Meadows on Sunset: Infection Control Failures - CA
Federal inspectors observed the violation on January 2 during a tour of the facility's clean laundry room. When the housekeeping supervisor moved a large rolling bin, two pillows fell to the ground. Instead of setting them aside for disinfection, he picked them up and placed them on a folded blanket.
The laundry attendant continued folding clothes nearby. The pillows remained on the blanket throughout the rest of the inspection tour.
When questioned, the laundry attendant acknowledged the blanket underneath was clean but said the pillows "should be disinfected because the pillows were on the ground." Only then did staff remove the pillows.
The housekeeping supervisor later admitted his mistake. He told inspectors he "should not have placed the pillows on top of clean linens because the pillows were considered dirty." The blanket underneath was now contaminated and "there was a potential that the dirty blanket would be used for residents."
The facility's Director of Nursing confirmed that pillows from the floor should never be placed on clean blankets. "Once the pillows touch the floor, they are considered dirty and could contaminate the clean blankets," she told inspectors. The practice created "an infection control issue that may result in the spread of infectious agents by cross contamination to residents."
Cross contamination occurs when bacteria or other microorganisms transfer from one object to another with harmful effects.
The facility's own policy, reviewed just a month earlier in December 2024, explicitly states that linen must be handled in a safe and sanitary method to prevent infection spread. Clean linen must be kept separate from soiled linen at all times. The policy warns that linen can become contaminated through contact with environmental contaminants and that transmission can occur through direct contact or airborne particles generated during handling.
But infection control problems extended beyond the laundry room.
Resident 77 signed a consent form on December 9 to receive the 2024-2025 COVID-19 booster vaccine. A visiting vaccine clinic arrived at the facility two days later on December 11. The resident never got the shot.
Nobody documented why.
The facility's Infection Preventionist couldn't explain what happened. During interviews with inspectors, she acknowledged there was no physician's order for the vaccine and no record of administration in the resident's medical chart. The resident's immunization report contained no information about the 2024-2025 COVID booster.
"I did not remember what happened and did not know why Resident 77's clinical record did not indicate if the resident had received or refused the 2024/2025 COVID-19 vaccine, but it should have been documented," the Infection Preventionist told inspectors.
The Administrator discovered the problem only after inspectors raised concerns. She confirmed that Resident 77 was supposed to receive the vaccine during the visiting clinic but that clinic staff never administered it. The Infection Preventionist should have followed up to ensure the resident received the vaccine or documented why she didn't, but no follow-up occurred.
When inspectors interviewed Resident 77 directly on January 3, the resident confirmed she had not received the 2024-2025 COVID vaccine. She wanted the vaccination and remembered being told about a month earlier that she would receive it, but "nobody ever came to administer it."
The resident had been readmitted to the facility in July 2024 with acute kidney infection, diabetes, and congestive heart failure. Her October assessment showed she could understand others and be understood, was independent with eating and personal hygiene, but required substantial help with showering and toileting.
The Director of Nursing emphasized the vaccine's importance for this particular resident. "It was important for Resident 77 to receive the vaccine because the resident is immunocompromised and susceptible to complications from infection," she told inspectors. The facility's policy was not followed when staff failed to track the resident's vaccination status.
The facility's COVID vaccination policy, also reviewed in December 2024, requires staff to obtain vaccination history, offer vaccines based on CDC recommendations, obtain consent, get physician orders, administer vaccines, and document everything in immunization records. None of these steps were completed properly for Resident 77.
In another resident's room, infection control failures took a different form.
Resident 402, admitted in December with diabetes, mobility problems, and muscle weakness, had physician's orders for floor mats next to the bed for fall protection. When inspectors observed the room on December 31, they found the right floor mat severely damaged.
The mat's top cover was torn and stripped away, exposing at least three inches of foam underneath. Both a certified nursing assistant and a licensed vocational nurse confirmed the damage during interviews.
"The exposed foam can absorb dirt and liquids and is an infection control issue," the licensed nurse told inspectors. The certified nursing assistant agreed that "the exposed foam can be an infection control."
Staff acknowledged they should notify the maintenance department when floor mats become damaged, but this mat remained in use despite the obvious tear and exposed foam. The Director of Nursing confirmed that damaged floor mats with exposed foam create infection control risks because they can absorb dirt and liquids.
The facility's infection prevention policy, updated in December 2024, aims to provide "a safe, sanitary, and comfortable environment" and decrease infection risk through proper cleaning and disinfecting of equipment. The policy requires implementation of control measures including standard precautions and cleaning procedures to protect residents from communicable diseases.
But the gap between policy and practice was evident in multiple areas. Clean linens contaminated by floor contact. Vaccine administration that never happened despite resident consent. Equipment left in use despite obvious damage and infection risk.
Resident 77 remains without her COVID booster shot more than a month after signing consent forms. The immunocompromised resident continues at elevated risk for complications from COVID infection while the facility works to correct its vaccination tracking failures.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Meadows On Sunset Post Acute from 2025-01-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 21, 2026 · Our methodology
The Meadows on Sunset Post Acute in LOS ANGELES, CA was cited for violations during a health inspection on January 3, 2025.
Federal inspectors observed the violation on January 2 during a tour of the facility's clean laundry room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.