward and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 31 of 53 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 12/23/2017 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 backward in constant motion. On December 23, 2017 at 10:30 a.m., during an interview and observation, Certified Nursing Assistant 1 (CNA 1) stated most of the time, when the resident is sitting he does a jerky, forward and backward movement constantly. On December 23, 2017 at 2:39 p.m., during an observation, Resident 9 was observed in the Activity Room sitting in a wheelchair and was observed with resting tremors (involuntary movements) in his left hand. The resident's index finger of the hand was in contact with the thumb, and was performing a circular movement or pattern. On December 23, 2017 at 4:30 p.m., during an observation in the presence of Licensed Vocational Nurse 1 (LVN 1), Resident 9 was still in the activity room sitting in wheelchair and was observed with resting tremors in his left hand. During the concurrent interview, LVN 1 stated the tremors observed might be a side effect of the antipsychotic medication. LVN 1 added that he will inform his Director of Nurses and the physician. A record review of Resident 9's Medication Administration Record (MAR) from December 1, 2017 to December 23, 2017, indicated no incident of tardive dyskinesia, cognitive impairment, akathisia, and Parkinsonism. A review of Resident 9's antipsychotic drug use care plan dated November 29, 2017, indicated a goal of resident will not have any side effects from current medication for the next 3 months. Interventions included monitor for antipsychotic side effects like tardive dyskinesia, cognitive impairment, akathisia, and Parkinsonism. According to Davis's Drug Guide (2015) some FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 32 of 53 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 12/23/2017 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 adverse reactions associated with Seroquel include neuroleptic malignant syndrome (a lifethreatening neurological disorder that can cause muscle cramps and tremors, fever, symptoms of autonomic nervous system instability such as unstable blood pressure, and sudden changes in mental status), seizures, dizziness, cognitive impairment, and extrapyramidal symptoms (dystonia [continuous spasms and muscle contractions], akathisia [motor restlessness], Parkinsonism [characteristic symptoms such as rigidity], bradykinesia [slowness of movement], tremor, and tardive dyskinesia [irregular, jerky movements]).

F761 SS=D Label/Store Drugs and Biologicals CFR(s): 483.45(g)(h)(1)(2)

F761 02/23/2018 §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 33 of 53 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 12/23/2017 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 stored is minimal and a missing dose can be readily detected. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure multi-dose insulin pen was dated and discarded within 28 days after it has been first accessed for one of one medication refrigerator. This deficient practice had a potential for medication contamination and poor drug reconciliation. Findings: On December 23, 2017 at 8:55 a.m., during medication storage inspection with Licensed Vocational Nurse 3 (LVN 3), one Novolog (Insulin to treat high blood sugar) pen was observed opened but not dated when it was first accessed. LVN 3 stated that it should have been dated when it was opened/accessed. According to 2007 facility's policy and procedure titled "Injectable Vials and Ampules," indicated the date opened and the initials of the first person to use the vial are recorded on multi-dose vials.

F790 SS=D Routine/Emergency Dental Srvcs in SNFs CFR(s): 483.55(a)(1)-(5)

