Brier Oak On Sunset

F-F584

Findings:

a. During a tour of the facility laundry area, on 1/2/2025, at 11:30 a.m., with the HSKS and Laundry Attendant (LA), observed the clean laundry room with the HSKS and LA. In the clean laundry room, the HSKS moved a large rolling bin to the side and two pillows were laying on the ground. The HSKS picked the pillows up off

the ground and placed them on top of a folded blanket. The LA continued to fold laundry and did not remove

the pillows from on top of the blanket. The laundry area tour continued with the HSKS. Upon return to the clean linen room, the two pillows remained on top of the blanket. The LA stated the blanket under the pillows was clean, but the pillows should be disinfected because the pillows were on the ground. The LA removed

the pillows. The HSKS returned to the clean linen area and stated he should not have placed the pillows on top of clean linens because the pillows were considered dirty. The HSKS stated the blanket that was under

the pillows was now considered dirty. The HSKS stated when he placed the pillows on the blanket, there was

a potential that the dirty blanket would be used for residents.

During an interview on 1/2/2025, at 3:30 p.m., with the Director of Nursing (DON), the DON stated pillows from the ground should not be picked up and placed on top of clean blankets. The DON stated once the pillows touch the floor, they are considered dirty and could contaminate the clean blankets. The DON stated

this practice is an infection control issue that may result in the spread of infectious agents by cross contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect) to residents.

During a review of the facility's policy and procedure (P&P) titled, Soiled Linen Handling, last reviewed 12/4/2024, the P&P indicated the facility will handle, store, and transport linen in a safe and sanitary method to prevent the spread of infection. Linen can become contaminated with pathogens from contact with intact skin, body substances, or from environmental contaminants. Transmission of pathogens can occur through direct contact with linen or aerosols generated from sorting and handling contaminated linens. Soiled linen will be kept separate from clean linen at all times. Linen includes sheets, blankets, pillows, towels, washcloths, and similar items.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 87 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of the facility's P&P titled, Clean Linen Handling, last reviewed 12/4/2024, the P&P indicated clean linen will be handled, stored, processed, and transported in a safe and sanitary method to prevent Level of Harm - Minimal harm or contamination of the linen, which can lead to infection. Linen is folded to ensure it does not come in contact potential for actual harm with other surfaces such as floors, walls, and doors. Clean linen will be kept separate from soiled linen at all times. Residents Affected - Some 43988

b. During a review of Resident 402's Admission Record, the Admission Record indicated the facility admitted

the resident on 12/11/2024, with diagnoses including type 2 diabetes mellitus (DM 2 - a disorder characterized by difficulty in blood sugar control and poor wound healing); abnormalities of gait and mobility; and generalized muscle weakness.

During a review of Resident 402's Minimum Data Set (MDS - resident assessment tool), dated 12/19/2024,

the MDS indicated Resident 402 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance with toileting, bathing, and lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 402's History and Physical (H&P) dated 12/19/2024, the H&P indicated Resident 402 had the capacity to understand and make decisions.

During a review of Resident 402's Order Summary Report, the Order Summary Report indicated the following physician's order dated 12/12/2024:

- Floor mats next to bed every shift for monitor proper placement as landing pad and fall precautions.

During a concurrent observation and interview, on 12/31/2024, at 9:42 a.m., while inside Resident 402's room, with Certified Nursing Assistant (CNA) 2, CNA 2 verified Resident 402's right floor mat had a tear with

the top cover stripped and the foam exposed. CNA 2 stated the stripped top cover of the floor mat measures at least three (3) inches. CNA 2 if the staff observed the floor mats have tears and/or damaged, the staff notifies the maintenance department, and they were responsible for changing the floor mats. CNA 2 stated

the resident's environment including equipment should be clean to ensure they have a pleasant stay in the facility. CNA 2 stated the exposed foam can be an infection control.

During a concurrent observation and interview, on 12/31/2024, at 9:45 a.m., while inside Resident 402's room, Licensed Vocational Nurse (LVN) 3 verified Resident 402's right floor mat was damaged and had the top cover stripped exposing the foam. LVN 3 stated the damaged on the top cover of the floor mat measures at least 3 inches. LVN 3 stated the resident's environment including equipment should always be safe, clean, and homelike to ensure they have a pleasant stay in the facility. LVN 3 stated the exposed foam can absorb dirt and liquids and is an infection control issue.

During an interview on 1/3/2025, at 3:00 p.m., with the DON, the DON stated floor mats should not be damaged or has tears. The DON stated the staff notifies the maintenance department to change the floor mat if damaged. The DON stated the floor mat should have been changed as the damaged floor mat with the foam exposed can absorb dirt and liquids and is an infection control issue.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 88 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 During a review of the facility's P&P titled, Infection Prevention and Control Program Description, last reviewed 12/4/2024, the P&P indicated the Infection Prevention and Control Program (IPCP) is a set of Level of Harm - Minimal harm or comprehensive processes that addresses preventing, identifying, reporting, investigating, and controlling of potential for actual harm infections and communicable diseases for residents, staff, volunteers, visitors, and other individuals providing services. The IPCP has been developed to provide staff with technical procedures, comprehensive Residents Affected - Some work practices, and guidelines to reduce the risk of transmission of infection or communicable diseases. The P&P further indicated the goals of the program include provide a safe, sanitary, and comfortable environments and decrease the risk of infection to residents and staff. The P&P further indicated the major activities of the program are:

- Implementation of control measures and precautions which include hand hygiene, standard and transmission-based precautions, cleaning/disinfecting equipment and measures to protect persons from communicable disease or infections.

- Prevention of infection includes staff and patient education focusing on risk of infection and practices to decrease risk. Policies, procedures, and infection prevention and control practices are followed by staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 89 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. Level of Harm - Minimal harm or potential for actual harm 44244

Residents Affected - Few Based on interview and record review the facility failed to ensure the 2024/2025 COVID-19 (a highly contagious viral infection that can trigger respiratory tract infection) booster vaccine (a supplemental dose of medication that is administered annually and used to prevent complications from COVID-19) was administered and the vaccination status of residents was known and documented in the resident's clinical

record for one of five sampled residents (Resident 77) reviewed during the Infection Control task.

This failure had the potential to result in increased risk of residents developing complications from COVID-19 including acute respiratory failure (a serious condition that occurs suddenly when the lungs cannot get enough oxygen).

Findings:

During a review of Resident 77's Admission Record, the Admission Record indicated the facility admitted the resident on 7/7/2022 and most recently readmitted the resident on 7/31/2024 with diagnoses that included acute pyelonephritis (a urinary tract infection that occurs when bacteria travels from the bladder to the kidneys), diabetes mellitus (DM - a disorder characterized by difficulty in blood sugar control and poor wound healing), and congestive heart failure (CHF - a heart disorder which causes the heart to not pump the blood efficiently, sometimes resulting in leg swelling).

During a review of Resident 77's Minimum Data Set (MDS - a resident assessment tool), dated 10/10/2024,

the MDS indicated Resident 77 had the ability to understand others and the ability to be understood. The MDS further indicated the resident was dependent on staff assistance for toileting, required substantial/maximal assistance with showering and lower body dressing, and was independent with eating and personal/oral hygiene.

During a review of Resident 77's Patient Informed Consent or Declination COVID-19 Vaccine form, signed by Resident 77 and the Infection Preventionist (IP) on 12/9/2024, the Patient Informed Consent or Declination COVID-19 Vaccine form indicated Resident 77 gave consent to be vaccinated. The form was not complete and did not indicate Resident 77's COVID-19 vaccination history and did not indicate if the resident was eligible to receive the vaccine.

During a review of Resident 77's Care Plan (CP) regarding the resident receiving the COVID-19 vaccine, initiated 9/19/2022 and last updated 10/4/2024, the CP indicated Resident 77 was administered a COVID-19 vaccine on 10/10/2023. The CP did not indicate the resident received the 2024/2025 COVID-19 booster vaccine. The CP indicated to assess if the resident has received another COVID-19 vaccine in the past and administer the medication intramuscularly as indicated.

During a review of Resident 77's CP regarding the resident is at risk for COVID-19 infection, initiated 8/17/2022 and last updated 10/4/2024, the CP indicated a goal that the resident would have no signs and symptoms of COVID-19 through the target date of 1/6/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 90 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 During a concurrent interview and record review on 1/2/2025 at 8:17 a.m., with the IP, the IP reviewed Resident 77's Patient Informed Consent or Declination COVID-19 Vaccine form signed by Resident 77 and Level of Harm - Minimal harm or the IP on 12/9/2024, Medication Administration Record (MAR), Progress Notes, and Immunization Report. potential for actual harm The IP stated residents are screened for vaccination history upon admission, readmission, and annually for seasonal vaccines. The IP stated the resident's immunization history is documented in the Immunization Residents Affected - Few Report. The IP stated if a resident consents to receive the COVID-19 vaccine the process is the following:

Written informed consent is obtained from the resident.

A physician's order is obtained for the vaccine and a visiting clinic administers the vaccine in the facility.

The administration of the vaccine is then documented in the MAR by facility staff.

The resident's Immunization Report is updated.

The IP stated Resident 77 signed the consent form on 12/9/2024, but the form was not complete and did not indicate the resident's COVID-19 history. The IP stated a visiting clinic came to the facility to administer the COVID-19 vaccine on 12/11/2024. The IP stated there was no physician's order to administer the vaccine and there was no record of vaccine administration in Resident 77's MAR. The IP stated Resident 77's Immunization Report did not indicate any information regarding the 2024/2025 COVID-19 booster vaccine and there was no documented evidence in the clinical record that the resident received or did not receive the vaccine. The IP stated she 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.

During an interview on 1/3/2025 at 8:00 a.m., with the Administrator (ADM), the ADM stated last evening she was made aware of a concern regarding Resident 77's 2024/2025 COVID-19 vaccine status and the ADM investigated the issue. The ADM stated Resident 77 was supposed to receive the 2024/2025 COVID-19 vaccine during a visiting vaccine clinic in the facility. The ADM stated the visiting vaccine clinic staff did not administer the vaccine. The ADM stated the IP should have followed up after the visiting vaccine clinic to ensure Resident 77 received the 2024/2025 COVID-19 vaccine or clarified any issues regarding why the resident did not receive the vaccine at that time, but the IP did not follow up and there was no documentation

in Resident 77's clinical record regarding the 2024/2025 COVID-19 vaccine.

During a follow up interview on 1/3/2025 at 8:21 a.m., with the IP, the IP stated it was her responsibility to document Resident 77's 2024/2025 COVID-19 vaccine status and she did not follow up, clarify the resident's vaccine status, or document if the resident had received or had not received the vaccine.

During an interview on 1/3/2025 at 2:40 p.m., with Resident 77, the resident stated she had not received the 2024/2025 COVID-19 vaccine. Resident 77 stated she did want the vaccine. Resident 77 stated about a month ago she was told that she would be receiving the vaccine, but nobody ever came to administer it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 91 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0887 During an interview on 1/3/2025 at 3:30 p.m., with the Director of Nursing (DON), the DON reviewed the facility policy and procedures regarding vaccine administration. The DON stated the importance of the Level of Harm - Minimal harm or 2024/2025 COVID-19 vaccine is to prevent or minimize complications from COVID-19. The DON stated it potential for actual harm was important for Resident 77 to receive the vaccine because the resident is immunocompromised and susceptible to complications from infection. The DON stated the facility policy was not followed when the IP Residents Affected - Few did not follow up regarding Resident 77's 2024/2025 COVID-19 vaccine status to ensure the resident received the vaccine.

During a review of the facility Policy and Procedure titled, COVID-19 - Vaccination of Residents, last reviewed 12/4/2024, the policy indicated the purpose was to prevent the spread of SARs-CoV-2 infection and its complications to residents and staff and to properly administer COVID-19 vaccination. The facility will provide the opportunity to receive COVID-19 vaccinations following Centers for Disease Control and Prevention (CDC) recommendations subject to availability, to residents unless the immunization is medically contraindicated, or the individual has already been immunized. The process includes the following:

- Obtain COVID-19 vaccination history. On admission, document patient COVID-19 vaccination status (receipt or lack of receipt of COVID-19 vaccine) in the medical record Immunization Record.

- Based on the resident's COVID-19 vaccination history, offer the vaccination following the manufacturer's recommended schedule.

- Obtain consent.

- Document refusals in the Immunization Record.

- Obtain physician order for COVID-19 vaccination.

- Administer the vaccine.

During a review of the facility provided Infection Prevention and Control Program Description manual, last revised 7/1/2024, the manual indicated the Infection Prevention and Control Program (IPCP) is a set of comprehensive processes that addresses preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for residents, staff, visitors, and other individuals providing services under a contractual agreement. The major activities of there program include the prevention of infection including immunizations offered and administered to residents as appropriate. The Infection Preventionist develops, implements, monitors, and maintains the IPCP and fulfills the basic requirements of the role.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 92 of 92 056056

F-F656.

Findings:

1. During a review of Resident 137's Admission Record, the Admission Record indicated the facility originally admitted Resident 137 with diagnoses including altered mental status, generalized muscle weakness, lack of coordination, and unsteadiness on his feet.

During a review of Resident 137's Minimum Data Set (MDS, a resident assessment tool), dated 12/2/2024,

the MDS indicated Resident 137 was sometimes able to make himself understood and sometimes able to understand others and required supervision with eating, moderate assistance to maximal assistance with hygiene, dressing, showering/bathing himself, and surface-to-surface transfers.

During a review of Resident 137's History and Physical (H&P) dated, 12/4/2024, the H&P indicated Resident 137 did not have the capacity to understand and make decisions.

During a review of Resident 137's Care Plans, current as of 1/2/2025, the Care Plans did not indicate focuses or interventions related to the placement of the resident's bed against the wall.

During a review of Resident 137's Order Summary Report, dated active as of 1/3/2025, the Order Summary Report did not indicate an order for placement of the resident's bed against the wall.

During a review of Resident 137's medical record, current as of 1/2/2025, the medical record did not indicate

an informed consent was obtained from the resident or the resident's responsible party and a restraint assessment was conducted for placement of the resident's bed against the wall.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 During an observation on 12/31/2024, at 9:36 a.m., inside Resident 137's room, Resident 137 was lying down in a bed placed against the wall, with the left side of the bed adjacent to the wall. Resident 137's bed Level of Harm - Minimal harm or had quarter rails at the head of the left and right side of the bed. The quarter rail at the left side of the head of potential for actual harm the bed created space between Resident 137's bed and the wall.

Residents Affected - Some During an interview on 1/2/2025, at 2:17 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated placing

the resident's bed against the wall is a restraint. LVN 4 stated it was important to have a physician's order, informed consent, and restraint assessment on the use of bed placed against the wall to ensure safety of its use. LVN 4 further stated the informed consent honors the right of the resident to accept or refuse the treatment and the restraint assessment is important to ensure accidents such as entrapment is prevented.

