Other·January 31, 2019

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 a recertification survey. Representing the California Department of Public Health: Surveyor 36396, Sr. HFEN Surveyor 40037, HFEN Surveyor 40354, HFEN Surveyor 40438, HFEN The facility census was 35 The sample size was 15 residents. Highest Severity and Scope: E

F582 SS=D Medicaid/Medicare Coverage/Liability Notice CFR(s): 483.10(g)(17)(18)(i)-(v)

F582 12/18/2018 §483.10(g)(17) The facility must-(i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of(A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. 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: PVI811 Facility ID: CA970000037 If continuation sheet 1 of 34 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 12/14/2018 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(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to ensure 2 of 3 sampled residents (Residents 14 and 26) who were reviewed for the "SNF Beneficiary Protection Notification Review" received written copies of the Notice of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 2 of 34 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 12/14/2018 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 Medicare Non-Coverage (NOMNC) after the termination of Medicare Part A services (skilled nursing services). This failure had the potential for the residents to not know their rights to appeal, including how to appeal the discharge from Medicare part A services. Findings: During a concurrent interview with the Social Service Director (SSD) and record review of Residents 14 and 16's medical record on 12/14/18, at 11:08 a.m., Residents 14 and 26 were given with the Skilled Nursing Facility Beneficiary Protection Notification Review for residents who received Medicare Part A Services but were not provided with the NOMNC form. The SSD indicated that she was using the form before but not this year. The SSD stated, "I have not been issuing the Notice of Medicare Non-Coverage." The SSD further stated Residents 14 and 26 did not receive any information on how to appeal the discharge from Medicare part A. A review of Resident 14's SNF Beneficiary Protection Notification Review, Resident 14's Medicare Part A skilled services episode start date was 6/14/18 and last covered day of Part A service was 8/27/18. A review of Resident 26's SNF Beneficiary Protection Notification Review, Resident 26's Medicare Part A skilled services episode start date was 1/5/18 and last covered day of Part A service was 3/16/18. The facility initiated the discharge from Medicare Part A services and the skilled benefit days were not exhausted. Both residents are still present in the facility. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 3 of 34 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 12/14/2018 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

F609 Reporting of Alleged Violations CFR(s): 483.12(c)(1)(4)

F609 SS=D PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE 12/18/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(1) Ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to report an allegation of abuse to the State licensing and certification agency (California Department of Public Health) for 2 of 2 sampled residents (Resident 1 and Resident 6) when a resident to resident altercation occurred on 10/20/18. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 4 of 34 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 12/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE This failure had the potential to compromise resident's safety when allegation of abuse is not reported. Findings: During an interview on 12/14/18, at 12:21 p.m., Resident 6 stated he had a fight with Resident 1 in the patio and was hit with a chair on his left leg. Resident 6 stated he punched back Resident 1. Resident 6 also stated Resident 1 is not here anymore because he was taken by the police the same day when the incident happened. Resident 6 further stated he could not remember when the incident happened. A review of Resident 1's Minimum Data Set (MDS), a standardized assessment and care planning tool, indicated a discharge date of 10/20/18. During an interview with the MDS Coordinator on 12/14/18, at 12:21 p.m., the MDS nurse Coordinator stated that Resident 1 had an altercation with Resident 6. She also stated that the Licensed Vocational Nurses (LVNs) 1 and 2 reported to her the resident-to-resident altercation. During an interview on 12/14/18, at 2:22 p.m., LVN 1 stated that Resident 1 and Resident 6 were arguing and Resident 1 threw a chair at Resident 6 while the residents were in the patio. LVN 2 stated she called 911 because Resident 6 was showing behaviors of aggressiveness, trying to hit staff and other residents. LVN 1 also stated that she was redirected to call Psychiatry Emergency Team (PET) team. LVN 1 further stated that the police came and picked up Resident 1. During an interview on 12/14/18 at 2:25 p.m., FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 5 of 34 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 12/14/2018 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 allegations of abuse include physical, financial, verbal, sexual, exploitation, neglect and isolation with bodily injuries should be reported within a few hours to the administrator, if with serious bodily injury and within 24 hours if without bodily injury. During an interview with the Administrator on 12/14/18, at 3:05 p.m., the Administrator stated he is the Abuse Coordinator of the facility. The Administrator also stated that he makes sure any allegation of abuse is reported to the police, Ombudsman, and Health Department as soon as he is made aware of it. The Administrator further stated he did not report to the Department of Public Health the allegation of abuse involving Residents 1 and 6. During an interview with the Director of Nursing (DON) on 12/14/18, at 3:22 p.m., the DON stated that she instructed the nurses to investigate the incident but did not instruct the LVNs to report it to the Department of Public Health. The DON stated that she cannot find the incident report written by LVN 1. The DON further stated that the facility did not report the incident to the Department of Public Health because Resident 6 was not hit by the chair when Resident 1 threw the chair. A review of the facility's policy titled, "Reporting Abuse to State Agencies and Other Entities/Individuals," dated December 2009 indicated, "...Should a suspected violation or substantiated incident of mistreatment, neglect, injuries of an unknown source, or abuse (including resident to resident abuse) be reported, the facility Administrator, or his/her designee, will promptly notify the following persons or agencies (verbally and written) of such incident:..The State licensing/certification agency responsible for surveying/licensing the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 6 of 34 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 12/14/2018 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 facility...The local/State Ombudsman...Adult Protective Services...Law enforcement officials...Verbal/written notices to agencies will be made within twenty-four (24) hours of the occurrence of such incident and such notice may be submitted via special carrier, fax, email, or by telephone."