F790 12/27/2017 §483.55 Dental services. The facility must assist residents in obtaining routine and 24-hour emergency dental care. §483.55(a) Skilled Nursing Facilities A facilityFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 34 of 53 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 12/23/2017 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 §483.55(a)(1) Must provide or obtain from an outside resource, in accordance with with §483.70(g) of this part, routine and emergency dental services to meet the needs of each resident; §483.55(a)(2) May charge a Medicare resident an additional amount for routine and emergency dental services; §483.55(a)(3) Must have a policy identifying those circumstances when the loss or damage of dentures is the facility's responsibility and may not charge a resident for the loss or damage of dentures determined in accordance with facility policy to be the facility's responsibility; §483.55(a)(4) Must if necessary or if requested, assist the resident; (i) In making appointments; and (ii) By arranging for transportation to and from the dental services location; and §483.55(a)(5) Must promptly, within 3 days, refer residents with lost or damaged dentures for dental services. If a referral does not occur within 3 days, the facility must provide documentation of what they did to ensure the resident could still eat and drink adequately while awaiting dental services and the extenuating circumstances that led to the delay. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review the facility failed to provide necessary dental services as indicated on the dental consult for one of 19 sample residents (Resident 29). FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 35 of 53 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 12/23/2017 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 Findings: a. A review of the admission information indicated Resident 29 was admitted to the facility on November 23, 2017, with diagnoses of arteriosclerotic heart disease (ASHD- a thickening and hardening of the walls of the coronary arteries), diabetes mellitus (high blood sugar), and major depressive disorder. A review of the physician's order dated November 23, 2017, indicated Resident 29 was to have a dental consult treatment and followup. A review of Resident 29's Minimum Data Set (MDS- a standardized assessment and care screening tool), dated December 5, 2017, indicated the resident's Brief Interview for Mental Status (BIMS) score indicated the resident's score was 12. A BIMS score of 12 indicates the resident is moderately impaired in cognitive skills. The MDS indicated the resident did not have loose fitting dentures. The Care Area Summary indicated dental concerns would be care planned. On December 23, 2017 at 3 p.m. and 5:45 p.m. Resident 29 was observed with loose dentures. In a concurrent interview the resident stated she saw the dentist and is waiting for a new pair of dentures. A review of Resident 29's care plan dated November 24, 2017, Social Service Notes of November 24, 2017, and Nutritional Screening and Assessment dated November 25, 2017, did not address the resident's loose dentures. A review of Resident 29's Nutritional Screening and Assessment dated November 25, 2017, indicated the resident had no problems chewing and had dentures. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 36 of 53 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 12/23/2017 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 A review of the Resident 29's Dental Notes indicated the resident had two (2) Initial Dental Assessment done one on December 6, 2017, and one on December 22, 2017. The Initial Dental Assessments done on December 6, 2017 and December 22, 2017, both indicated the resident's treatment recommendation was for a full upper and full lower dentures. On December 23, 2017 at 6:30 p.m., the Assistant Director of Nurses (ADON) when asked about the reason for two (2) Initial Dental Assessments (Consults) with a recommendation for Resident 29's to have full upper and full lower dentures, she did not answer.

F812 SS=F Food Procurement,Store/Prepare/ServeSanitary CFR(s): 483.60(i)(1)(2)

F812 02/23/2018 §483.60(i) Food safety requirements. The facility must §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. This REQUIREMENT is not met as evidenced FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 37 of 53 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 12/23/2017 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 by: Based on observation, interview, and record review, the facility failed to ensure 30 of 30 residents' food was prepared in a kitchen free of dust. This deficient practice placed the residents at risk of food contamination (means the unintended presence of potentially harmful substances, including, but not limited to microorganisms, chemicals, or physical objects in food). Findings: On December 23, 2017 at 8:15 a.m., during kitchen inspection in the presence of Cook I, the following was observed: 1. The outer part of ice machine was dusty. 2. The freezer bottom part had unidentified brown dried mark substance. 3. The refrigerator bottom part had loose dirt (dust). 4. The dry storage bids, boxes of food, cans foods and jar of seasoning has thin layer of dust. The shelves also has thin layer of dust. During concurrent interview with Cook I, the door leading to main busy street with metal screen was observed wide open and cold air was entering the kitchen. Cook I stated that it's very hot in the kitchen and they keep the door open for cold air. Cook 1 agreed that the dust was coming from the street.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 12/31/2017 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 38 of 53 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 12/23/2017 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 agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 39 of 53 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 12/23/2017 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 (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain medical records that are complete by incorporating the results and recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination evaluation report into a resident's medical records for two out of 19 sampled residents (Residents 9 and 26). Findings: a. A review of the admission record indicated Resident 26 was originally admitted to the facility on June 6, 2014, and was readmitted on December 22, 2017, with diagnoses that included Schizopherniform (a mental disorder) and hypertension (high blood pressure). A review of the Minimum Data Set [MDS- a FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 40 of 53 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 12/23/2017 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 standardized assessment and care planning tool], dated October 7, 2017, indicated Resident 26 had moderately impaired cognitive skills and required limited assistance for transfer, toilet use, and bathing. During the medical record review of Resident 26 on December 23, 2017 at 5:55 p.m., a result of PASRR Level I screen dated December 17, 2016, indicated the need for a PASSR level II evaluation. During the review, there was no PASSR level II evaluation result present in Resident 26's medical chart. During an interview on December 23, 2017 at 5:58 p.m., the Director of Nursing (DON) stated that he does not know if Resident 26's PASSR level II evaluation was done. The DON did not answer when asked if the facility knows and follows the recommendation from the PASSAR II evaluation. During an interview on December 23, 2017 at 06:21 p.m., the Medical Records Director (MRD) stated all documentation of laboratory results, consults and evaluations like the PASSR should be in the medical chart. The MRD stated PASSR evaluations are coordinated by the Social Services. b. A review of the admission record indicated Resident 9 was originally admitted to the facility on July 10, 2017, and was readmitted on November 28, 2017, with diagnoses that included Schizophrenia (a mental disorder) and Chronic Obstructive Pulmonary Disease [COPD- a lung disease characterized by long term poor airflow]. A review of Resident 9's Minimum Data Set [MDS- a standardized assessment and care planning tool], dated July 20, 2017, indicated FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 41 of 53 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 12/23/2017 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 resident had severe cognitive impairment and required limited assistance for dressing, toilet use, and bathing. During the medical record review of Resident 9 on December 23, 2017 at 03:48 p.m., a result of the PASSR Level I screen dated July 11, 2017, indicated the need for a PASSR level II evaluation. During the review of Resident 9's medical chart, a PASSR level II evaluation result was not available. During the concurrent interview the Director of Nursing (DON) stated he is not sure if Resident 9's PASSR level II evaluation was done. During an interview on December 23, 2017 at 5:58 p.m., the Director of Nursing (DON) stated that he does not know if Resident 9's PASSR level II evaluation was done. The DON did not answer when asked if the facility knows and follows the recommendation from the PASSAR II evaluation. During an interview on December 23, 2017 at 06:21 p.m., the Medical Records Director (MRD) stated all documentation of laboratory results, consults and evaluations like the PASSR should be in the medical chart. The MRD stated PASSR evaluations are coordinated by the Social Services.