During an interview on 1/3/2025, at 8:58 a.m., with Registered Nurse (RN) 2, RN 2 stated placing the bed against the wall is a restraint. RN 2 stated by placing the resident's bed against the wall they are limiting the way the resident gets out of bed on one side only. RN 2 stated before placing the resident's bed against the wall they should have obtained a physician's order, obtained an informed consent from the resident or resident representative, and performed a restraint assessment on the use of bed against the wall to ensure its safe use.

During an interview with the Director of Nursing (DON), on 1/3/2025, at 2:40 p.m., the DON stated if a bed is placed against the wall, the resident would not have access to one side for exit and considers that as a restraint. The DON stated placing the bed against the wall can place the resident at risk for entrapment. The DON stated when placing a resident's bed against the wall, there should be a physician's order, an informed consent, and an assessment in place to ensure the preferences of the residents are honored, ensure the safety of the resident, and to prevent injury from occurring.

During a review of the facility's policy and procedure (P&P) titled, Restraints: Use of, last reviewed 12/4/2024, the P&P indicated if the device cannot be easily removed by a resident and/or restricts freedom of movement or normal access to their body, the Restraint Evaluation/Reduction will be completed prior to the application of any restraint and upon admission to residents with restraints. The P&P indicated residents with restraints will be re-assessed monthly for three months, then quarterly, and with any significant change in condition. The P&P indicated a physician or advance practice provider order alone, without supporting clinical documentation, is not sufficient to warrant the use of the restraint. The P&P further indicated consent must be obtained prior to the application of the restraint.

44376

2. During a review of Resident 61's Admission Record, the Admission Record indicated the facility admitted

the resident on 8/26/2024, with diagnoses including dementia (a progressive state of decline in mental abilities), muscle weakness, and unsteadiness on feet.

During a review of Resident 61's Nursing Documentation, dated 8/26/2024, the Nursing Documentation indicated the resident was at risk for falls.

During a review of Resident 61's H&P, dated 9/1/2024, the H&P indicated the resident can make needs known but does not have the capacity to consent.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 During a review of Resident 61's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and to understand others and had mildly impaired cognition (a condition in which people Level of Harm - Minimal harm or have more memory or thinking problems than other people their age). The MDS indicated the resident potential for actual harm required supervision to set up assistance on mobility and activities of daily living (ADLs, activities such as bathing, dressing and toileting a person performs daily). Residents Affected - Some

During a concurrent observation and interview on 1/2/2025, at 1:58 p.m., with RN 3, inside Resident 61's room, observed Resident 61's bed was placed against the wall on the right side of the bed. RN 3 stated placing the bed against the wall was not a restraint. RN 3 stated the bed was placed against the wall to prevent the resident from falling.

During a concurrent interview and record review on 1/2/2025, at 2:17 p.m., with LVN 4, LVN 4 stated placing

the resident's bed against the wall is a restraint. Resident 61's Order Summary Report, Informed Consents, Restraint Assessments, and Care Plans were reviewed. LVN 4 stated there was no order, informed consent, or restraint assessment for the bed to be placed against the wall on the resident's medical chart. LVN 4 stated it was important to have a physician's order, informed consent, and restraint assessment for the bed to be placed against the wall to ensure safety of its use. LVN 4 stated the informed consent honors the right of the resident to accept or refuse the treatment and the restraint assessment is important to ensure accidents such as entrapment is prevented.

During an interview on 1/3/2025, at 8:58 a.m., with RN 2, RN 2 stated placing the bed against the wall is a restraint. RN 2 stated they were placing the resident's bed against the wall to help prevent a fall. RN 2 stated by placing the resident's bed against the wall they are limiting the way the resident gets out of bed on one side only. RN 2 stated before placing the resident's bed against the wall they should have obtained a physician's order, obtained an informed consent from the resident or resident representative, and performed

a restraint assessment for the use of bed against the wall to ensure its safe use.

During an interview on 1/3/2025, at 2:45 p.m., with the DON, the DON stated placing the bed against the wall is a restraint. The DON stated the staff should obtain a physician's order, obtain an informed consent, and perform a restraint assessment before applying the restraint. The DON stated it was important to have a physician's order, and restraint assessment to ensure its safe use and the informed consent to honor the resident's right to accept or refuse treatment.

3. During a review of Resident 131's Admission Record, the Admission Record indicated the facility admitted

the resident on 11/7/2024, with diagnoses including muscle weakness, unsteadiness on feet, and lack of coordination.

During a review of Resident 131's Nursing Documentation, dated 11/7/2024, the Nursing Documentation indicated the resident was at risk for falls.

During a review of Resident 131's H&P, dated 11/9/2024, the H&P indicated the resident did not have the capacity to understand and make decisions.

During a review of Resident 131's MDS, dated [DATE REDACTED], the MDS indicated the resident usually make self-understood and sometimes had the ability to understand others and had moderately impaired cognition.

The MDS indicated the resident required substantial to supervision assistance on mobility and activities of daily living (ADLs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 During a concurrent observation and interview on 1/2/2025, at 1:58 p.m., with RN 3, while inside Resident 131's room, Resident 131's bed was placed against the wall at the right side of the bed. RN 3 stated placing Level of Harm - Minimal harm or the bed against the wall was not a restraint. RN 3 stated the bed was placed against the wall to prevent the potential for actual harm resident from falling.

Residents Affected - Some During a concurrent interview and record review on 1/2/2025, at 2:17 p.m., with LVN 4, LVN 4 stated placing

the resident's bed against the wall is a restraint. Resident 131's Order Summary Report, Informed Consents, Restraint Assessments, and Care Plans were reviewed. LVN 4 stated there was no order, informed consent, or restraint assessment for the bed to be placed against the wall on the resident's medical chart. LVN 4 stated it was important to have a physician's order, informed consent, and restraint assessment for the bed to be placed against the wall to ensure safety of its use. LVN 4 stated the informed consent honors the right of the resident to accept or refuse the treatment and the restraint assessment is important to ensure accidents such as entrapment is prevented.

During an interview on 1/3/2025, at 8:58 a.m., with RN 2, RN 2 stated placing the bed against the wall is a restraint. RN 2 stated they were placing the resident's bed against the wall to help prevent resident's fall. RN 2 stated by placing the resident's bed against the wall they are limiting the way the resident gets out of bed

on one side only. RN 2 stated before placing the resident's bed against the wall they should have obtained a physician's order, obtained an informed consent from the resident or resident representative, and performed

a restraint assessment on the use of bed against the wall to ensure its safe use.

During an interview on 1/3/2025, at 2:45 p.m., with the DON, the DON stated placing the bed against the wall is a restraint. The DON stated the staff should obtain a physician's order, obtain an informed consent, and perform a restraint assessment before applying the restraint. The DON stated it was important to have a physician's order, and restraint assessment to ensure its safe use and the informed consent to honor the resident's right to accept or refuse treatment.

4. During a review of Resident 123's Admission Record, the Admission Record indicated the facility admitted

the resident on 9/27/2024, with diagnoses including acquired absence of right and left below knee, muscle weakness, and unsteadiness on feet.

During a review of Resident 123's H&P, dated 9/28/2024, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 123's Care Plan regarding at risk for falls status post below-knee amputee (BKA,

an amputation often performed for foot and ankle problems) last revised on 9/28/2024, the care plan indicated an intervention to assist resident/caregiver to organize belongings for clutter-free environment in

the resident's room and consistent furniture arrangement.

During a review of Resident 123's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (being able to perform mental processes like thinking, paying attention, learning, and remembering). The MDS indicated the resident required partial to supervision assistance on mobility and activities of daily living (ADLs).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 During a concurrent observation and interview on 1/2/2025, at 1:58 p.m., with RN 3, inside Resident 123's room, Resident 123's bed was placed against the wall on the right side of the bed. RN 3 stated placing the Level of Harm - Minimal harm or bed against the wall was not a restraint. RN 3 stated the bed was placed against the wall to prevent the potential for actual harm resident from falling.

Residents Affected - Some During a concurrent interview and record review on 1/2/2025, at 2:17 p.m., with LVN 4, LVN 4 stated placing

the resident's bed against the wall is a restraint. Resident 123's Order Summary Report, Informed Consents, Restraint Assessments, and Care Plans were reviewed. LVN 4 stated there was no order, informed consent, and restraint assessment for the bed to be placed against the wall on the resident's medical chart. LVN 4 stated it was important to have a physician's order, informed consent, and restraint assessment for the bed to be placed against the wall to ensure safety of its use. LVN 4 stated the informed consent honors the right of the resident to accept or refuse the treatment and the restraint assessment is important to ensure accidents such as entrapment is prevented.

During an interview on 1/3/2025, at 8:58 a.m., with RN 2, RN 2 stated placing the bed against the wall is a restraint. RN 2 stated they were placing the resident's bed against the wall to help prevent a fall. RN 2 stated by placing the resident's bed against the wall they are limiting the way the resident gets out of bed on one side only. RN 2 stated before placing the resident's bed against the wall they should have obtained a physician's order, obtained an informed consent from the resident or resident representative, and performed

a restraint assessment on the use of bed against the wall to ensure its safe use.

During an interview on 1/3/2025, at 2:45 p.m., with the DON, the DON stated placing the bed against the wall is a restraint. The DON stated the staff should obtain a physician's order, obtain an informed consent, and perform a restraint assessment before applying the restraint. The DON stated it was important to have a physician's order, and restraint assessment to ensure its safe use and the informed consent to honor the resident's right to accept or refuse treatment.

5. During a review of Resident 132's Admission Record, the Admission Record indicated the facility admitted

the resident on 11/7/2024, and readmitted the resident on 12/18/2024, with diagnoses including muscle weakness, unsteadiness on feet, lack of coordination.

During a review of Resident 132's H&P, dated 11/8/2024, the H&P indicated the resident had the capacity to consent.

During a review of Resident 132's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident required substantial to supervision for mobility and activities of daily living (ADLs).

During a concurrent observation and interview on 1/2/2025, at 1:58 p.m., with RN 3, while inside Resident 132's room, observed Resident 132's bed was placed against the wall on the right side of the bed. RN 3 stated placing the bed against the wall was not a restraint. RN 3 stated the bed was placed against the wall to prevent the resident from falling.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 During a concurrent interview and record review on 1/2/2025, at 2:17 p.m., with LVN 4, LVN 4 stated placing

the resident's bed against the wall is a restraint. Resident 132's Order Summary Report, Informed Consents, Level of Harm - Minimal harm or Restraint Assessments, and Care Plans were reviewed. LVN 4 stated there was no order, informed consent, potential for actual harm or restraint assessment for the bed to be placed against the wall on the resident's medical chart. LVN 4 stated it was important to have a physician's order, informed consent, and restraint assessment for the bed Residents Affected - Some to be placed against the wall to ensure safety of its use. LVN 4 stated the informed consent honors the right of the resident to accept or refuse the treatment and the restraint assessment is important to ensure accidents such as entrapment is prevented.

During an interview on 1/3/2025, at 8:58 a.m., with RN 2, RN 2 stated placing the bed against the wall is a restraint. RN 2 stated they were placing the resident's bed against the wall was to help prevent resident's fall. RN 2 stated by placing the resident's bed against the wall they are limiting the way the resident gets out of bed on one side only. RN 2 stated before placing the resident's bed against the wall they should have obtained a physician's order, obtained an informed consent from the resident or resident representative, and performed a restraint assessment on the use of bed against the wall to ensure its safe use.

During an interview on 1/3/2025, at 2:45 p.m., with the DON, the DON stated placing the bed against the wall is a restraint. The DON stated the staff should obtain a physician's order, obtain an informed consent, and perform a restraint assessment before applying the restraint. The DON stated it was important to have a physician's order, and restraint assessment to ensure its safe use and the informed consent to honor the resident's right to accept or refuse treatment.

6. During a review of Resident 42's Admission Record, the Admission Record indicated the facility admitted

the resident on 3/17/2022, and readmitted the resident on 11/14/2023, with diagnoses including acquired absence of right foot and partial traumatic amputation (a significant injury to a limb that results in the loss of a portion of the limb, but some soft tissue and bone remain intact) of left foot.

During a review of Resident 42's H&P, dated 11/7/2024, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 42's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident required substantial to independent assistance on mobility and activities of daily living (ADLs).

During a concurrent observation and interview on 1/2/2025, at 1:58 p.m., with RN 3, while inside Resident 42's room, Resident 42's bed was placed against the wall at the right side of the bed. RN 3 stated placing the bed against the wall was not a restraint. RN 3 stated the bed was placed against the wall to prevent the resident from falling.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 During a concurrent interview and record review on 1/2/2025, at 2:17 p.m., with LVN 4, LVN 4 stated placing

the resident's bed against the wall is a restraint. Resident 42's Order Summary Report, Informed Consents, Level of Harm - Minimal harm or Restraint Assessments, and Care Plans were reviewed. LVN 4 stated there was no order, informed consent, potential for actual harm and restraint assessment on the use of bed placed against the wall on the resident's medical chart. LVN 4 stated it was important to have a physician's order, informed consent, and restraint assessment on the use of Residents Affected - Some bed placed against the wall to ensure safety of its use. LVN 4 stated the informed consent honors the right of

the resident to accept or refuse the treatment and the restraint assessment is important to ensure accidents such as entrapment is prevented.

During an interview on 1/3/2025, at 8:58 a.m., with RN 2, RN 2 stated placing the bed against the wall is a restraint. RN 2 stated they were placing the resident's bed against the wall to help prevent a fall. RN 2 stated by placing the resident's bed against the wall they are limiting the way the resident gets out of bed on one side only. RN 2 stated before placing the resident's bed against the wall they should have obtained a physician's order, obtained an informed consent from the resident or resident representative, and performed

a restraint assessment on the use of bed against the wall to ensure its safe use.

During an interview on 1/3/2025, at 2:45 p.m., with the DON, the DON stated placing the bed against the wall is a restraint. The DON stated the staff should obtain a physician's order, obtain an informed consent, and perform a restraint assessment before applying the restraint. The DON stated it was important to have a physician's order, and restraint assessment to ensure its safe use and the informed consent to honor the resident's right to accept or refuse treatment.

During a review of the facility's recent policy and procedure (P&P) titled Restraint: Use of, last reviewed on 12/4/2024, the P&P indicated patients have the right to be free from any physical or chemical restraints imposed for purposes of discipline or convenience, and not required to treat the patient's medical symptoms. Physical restraint is defined as any manual method, physical or mechanical device, equipment, or material that meets all of the following criteria:

- Is attached or adjacent to the patient's body;

- Cannot be removed easily by the patient, and

- Restricts the patient's freedom of movement or normal access to their body.

