LOS ANGELES, CA — A Hollywood nursing home faces a $120,000 fine after state regulators cited the facility following the death of a 92-year-old resident who bled to death over a 40-hour period while staff continued administering blood-thinning medication, according to the California Department of Public Health.
Brier Oak on Sunset received an AA citation — the most severe designation issued when care violations substantially contribute to a patient's death — after the September 27 incident, as reported by LAist. The citation marks the third time since late 2022 that state authorities have issued the facility an AA citation for deaths linked to substandard care.
According to the state citation, the resident had been prescribed heparin, a blood thinner used to prevent clot formation in immobile patients. When nursing staff discovered bright red blood in the patient's diaper the day before her death, they failed to follow established protocols for documenting the bleeding or notifying medical providers. The facility's nurses told state investigators they delayed contacting physicians because doctors "get mad" when called during nighttime hours, according to the citation report.
Staff members also failed to conduct a complete assessment to identify potential bleeding sources and did not properly monitor the patient during critical periods, as reported by state authorities. The resident experienced four separate internal bleeding episodes across the 40-hour period, yet continued receiving blood thinner injections — a protocol that clinical guidelines prohibit once active bleeding occurs, since anticoagulants worsen hemorrhaging.
A nurse practitioner at the facility later told state licensing investigators that had she been informed about the ongoing bleeding, she would have immediately discontinued the blood thinner treatment, according to the citation.
CMS Inspection History
Brier Oak on Sunset's recent citation reflects a broader pattern of regulatory concerns at the 159-bed facility. Federal inspection data shows the nursing home currently holds a one-star overall rating from the Centers for Medicare & Medicaid Services — the lowest possible score on the agency's five-star quality scale.
The facility has accumulated 206 total deficiencies across 74 inspections on record with CMS, according to federal data. While Brier Oak maintains relatively strong staffing and quality measure ratings of four stars each, its health inspection rating stands at just one star, reflecting serious concerns identified during state surveys.
The most recent CMS inspection on November 18, 2025, cited the facility for failing to provide pharmaceutical services meeting professional standards — a severity level E citation. That same inspection also found deficiencies in providing appropriate activities for residents and ensuring safe dialysis care.
An October 2025 inspection identified failures to develop complete care plans with measurable actions and timetables, and cited the facility for not ensuring services met professional quality standards, according to CMS records.
State regulations require authorities to suspend or revoke licenses for facilities receiving two AA citations within 24 months. The California Department of Public Health initiated license suspension proceedings against Brier Oak in May based on resident deaths in 2022 and 2024, but later dropped the action after determining the deaths occurred 26 months apart — narrowly outside the two-year enforcement window, as reported by LAist.
Ownership & Operations
Brier Oak on Sunset operates as a for-profit limited liability company. A spokesperson for the ownership group told LAist the company has appealed the first two AA citations and is evaluating whether to appeal the most recent citation. The facility has until December 19 to notify the state department if it intends to file an appeal, according to regulatory procedures.
AA citations represent the most serious enforcement action California's public health department can take against nursing facilities. These citations are issued fewer than 20 times annually on average across California's more than 1,200 skilled nursing facilities, according to state data cited by LAist.
Advocacy organizations have questioned whether the September death could have been prevented through earlier state intervention. "There were red flags, and a lot of these red flags existed prior to the death of this poor resident," Tony Chicotel, senior staff attorney with California Advocates for Nursing Home Reform, told LAist.
The case highlights critical gaps in clinical communication protocols and medical monitoring systems that federal and state regulations require nursing facilities to maintain. Federal guidelines mandate that skilled nursing facilities establish clear processes for documenting changes in patient condition, communicating urgent medical information to physicians, and adjusting treatment plans when complications arise.
The failure to halt anticoagulant therapy once bleeding was detected represents a fundamental breach of clinical standards that govern blood thinner administration. Medical protocols require immediate discontinuation of heparin and similar medications when patients show signs of active hemorrhaging.
Resources for Families
Families with loved ones at Brier Oak on Sunset or other California nursing facilities experiencing concerns about care quality can contact the California Long-Term Care Ombudsman at 1-800-231-4024. The ombudsman program provides free advocacy services for nursing home residents and investigates complaints about care standards.
Additional support is available through the National Long-Term Care Ombudsman Resource Center at 1-800-677-1116 or online at https://ltcombudsman.org. Family members can also file complaints directly with the California Department of Public Health's Licensing and Certification Program, which conducts inspections and investigates reported violations at skilled nursing facilities statewide.
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