F610 SS=D Investigate/Prevent/Correct Alleged Violation CFR(s): 483.12(c)(2)-(4)

F610 12/18/2018 §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to thoroughly investigate and document in the clinical records an allegation of abuse for 2 of 2 sampled residents (Resident 1 and Resident 6) that occurred on 10/20/18. This failure had the potential for an allegation of abuse not to be completely investigated which could lead to an occurrence of further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 7 of 34 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 12/14/2018 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 abuse. Findings: During an interview on 12/14/18, at 12:21 p.m., Resident 6 stated he had a fight with Resident 1 in the patio and was hit with a chair on his left leg. Resident 6 stated he punched back Resident 1. Resident 6 also stated Resident 1 is not here anymore because he was taken by the police the same day when the incident happened. Resident 6 further stated he could not remember when the incident happened. During an interview with the Minimum Data Set Nurse (MDS nurse) Coordinator on 12/14/18, at 12:21 p.m., the MDS Coordinator stated that Resident 1 had an altercation with Resident 6. She also stated that the Licensed Vocational Nurses (LVNs) 1 and 2 reported to her the resident-to-resident altercation. During an interview on 12/14/18, at 2:22 p.m., LVN 1 stated that Resident 1 and Resident 6 were arguing and Resident 1 threw a chair at Resident 6 while the residents were in the patio. LVN 2 stated she called 911 because Resident 6 was showing behaviors of aggressiveness, trying to hit staff and other residents. LVN 1 also stated that she was redirected to call Psychiatry Emergency Team (PET) team. LVN 1 further stated that the police came and picked up Resident 1. During an interview on 12/14/18 at 2:25 p.m., LVN 2 stated that allegations of abuse include physical, financial, verbal, sexual, exploitation, neglect and isolation with bodily injuries should be reported within a few hours to the administrator and within 24 hours if without bodily injury. During a concurrent interview and record FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 8 of 34 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 12/14/2018 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 review on 12/14/18 at 2:49 p.m. with LVN 1, clinical records including nursing notes, doctor's progress notes, interdisciplinary team (IDT) notes and social worker's notes for Residents 1 and 6 did not have any documentation regarding the resident-toresident altercation. LVN 1 verified and stated that there was no documentation in the chart but she stated that she wrote an incident report. During an interview with the Administrator on 12/14/18, at 3:05 p.m., the Administrator stated he is the Abuse Coordinator of the facility. The Administrator also stated that he makes sure any allegation of abuse is reported to the police, Ombudsman, and Health Department as soon as he is made aware of it. The Administrator further stated he did not report to the Department of Public Health the allegation of abuse involving Residents 1 and 6. During an interview with the Director of Nursing (DON) on 12/14/18, at 3:22 p.m., the DON stated that she instructed the nurses to investigate the incident but did not instruct the LVNs to report it to the Department of Public Health. The DON stated that she cannot find the incident report written by LVN 1. The DON further stated that the facility did not report the incident to the Department of Public Health because Resident 6 was not hit by the chair when Resident 1 threw the chair. A review of the facility's policy titled "Reporting Abuse to State Agencies and Other Entities/Individuals," dated 12/2009, revised 1/24/18 indicated "When suspicion of abuse, neglect or exploitation, or reports of abuse, neglect or exploitation occur, an investigation is immediately warranted. Once the resident is cared for and initial reporting has occurred, an FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 9 of 34 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 12/14/2018 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 investigation should be conducted. Components of an investigation may include: a. Interview the involved resident, if possible, and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. b. If there is no discernible response from the resident, or if the resident's response is incongruent with that of a reasonable person, interview the resident's family, responsible parties, or other individuals involved in the resident's life to gather how he/she believes the resident would react to the incident. c. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. Obtain witness statements, according to appropriate policies. All statements should be signed and dated by the person making the statement. d. Document the entire investigation chronologically."