Removes easily means that the manual method, physical or mechanical device, equipment, or material can be removed intentionally by the patient in the manner as it was applied by staff.

Patients will be evaluated for use of restraints or protective devices during the nursing assessment process. If the device cannot be easily removed by the patient and/or restricts freedom of movement or normal access to their body, the Restraint Evaluation/Reduction will be completed:

- Prior to the application of any restraint, including bed rails, and

- Upon admission of patients with restraints.

Patients with a restraint will be re-assessed as follows or per state regulations:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0604 - Monthly for three months,

Level of Harm - Minimal harm or - Then quarterly, and potential for actual harm - With any significant change in condition. Residents Affected - Some

A physician/advanced practice provider order alone (without supporting clinical documentation) is not sufficient to warrant the use of the restraint. Consent must be obtained prior to the application of the restraint.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment.

Level of Harm - Potential for **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44244 minimal harm Based on interview and record review the facility failed to ensure an accurate assessment was conducted by Residents Affected - Some failing to ensure the Minimum Data Set (MDS - resident assessment tool) was coded correctly to indicate a resident was discharged to a skilled nursing facility for one of one sampled resident (Resident 143) reviewed

during the hospitalization Closed Record Review care area.

This failure had the potential to result in negatively affecting Resident 143's delivery of care and services.

Findings:

During a review of Resident 143's Admission Record, the Admission Record indicated the facility admitted Resident 143 on 9/17/2024 with diagnoses that included primary osteoarthritis (a progressive disorder of the joints, caused by a gradual loss of cartilage) of the right hip, idiopathic aseptic necrosis of the right femur (a condition that occurs when the blood supply to the thigh bone is disrupted, causing bone cells to die), and unsteadiness on the feet.

During a review of Resident 143's MDS, dated [DATE REDACTED], the MDS indicated Resident 143 discharged from the facility on 10/3/2024 to a short-term general hospital.

During a review of Resident 143's Physician Order, dated 10/3/2024, the Physician Order indicated to transfer the resident to Skilled Nursing Facility 1 (SNF 1).

During a review of Resident 143's Social Services Progress Note, dated 10/4/2024 at 12:18 p.m., the Social Services Progress note indicated the resident was self-responsible and able to make her needs known. The Social Services Progress note further indicated SNF 1 accepted the resident and the resident's family was aware of the resident's transfer to SNF 1.

During a concurrent interview and record review on 1/2/2025 at 4:25 p.m. with Minimum Data Set Coordinator 1 (MDSC 1), MDSC 1 reviewed Resident 143's Social Services Progress Note dated 10/4/2024 at 12:18 p.m., Physician Order dated 10/3/2024, MDS dated [DATE REDACTED], and the CMS RAI Version 3.0 Manual (instructional guide for coding the MDS). MDSC 1 stated when a resident is discharged from the facility, an MDS discharge assessment is completed and submitted. MDSC 1 stated staff reviews the resident's clinical

record when completing the MDS Discharge Assessment. MDSC 1 stated Resident 143 discharged to SNF 1, but the MDS indicated the resident discharged to the hospital. MDSC 1 stated SNF 1 is not a hospital. MDSC 1 stated the MDS was not correct and there was a coding error. MDSC 1 stated the MDS should be accurate because it is a part of the resident's medical record and the MDS is transmitted to the state. MDSC 1 stated Resident 143's MDS was not completed per the guidance of RAI Manual.

During an interview on 1/3/2025 at 3:30 p.m. with the Director of Nursing (DON), the DON stated coding in

the MDS reflects resident care for billing purposes. The DON stated the MDS is completed at a resident's discharge and should be accurate to reflect a resident's discharge status to ensure the proper discharge follow up. The DON stated the facility did not accurately code Resident 143's MDS when the MDS indicated

the resident was discharge to the hospital.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 During a review of the facility provided CMS RIA Version 3.0 Manual, dated 10/2024, the manual indicated

the discharge status of the MDS documents the location to which a resident is being discharged at the time Level of Harm - Potential for of discharge. Knowing the setting to which the individual was discharged helps to inform discharge planning. minimal harm Review the medical record including the discharge plan and discharge orders for documentation of the discharge location. Select the two-digit code that corresponds to the resident's discharge status. Code 01: for Residents Affected - Some home/community discharge to a private home, apartment, board and care, assisted living facility, or group home.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities

Level of Harm - Minimal harm or 43988 potential for actual harm Based on interview and record review, the facility failed to accurately code one (1) of two (2) sampled Residents Affected - Few residents (Resident 103) Preadmission Screening and Resident Review (PASARR - a federal requirement to help ensure that individuals are not inappropriately placed in nursing homes for long term care) when the PASARR prior to admission did not indicate Resident 103 had major depressive disorder (a major disorder that causes persistent feeling of sadness and loss of interest).

This deficient practice had the potential to result in the resident's medical and nursing care needs not being met.

Findings:

During a review of Resident 103's Admission Record, the Admission Record indicated the facility admitted

the resident on 12/11/2023, with diagnoses including major depressive disorder; schizophrenia (a mental illness that can affect thoughts, mood, and behavior) and anxiety disorder (a mental health condition that causes excessive and persistent feelings of fear, dread, and worry).

During a review of Resident 103's PASARR, date started 12/12/2023, the PASARR indicated that the resident did not have a diagnosis of a mental disorder.

During a review of Resident 103's Minimum Data Set (MDS - a resident assessment tool) dated 12/19/2024,

the MDS indicated Resident 402 had moderately impaired cognition (mental action or process of acquiring knowledge and understanding) and was independent with eating and oral hygiene, required partial/moderate assistance with personal hygiene; substantial/maximal assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 103's History and Physical (H&P) dated 12/30/2024, the H&P indicated Resident 103 had the capacity to understand and make decisions.

During a concurrent interview and record review on 1/3/2024 at 2:36 p.m. with the ADON, Resident 103's PASARR Level 1 Screening form (a preliminary assessment that determines if someone might have a mental illness or intellectual disability before being admitted to a nursing facility) was reviewed with the Assistant Director of Nursing (ADON). The ADON verified Resident 103's PASARR Level 1 Screening was not completed accurately prior to admission to the facility. The ADON stated prior to admission, or if the resident has a significant change of condition. The ADON stated the PASARR should be coded accurately to reflect the resident's current medical condition such as diagnosis or behavioral issues or mental illness or mood disorder. The ADON stated the Admission's Director (AD) and/or admitting nurse should have ensured

the screening was accurate to ensure Resident 103 received the proper care and services the resident needed.

During a review of the facility's policy and procedure (P&P) titled, PASRR Completion Policy, last reviewed

on 12/4/2024, the P&P indicated the facility will make sure that all admissions have appropriate PASARR completed. The P&P further indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0645 - The Administrator (Adm) will designate either the AD or social worker to make sure that the PASARR is done on all potential residents. If the referral indicates anything which might constitute and mental illness or Level of Harm - Minimal harm or intellectual disability, the PASARR must be completed prior to admission. potential for actual harm - The facility will follow state-specific guidelines for completion. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43988

Residents Affected - Few Based on interview and record review the facility failed to develop a baseline care plan (initial written guide that organizes information about the resident's care) addressing the use of oxygen for one (1) out of 1 sampled resident (Resident 129) reviewed for respiratory care.

This deficient practice had the potential for Resident 129 not to receive the appropriate care and treatment specific to the resident's needs.

Findings:

During a review of Resident 129's Admission Record, the Admission Record indicated the facility originally admitted the resident on 10/15/2024 and readmitted Resident 129 into the facility on [DATE REDACTED] with diagnoses including chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing), urinary tract infection (UTI - an infection in the bladder/urinary tract) and generalized muscle weakness.

During a review of Resident 129's Minimum Data Set (MDS - a resident assessment tool) dated 10/22/2024,

the MDS indicated Resident 129 had intact cognition (mental action or process of acquiring knowledge and understanding), required setup or clean-up assistance with eating; supervision or touching assistance to partial/moderate assistance with all activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive).

During a review of Resident 129's History and Physical (H&P) dated 12/16/2024, the H&P indicated Resident 129 did not have the capacity to understand and make decisions.

During a review of Resident 129's Order Summary Report, the Order Summary Report indicated the following physician's order dated 12/20/2024:

- Oxygen at 1-2 liters per minute (L/min - a unit of measurement) via nasal cannula (a small plastic tube, which fits into the person's nostrils for providing supplemental oxygen) continuously. May titrate to keep oxygen saturation (O2 sat - a measurement of how much oxygen the blood is carrying as a percentage) at or above 90 percent (% - a unit of measurement) every shift for COPD, shortness of breath.

During a review of Resident 129's baseline care plan (CP), the baseline CP, dated 12/14/2024, did not address Resident 129's use of oxygen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0655 During a concurrent interview and record review on 1/2/2025 at 2:55 p.m., Resident 129's baseline CP with Registered Nurse 2 (RN 2) was reviewed. RN 2 verified there was no baseline CP initiated addressing Level of Harm - Minimal harm or Resident 129's use of oxygen. RN 2 stated the admitting nurse initiate the baseline CP within 48 hours of potential for actual harm admission and the Minimum Data Set Coordinator (MDSC) will complete the comprehensive care plan together with the completion of admission MDS assessment. RN 2 stated the baseline CP should have been Residents Affected - Few initiated within 48 hours of the resident's admission. RN 2 stated the purpose of the baseline CP is for all staff of Resident 129's plan of care to prevent delay in the delivery of appropriate care and treatment specific to the resident's needs.

During a review of the facility's policy and procedure (P&P) titled, Care Plan-Baseline, last reviewed 12/4/2024, the P&P indicated a baseline CP for each resident that includes instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care shall be developed and implemented for each resident. The P&P further indicated:

- The baseline CP is developed within 48 hours.

- The baseline CP includes the minimum healthcare information necessary to properly care for a resident including but not limited to initial goals based on admission orders and physician orders.

- The baseline CP will be used until a comprehensive assessment is conducted and develop the comprehensive care plan within seven (7) days of the completion of the comprehensive assessment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43418

Residents Affected - Few Based on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan (CP, a document outlining a detailed approach to care customized to an individual resident's need) for one of six sampled residents (Resident 137) investigated under the accident hazards care area, one of seven sampled residents (Resident 137) investigated under the physical restraints (any manual method, physical or mechanical device, equipment, or material that is attached or adjacent to the resident's body, cannot be removed easily by the resident, and restricts the resident's freedom of movement or normal access to his/her body) care area, and one of five sampled residents (Resident 128) investigated under infection control task, when:

1. The facility failed to implement Resident 137's care plan for storing the resident's smoking material.

2. The facility failed to develop a care plan for placement of Resident 137's bed against the wall.

3. The facility failed to develop and implement a care plan for Resident 128's use of ciprofloxacin (an antibiotic [a medication that inhibits the growth of or destroys microorganisms]).

These failures had the potential to result in delayed provision of necessary care and services for residents.

Cross-reference

F-F689.

Findings:

1. During a review of Resident 137's Admission Record (a document containing demographic and diagnostic information), the Admission Record indicated the facility originally admitted Resident 137 with diagnoses including altered mental status, generalized muscle weakness, lack of coordination, and unsteadiness on his feet.

During a review of Resident 137's Minimum Data Set (MDS, a resident assessment tool), dated 12/2/2024,

the MDS indicated Resident 137 was sometimes able to make himself understood and sometimes able to understand others and required supervision with eating, moderate assistance to maximal assistance with hygiene, dressing, showering/bathing himself, and surface-to-surface transfers.

During a review of Resident 137's History and Physical (H&P) dated, 12/4/2024, the H&P indicated Resident 137 did not have the capacity to understand and make decisions.

During a review of Resident 137's Smoking Evaluation, dated 11/26/2024, the Smoking Evaluation indicated independent smoking is allowed and smoking supplies including, but not limited to, tobacco, matches, lighters, lighter fluid, batteries, refill cartridges, etc. will be labeled with the resident's name, room number, and bed number, maintained by staff, and stored in a suitable cabinet kept at the nursing station.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a review of Resident 137's Care Plan titled, Resident may smoke independently per smoking evaluation, dated 11/26/2024, the Care Plan indicated interventions including to monitor the resident's Level of Harm - Minimal harm or compliance to smoking policy and provide a lock box for safe keeping of smoking materials. potential for actual harm

During a concurrent observation and interview with Resident 137, on 12/31/2024, at 9:36 a.m., inside Residents Affected - Few Resident 137's room, Resident 137's nightstand contained a pack of cigarettes and a red colored lighter. Resident 137 stated the cigarettes and lighter belonged to him.

During an interview with Certified Nursing Assistant (CNA) 4, on 1/2/2025, at 2:52 p.m., CNA 4 stated she is assigned to Resident 137 and has seen the resident get up into a wheelchair to go outside of the facility to smoke. CNA 4 stated Resident 137 keeps his cigarettes and lighter with him on top of his nightstand. CNA 4 further stated residents do not keep smoking material with them.

During an interview with Registered Nurse (RN) 4, on 1/2/2025, RN 4 stated she is assigned to Resident 137 and has seen the resident go outside to the patio to smoke. RN 4 stated she does not know where Resident 137 stores his smoking material. RN 4 further stated the staff that supervise the residents who go out to smoke store the smoking material for the residents for the safety of the residents and to prevent incidences of accidental fires and injury for burns.

During an interview with the Director of Nursing (DON), on 1/3/2025, at 2:40 p.m., the DON stated it is important to implement care plans to provide adequate care for the residents and if the care plan is not followed, it can place the residents at risk for harm. The DON further stated the purpose of a care plan is to individualize care to each resident and provide guidance to the facility staff for care provided to the resident.

During a review of the facility's policy and procedure (P&P) titled, Care Plan Comprehensive, last reviewed 12/4/2024, the P&P indicated the facility's interdisciplinary team in coordination with the resident and/or his/her family or representative, must develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, physical, and mental and psychosocial needs that are identified in the comprehensive assessment.

During a review of the facility's P&P titled, Smoking, last reviewed 12/4/2024, the P&P indicated the interdisciplinary team will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision, if necessary, for residents who smoke.

2. During a review of Resident 137's Admission Record, the Admission Record indicated the facility originally admitted Resident 137 with diagnoses including altered mental status, generalized muscle weakness, lack of coordination, and unsteadiness on his feet.

During a review of Resident 137's MDS, dated [DATE REDACTED], the MDS indicated Resident 137 was sometimes able to make himself understood and sometimes able to understand others and required supervision with eating, moderate assistance to maximal assistance with hygiene, dressing, showering/bathing himself, and surface-to-surface transfers.