F842 SS=D Resident Records - Identifiable Information CFR(s): 483.20(f)(5), 483.70(i)(1)-(5)

F842 12/31/2017 §483.20(f)(5) Resident-identifiable information. (i) A facility may not release information that is resident-identifiable to the public. (ii) The facility may release information that is resident-identifiable to an agent only in accordance with a contract under which the agent agrees not to use or disclose the information except to the extent the facility itself is permitted to do so. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 42 of 53 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 12/23/2017 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 §483.70(i) Medical records. §483.70(i)(1) In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are(i) Complete; (ii) Accurately documented; (iii) Readily accessible; and (iv) Systematically organized §483.70(i)(2) The facility must keep confidential all information contained in the resident's records, regardless of the form or storage method of the records, except when release is(i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512. §483.70(i)(3) The facility must safeguard medical record information against loss, destruction, or unauthorized use. §483.70(i)(4) Medical records must be retained for(i) The period of time required by State law; or (ii) Five years from the date of discharge when there is no requirement in State law; or (iii) For a minor, 3 years after a resident FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 43 of 53 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 12/23/2017 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 reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; (ii) A record of the resident's assessments; (iii) The comprehensive plan of care and services provided; (iv) The results of any preadmission screening and resident review evaluations and determinations conducted by the State; (v) Physician's, nurse's, and other licensed professional's progress notes; and (vi) Laboratory, radiology and other diagnostic services reports as required under §483.50. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to maintain medical records that are complete by incorporating the results and recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination evaluation report into a resident's medical records for two out of 19 sampled residents (Residents 9 and 26). Findings: a. A review of the admission record indicated Resident 26 was originally admitted to the facility on June 6, 2014, and was readmitted on December 22, 2017, with diagnoses that included Schizopherniform (a mental disorder) and hypertension (high blood pressure). A review of the Minimum Data Set [MDS- a standardized assessment and care planning tool], dated October 7, 2017, indicated Resident 26 had moderately impaired cognitive FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 44 of 53 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 12/23/2017 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 skills and required limited assistance for transfer, toilet use, and bathing. During the medical record review of Resident 26 on December 23, 2017 at 5:55 p.m., a result of PASRR Level I screen dated December 17, 2016, indicated the need for a PASSR level II evaluation. During the review, there was no PASSR level II evaluation result present in Resident 26's medical chart. During an interview on December 23, 2017 at 5:58 p.m., the Director of Nursing (DON) stated that he does not know if Resident 26's PASSR level II evaluation was done. The DON did not answer when asked if the facility knows and follows the recommendation from the PASSAR II evaluation. During an interview on December 23, 2017 at 06:21 p.m., the Medical Records Director (MRD) stated all documentation of laboratory results, consults and evaluations like the PASSR should be in the medical chart. The MRD stated PASSR evaluations are coordinated by the Social Services. b. A review of the admission record indicated Resident 9 was originally admitted to the facility on July 10, 2017, and was readmitted on November 28, 2017, with diagnoses that included Schizophrenia (a mental disorder) and Chronic Obstructive Pulmonary Disease [COPD- a lung disease characterized by long term poor airflow]. A review of Resident 9's Minimum Data Set [MDS- a standardized assessment and care planning tool], dated July 20, 2017, indicated the resident had severe cognitive impairment and required limited assistance for dressing, toilet use, and bathing. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 45 of 53 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 12/23/2017 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 the medical record review of Resident 9 on December 23, 2017 at 03:48 p.m., a result of the PASSR Level I screen dated July 11, 2017, indicated the need for a PASSR level II evaluation. During the review of Resident 9's medical chart, a PASSR level II evaluation result was not available. During the concurrent interview the Director of Nursing (DON) stated he is not sure if Resident 9's PASSR level II evaluation was done. During an interview on December 23, 2017 at 5:58 p.m., the Director of Nursing (DON) stated that he does not know if Resident 9's PASSR level II evaluation was done. The DON did not answer when asked if the facility knows and follows the recommendation from the PASSAR II evaluation. During an interview on December 23, 2017 at 06:21 p.m., the Medical Records Director (MRD) stated all documentation of laboratory results, consults and evaluations like the PASSR should be in the medical chart. The MRD stated PASSR evaluations are coordinated by the Social Services.

