Meadows on Sunset: Care Plan Failure for Refusing Resident - CA
The Director of Nursing confirmed it herself. Reviewing Resident 1's care plans dated September 26, 2025, she told inspectors there was no care plan created to address the refusal. She said one should have existed, one that identified specific interventions to address why the resident was refusing and what staff could do about it.
That acknowledgment was the finding.
A CBC STAT is not a routine lab draw scheduled for convenience. The word "STAT" signals urgency. When a resident refuses it, the refusal itself becomes a clinical event, one that warrants documentation, a plan, and a coordinated response from the team responsible for that person's care. Without a care plan, there is no record of what was tried, no guidance for the next nurse who walks into the room, and no structure for following up.
The facility's own policy, last reviewed on September 11, 2025, less than three weeks before Resident 1's care plans were dated, described exactly what was required. A baseline care plan for each resident, it stated, must include the instructions needed to provide effective and person-centered care, developed and implemented by the Interdisciplinary Team. The policy was current. The care plan was not.
The inspection was a complaint survey, meaning someone had raised a concern before inspectors arrived. The deficiency was cited at a level of minimal harm or potential for actual harm, the lower end of the harm scale, affecting few residents. CMS assigned it tag F0656, which covers the requirement to develop and implement comprehensive, person-centered care plans.
What the record does not show is how long the gap existed between the refusal and the inspection, what the underlying reason for the CBC STAT order was, or whether anyone attempted to address Resident 1's refusal in the weeks between September 26 and October 10. The care plans reviewed by inspectors carried a September 26 date. The inspection was two weeks later. During that interval, there was no documented plan.
The Director of Nursing did not dispute any of it. She confirmed the omission and confirmed what should have been done. That is, in some ways, the simplest version of a care planning failure: not a disagreement about what happened, not a missing chart buried in a records room, but a straightforward acknowledgment that a resident refused an urgent test and nobody wrote down what to do next.
The facility operates at 5154 Sunset Boulevard in Los Angeles under the name Brier Oak on Sunset, as listed on the CMS inspection form, though the inspection was conducted under the name The Meadows on Sunset Post Acute.
Resident 1's situation, a person who declined a blood draw ordered on an urgent basis, is not uncommon in post-acute care. Residents have the right to refuse treatment. That right does not eliminate the facility's responsibility to respond to the refusal with a plan, to document what was communicated to the resident, what alternatives were considered, and what the team agreed to do. The Director of Nursing said as much herself.
What was in place for Resident 1 after the refusal, and what was done in the two weeks before inspectors arrived, the care plans did not say. There was nothing in them to say.
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 2025-10-10 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 10, 2026 · Our methodology
The Meadows on Sunset Post Acute in LOS ANGELES, CA was cited for violations during a health inspection on October 10, 2025.
The Director of Nursing confirmed it herself.
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.