During a review of Resident 137's H&P dated, 12/4/2024, the H&P indicated Resident 137 did not have the capacity to understand and make decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a review of Resident 137's Care Plans, current as of 1/2/2025, the Care Plans did not indicate focuses or interventions related to the placement of the resident's bed against the wall. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 137's Order Summary Report, dated active as of 1/3/2025, the Order Summary Report did not indicate an order for placement of the resident's bed against the wall. Residents Affected - Few

During a review of Resident 137's medical record, current as of 1/2/2025, the medical record did not indicate

an informed consent was obtained from the resident or the resident's responsible party and a restraint assessment was conducted for placement of the resident's bed against the wall.

During an observation on 12/31/2024, at 9:36 a.m., inside Resident 137's room, Resident 137 was lying down in a bed placed against the wall, with the left side of the bed adjacent to the wall. Resident 137's bed had quarter rails at the head of the left and right side of the bed. The quarter rail at the left side of the head of

the bed created space between Resident 137's bed and the wall.

During an interview on 1/2/2025, at 2:17 p.m., with Licensed Vocational Nurse (LVN) 4, LVN 4 stated placing

the resident's bed against the wall is a restraint. LVN 4 stated it was important to have a physician's order, informed consent, and restraint assessment on the use of bed placed against the wall to ensure safety of its use. LVN 4 further stated the informed consent honors the right of the resident to accept or refuse the treatment and the restraint assessment is important to ensure accidents such as entrapment is prevented.

During an interview on 1/3/2025, at 8:58 a.m., with RN 2, RN 2 stated placing the bed against the wall is a restraint. RN 2 stated by placing the resident's bed against the wall they are limiting the way the resident gets out of bed on one side only. RN 2 stated before placing the resident's bed against the wall they should have obtained a physician's order, obtained an informed consent from the resident or resident representative, and performed a restraint assessment on the use of bed against the wall to ensure its safe use.

During an interview with the DON, on 1/3/2025, at 2:40 p.m., the DON stated it is important to develop a care plan to make sure it is safe to place a resident's bed against the wall and does not place them at risk for injury and makes the facility staff aware of the treatment plan for the resident. The DON further stated the purpose of the care plan is to individualize the care provided to residents and to provide guidance to the facility for care of the resident.

During a review of the facility's P&P titled, Care Plan Comprehensive, last reviewed 12/4/2024, the P&P indicated care plan interventions are designed after careful consideration of the relationship between the resident's problem areas and their causes. The P&P further indicated when possible, interventions address

the underlying source of the problem areas, rather than addressing only symptoms or triggers.

During a review of the facility's P&P titled, Restraints: Use of, last reviewed 12/4/2024, the P&P indicated residents will be evaluated for the use of restraints or protective devices during the nursing assessment process. The P&P indicate there must be documentation identifying the medical symptom being treated and

an order for the use of the specific type of restraint.

44244

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 3. During a review of Resident 128's Admission Record, the Admission Record indicated Resident 128 was admitted to the facility on [DATE REDACTED] with diagnoses including orthopedic (a medical specialty that focuses on Level of Harm - Minimal harm or the musculoskeletal system) aftercare following surgical amputation (removal of a limb), partial traumatic potential for actual harm amputation of right foot, and cellulitis (a skin infection that causes swelling and redness) of the right lower limb. Residents Affected - Few

During a review of Resident 128's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to understand others and the ability to be understood. The MDS further indicated the resident required substantial/maximal assistance with toileting, bathing, dressing, and transferring from bed to chair/toilet. The MDS indicated the resident was taking antibiotics, a high-risk drug class (drugs that increase the potential for adverse events and possible side effect [also known as adverse effects - unwanted, uncomfortable, or dangerous effects that a drug may have]).

During a review of Resident 128's Order Summary Report, the Order Summary Report indicated Resident 128 was prescribed ciprofloxacin, 325 milligram ([mg], a unit of measure of mass) tablet, give one tablet by mouth every 12 hours for extended spectrum beta-lactamase (ESBL, an enzyme found in some strains of bacteria) in the right trans metatarsal amputation (TMA, a surgery to remove part of the foot) wound until 1/12/2025, starting 12/30/2024.

During a concurrent interview and record review, on 1/2/2025, at 8:17 a.m., with the Infection Preventionist (IP), the IP reviewed Resident 128's physician orders, Medication Administration Record (MAR), and CPs.

The IP stated when a resident begins taking an antibiotic a care plan is created that includes the use of the specific antibiotic prescribed with interventions to monitor for side effects and the effectiveness of the antibiotic treatment. The IP stated antibiotics have side effects like nausea and vomiting. The IP stated there was no documented evidence of a CP for Resident 128's use of ciprofloxacin. The IP stated without a CP for ciprofloxacin it could potentially result in the unidentified side effects of the medication that may warrant a change to a different antibiotic.

During a concurrent interview and record review, on 1/2/2025, at 3:30 p.m., with the DON, the DON reviewed Resident 128's physician orders, MAR, and CPs. The DON stated a CP is a tool that guides the care of residents. The DON stated a CP for antibiotics should be developed when residents require antibiotics to treat an infection. The DON stated the antibiotic CP should include interventions for monitoring for allergic reactions, monitoring for side effects, and monitoring the effectiveness of the medication. The DON stated antibiotics are a type of medication that are known to have adverse effects and the licensed nurse needs to know the plan of care with the specific medication they are giving. The DON stated Resident 128 was prescribed and taking ciprofloxacin and should have a CP for ciprofloxacin. The DON stated Resident 128 did not have a CP for the use of ciprofloxacin. The DON stated when Resident 128 did not have a CP for ciprofloxacin it could potentially result in nurses not monitoring for medication side effects and not monitoring

the effectiveness of the medication. The DON stated when antibiotics are not monitored for effectiveness it could potentially result in a worsening of the resident's infection. The DON stated the facility policy and procedures regarding comprehensive CPs was not followed when Resident 128 did not have a CP for the use of ciprofloxacin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 During a review of the facility's P&P titled, Care Plans, Comprehensive, last reviewed 10/4/2024, the P&P indicated an individualized comprehensive care plan that includes measurable objectives and timetables to Level of Harm - Minimal harm or meet the resident's medical, physical, mental, and psychosocial needs shall be developed for each resident. potential for actual harm Each residents comprehensive CP is designed to: reflect treatment goals, timetables, and objectives in measurable outcomes; and aid in preventing or reducing declines in the resident's functional status and/or Residents Affected - Few functional levels. The comprehensive CP includes the services that are to be furnished to attain or maintain

the resident's highest practicable physical, mental, and psychosocial well-being. Assessments of residents are ongoing and care plans are reviewed as information about the resident and resident's condition change.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 potential for actual harm Based on interview and record review, the facility's licensed nursing staff failed to provide care in accordance Residents Affected - Some with professional standards to four out of 4 sampled residents (Residents 29, 42, 402, and 134) investigated under insulin (a hormone that lowers the level of glucose [a type of sugar] in the blood) and heparin (an anticoagulant [blood thinner] that stops the blood from forming blood clots or making them bigger) by failing to:

1. Rotate (a method to ensure repeated injections are not administered in the same area) Residents 29 and 402's (a method to ensure repeated injections are not administered in the same area) subcutaneous (beneath the skin) insulin and heparin administration sites.

2. Rotate Resident 42 and 134's insulin subcutaneous administration sites.

These failures had the potential to result in adverse effects (unwanted, unintended result) of same site subcutaneous administration of insulin and enoxaparin such as bruising, lipodystrophy (abnormal distribution of fat), and cutaneous amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin).

Cross reference

F-F690

Findings:

During a concurrent interview and record review on 1/2/2025 at 2:38 p.m. with the Director of Staff Development (DSD - a licensed nurse that provides education and training designed to increase the professional knowledge and skills of staff members), the DSD reviewed RN 1's employee file and noted the following:

1. RN 1 became a registered nurse on 8/29/2024 and was hired by the facility on 10/14/2024.

2. There was no documented evidence that RN 1 completed a clinical skills competency assessment (process of evaluating a healthcare professional's abilities and knowledge in performing clinical tasks effectively and safely) for the care of residents with FCs.

During a concurrent interview and record review on 1/2/2025 at 3:14 p.m. with the Director of Nursing (DON) and DSD, the DON reviewed RN 1's employee file. The DSD stated she was not sure if it was required to complete a FC skills competency assessment during the registered nurse's orientation. The DON stated

during a licensed nurse's orientation a Competency Completion Log, Licensed Nurse form should be completed. The DON stated the form includes a FC care assessment check off. Observed the DSD exited

the interview. Observed the DON entered her office and stated after a thorough search there was no documented evidence that a FC skills competency assessment was completed for RN 1. The DON stated

the DSD should know FC care is a skill that requires a competency assessment for all licensed nurses. The DON stated it was important to complete the assessment to ensure residents get proper FC care without complications. The DON stated RN 1 is a new nurse and when the FC competency assessment was not completed, it could have potentially resulted in FC complications like trauma (damage to the urinary track resulting in bleeding and pain) to the residents with FCs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0726 During a review of the facility's policy and procedure (P&P) titled, Staffing, Sufficient and Competent Nursing, last reviewed 12/4/2024, the P&P indicated the facility provides nursing staff with the appropriate skills and Level of Harm - Minimal harm or competency necessary to provide nursing and related care and services for all residents in accordance with potential for actual harm resident care plans and the facility assessment. Staffing numbers and skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident Residents Affected - Few assessments and the facility assessment. Competency is a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully. Staff must demonstrate the skills and techniques necessary to care for resident needs including (but not limited to) basic nursing skills and person-centered care. Competency requirements and training for nursing staff are established and monitored by nursing leadership.

During a review of the facility's Job Description for Registered Nurse Supervisor, last revised 6/16/2017, the job description indicated the registered nurse demonstrates nursing skills utilized in direct patient care of the facility's specific patient population. The registered nurse ensures staff participates in orientation and training programs including but not limited to all required compliance courses and that such training is properly documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm 43455

Residents Affected - Some Based on interview and record review the facility failed to include the verifying signatures of either the Director of Nursing (DON) or a Registered Nurse (RN) along with Licensed Vocational Nurse (LVN) on the Antibiotic or Controlled Drug Record accountability logs for two (2) of two (2) sampled records awaiting disposal (removal, destroying) in DON's office.

As a result, control and accountability of Controlled Substances ([CS] - also known as Controlled Drug and Controlled Medications [CD, CM]- medications which have a potential for abuse and may also lead to physical or psychological dependence) did not follow state and federal regulations and facility policy and procedures.

These failures increased the opportunity for CS diversion (the transfer of a controlled medication or other medication from a lawful to an unlawful channel of distribution or use,) and accidental exposure to harmful medications to all residents in the facility, possibly leading to physical and psychosocial harm and hospitalization .

Findings:

During a concurrent interview and record review , on 12/31/2024, at 1:12 p.m., inside the DON's office, with

the DON, two (2) Antibiotic or Controlled Drug Record accountability logs for CS's awaiting final disposition did not contain verifying signatures. The DON stated the DON was unable to locate the verifying signatures of RN /DON on the 2 Antibiotic or Controlled Drug Record accountability logs. The DON stated the DON failed to sign the Antibiotic or Controlled Drug Record accountability logs upon receipt of the CSs from the LVNs . The DON stated the DON counts the CSs with the LVNs upon receipt of the accountability logs and knows who gave them to her, however there was no consistent process to sign & date the logs by the RN/DON. The DON stated the DON understood the importance of CS accountability to ensure each CS dose was accounted for until disposed throughout the process of CS accountability. The DON stated it was important to verify and sign these logs to prevent medication diversions and accidental exposure of harmful substances to residents.

During a review of the policy and procedures (P&P), titled Controlled Substances, last reviewed 12/4/2024,

the P&P indicated that The facility complies with all laws, regulations and other requirements related to handling, storage, disposal, and documentation of CM.

10. Upon Administration

a. The nurse administering the mediation is responsible for recording:

(2) name, strength, and dose of the medication

(3) time of administration

(4) method of administration

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 (5) quantity of the medication remaining

Level of Harm - Minimal harm or (6) signature of nurse administering medication. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43455 potential for actual harm Based on observation, interview, and record review, the facility failed to ensure that its medication error rate Residents Affected - Some was less than five (5) percent (%). Four (4) medication errors out of 27 total opportunities contributed to an overall medication error rate of 14.81% affecting two (2) of seven (7) residents observed for medication administration (Resident 71 and 88.) The medication errors were as follows:

1. Resident 71 did not receive psyllium husk powder (a medication used to form a bulky stook to pass easily) as ordered by Resident 71's physician and received a dose of oyster shell calcium (a medication used as a dietary supplement to provide support to bones) that was different than the one ordered by Resident 71's physician.

2. Resident 88 received a form of multivitamin (a medication used as a dietary supplement to provide essential vitamins, minerals, and other nutritional elements) and calcium with vitamin D (a combination medication used as a dietary supplement to provide support to bones) that was different than the one ordered by Resident 88's physician.

These failures had the potential to result in Residents 71 and 88 to experience medication adverse effects (unwanted, uncomfortable, or dangerous effects that a medication may have) and the potential to result in Residents 71's and 88's health and well-being to be negatively impacted.

Findings:

1. During a review of Resident 71's Admission Record (a document containing demographic and diagnostic information,) dated 12/31/24, the Admission Record indicated Resident 71 was originally admitted to the facility on [DATE REDACTED] with a diagnosis including difficulty in walking, reduced mobility, history of falling, gastrointestinal (related to intestines/bowel) hemorrhage (bleeding) and diverticulitis (inflammation) of large intestine.

During a review of Resident 71's Order Summary Report (a report listing the physician order for the resident,) dated 12/31/24, the Order Summary Report indicated Resident 71 was prescribed oyster shell calcium 500 milligrams (mg - a unit of measure for mass) with vitamin D five (5) micrograms (mcg - a unit of measure for mass) to give one (1) tablet by mouth once a day for supplement, starting 11/28/2024, and psyllium husk powder (a medication used for constipation) to give one (1) packet by mouth once a day for bowel management, starting 12/2/2024.

During a review of Resident 71's Medication Administration Record ([MAR] - a record of mediations administered to residents,) for December 2024, the MAR indicated Resident 71 was prescribed oyster shell calcium 500 mg with vitamin D 5 mcg to give one (1) tablet by mouth once a day for supplement, and psyllium husk powder to give one (1) packet by mouth once a day for bowel management, at 9 a.m.