F880 SS=E Infection Prevention & Control CFR(s): 483.80(a)(1)(2)(4)(e)(f)

F880 01/31/2018 §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 46 of 53 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 12/23/2017 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 include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which 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; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 47 of 53 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 12/23/2017 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 §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to observe infection control measures for three of 19 sampled residents (Resident 18, Resident 15, and Resident 34), and for all the residents in the facility (Census of 30) by: 1. Failing to ensure clean linens are stored by methods that safeguard cleanliness. 2. Failing to ensure that Resident 18's respiratory care equipment that included nebulizer (a device for breathing mist treatment) tubing and oxygen tubing were properly stored, and not touching the floor. 3. Failing to ensure the glucometer (a medical device for determining the approximate concentration of glucose in the blood) was sanitized before storing the glucometer in the medication cart (Resident 15 and Resident 34). These deficient practices caused the potential for the development and the spread of infection and use of an unsanitary glucometer used to monitor multiple resident's blood sugar and can lead to spread of blood borne infections such as hepatitis. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 48 of 53 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 12/23/2017 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 Findings: a. On December 23, 2017 at 12:30 p.m., during an observation in the presence of Housekeeping Staff 2 (HS 2) the linen storage room was stocked with a disarray of clean linens. The linens in the lower shelves were touching the dirty and dusty floor. During the concurrent interview, HS 2 stated the linens stored in the storage room are all clean. On December 23, 2017 at 12:30 p.m., during an observation and interview the Director of Staff Development (DSD) stated the linen storage needs to be clean and organized. The DSD stated they should place the clean linen in a plastic bags. A review of undated facility policy titled "Handling Soiled Linen" indicated staff shall handle, store, and transport clean linen in a manner to prevent contamination. Guidelines for handling, storage, processing, transporting linens include but not limited to the following: linen should not be allowed to touch the uniform or floor. b. A review of the admission record indicated Resident 18 was originally admitted to the facility on July 5, 2015, and was readmitted on January 26, 2017, with diagnoses that included Chronic Obstructive Pulmonary Disease [COPD- a lung disease characterized by long term poor airflow], and hypertension (high blood pressure). A review of Resident 18's Minimum Data Set [MDS- a standardized assessment and care planning tool], dated October 5, 2017, indicated the resident was cognitively intact and required supervision for transfer, ambulation, and personal hygiene. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 49 of 53 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 12/23/2017 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 the observation on December 23, 2017 at 9:10 a.m., at Resident 18' room, oxygen and the nebulizer (a device for breathing mist treatment) tubing was undated, not properly stored, and was touching the floor. During the interview on December 23, 2017 at 10:05 a.m., the Director of Staff Development (DSD) stated the oxygen tubing and nebulizer kit should be dated and stored in a plastic bag. The DSD stated since the tubing was touching the floor she will replace the whole set of oxygen tubing. A review of Resident 18's physician order dated August 20, 2017, indicated to give the resident Duoneb (a medication used for management of chronic obstructive pulmonary disease and asthma) 0.5/3 milligrams (mg) via hand held nebulizer every 8 hours for COPD and Pulmicort (a medication used for prevention of asthma) 0.5/2 millimeter (ml) unit dose twice a day at 6 a.m. and 10 p.m. for COPD. No order for oxygen. A review of undated facility policy titled "Oxygen Concentrator" indicated to change the tubing weekly and as needed if becomes dirty and or suspected contamination has occurred. c. On December 23, 2017 at 4 p.m. during a medication administration observation, Licensed Vocational Nurse 1 (LVN 1) was observed to take a glucometer out of the medication cart drawer and without sanitizing, used the glucometer to check the finger stick blood sugar (FSBS-a procedure in which a finger is pricked with a lancet to obtain a small quantity of blood for testing) of Resident 15. After the glucometer was used for Resident 15, LVN 1 without sanitizing the glucometer, placed FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 50 of 53 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 12/23/2017 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 glucometer into the clean medication cart drawer. On December 23, 2017 at 4:40 p.m., LVN 1 took the soiled glucometer out of the medication cart drawer, placed a clean glucose test strip into the glucometer, without sanitizing the glucometer. LVN 1, sanitized the glucometer, disposed of the unused glucose test strip and placed a clean glucose test strip into the glucometer before completing the FSBS test for Resident 34. On December 23, 2017, at 5:55 p.m. in an interview with LVN 1, he stated the glucometer is usually cleaned after each use. A summary report dated February 21, 2012, by the The Centers for Disease Control and Prevention (CDC), titled Infection Prevention during Blood Glucose Monitoring and Insulin Administration indicates the CDC has become increasingly concerned about the risks for transmitting hepatitis B virus (HBV) and other infectious diseases during assisted blood glucose (blood sugar) monitoring and insulin administration. CDC is alerting all persons who assist others with blood glucose monitoring and/or insulin administration of the following infection control requirements: Whenever possible, blood glucose meters should be assigned to an individual person and not be shared. If blood glucose meters must be shared, the device should be cleaned and disinfected after every use, per manufacturer's instructions, to prevent carry-over of blood and infectious agents. Unused supplies and medications should be maintained in clean areas separate from used supplies and equipment (e.g., glucose meters).