F623 SS=D Notice Requirements Before Transfer/Discharge CFR(s): 483.15(c)(3)-(6)(8)

F623 12/18/2018 §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State LongTerm Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 10 of 34 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 12/14/2018 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 accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 11 of 34 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 12/14/2018 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 submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l). This REQUIREMENT is not met as evidenced by: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 12 of 34 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 12/14/2018 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 interview and record review, the facility failed to provide notification to Ombudsman of a discharge for 1 of 2 sampled residents (Resident 21). This failure had the potential to result in Resident 21 being inappropriately discharged without added protection from Ombudsman who advocates resident's rights and options. Findings: A review of Resident 21's face sheet indicated that Resident 21 was admitted on 9/9/18. A review of Resident 21's Notification of Proposed Transfer/Discharge indicated Resident 21 was discharged to General Acute Care Hospital (GACH) on 12/8/18. A review of Resident 21's medical record did not indicate any document that the facility notified the Ombudsman of Resident 21's discharge. On 12/13/18, at 10:24 a.m., during an interview with the Social Service Director (SSD), she stated that when the facility discharges a resident, the facility should notify the resident, their family, public guardian if any, and also the Ombudsman. The SSD also stated the facility notifies ombudsman on a weekly basis via fax that includes Fax Cover Sheet, Notice of Proposed Transfer/Discharge, Resident Transfer Record and Monthly Ombudsman Notification. The SSD also stated that they normally do follow up calls after the transmission of the faxes to the Ombudsman making sure that the Ombudsman receives all the documents the facility faxed. The SSD admitted that there was no confirmation of discharge notification to the Ombudsman. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 13 of 34 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 12/14/2018 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 facility's Ombudsman Notification binder indicated that the last documented successful transmission of fax confirmation was on 8/17/18. Further review of the contents of the facility's Ombudsman Notification binder did not indicate fax confirmations on the fax cover sheets dated 8/28/18, 9/7/18, 9/28/18, 11/20/18, 11/23/18 and 12/7/18. A review of facility's policy titled "Transfer and Discharge (including AMA)," dated 1/24/18 indicated social Service Director, or designee, shall provide notice of transfer to a representative of the State Long-Term Care Ombudsman via monthly list.

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

F640 12/18/2018 §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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 14 of 34 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 12/14/2018 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 §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's 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 Minimum Data Set (MDS), a comprehensive assessment and care screening tool, were successfully transmitted to Center of Medicare and Medicaid Services (CMS) for 1 of 3 residents (Resident 138). This deficient practice did not provide CMS specific resident information for quality care measure purposes on a quarterly and annual basis. Findings: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 15 of 34 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 12/14/2018 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 Resident 138's face sheet indicated the resident was readmitted on 8/1/14 with diagnosis that included Chronic Obstructive Pulmonary Disease (constriction of the airways and difficulty of discomfort in breathing). During an observation and concurrent interview on 12/12/18, at 9:43 a.m., Resident 138 was sitting in a wheelchair in hallway. Resident 138 stated "I have been here for many years." During an interview with the MDS Coordinator (MDSC) on 12/13/18, at 8:45 a.m., she stated that the latest annual MDS for Resident 138 was submitted to CMS on 10/17/18. The MDSC also stated that she was not aware that the MDS assessment report was rejected. She further stated "I don't have any answers why MDS did not transmit to CMS. I normally look back after I submitted, but I don't know what happened." A review of the facility's document titled, "CMS Submission Report/MDS3.0 NH Final Validation" dated 12/13/18 indicated Resident 138's quarterly MDS assessment dated 4/18/18 and annual MDS assessment date 7/18/18 were rejected. A review of the facility's policy titled," Minimum Data set 3.0 assessment Complete, Transmission and Validation," dated 1/24/18 indicated The RAI Coordinator will facilitate the correction of any fatal errors immediately and retransmit the assessment until an accepted validation report is received.