During an observation on 12/31/2024, at 9:10 a.m., in medication cart 4, Licensed Vocational Nurse (LVN) 1 administered oyster shell calcium 500 mg tablet and polyethylene glycol solution to Resident 71. Resident 71 swallowed the oyster shell calcium tablet with the polyethylene glycol solution.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 During an interview on 12/31/2024, at 10:58 a.m., with LVN 1, LVN 1 stated that LVN 1 administered oyster shell calcium 500 mg with polyethylene glycol solution to Resident 71, during the morning medication Level of Harm - Minimal harm or administration at 9:10 a.m. LVN 1 stated that LVN 1 failed to administer calcium 500 mg with vitamin D 5 potential for actual harm mcg tablet and psyllium husk powder to Resident 71, as prescribed by Resident 71's physician. LVN 1 stated not receiving vitamin D can harm Resident 71 by not only decreasing the absorption of the calcium but also Residents Affected - Some leading to osteoporosis (a condition where the bones become brittle and fragile from low calcium or vitamin D levels) especially in those after the age 50, fragile bones and breakage of bones, and not receiving psyllium husk powder would not help with passing stool easily. LVN 1 stated these were considered medication errors. LVN 1 stated that LVN 1 will notify the physician for not administering oyster shell calcium with vitamin D and not administering psyllium husk powder to Resident 71 and obtain additional orders as necessary.

2. During a review of Resident 88's Admission Record, dated 12/31/2024, the Admission Record indicated

the resident was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnoses including fracture (breakage) of left femur (thigh bone) and iron deficiency.

During a review of Resident 88's Order Summary Report, dated 12/31/2024, the Order Summary Report indicated Resident 88 was prescribed multivitamin tablet to give one (1) tablet by mouth once a day, and calcium carbonate-vitamin D with minerals 600-400 mg-unit tablet to give one (1) tablet by mouth once a day for supplement, starting 12/4/2023.

During a review of Resident 88's MAR for December 2024, the MAR indicated Resident 88 was prescribed multivitamin tablet to give one (1) tablet by mouth once a day at 9 a.m., and calcium carbonate-vitamin D with minerals 600-400 mg-unit tablet to give one (1) tablet by mouth once a day for supplement at 9 a.m.an 5 p.m.

During an observation on 12/31/2024, at 9:14 a.m., in medication cart 4, LVN 1 administered calcium 600 mg with vitamin D 5 mcg tablet and multivitamin with minerals tablet orally to Resident 88. Resident 88 swallowed the calcium with vitamin D tablet and multivitamin with mineral tablet with full glass of water.

During an interview on 12/31/2024, at 10:58 a.m., with LVN 1, LVN 1 stated LVN 1 administered multivitamin with minerals tablet and calcium 600 mg with vitamin D 5 mcg tablet to Resident 88, during the morning medication administration at 9:14 a.m. LVN 1 stated LVN 1 failed to administer the correct multivitamin and correct dose of calcium with vitamin D to Resident 88, as prescribed by Resident 88's physician. LVN 1 stated that LVN 1 also failed to clarify the medication order for the dose of vitamin D as it was unclear. LVN 1 stated administering multivitamin with minerals to Resident 88 may not be beneficial to their health and may cause adverse effects, and that administering the wrong dose of calcium with vitamin D can harm the resident by causing low vitamin D levels, lead to fragile bones and potentially cause breakage of bones. LVN 1 stated these were considered medication errors. LVN 1 stated LVN 1 will notify the physician for administering the incorrect multivitamin and calcium with vitamin D to Resident 88, clarify the calcium with vitamin D order, and obtain additional orders as necessary.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 During an interview on 12/31/2024, at 2:28 p.m., with the Director of Nursing (DON,) the DON stated that LVN 1 failed to administer medications as ordered by the physician to Resident 71 and 88 and should follow Level of Harm - Minimal harm or facility medication administration guidelines to ensure physician orders are followed and the right potential for actual harm medications and doses are administered. The DON stated that LVN 1 failed to administer calcium 500 mg with vitamin D 5 mcg and psyllium husk powder to Resident 71 and failed to administer the correct Residents Affected - Some multivitamin and correct dose of calcium with vitamin D to Resident 88, as prescribed by Resident 71's and 88's physician. The DON stated the order for calcium with vitamin D for Resident 88 was unclear and confusing and did not indicate to administer a dose of vitamin D 5 mcg and needed to be clarified. The DON stated these were considered medication errors. The DON stated vitamin D was necessary for maintaining levels of vitamin D that was adequate for bone strength, preventing brittle bones and breakage of bones, and

the psyllium husk was needed to pass stool easily, and administering incorrect medications or doses to Residents 71 and 88 will not help treat the resident's condition and possibly worsen it.

During a review of the facility's policy and procedures (P&P), titled Procedures for All Medications, last reviewed 12/4/24, the P&P indicated To administer medications in a safe and effective manner.

F. Read medication label before administering.

During a review of the facility's P&P, titled Medication Administration - General Guidelines, last reviewed 12/4/24, the P&P indicated that Medications are administered as prescribed .Personnel authorized to administer medications do so only after they have familiarized themselves with the medication.

A. Preparation

1. Prior to administration, the medication and dosage schedule on the resident's MAR is compared with the medication label. If the label and MAR are different .the physician's orders are checked for the correct dosage schedule.

B. Administration

2. Medications are administered in accordance with written orders of the attending physician.

During a review of the facility's P&P, titled Medication Errors, last reviewed 12/4/24, the P&P indicated: Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specifications (not recommendations) regarding the preparation and administration of the medication or biological; or accepted professional standards and principles which apply to professional providing services. Types of errors include: medication omission; wrong patient, dose, route, rate, or time; incorrect administration; and/or incorrect administration technique. Medication Error Rate is determined by calculating the percentage of errors observed during a medication administration observation. The numerator is the total number of errors observed, both significant and non-significant. The denominator consists of the total number of observations or 'opportunities for error' and include all doses observed being administered, plus the doses ordered but not administered.

2. The Center shall ensure medications will be administered as follows:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 1.1 According to prescriber's orders

Level of Harm - Minimal harm or 3. The Center will consider factors indicating errors in medication administration including, but not limited to: potential for actual harm 2.1 Medication administered not in accordance with prescriber's order. Examples include, but are not limited Residents Affected - Some to:

2.1.1 Incorrect dose

2.1.2 Incorrect medication

5. To prevent medication errors and ensure safe medication administration, nurses should verify the following information:

5.1 Right medication, dose, route, and time of administration.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376 potential for actual harm Based on observation, interview and record review, the facility failed to ensure residents were free of any Residents Affected - Some significant medication errors (means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order, manufacturer's specifications, and accepted professional standards) by failing to:

1. Rotate (a method to ensure repeated injections are not administered in the same area) a resident's subcutaneous ([SQ] - beneath the skin) insulin (a hormone that lowers the level of glucose [a type of sugar]

in the blood) and heparin (an anticoagulant [blood thinner] that stops the blood from forming blood clots or making them bigger) administration sites for two (2) of five (5) sampled residents (Resident 29 and 402) investigated under unnecessary medications.

2. Rotate insulin SQ administration sites for two (2) of four (4) sampled residents (Resident 42 and 134) investigated under insulin.

3. Ensure 10 doses of expired insulin (a medication used to control high blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) was not administered by five (5) different licensed nursing staff to Resident 63 from one (1) of two (2) inspected medications carts (Medication cart 4.) As a result, Resident 63 received a total of 10 doses of expired insulin from [DATE REDACTED] to [DATE REDACTED] which was not in accordance with manufacturer guidelines, standards of practice and facility policy and procedures.

4. Ensure 3 doses of expired insulin Lantus was not administered by two (2) different licensed nursing staff to Resident 71 from one (1) of two (2) inspected medications carts (Medication cart 4.) As a result, Resident 71 received a total of 3 doses of expired insulin from [DATE REDACTED] to [DATE REDACTED] which was not in accordance with manufacturer guidelines, standards of practice and facility policy and procedures.

5. Ensure 9 doses of expired insulin Humulin ,d+[DATE REDACTED] (brand name combination insulin for isophane human and regular human; an intermediate-acting insulin combined with rapid onset regular insulin) was not administered by four (4) different licensed nursing staff to Resident 141 from one (1) of two (2) inspected medications carts (Medication cart 4.) As a result, Resident 141 received a total of 9 doses of expired insulin from [DATE REDACTED] to [DATE REDACTED] which was not in accordance with manufacturer guidelines, standards of practice and facility policy and procedures.

6. Ensure the timely administering of Resident 495's Tacrolimus Oral capsules (medication to prevent transplant rejection) in the morning scheduled at 8 a.m. and in the evening scheduled at 8 p.m. during a sample screening.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 These deficient practices had the potential to cause Resident 29, 42, 63, 71, 134, 141, 402 and 495 to experience adverse effects (unwanted, unintended results) and serious health complications due to same Level of Harm - Minimal harm or site SQ administration of insulin and heparin such as lipodystrophy (abnormal distribution of fat), cutaneous potential for actual harm amyloidosis (is a condition in which clumps of abnormal proteins called amyloids build up in the skin) and abnormal bruising, potential for kidney transplant organ rejection (occurs when the body's immune system Residents Affected - Some attacks the transplanted kidney, treating it as a foreign object), and improper management of blood sugar resulting in a possible coma, hospitalization and/or death.

Cross Reference

F-F760

Findings:

1. During a review of Resident 29's Admission Record, the Admission Record indicated the facility admitted

the resident on 5/3/2024, and readmitted the resident on 12/25/2024, with diagnoses including type 2 diabetes mellitus (DM 2 or DM, a disorder characterized by difficulty in blood sugar control and poor wound healing) with foot ulcer (open sores or lesions that will not heal or that return over a long period of time), acute kidney failure (a condition where the kidneys suddenly stop working properly and cannot filter waste from the blood), and acute osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of left ankle and foot.

During a review of Resident 29's History and Physical (H&P), dated 5/5/2024, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated 10/30/2024,

the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (being able to perform mental processes like thinking, paying attention, learning, and remembering). The MDS also indicated the resident was on insulin injections and was taking a high-risk drug class hypoglycemic (medication that lowers blood sugar) and anticoagulant medications.

During a review of Resident 29's Order Summary Report, the Order Summary Report indicated an order for:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 12/25/2024 Heparin Sodium (porcine) Injection Solution 5000 unit (an amount approximately equivalent to 0. 002 milligrams [mg, a unit of weight] of pure heparin)/milliliters (ml, a unit of volume) (Heparin Sodium Level of Harm - Minimal harm or [Porcine]). Inject 1 ml subcutaneously every 8 hours for blood clot prophylaxis (PPX, an attempt to prevent potential for actual harm disease).

Residents Affected - Some 12/25/2024 Insulin Aspart Injection Solution 100 unit/ml (Insulin Aspart). Inject as per sliding scale (the increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal): if 140 - 199 = 2 units blood sugar (BS); less than 140 = 0 unit.; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350 - 400 = 12 units BS: greater than 400= units call physician., subcutaneously before meals and at bedtime for DM.

12/11/2024 Insulin Glargine Subcutaneous Solution 100 unit/ml (Insulin Glargine). Inject 50 unit subcutaneously at bedtime for DM.

During a review of Resident 29's Location of Administration of insulin and heparin, dated between 11/2024 to 1/2025, the Location of Administration indicated:

-Heparin Sodium (Porcine) Injection Solution 5000 unit/ml was administered subcutaneously on:

12/27/2024 at 9:45 p.m. on the Abdomen - Left Lower Quadrant (LLQ)

12/28/2024 at 6:28 a.m. on the Abdomen - LLQ

12/28/2024 at 9:49 a.m. on the Abdomen - Right Upper Quadrant (RUQ)

12/29/2024 at 5:52 a.m. on the Abdomen - RUQ

12/29/2024 at 1:33 p.m. on the Abdomen- Right Lower Quadrant (RLQ)

12/29/2024 at 9:36 p.m. on the Abdomen- RLQ

12/30/2024 at 2:57 p.m. on the Abdomen- LLQ

12/30/2024 at 9:02 p.m. on the Abdomen- LLQ

- Insulin Aspart Injection Solution 100 unit/ml was administered subcutaneously on:

12/1/2024 at 11:33 a.m. on the Arm - left

12/1/2024 at 4:46 p.m. on the Arm - left

12/3/2024 at 11:52 a.m. on the Arm - left

12/3/2024 at 4:38 p.m. on the Arm - left

12/4/2024 at 11:48 a.m. on the Arm - left

12/4/2024 at 5:09 p.m. on the Arm - left

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 12/5/2024 at 12:23 p.m. on the Arm - left

Level of Harm - Minimal harm or 12/5/2024 at 5:15 p.m. on the Arm - left potential for actual harm 12/6/2024 at 6:22 a.m. on the Arm - right Residents Affected - Some 12/6/2024 at 2:05 a.m. on the Arm - right

12/7/2024 at 4:47 p.m. on the Arm - left

12/7/2024 at 9:01 p.m. on the Arm - left

12/8/2024 at 11:48 a.m. on the Arm - left

12/8/2024 at 5:09 p.m. on the Arm - left

12/9/2024 at 12:10 p.m. on the Arm - left

12/9/2024 at 4:50 p.m. on the Arm - left

12/9/2024 at 9:30 p.m. on the Arm - left

12/10/2024 at 6:06 a.m. on the Arm - right

12/10/2024 at 11:59 a.m. on the Arm - right

12/11/2024 at 5:48 a.m. on the Arm - left

12/11/2024 at 11:30 a.m. on the Arm - left

12/11/2024 at 4:59 p.m. on the Arm - right

12/11/2024 at 9:37 p.m. on the Arm - right

12/12/2024 at 6:02 a.m. on the Arm - left

12/12/2024 at 11:34 a.m. on the Arm - left

12/12/2024 at 4:52 p.m. on the Arm - left

12/12/2024 at 8:56 p.m. on the Arm - left

12/14/2024 at 4:55 p.m. on the Arm - right

12/14/2024 at 8:39 p.m. on the Arm - right

12/15/2024 at 11:48 a.m. on the Arm - left

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 12/15/2024 at 4:44 p.m. on the Arm - left

Level of Harm - Minimal harm or 12/16/2024 at 11:53 a.m. on the Arm - right potential for actual harm 12/16/2024 at 4:49 p.m. on the Arm - right Residents Affected - Some 12/16/2024 at 8:42 p.m. on the Arm - left

12/17/2024 at 5:56 a.m. on the Arm - left

12/17/2024 at 5:31 p.m. on the Abdomen - RUQ

12/17/2024 at 9:02 p.m. on the Abdomen - RUQ

12/18/2024 at 7:46 p.m. on the Abdomen - LLQ

12/18/2024 at 11:48 p.m. on the Abdomen - LLQ

12/20/2024 at 3:58 p.m. on the Arm - right

12/20/2024 at 5:08 p.m. on the Arm - right

12/20/2024 at 12:07 a.m. on the Arm - right

12/22/2024 at 5:56 a.m. on the Arm - left

12/22/2024 at 11:39 a.m. on the Arm - left

12/27/2024 at 12:04 p.m. on the Arm - left

12/27/2024 at 4:44 p.m. on the Arm - left

12/27/2024 at 8:33 p.m. on the Arm - left

During a review of Resident 29's Care Plan (CP) regarding Resident 29 had a diagnosis of diabetes and was insulin dependent (the pancreas makes little or no insulin), last revised on 5/4/2024, the CP indicated interventions to administer hypoglycemic medications as ordered and anticoagulant to be given as ordered.