F912 SS=B Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 51 of 53 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 12/23/2017 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 §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms; This REQUIREMENT is not met as evidenced by: Based on observation, interview, and record review, the facility failed to meet the requirement of 80 square feet per resident in multiple resident bedrooms for seven (7) of 21 resident rooms, Room 6, 4, 2, 10, 14, 16 and 18. This failure had the potential to result in inadequate space for the residents and can impact the residents' quality of life or quality of care. Findings: During an observation of the resident's rooms on December 23, 2017 at 8:30 a.m., there were no concerns observed regarding space in Room 6, 4, 2, 10, 14, 16 and 18. At the time of the observation, the rooms provided enough space for care, dignity, privacy, and resident equipment. There was ample room for the residents to move about freely. There were no concerns observed related to the space or to the safe provision of care to the residents residing in the rooms. During an interview with residents during the Group Interview on December 23, 2017, at 1:30 p.m., the residents did not report concerns with space while providing care to the residents in the rooms. A review of the letter from the Administrator regarding a request for room size waiver dated December 23, 2017, indicated a request for a continuing waiver for Rooms 6, 4, 2, 10, 14, 16 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 52 of 53 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 12/23/2017 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 18. The letter indicated the rooms provide sufficient space for the residents' care with sufficient space for freedom of movement. The rooms have adequate space for getting in and out of their wheelchairs. The rooms are in accordance with the special needs of the residents and would not have adverse effects on the residents' health and safety and do not impede the ability of the residents in that room to obtain his highest practicable well-being. A review of the Client Accommodations Analysis submitted by the Administrator on December 23, 2017, indicated the rooms and the space measurements were as follows: Room No. Floor Area (square feet) Beds Square footage per resident Room 2 77.0 Room 4 Room 6 77.0 Room 10 Room 14 Room 16 Room 18 154.0 2 154.0 77.0 154.0 2 154.0 77.0 154.0 77.0 154.0 77.0 154.0 77.0 2 FORM CMS-2567(02-99) Previous Versions Obsolete 2 2 2 2 Event ID: WTEI11 Facility ID: CA970000037 If continuation sheet 53 of 53