F656 SS=D Develop/Implement Comprehensive Care Plan F656 CFR(s): 483.21(b)(1) 12/18/2018 §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 16 of 34 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 12/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE resident 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 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 interview and record review, the facility failed to develop a person-centered care plan pertaining to stress incontinence FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 17 of 34 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 12/14/2018 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 (unintentional loss of urine) for 1 out of 2 residents (Resident 35). This failure had the potential for Resident 35's preferences, goals and care needs not to be met. Findings: A review of the Face Sheet indicated that Resident 35 was admitted 11/20/18 with diagnoses that include stress incontinence. A review of Resident 35's Minimum Data Set (MDS), a standardized assessment and care planning tool dated 12/1/18, indicated a brief interview for mental status (BIMS) score of 15 (a score of 13-15 indicates the resident as intact cognition (thought process). The MDS also indicated that Resident 35 required limited assistance with one-person physical assist for locomotion on unit, toilet use and personal hygiene. Resident 35 required extensive assistance with one-person physical assist for locomotion off unit and dressing. The MDS also indicated that Resident 35 was always incontinent for urinary continence and frequently incontinent for bowel continence (inability to control bowel movemement). During a concurrent interview with Licensed Vocational Nurse (LVN) 1 and a record review of Resident 35's medical record on 12/12/18, at 10:19 a.m., LVN 1 verified and stated that Resident 35 has Stress Incontinence and that resident uses pads and diapers. LVN further stated that "there was no care plan for stress incontinence." A review of the facility's undated Policy and Procedure on Care Plans - Comprehensive indicated the following: "Each resident's comprehensive care plan is designed to: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 18 of 34 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 12/14/2018 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. Incorporate identified problem areas; b. Incorporate risk factors associated with identified problems; c. Build on the resident's strengths; d. Reflect the resident's expressed wishes regarding care and treatment goals; e. Reflect treatment goals, timetables and objectives in measurable outcomes; f. Identify the professional services that are responsible for each element of care; g. Aid in preventing or reducing declines in the resident's functional status and/or functional levels; h. Enhance the optimal functioning of the resident by focusing on a rehabilitative program; and i. Reflect currently recognized standards of practice for problem areas and conditions.

F690 SS=D Bowel/Bladder Incontinence, Catheter, UTI CFR(s): 483.25(e)(1)-(3)

F690 12/18/2018 §483.25(e) Incontinence. §483.25(e)(1) The facility must ensure that resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain. §483.25(e)(2)For a resident with urinary incontinence, based on the resident's comprehensive assessment, the facility must ensure that(i) A resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; (ii) A resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 19 of 34 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 12/14/2018 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 necessary; and (iii) A resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible. §483.25(e)(3) For a resident with fecal incontinence, based on the resident's comprehensive assessment, the facility must ensure that a resident who is incontinent of bowel receives appropriate treatment and services to restore as much normal bowel function as possible. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to correctly assess bladder function and provide appropriate treatment and services for resident who has intermittent urinary incontinence for 1 of 3 sampled residents (Resident 19). This failure did not provide necessary treatment and care to maintain the resident's highest practicable physical, mental, and emotional well-being which could lead to the worsening of Resident 19's urinary incontinence. Findings A review of Resident 19's face sheet indicated admission on 10/26/18 with diagnoses that included convulsions (uncontrolled shaking of the body) and hypertension (high blood pressure). During an observation on 12/11/18, at 12:15 p.m., Resident 19 came out of bathroom sitting in a wheel chair with his pants wet in middle front area. Resident 19 was propelling himself in a wheel chair using his left arm and left leg. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 20 of 34 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 12/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview on 12/14/18, at 10:11 a.m., Licensed Vocational Nurse (LVN) 1 stated that she sometimes notice Resident 19's pants, in the front area, wet. LVN 1 also stated that Resident 19 get upset when being asked about the wet pants. During an interview and concurrent record review on 12/14/18, at 10:24 a.m. with the Director of Nursing (DON), she stated that she conducted an admission bowel and bladder assessment for Resident 19. The DON also stated Resident 19 told her that he has episodes of urinary incontinence. A review of Resident 19's "Bowel and Bladder Assessment Record," dated 10/26/18, indicated Resident 19 had urinary incontinence episodes once a week or less. Further review of the document indicated Resident 19 did not require bladder & bowel training even with episodes of urinary incontinence. A review of the facility's policy titled, "Bowel and Bladder Incontinence," dated 1/24/18 indicated "...Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. ie Bowel and Bladder retraining..."