During a concurrent interview and record review, on 1/3/2024, at 9:03 a.m., with Registered Nurse (RN) 2, Resident 29's Order Summary Report, Location of Administration of insulin and heparin from 11/2024 to 1/2025, and care plans were reviewed. RN 2 stated there were multiple instances that the subcutaneous administration sites of insulin and heparin were not rotated by the licensed staff between 11/2024 to 1/2025. RN 2 stated heparin and insulin administration sites should be rotated to prevent lipodystrophy and bruising

on the frequented site of administration on the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During an interview on 1/3/2024, at 2:48 p.m., with the Director of Nursing (DON), the DON stated the staff should rotate insulin and heparin administration sites to prevent lipodystrophy, malabsorption of the Level of Harm - Minimal harm or medication, and to prevent bruising on the frequented sites of administration on the resident. potential for actual harm

During a review of the facility's policy and procedure (P&P) titled Insulin Administration, last reviewed on Residents Affected - Some 12/4/2024, the P&P indicated to select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh upper arm).

During a review of the facility-provided Highlights of Prescribing Information for Heparin Sodium Injection, for intravenous or subcutaneous use, with initial U.S. approval in 1939, the highlights of prescribing information indicated a different site should be used for each injection to prevent the development of massive hematoma.

During a review of the facility-provided Highlights of Prescribing Information for Novolog (insulin aspart) injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

During a review of the facility-provided Highlights of Prescribing Information for Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

2. During a review of Resident 42's Admission Record, the Admission Record indicated the facility admitted

the resident on 3/17/2022, and readmitted the resident on 11/14/2023, with diagnoses including type 2 diabetes mellitus with hyperglycemia (high blood sugar), and cellulitis (a skin infection that causes swelling and redness) of left lower limb.

During a review of Resident 42's H&P, dated 11/7/2024, the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 42's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was on insulin injections and was taking a high-risk drug class hypoglycemic medication.

During a review of Resident 42's Order Summary Report, the Order Summary Report indicated an order for:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 12/3/2024 Insulin Regular Human Solution. Inject as per sliding scale: if 71 - 150 = 0 BS less than (<) 70 Initiate hypoglycemic protocol (steps to increase blood sugar level) and call MD; 151 - 200 = 6; 201 - 250 = Level of Harm - Minimal harm or 8; 251 - 300 = 12; 301 - 350 = 14; 351 - 400 = 16 400+, give 16 units, recheck in 30 minutes, and call MD, potential for actual harm subcutaneously before meals and at bedtime for DM If BS<70, implement hypoglycemic protocol. If BS greater than (>)400, give 16 units and call MD. Give 30 minutes before a meal. Residents Affected - Some 11/21/2024 Insulin Glargine Solution 100 UNIT/ML. Inject 24 unit subcutaneously one time a day for DM If BS<70, implement hypoglycemic protocol. If BS>401, call MD.

During a review of Resident 42's Location of Administration of Insulin for 11/2024 to 1/2025, the Location of Administration indicated:

-Insulin Glargine Solution 100 unit/ml was administered on:

12/4/2024 at 9:09 p.m. on the Abdomen - LLQ

12/5/2024 at 9:18 p.m. on the Abdomen - LLQ

12/8/2024 at 9:11 p.m. on the Abdomen - RLQ

12/9/2024 at 9:44 p.m. on the Abdomen - RLQ

12/22/2024 at 9:58 p.m. on the Abdomen - RLQ

12/23/2024 at 9:44 p.m. on the Abdomen - RLQ

12/25/2024 at 10 p.m. on the Abdomen - LLQ

12/26/2024 at 8:40 p.m. on the Abdomen - LLQ

12/27/2024 at 9:19 p.m. on the Abdomen - LLQ

12/28/2024 at 9:57 p.m. on the Abdomen - LLQ

12/29/2024 at 9:57 p.m. on the Abdomen - RLQ

12/30/2024 at 9:22 p.m. on the Abdomen - RLQ

-Insulin Regular Human Solution was administered on:

12/01/2024 at 11:43 a.m. on the Abdomen - Left Upper Quadrant (LUQ)

12/01/2024 at 4:57 p.m. on the Abdomen - LUQ

12/04/2024 at 9:08 p.m. on the Abdomen - LLQ

12/05/2024 at 9:18 p.m. on the Abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 12/09/2024 at 4:57 p.m. on the Abdomen - RLQ

Level of Harm - Minimal harm or 12/09/2024 at 9:38 p.m. on the Abdomen - RLQ potential for actual harm 12/14/2024 at 5:26 p.m. on the Abdomen - RUQ Residents Affected - Some 12/14/2024 at 9:59 p.m. on the Abdomen - RUQ

12/25/2024 at 9:59 p.m. on the Abdomen - LLQ

12/25/2024 at 10 p.m. on the Abdomen - LLQ

12/26/2024 at 4:32 p.m. on the Abdomen - LLQ

12/28/2024 at 5:29 a.m. on the Abdomen - LLQ

12/28/2024 at 4:35 p.m. on the Abdomen - LLQ

12/30/2024 at 5:51 a.m. on the Abdomen - LLQ

12/30/2024 at 4:47 p.m. on the Abdomen - LLQ

During a review of Resident 42's Care Plan regarding Resident 42 had a diagnosis of diabetes and was insulin dependent, last revised on 3/18/2022, the CP indicated interventions to administer hypoglycemic medications as ordered.

During a concurrent interview and record review, on 1/2/2025, at 2:27 p.m., with Licensed Vocational Nurse (LVN) 4, Resident 42's Order Summary Report, Location of Administration Report of insulin from 11/2024 to 1/2025, and Care Plans were reviewed. LVN 4 stated there were multiple instances that the administration sites of insulin were not rotated for the month of 11/2024 to 1/2025. LVN 4 stated insulin administration sites should be rotated to avoid bruises, for proper absorption of the insulin, and to avoid lipodystrophy on the resident.

During an interview on 1/3/2025, at 9:03 a.m., with RN 2, RN 2 stated insulin administration sites should be rotated to prevent lipodystrophy and bruising on the frequented site of administration on the resident.

During an interview on 1/3/2024, at 2:48 p.m., with the DON, the DON stated the staff should rotate insulin and heparin administration sites to prevent lipodystrophy, malabsorption of the medication, and to prevent bruising on the frequented sites of administration.

During a review of the facility's P&P, titled Insulin Administration, last reviewed on 12/4/2024, the P&P indicated to select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh upper arm).

Level of Harm - Minimal harm or During a review of the facility-provided Highlights of Prescribing Information for Humulin R (insulin human) potential for actual harm injection, for subcutaneous or intravenous use, with initial U.S. approval in 1982, the highlights of prescribing information indicated to inject subcutaneously 30 minutes before a meal into the thigh, upper arm, abdomen, Residents Affected - Some or buttocks. Rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

During a review of the facility-provided Highlights of Prescribing Information for Novolog (insulin aspart) injection, for subcutaneous or intravenous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites within the same region from one injection to the next to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

During a review of the facility- provided Highlights of Prescribing Information for Lantus (insulin glargine) injection, for subcutaneous use, with initial U.S. approval in 2000, the highlights of prescribing information indicated to rotate injection sites to reduce risk of lipodystrophy and localized cutaneous amyloidosis.

43988

3. During a review of Resident 402's Admission Record, the Admission Record indicated the facility admitted

the resident on 12/11/2024, with diagnoses including DM 2, abnormalities of gait and mobility, and generalized muscle weakness.

During a review of Resident 402's MDS, dated [DATE REDACTED], the MDS indicated Resident 49 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance with toileting, bathing, and lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 402 had a diagnosis of DM 2 and received insulin and anticoagulant.

During a review of Resident 402's H&P, dated 12/19/2024, the H&P indicated Resident 402 had the capacity to understand and make decisions.

During a review of Resident 402's Order Summary Report, the Order Summary Report indicated the following physician's order:

- 12/12/2024: Insulin lispro (a fast-acting insulin) injection solution 100 unit per milliliter (unit/ml - a unit of measurement). Inject as per sliding scale (the increasing administration of the pre-meal insulin dose based

on the blood sugar level before the meal): if 70 - 150 = 0 If blood sugar (BS) is less than (<) 70, Initiate (start) hypoglycemic (low blood sugar level) protocol (procedure to be followed); 151 - 199 = 2 units; 200 - 249 = 3 units; 250 - 299 = 4 units; 300 - 349 = 5 units; 350 - 399 = 6 units; If BS is equal (=) or more than (>) 400, give eight (8) units and call physician (MD), subcutaneously before meals and at bedtime for DM.

- 12/11/2024: Heparin sodium porcine injection solution 5000 unit/ml. Inject 5000 unit subcutaneously every 8 hours for clot prevention. Monitor for bleeding.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During a concurrent interview and record review, on 01/3/25, at 9:03 a.m., reviewed Resident 402's Medication Administration Record (MAR - a daily documentation records used by a licensed nurse to Level of Harm - Minimal harm or document medications and treatments given to a resident) from for 12/2024 with Registered Nurse 2 (RN 2), potential for actual harm RN 2 verified the MAR indicated the insulin lispro, and heparin were administered as follows:

Residents Affected - Some - Heparin sodium porcine injection solution 5000 unit/ml:

12/12/24 1:17 p.m. subcutaneously Arm - right

12/14/24 5:24 a.m. subcutaneously Arm - right

12/15/24 1:24 p.m. subcutaneously Arm - left

12/15/24 10:38 p.m. subcutaneously Arm - left

12/19/24 1:22 p.m. subcutaneously Arm - left

12/19/24 9:18 p.m. subcutaneously Arm - left

12/22/24 1:32 p.m. subcutaneously Abdomen - right lower quadrant (RLQ)

12/22/24 11:18 p.m. subcutaneously Abdomen - RLQ

12/26/24 2:14 p.m. subcutaneously Abdomen - left lower quadrant (LLQ)

12/27/24 5:55 a.m. subcutaneously Abdomen - LLQ

12/27/24 1:12 p.m. subcutaneously Abdomen - LLQ

12/29/24 6:23 a.m. subcutaneously Abdomen - LLQ

12/29/24 12:57 p.m. subcutaneously Abdomen - LLQ

12/29/24 9:44 p.m. subcutaneously Abdomen - LLQ

- Insulin lispro injection solution 100 unit/ml:

12/22/24 6:25 a.m. subcutaneously Abdomen - LLQ

12/24/24 9:53 a.m. subcutaneously Abdomen - LLQ

12/26/24 12:04 p.m. subcutaneously Abdomen - LLQ

12/27/24 5:19 p.m. subcutaneously Abdomen - LLQ

12/30/24 8:32 p.m. subcutaneously Abdomen - LLQ

12/31/24 8:59 p.m. subcutaneously Abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 RN 2 stated the standard of practice is to rotate administration site of heparin and insulin to prevent development of lipodystrophy and bruising. RN 2 stated the licensed nurses should have rotated the insulin Level of Harm - Minimal harm or and heparin sites for Resident 402 as it placed the resident at risk for complications of not rotating potential for actual harm administration sites such as trauma, bruising, and development of lipodystrophy.

Residents Affected - Some During an interview on 1/3/2024 at 2:49 p.m., the DON stated the standards of practice regarding administration of medication subcutaneously is to rotate the administration sites to prevent bruising, pain, lipodystrophy, and amyloidosis. The DON stated Resident 402's administration sites for heparin and insulin should have been rotated by the licensed nurses as it placed the resident at risk for trauma, bruising, lipodystrophy, and amyloidosis to the administration site.

During a review of the facility's P&P titled, Insulin Administration, last reviewed on 12/4/2024, the P&P indicated to select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately 2 inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh upper arm).

During a review of facility-provided manufacturer's guideline for heparin sodium injection last revised 9/2019,

the manufacturer's guideline indicated recommended adult dosages for deep subcutaneous injection should use a different site for each injection to prevent the development of massive hematoma. The manufacturer's guideline further indicated injection site irritation and bleeding are some of the most common adverse reactions.

During a review of the facility-provided manufacturer's guideline for insulin lispro, last revised 8/2023, the manufacturer's guideline indicated rotate injection sites to reduce risk for lipodystrophy and localized cutaneous amyloidosis. The manufacturer's guideline further indicated adverse reactions associated with insulin lispro include injection site reactions, lipodystrophy, itchiness, and rash.

4. During a review of Resident 134's Admission Record, the Admission Record indicated the facility originally admitted the resident on 11/6/2024 and readmitted in the facility on 12/30/2024, with diagnoses including DM 2, unsteadiness on feet, and generalized muscle weakness.

During a review of Resident 134's MDS, dated [DATE REDACTED], the MDS indicated Resident 134 had an intact cognition (mental action or process of acquiring knowledge and understanding) and was independent with eating; required set-up or clean-up assistance with oral hygiene; supervision with personal hygiene; substantial/maximal assistance with bathing, and lower body dressing; partial/moderate assistance with all other ADLs. The MDS indicated Resident 134 had a diagnosis of DM 2 and received insulin.

During a review of Resident 134's H&P, dated 11/23/2024, the H&P indicated Resident 134 had the capacity to understand and make decisions.

During a review of Resident 134's Order Summary Report, the Order Summary Report indicated the following physician's order:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 - 11/7/2024 to 12/2/2024: Insulin lispro injection solution 100 unit/ml. Inject (seven) 7 units subcutaneously three times a day for DM with meals. Level of Harm - Minimal harm or potential for actual harm - 11/7/2024 to 12/19/2024: Insulin glargine (a fast-acting insulin) subcutaneous solution 100 unit/ml. Inject 15 units subcutaneously one time a day for DM. Hold if BS < 110. Residents Affected - Some - 12/3/2024 to 12/19/2024: Insulin lispro injection solution 100 unit/ml. Inject 7 units subcutaneously with meals for DM.

- 12/20/2024 to 12/30/2024: Insulin glargine subcutaneous solution 100 unit/ml. Inject 15 units subcutaneously one time a day for DM. Hold if BS < 110.

- 12/20/2024 to 12/30/2024: Insulin lispro injection solution 100 unit/ml. Inject 7 units subcutaneously with meals for DM.

- 12/30/2024 to Current:

Insulin glargine subcutaneous Solution 100 unit/ml. Inject 15 units subcutaneously at bedtime for DM. Hold for BS < 110.

Insulin lispro injection solution 100 unit/ml. Inject 7 units subcutaneously three times a day for DM with meals.

