Flower Villa, Inc

In the surveyor’s words

From the most serious findings on record at Flower Villa, Inc, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 28, 2024

  Based on observation, interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who are at high risk of fracture (break in the bone) and who required maximum assistance with at least two-people assist during repositioning and perineal (involves washing the genital and rectal areas of the body) care was provided an environment to prevent accident, by failing to: 1. Properly reposition Resident 1 with at least two- three persons assist on 6/10/2024 during perineal care and utilizing according to Resident 1's plan of care dated 7/16/2023 2. […]

• No harm, potential for more than minimal, widespreadF727Mar 9, 2025

  Based on observation, interview, and record review, the facility failed to ensure that a Registered Nurse (RN) worked onsite for at least 8 consecutive hours a day, seven days a week. This deficient practice had the potential for the facility's inability to manage and oversee nursing services provided to 31 residents including resident assessments, consulting with physicians, and administering intravenous fluids or medications. Cross Reference F851 Findings: During A review of Center for Medicare and Medicaid Services (CMS) Staffing Data Report, run date 3/4/2025, the PBJ Payroll Based Journal (PBJ- information of the provider's daily staffing hours for the appropriate care of the residents) staffing data report indicated, on 1st fiscal quarter, facility has no RN hours coverage for the… […]

• No harm, potential for more than minimal, widespreadF727Nov 7, 2021

  Based an interview and record review, the facility failed to ensure that a Registered Nurse (RN), worked onsite for at least 8 consecutive hours a day seven days a week. This deficient practice had the potential for the facility to not manage and oversee nursing services provided to 40 residents. Findings: A review of facility's Registered Nurse and Licensed Vocational Nurse (LVN) monthly schedule dated November 2021, indicated the Director of Nursing (DON) was the only RN for the whole facility. A review of facility's Nursing staffing assignment and sign-in sheet on document dated September 2021 to October 2021, indicated the facility did not have RN coverage onsite on all weekends from 9/4/2021 through 10/31/2021. […]

• No harm, potential for more than minimal, widespreadF801Nov 7, 2021

  Based on observation, interview, and record review, the facility failed to ensure the Dietary Supervisor (DS) was hired as full time to carry out the functions of the food and nutrition services and to ensure dietary services met professional standard of practice and the residents' needs. This deficient practice resulted in lack of identification of deficient practices in the food and nutrition services that can potentially cause foodborne and waterborne illnesses for 39 out of 40 residents. Findings: During an interview with the DS, on 11/6/2021 at 2:20 p.m., the DS stated he only works in the facility four to six hours a day twice a week. The DS stated the Registered Dietitian comes in only once or twice a month. […]

• No harm, potential for more than minimal, widespreadF802Nov 7, 2021

  Based on observations, interviews, and records review, the facility failed to ensure there were competent staffs to carry out position related duties when: 1. Dietary Supervisor (DS) did not wear hair net upon entering the kitchen multiple times. 2. Dietary supervisor (DS) did not wear appropriate surgical mask inside the kitchen. 3. Dietary staff 3 was not wearing hairnet twice inside the kitchen. 4. Dietary staff 4 did not hand wash in between dirty task and clean task. 5. Dietary Supervisor did not intervene when Dietary Staff 4 observed not performing handwashing in between tasks during the tray line. 6. The Director of Staff Development (DSD) was doing the kitchen staff competency assessment for two of four dietary staff (Dietary staff 3 and 4). […]