F700 SS=D Bedrails CFR(s): 483.25(n)(1)-(4)

F700 12/18/2018 §483.25(n) Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. §483.25(n)(1) Assess the resident for risk of entrapment from bed rails prior to installation. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 21 of 34 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 12/14/2018 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 §483.25(n)(2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. §483.25(n)(3) Ensure that the bed's dimensions are appropriate for the resident's size and weight. §483.25(n)(4) Follow the manufacturers' recommendations and specifications for installing and maintaining bed rails. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to do a risk assessment for bed entrapment before use of bedrails for 1 out of 1 resident (Resident 188). This failure had the potential for Resident 188 to have significant harm from bed entrapment. Findings: A review of Resident 188's Face Sheet indicated an admission on 1/7/15 with diagnoses that include schizophrenia (long term mental disorder), dementia (chronic or persistent disorder of the mental process marked by memory disorders, personality changes and impaired reasoning) and osteoarthritis (degeneration of joint cartilage and the underlying bone) of knee. A review of the Resident 188's Minimum Data Set (MDS), a standardized assessment and care planning tool, dated 1/12/18, indicated a Brief Interview for Mental Status (BIMS) score of 15 (a score of 13-15 indicates intact cognition (thought process) The MDS indicated Resident 188 required extensive assistance one-person physical assistance in FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 22 of 34 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 12/14/2018 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 bed mobility and personal hygiene. Further review of the MDS indicated Resident 188 was totally dependent to staff and needed oneperson physical assistance for locomotion on/off unit, dressing and toilet use. During a concurrent observation and interview with Resident 188 on 12/11/18, at 11:57 a.m., Resident 188 was observed lying in bed with bilateral side rails up. Resident 188 stated that she needs the side rails to stabilize herself in bed. During an interview on 12/14/18 at 8:31 a.m., the Director of Nursing (DON) indicated that there was "no risk assessment for bed entrapment" done before the use of the bed rails for Resident 188. During an interview on 12/14/18 at 11:42 a.m., the Maintenance Staff (MS) indicated that he "did not do the risk for bed entrapment" for Resident 188 before bedrail use. He said he only "did the daily checking of the bedrails." A review of the facility's Policy on "Bed Safety" indicated the following: "To try to prevent deaths/injuries from the beds and related equipment (including the frame, mattress, side rails, headboard, footboard and bed accessories), the facility shall promote the following approaches: a. Inspection by maintenance staff of all beds and related equipment as part of our regular bed safety program to identify risks and problems including potential entrapment risks; b. Review that gaps within the bed system are within the dimensions established by the FDA (Note: The review shall consider situations that could be caused by the resident's weight, FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 23 of 34 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 12/14/2018 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 movement or bed position.); c. Ensure that bed side rails are properly installed using the manufacturer's instruction and other pertinent safety guidance to ensure proper fit (e.g., avoid bowing, ensure proper distance from the headboard and footboard, etc.); and d. Identify additional safety measures for residents who have been identified as having a higher than usual risk for injury including entrapment (e.g., altered mental status, restlessness, etc.)."