Insulin lispro injection solution 100 unit/ml. Inject as per sliding scale subcutaneously before meals and at bedtime for DM: if 60 - 150 = 0 unit; 151 - 200 = 4 units; 201 - 250 = 6 units; 251 - 300 = 8 units; 301 - 350 = 12 units; 351 - 400 = 14 units; =/> 401 = 16 units and call MD.

During a concurrent interview and record review, on 01/3/25, at 9:03 a.m., with RN 2, Resident 134's MAR, dated between 11/2024 to 12/2024, RN 2 verified the MAR indicated the insulin lispro and insulin glargine were administered as follows:

- Insulin lispro injection solution 100 unit/ml:

11/07/24 4:59 p.m. subcutaneously Abdomen - right upper quadrant (RUQ)

11/08/24 8:52 a.m. subcutaneously Abdomen - RUQ

11/11/24 12:25 p.m. subcutaneously Abdomen - RUQ

11/11/24 3:50 p.m. subcutaneously Abdomen - RUQ

11/21/24 4:52 p.m. subcutaneously Abdomen - left lower quadrant (LLQ)

11/22/24 8:07 a.m. subcutaneously Abdomen - LLQ

11/22/24 1:16 p.m. subcutaneously Abdomen - LLQ

11/24/24 5:39 p.m. subcutaneously Abdomen - left upper quadrant (LUQ)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 11/25/24 10:36 a.m. subcutaneously Abdomen - LUQ

Level of Harm - Minimal harm or 11/26/24 8:35 a.m. subcutaneously Abdomen - LLQ potential for actual harm 11/26/24 11:56 a.m. subcutaneously Abdomen - LLQ Residents Affected - Some 11/27/24 4:57 p.m. subcutaneously Abdomen - LUQ

11/28/24 8:44 a.m. subcutaneously Abdomen - LUQ

11/30/24 8:18 a.m. subcutaneously Abdomen - right lower quadrant (RLQ)

11/30/24 12:15 p.m. subcutaneously Abdomen - RLQ

12/01/24 12:28 p.m. subcutaneously Abdomen - RUQ

12/02/24 8:42 a.m. subcutaneously Abdomen - RUQ

12/11/24 4:52 p.m. subcutaneously Abdomen - RLQ

12/12/24 11:07 a.m. subcutaneously Abdomen - RLQ

12/12/24 2:25 p.m. subcutaneously Abdomen - RLQ

12/13/24 8:47 a.m. subcutaneously Abdomen - RUQ

12/14/24 2:16 a.m. subcutaneously Abdomen - RUQ

12/14/24 5:14 p.m. subcutaneously Abdomen - LUQ

12/15/24 8:19 a.m. subcutaneously Abdomen - LUQ

12/15/24 12:25 p.m. subcutaneously Abdomen - LLQ

12/15/24 4:26 p.m. subcutaneously Abdomen - LLQ

12/22/24 11:34 a.m. subcutaneously Abdomen - RUQ

12/22/24 4:12 p.m. subcutaneously Abdomen - RUQ

12/31/24 11:48 a.m. subcutaneously Abdomen - LLQ

12/31/24 4:59 p.m. subcutaneously Abdomen - LLQ

- Insulin glargine subcutaneous solution 100 unit/ml:

11/13/24 8:22 a.m. subcutaneously Abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 11/14/24 9:14 a.m. subcutaneously Abdomen - LLQ

Level of Harm - Minimal harm or 11/16/24 8:24 a.m. subcutaneously Abdomen - RLQ potential for actual harm 11/17/24 9:44 a.m. subcutaneously Abdomen - RLQ Residents Affected - Some 11/20/24 9:40 a.m. subcutaneously Abdomen - LLQ

11/21/248:30 a.m. subcutaneously Abdomen - LLQ

11/28/24 8:46 a.m. subcutaneously Abdomen - LLQ

11/29/24 9:25 a.m. subcutaneously Abdomen - LLQ

11/30/24 10:05 a.m. subcutaneously Abdomen - LLQ

12/04/24 9:42 a.m. subcutaneously Abdomen - LLQ

12/05/24 10:27 a.m. subcutaneously Abdomen - LLQ

12/11/24 8:01 a.m. subcutaneously Abdomen - LLQ

12/12/24 11:09 a.m. subcutaneously Abdomen - LLQ

12/14/24 9:27 a.m. subcutaneously Abdomen - RLQ

12/15/24 8:23 a.m. subcutaneously Abdomen - RLQ

RN 2 stated the standard of practice is to rotate administration site insulin to prevent development of lipodystrophy and bruising. RN 2 stated the licensed nurses should have rotated the insulin administration sites for Resident 134 as it placed the resident at risk for complications of not rotating administration sites such as trauma, bruising, and development of lipodystrophy.

During an interview on 1/3/2024, at 2:49 p.m., the DON stated the standards of practice regarding administration of medication subcutaneously is to rotate the administration sites to prevent bruising, pain, lipodystrophy, and amyloidosis. The DON stated Resident 134's administration sites for insulin should have been rotated by the licensed nurses as it placed the resident at risk for trauma, bruising, lipodystrophy, and amyloidosis to the administration site.

During a review of the facility's P&P titled, Insulin Administration, last reviewed on 12/4/2024, the P&P indicated to select an injection site.

a. Insulin may be injected into the subcutaneous tissue of the upper arm, and the anterior or lateral areas of

the thighs and abdomen. Avoid the area approximately two inches around the navel.

b. Injection sites should be rotated, preferably within the same general area (abdomen, thigh upper arm).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 During a review of the facility-provided manufacturer's guideline for insulin lispro, last revised 8/2023, the manufacturer's guideline indicated rotate injection sites to reduce risk for lipodystrophy and localized Level of Harm - Minimal harm or cutaneous amyloidosis. The manufacturer's guideline further indicated adverse reactions associated with potential for actual harm insulin lispro include injection site reactions, lipodystrophy, itchiness, and rash.

Residents Affected - Some During a review of the facility-provided manufacturer's guideline for insulin glargine, last revised 6/2022, the manufacturer's guideline indicated to rotate injection sites to reduce the risk of lipodystrophy and localized cutaneious amyloidosis. The manufacturer's guideline further indicated a few of the adverse reactions associated with insulin glargine include injection site reactions, lipodystrophy, rash, and edema (swelling).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 44376

Residents Affected - Some Based on observation, interview, and record review, the facility failed to ensure the resident environment was free of accident hazards for six of 6 sampled residents (Residents 495, 61, 402, 11, 52, and 137) investigated under accidents by failing to ensure:

1. Resident 495's tube of triamcinolone acetonide cream 0.1 percent (helps relieve redness, itching, swelling, or other discomfort caused by skin conditions), travatan (travoprost ophthalmic solution) 0.004 % (to reduce pressure in the eyes with glaucoma [a common eye condition where the optic nerve, which connects the eye to the brain, becomes damaged] and high pressure in the eyes), bisacodyl 5 milligrams (mg, a unit of weight) tablet (used to treat constipation), bromonidine tartrate ophthalmic Solution 0.2 % (used to lower pressure in

the eyes), and dorzolamide HCl and timolol maleate ophthalmic solution, 2 %/0.5 % (used to treat glaucoma) were not left at the bedside of the resident.

This failure increased the risks of harm to the resident due to the possibility of omitting the dose, double dosing, and mixing the medications that could cause adverse (unfavorable) or even fatal effects on the resident.

2. Resident 61 and 52's fall mat (a safety pad placed on the floor by a resident's bed to reduce the risk of injury from a fall) did not have any furniture or medical equipment on top of them.

3. Resident 11's floor was not wet, and the resident was not standing over wet floor.

This failure increased the risk of injury when the resident slips, trips, and falls by hitting the hard surface of

the equipment or furniture that is on top of the fall mat.

4. The facility stored Resident 137's smoking material in a secure area.

This failure had the potential to place residents at risk for harm such as skin burns.

Cross-reference

F-F761

Findings:

a). During a review of Resident 29's Admission Record (a document containing demographic and diagnostic information) the Admission Record indicated the facility admitted the resident on [DATE REDACTED], and readmitted the resident on [DATE REDACTED], with diagnoses including type 2 diabetes mellitus ([DM2] - a disorder characterized by difficulty in blood sugar control and poor wound healing) with a foot ulcer (open sores or lesions that will not heal or that return over a long period of time), acute kidney failure (a condition where the kidneys suddenly stop working properly and cannot filter waste from the blood), and acute osteomyelitis (inflammation of bone or bone marrow, usually due to infection) of the left ankle and foot.

During a review of Resident 29's History and Physical (H&P), dated [DATE REDACTED], the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 29's Minimum Data Set (MDS, a resident assessment tool), dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition (being able to perform mental processes like thinking, paying attention, learning, and remembering). The MDS also indicated the resident was on insulin injections and was taking a high-risk drug class hypoglycemic (medication that lowers blood sugar) and anticoagulant medications.

During a review of Resident 29's Order Summary Report (a report listing the physician order for the resident,)

the Order Summary Report indicated an order for:

[DATE REDACTED] Heparin Sodium (porcine) Injection Solution 5000 unit (an amount approximately equivalent to 0.002 milligrams [mg, a unit of weight] of pure heparin)/milliliters (ml, a unit of volume) (Heparin Sodium [Porcine]). Inject 1 ml SQ every 8 hours for blood clot prophylaxis (PPX, an attempt to prevent disease).

[DATE REDACTED] Insulin Aspart Injection Solution 100 unit/ml (Insulin Aspart). Inject as per sliding scale (the increasing administration of the pre-meal insulin dose based on the blood sugar level before the meal): if 140 - 199 = 2 units blood sugar (BS); less than 140 = 0 unit.; 200 - 249 = 4 units; 250 - 299 = 7 units; 300 - 349 = 10 units; 350 - 400 = 12 units BS: greater than 400= units call physician., SQ before meals and at bedtime for DM.

[DATE REDACTED] Insulin Glargine SQ Solution 100 unit/ml (Insulin Glargine). Inject 50 unit SQ at bedtime for DM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a review of Resident 29's Location of Administration of insulin and heparin, for ,d+[DATE REDACTED] to , d+[DATE REDACTED], the Location of Administration indicated: Level of Harm - Minimal harm or potential for actual harm -Heparin Sodium (Porcine) Injection Solution 5000 unit/ml was administered SQ on the following dates:

Residents Affected - Some [DATE REDACTED] at 9:45 p.m. on the Abdomen - Left Lower Quadrant (LLQ)

[DATE REDACTED] at 6:28 a.m. on the Abdomen - LLQ

[DATE REDACTED] at 9:49 a.m. on the Abdomen - Right Upper Quadrant (RUQ)

[DATE REDACTED] at 5:52 a.m. on the Abdomen - RUQ

[DATE REDACTED] at 1:33 p.m. on the Abdomen- Right Lower Quadrant (RLQ)

[DATE REDACTED] at 9:36 p.m. on the Abdomen- RLQ

[DATE REDACTED] at 2:57 p.m. on the Abdomen- LLQ

[DATE REDACTED] at 9:02 p.m. on the Abdomen- LLQ

- Insulin Aspart Injection Solution 100 unit/ml was administered SQ on:

[DATE REDACTED] at 11:33 a.m. on the Arm - left

[DATE REDACTED] at 4:46 p.m. on the Arm - left

[DATE REDACTED] at 11:52 a.m. on the Arm - left

[DATE REDACTED] at 4:38 p.m. on the Arm - left

[DATE REDACTED] at 11:48 a.m. on the Arm - left

[DATE REDACTED] at 5:09 p.m. on the Arm - left

[DATE REDACTED] at 12:23 p.m. on the Arm - left

[DATE REDACTED] at 5:15 p.m. on the Arm - left

[DATE REDACTED] at 6:22 a.m. on the Arm - right

[DATE REDACTED] at 2:05 a.m. on the Arm - right

[DATE REDACTED] at 4:47 p.m. on the Arm - left

[DATE REDACTED] at 9:01 p.m. on the Arm - left

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 [DATE REDACTED] at 11:48 a.m. on the Arm - left

Level of Harm - Minimal harm or [DATE REDACTED] at 5:09 p.m. on the Arm - left potential for actual harm [DATE REDACTED] at 12:10 p.m. on the Arm - left Residents Affected - Some [DATE REDACTED] at 4:50 p.m. on the Arm - left

[DATE REDACTED] at 9:30 p.m. on the Arm - left

[DATE REDACTED] at 6:06 a.m. on the Arm - right

[DATE REDACTED] at 11:59 a.m. on the Arm - right

[DATE REDACTED] at 5:48 a.m. on the Arm - left

[DATE REDACTED] at 11:30 a.m. on the Arm - left

[DATE REDACTED] at 4:59 p.m. on the Arm - right

[DATE REDACTED] at 9:37 p.m. on the Arm - right

[DATE REDACTED] at 6:02 a.m. on the Arm - left

[DATE REDACTED] at 11:34 a.m. on the Arm - left

[DATE REDACTED] at 4:52 p.m. on the Arm - left

[DATE REDACTED] at 8:56 p.m. on the Arm - left

[DATE REDACTED] at 4:55 p.m. on the Arm - right

[DATE REDACTED] at 8:39 p.m. on the Arm - right

[DATE REDACTED] at 11:48 a.m. on the Arm - left

[DATE REDACTED] at 4:44 p.m. on the Arm - left

[DATE REDACTED] at 11:53 a.m. on the Arm - right

[DATE REDACTED] at 4:49 p.m. on the Arm - right

[DATE REDACTED] at 8:42 p.m. on the Arm - left

[DATE REDACTED] at 5:56 a.m. on the Arm - left

[DATE REDACTED] at 5:31 p.m. on the Abdomen - RUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 [DATE REDACTED] at 9:02 p.m. on the Abdomen - RUQ

Level of Harm - Minimal harm or [DATE REDACTED] at 7:46 p.m. on the Abdomen - LLQ potential for actual harm [DATE REDACTED] at 11:48 p.m. on the Abdomen - LLQ Residents Affected - Some [DATE REDACTED] at 3:58 p.m. on the Arm - right

[DATE REDACTED] at 5:08 p.m. on the Arm - right

[DATE REDACTED] at 12:07 a.m. on the Arm - right

[DATE REDACTED] at 5:56 a.m. on the Arm - left

[DATE REDACTED] at 11:39 a.m. on the Arm - left

[DATE REDACTED] at 12:04 p.m. on the Arm - left

[DATE REDACTED] at 4:44 p.m. on the Arm - left

[DATE REDACTED] at 8:33 p.m. on the Arm - left

During a review of Resident 29's Care Plan (CP) last revised on [DATE REDACTED], Resident 29 had a diagnosis of diabetes and was insulin dependent (the pancreas makes little or no insulin), the CP indicated interventions to administer hypoglycemic medications as ordered and anticoagulant to be given as ordered. b). During a

review of Resident 42's Admission Record, the Admission Record indicated the facility admitted the resident

on [DATE REDACTED], and readmitted the resident on [DATE REDACTED], with diagnoses including DM2 with hyperglycemia (high blood sugar), and cellulitis (a skin infection that causes swelling and redness) of left lower limb.

b). During a review of Resident 42's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. The MDS indicated the resident was

on insulin injections and was taking a high-risk drug class hypoglycemic medication.