F755 SS=E Pharmacy Srvcs/Procedures/Pharmacist/Records CFR(s): 483.45(a)(b)(1)-(3)

F755 12/18/2018 §483.45 Pharmacy Services The facility must provide routine and emergency drugs and biologicals to its residents, or obtain them under an agreement described in §483.70(g). The facility may permit unlicensed personnel to administer drugs if State law permits, but only under the general supervision of a licensed nurse. §483.45(a) Procedures. A facility must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident. §483.45(b) Service Consultation. The facility must employ or obtain the services of a licensed pharmacist who§483.45(b)(1) Provides consultation on all aspects of the provision of pharmacy services in the facility. §483.45(b)(2) Establishes a system of records FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 24 of 34 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 12/14/2018 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 receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation; and §483.45(b)(3) Determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled. This REQUIREMENT is not met as evidenced by: Based on observation, interview and record review, the facility failed to ensure that only licensed personnel have access to medications, including controlled medications (medications whose use is regulated), for disposition. This deficient practice had the potential for diversion of controlled medications. Findings: On 12/13/18, at 3:23 p.m., during an interview with Licensed Vocational Nurse (LVN) 3, she stated that all medications, including controlled medications that were refused by the residents and medications that fell on the floor will be disposed in a bin located in the Administrator's office. LVN 3 also stated the facility uses the same bin for all medications, including controlled medications for disposition. During an observation of the Administrator's office with LVN 3 on 12/13/18, at 3:30 p.m., a white, oblong disposable bin with blue lid and hole on top with yellow cover was seen under the Administrator's table. The disposable bin was observed with multiple medications of different colors and sizes inside. During an interview with the Director of Nursing (DON) on 12/13/18 at 3:33 p.m., , the DON stated controlled medications that accidentally FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 25 of 34 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 12/14/2018 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 fell on the floor were thrown away in the bin located under the table of the Administrator for disposal. The DON also stated the Pharmacy Consultant comes every first day or middle of the month and conducts disposal of medications with her. The DON further stated that the Administrator, the Social Service Director both have access to the bin. During an interview with the Administrator on 12/13/18, at 4:26 p.m., the Administrator stated the DON, SSD and himself have access to his office. The administrator also stated he is a licensed nurse. During an interview with the SSD on 12/14/18, at 9:58 a.m., the SSD stated she is not a licensed nurse. A review of the facility's policy titled "Disposal of Medications, Syringes and Needles," dated October 2007 indicated " ...Only authorized licensed nursing and pharmacy personnel have access to controlled medications ..."

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

F842 12/18/2018 §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. §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 areFORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 26 of 34 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 12/14/2018 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 (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 reaches legal age under State law. §483.70(i)(5) The medical record must contain(i) Sufficient information to identify the resident; FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 27 of 34 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 12/14/2018 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) 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 interview and record review, the facility failed to ensure documentation for Advance Directive/Medical Treatment Decisions was complete for 2 of 2 sampled residents (Residents 11 and 22). This failure had the potential to create confusion on whether the advance directive was discussed or offered to the resident. Findings: A review of the Advance Directive / Medical Treatment Decisions forms indicated the following: 1. For Resident 11, the form indicated that attending the physician discussed and signed the advance directive/medical treatment decisions on 4/7/18. Further review of the form did not indicate a response of "Yes", "No", or "Never Expressed" from the resident. 2. For Resident 22, the form did not indicate that attending the physician signed the advance directive/medical treatment decisions on 11/7/18. Further review of the form did not indicate a response of "Yes", "No", or "Never Expressed" from the resident. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 28 of 34 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 12/14/2018 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE FLOWER VILLA, INC. 1480 S La Cienega Blvd Los Angeles, CA 90035 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE During an interview with the Licensed Vocational Nurse (LVN) 1 and concurrent record review on 12/12/18, at 3:01 p.m., LVN 1 stated that it was not clear if the attending physician discussed the advanced directives to the residents because the "Yes, No or Never Expressed" options were left blank. During an interview and concurrent record review on 12/13/18, at 4:20 p.m. with the Director of Nursing (DON), she stated that the documents were "just signed but no indication what" and that "information was not complete."

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

F880 12/18/2018 §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 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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 29 of 34 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 12/14/2018 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 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. §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 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 30 of 34 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 12/14/2018 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 observe infection control measures for 15 of 15 residents (Residents 11, 14, 15, 22, 36, 138, 188, 33, 17, 26, 19, 9, 34, 3 and 35) when the facility did not use an acceptable sanitizing solution when washing soiled clothes. This deficient practice had the potential for the development and spread of infection if soiled clothes were not washed using a sanitizing solution. Findings: During an observation of the laundry room and concurrent interview with the Laundry Services Staff (LSS) on 12/14/18, at 9:04 a.m., the facility washer was turned on and washing colored clothes of the residents. The LSS stated that "Residents' clothes with poop or urine," were washed in the laundry room "using detergent." The LSS also stated that she only uses a sanitizing solution (Clorox bleach) when she washes white clothes of the residents. The LSS further stated that the residents use the facility's laundry services for their personal clothes. During concurrent observation and interview on 12/14/18, at 9:20 a.m., the Maintenance Staff (MS) stated that the facility does not use high temperature water as a means of sanitizing personal clothes of the residents. The MS checked the temperature of the water supplying the washer and had a reading of 122 Fahrenheit (F). A review of the facility's Policy on Laundry indicates that "Laundry may be processed with hot or low-temperature processes: FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 31 of 34 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 12/14/2018 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. Hot-water cycle: Wash with detergent in a water temperature of 160 degrees or above for at least 25 minutes. b. Low-temperature cycle: Wash with chemicals suitable for low-temperature washing (less than 160 degrees) at the proper concentration. c. A 125-part-per-million (PPM) chlorine bleach rinse will be used to destroy microorganisms whenever possible.

F912 SS=C Bedrooms Measure at Least 80 Sq Ft/Resident F912 CFR(s): 483.90(e)(1)(ii) §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 18 of 21 resident rooms (Rooms 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 14, 15, 16, 18, 19, 21, 23, and 25. This failure had the potential to result in inadequate space for the residents and can impact the residents' quality of life and/or quality of care. Findings: During the entrance conference on 12/11/18, at 10:19 a.m., the Director of Nursing (DON) stated that the facility has rooms with less than the required square footage and that they will continue to apply for a room waiver. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 32 of 34 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 12/14/2018 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 12/12/18, at 10:30 a.m., the DON submitted the Client Accommodation Analysis and the request for waiver of rooms size letter. During an observation of the residents' rooms on 12/14/18 at 8:15 a.m., there were no concerns observed regarding space in rooms 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 14, 15, 16, 18, 19, 21, 23 and 25. At the time of the observation, the rooms provided enough space for the care, dignity, privacy and resident appliances. There was ample room space for the residents to move about freely. There were no concerns observed related to the space or to the safe provisions of care to the residents residing in the rooms. During an interview with the residents during the resident council meeting on 12/12/18 at 11:04 a.m., there were no reported concerns with room space while facility staff were providing care to the residents. A review of the letter from the Administrator regarding a "Request for Waiver of Room Size" originally dated 10/2/18 and revised on 12/20/18, indicated a request for a waiver for rooms 1, 2, 3, 4, 5, 6, 7, 9, 10, 11, 14, 15, 16, 18, 19, 21, 23 and 25. The letter indicated "the closets (in the rooms) are built in and do not have an adverse effect on the residents' health and safety or do not impede the ability of any resident in that room to attain his or her highest practicable well-being." The letter also stated that "there is adequate space for residents to get in and out of wheelchairs. The residents have sufficient freedom for movement. There is sufficient room to provide proper care for residents in the rooms. The facility ... indicated in its request that granting of the room variance will not adversely affect the residents' health and safety and that the waiver was in accordance with the special needs of the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 33 of 34 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 12/14/2018 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 residents." A review of the Client Accommodations Analysis submitted by the facility on 12/12/18 at 10:30 AM indicated the rooms and the space measurements were as follows: Room No. Floor Area (square feet) Beds Square footage per resident Room 1 144.72 2 72.36 Room 2 144.72 2 72.36 Room 3 144.72 2 72.36 Room 4 147.40 2 73.70 Room 5 147.40 2 73.70 Room 6 144.72 2 72.36 Room 7 152.76 2 76.38 Room 9 144.72 2 72.36 Room 10 147.40 2 73.70 Room 11 144.72 2 72.36 Room 14 134.00 2 67.00 Room 15 144.72 2 72.36 Room 16 144.72 2 72.36 Room 18 144.72 2 72.36 Room 19 144.72 2 72.36 Room 21 144.72 2 72.36 Room 23 144.72 2 72.36 Room 25 144.72 2 72.36 FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: PVI811 Facility ID: CA970000037 If continuation sheet 34 of 34