During a review of Resident 42's H&P, dated [DATE REDACTED], the H&P indicated the resident had the capacity to understand and make decisions.

During a review of Resident 42's Order Summary Report, the Order Summary Report indicated the following orders:

[DATE REDACTED] Insulin Glargine Solution 100 UNIT/ML. Inject 24-unit SQ one time a day for DM If BS<70, implement hypoglycemic protocol. If BS>401, call MD.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 [DATE REDACTED] administer Insulin Regular Human Solution. Inject as per sliding scale: if 71 - 150 = 0 BS less than (<) 70 Initiate hypoglycemic protocol (steps to increase blood sugar level) and call MD; 151 - 200 = 6; 201 - Level of Harm - Minimal harm or 250 = 8; 251 - 300 = 12; 301 - 350 = 14; 351 - 400 = 16 400+, give 16 units ([un] - a measure of dosage for potential for actual harm insulin) recheck in 30 minutes, and call MD, SQ before meals and at bedtime for DM If BS<70, implement hypoglycemic protocol. If BS greater than (>)400, give 16 units and call MD. Give 30 minutes before a meal. Residents Affected - Some

During a review of Resident 42's Location of Administration of Insulin for ,d+[DATE REDACTED] to ,d+[DATE REDACTED], the Location of Administration indicated:

-Insulin Glargine Solution 100 unit/ml was administered on:

[DATE REDACTED] at 9:09 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 9:18 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 9:11 p.m. on the Abdomen - RLQ

[DATE REDACTED] at 9:44 p.m. on the Abdomen - RLQ

[DATE REDACTED] at 9:58 p.m. on the Abdomen - RLQ

[DATE REDACTED] at 9:44 p.m. on the Abdomen - RLQ

[DATE REDACTED] at 10 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 8:40 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 9:19 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 9:57 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 9:57 p.m. on the Abdomen - RLQ

[DATE REDACTED] at 9:22 p.m. on the Abdomen - RLQ

-Insulin Regular Human Solution was administered on:

[DATE REDACTED] at 11:43 a.m. on the Abdomen - Left Upper Quadrant (LUQ)

[DATE REDACTED] at 4:57 p.m. on the Abdomen - LUQ

[DATE REDACTED] at 9:08 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 9:18 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 4:57 p.m. on the Abdomen - RLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 [DATE REDACTED] at 9:38 p.m. on the Abdomen - RLQ

Level of Harm - Minimal harm or [DATE REDACTED] at 5:26 p.m. on the Abdomen - RUQ potential for actual harm [DATE REDACTED] at 9:59 p.m. on the Abdomen - RUQ Residents Affected - Some [DATE REDACTED] at 9:59 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 10 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 4:32 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 5:29 a.m. on the Abdomen - LLQ

[DATE REDACTED] at 4:35 p.m. on the Abdomen - LLQ

[DATE REDACTED] at 5:51 a.m. on the Abdomen - LLQ

[DATE REDACTED] at 4:47 p.m. on the Abdomen - LLQ

During a review of Resident 42's Care Plan last revised on [DATE REDACTED], indicated Resident 42 had a diagnosis of diabetes and was insulin dependent, the CP included interventions to administer hypoglycemic medications as ordered.

43455

c). During a review of Resident 63's Admission Record, dated [DATE REDACTED], the Admission Record indicated Resident 63 was originally admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] with diagnosis including DM2.

During a review of Resident 63's Order Summary Report, dated [DATE REDACTED], the report indicated Resident 63 was prescribed Lantus to inject 7 un SQ at bedtime for DM, starting [DATE REDACTED].

During a review of Resident 63's Medication Administration Record ([MAR] - a document of the medications administered to a resident that is part of the resident's permanent medical record], for [DATE REDACTED], the MAR indicated Resident 63 was prescribed insulin Lantus 7 units SQ at bedtime for DM, at 9 PM, and that Resident 63 received 10 doses of expired insulin Lantus from the following nurses at 9 p.m. on the following dates:

- Registered Nurse (RN) 4 - 1 dose on [DATE REDACTED]

- Licensed Vocational Nurse (LVN) 6 - 6 doses (on [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED], [DATE REDACTED])

- LVN 8 - 1 dose on [DATE REDACTED]

- LVN 5 - 1 dose on [DATE REDACTED]

- LVN 7 - 1 dose on [DATE REDACTED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 70 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 d). During a review of Resident 71's Admission Record, dated [DATE REDACTED], the Admission Record indicated Resident 71 was originally admitted to the facility on [DATE REDACTED] with a diagnosis including DM 2. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 71's Order Summary, dated [DATE REDACTED], the report indicated Resident 71 was prescribed glargine 10 units SQ at bedtime for DM, starting [DATE REDACTED]. Residents Affected - Some

During a review of Resident 71's MAR, for [DATE REDACTED], the MAR indicated Resident 71 was prescribed insulin glargine 10 units SQ at bedtime for DM, at 9 p.m., and that Resident 71 received 3 doses of expired insulin Lantus from the following nurses at 9 p.m. on the following dates:

- LVN 6 - 1 dose on [DATE REDACTED]

- LVN 7 - 2 doses (on [DATE REDACTED] and [DATE REDACTED])

43988

g). During a review of Resident 402's Admission Record, the Admission Record indicated the facility admitted

the resident on [DATE REDACTED], with diagnoses including DM2, abnormalities of gait and mobility, and generalized muscle weakness.

During a review of Resident 402's MDS dated [DATE REDACTED], the MDS indicated Resident 402 had an intact cognition (mental action or process of acquiring knowledge and understanding) and required substantial/maximal assistance with toileting, bathing, and lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). The MDS indicated Resident 402 had a diagnosis of DM 2 and received insulin and an anticoagulant.

During a review of Resident 402's Order Summary Report, the Order Summary Report indicated the following physician's order:

- [DATE REDACTED]: Insulin lispro (a fast-acting insulin) injection solution 100 unit per milliliter (unit/ml - a unit of measurement). Inject as per sliding scale (the increasing administration of the pre-meal insulin dose based

on the blood sugar level before the meal): if 70 - 150 = 0 If blood sugar (BS) is less than (<) 70, Initiate (start) hypoglycemic (low blood sugar level) protocol (procedure to be followed); 151 - 199 = 2 units; 200 - 249 = 3 units; 250 - 299 = 4 units; 300 - 349 = 5 units; 350 - 399 = 6 units; If BS is equal (=) or more than (>) 400, give eight (8) units and call physician (MD), subcutaneously before meals and at bedtime for DM.

- [DATE REDACTED]: Heparin sodium porcine injection solution 5000 unit/ml. Inject 5000 unit subcutaneously every 8 hours for clot prevention. Monitor for bleeding.

h). During a review of Resident 495's Admission Record, the Admission Record indicated the facility admitted

the resident on [DATE REDACTED], with diagnoses including kidney transplant status (a surgery done to replace a diseased or injured kidney with a healthy kidney from a donor), edema (swelling caused by excess fluid in

the spaces around the body's tissues and organs), and essential hypertension (high blood pressure that is not due to another medical condition).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 71 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a review of Resident 495's H&P, dated [DATE REDACTED], the H&P indicated the resident had the capacity to understand and make decisions. Level of Harm - Minimal harm or potential for actual harm During a review of Resident 495's MDS, dated [DATE REDACTED], the MDS indicated the resident had the ability to make self-understood and understand others and had intact cognition. Residents Affected - Some

During a review of Resident 495's Order Summary Report, dated [DATE REDACTED], the Order Summary Report indicated an order for Tacrolimus Oral Capsule 1 milligram (mg, a unit of weight) (Tacrolimus). Give 2 capsules by mouth in the morning and give 3 capsules by mouth in the evening to prevent kidney transplant rejection.

During a review of Resident 495's Tacrolimus Oral Capsule 1 mg Administration History, the Administration History indicated that Tacrolimus Oral Capsule 1 mg was given on:

Evening Shift (medication is scheduled to be given at 8 p.m.)

[DATE REDACTED], the medication was given at 10:17 p.m.

[DATE REDACTED], the medication was given at 9:06 p.m.

[DATE REDACTED], the medication was given at 9:02 p.m.

[DATE REDACTED], the medication was given at 9:48 p.m.

[DATE REDACTED], the medication was given at 9:22 p.m.

Day Shift (medication is scheduled to be given at 8 a.m.)

[DATE REDACTED], the medication was given at 11:34 a.m.

[DATE REDACTED], the medication was given at 11:27 a.m.

[DATE REDACTED], the medication was given at 9:50 a.m.

[DATE REDACTED], the medication was given at 10:28 a.m.

During an interview on [DATE REDACTED], at 9:53 a.m., with Resident 495, while inside Resident 495's room, Resident 495 stated she has not been getting her medications for her kidneys on time. Resident 495 stated that she was the one reminding the staff to give her kidney medications.

During an observation on [DATE REDACTED] at 11:16 a.m., in Medication Cart 4, in the presence of LVN 1, the following were found:

1. One open insulin Lantus Solostar pen (an injection device containing Lantus) for Resident 63 was found stored at room temperature with a label indicating that use at room temperature began on [DATE REDACTED], and to discard unused portion after 28 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 72 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 According to the manufacturer's product labeling, open Lantus Solostar insulin pens should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening pen. Level of Harm - Minimal harm or potential for actual harm 2. One open insulin Lantus Solostar pen for Resident 71 was found stored at room temperature with a label indicating that use at room temperature began on [DATE REDACTED], and to discard unused portion after 28 days. Residents Affected - Some According to the manufacturer's product labeling, open Lantus Solostar insulin pens should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening pen.

3. One open insulin Humulin ,d+[DATE REDACTED] Kwikpen (an injection device containing Humulin ,d+[DATE REDACTED]) for Resident 141 was found stored at room temperature with a label indicating that use at room temperature began on [DATE REDACTED], and to discard unused medication after 10 days.

According to the manufacturer's product labeling, open Humulin ,d+[DATE REDACTED] Kwikpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 10 days of opening pen.

During a concurrent interview with LVN 1, LVN 1 stated that insulin Lantus Solostar pen for Resident 63 was opened on [DATE REDACTED] and expired on [DATE REDACTED], Lantus Solostar pen for Resident 71 was opened on [DATE REDACTED] and expired on [DATE REDACTED] and needed to be removed from the medication cart 28 days after opening and replaced with a new pen from the pharmacy immediately. LVN 1 stated Humulin ,d+[DATE REDACTED] Kwikpen for Resident 141 was opened on [DATE REDACTED] and expired on [DATE REDACTED] and needed to be removed from the medication cart 10 days

after opening and replaced with a new pen from the pharmacy immediately. LVN 1 stated there was no new Lantus Solostar pens and Humulin ,d+[DATE REDACTED] Kwikpen in the facility for Resident 63, 71 and 141 and that several licensed nurses administered several doses of expired Lantus to Resident 63 from [DATE REDACTED] to [DATE REDACTED], to Resident 71 from [DATE REDACTED] to [DATE REDACTED] and Humulin ,d+[DATE REDACTED] to Resident 141 from [DATE REDACTED] to [DATE REDACTED] . LVN 1 stated that administering expired insulin has lost its potency (strength) will not be effective in keeping the blood sugar levels stable and can harm Resident 63 by causing hyperglycemia and diabetic ketoacidosis (a condition that develops when the body doesn't have enough insulin resulting in the buildup of acid in the blood to levels that can be life threatening,) leading to hospitalization and death.

During an interview and concurrent record review on [DATE REDACTED] at 2:28 p.m., with the Director of Nurisng (DON, ) the DON reviewed Resident 63, 71 and 141's MAR. The DON stated insulin Lantus Solostar for Resident 63 and 71 and Humulin ,d+[DATE REDACTED] kwikpen for Resident 141 were expired and needed to be removed from

the medication cart and replaced with a new pen from the pharmacy. The DON acknowledged that several LVN's failed to remove the expired insulin from the medication cart, and according to the MAR's Resident 63 was administered expired insulin from [DATE REDACTED] to [DATE REDACTED], Resident 71 and 141 from [DATE REDACTED] to [DATE REDACTED], resulting in significant medication errors. The DON stated administering expired insulin to Resident 63, 71 and 141 will not be effective in controlling the blood sugar levels and can harm the resident by causing high blood sugar levels, leading to diabetic ketoacidosis, coma, hospitalization and death.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 73 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During a concurrent interview and record review on [DATE REDACTED], at 2:27 p.m., with LVN 4, Resident 42's Order Summary Report, Location of Administration Report of insulin from ,d+[DATE REDACTED] to ,d+[DATE REDACTED], and Care Plans Level of Harm - Minimal harm or were reviewed. LVN 4 stated there were multiple instances that the administration sites of insulin were not potential for actual harm rotated for the month of ,d+[DATE REDACTED] to ,d+[DATE REDACTED]. LVN 4 stated insulin administration sites should be rotated to avoid bruises, for proper absorption of the insulin, and to avoid lipodystrophy on the resident. LVN 4 stated Residents Affected - Some not rotating insulin administration sites as a medication error.

During an interview and record review on [DATE REDACTED], at 2:40 p.m., with LVN 4, Resident 495's Order Summary Report, MAR, and the Tacrolimus Oral Capsule 1mg Administration History was reviewed. LVN 2 stated Resident 495 gets two capsules of Tacrolimus in the morning at 8 a.m. and three capsules of Tacrolimus in

the evening at 8 p.m. LVN 2 stated the medication can be given an hour before or an hour after the scheduled administration times of the medication. LVN 4 stated it is important to give the medication on time and follow the facility's policy and procedure on administering medications to avoid the adverse effect of the medication.

During a concurrent interview and record review on [DATE REDACTED], at 9:03 a.m., with RN 2, the following was reviewed:

- Resident 29's Order Summary Report, Location of Administration of insulin and Heparin from ,d+[DATE REDACTED] to , d+[DATE REDACTED], and care plans were reviewed. RN 2 stated there were multiple instances that the SQ administration sites of insulin and heparin were not rotated by the licensed staff between ,d+[DATE REDACTED] to , d+[DATE REDACTED]. RN 2 stated heparin and insulin administration sites should be rotated to prevent lipodystrophy and bruising on the frequented site of administration on the residents. RN 2 stated not rotating insulin and heparin SQ injection sites is considered a medication error.

- Resident 134's MAR from for ,d+[DATE REDACTED] and ,d+[DATE REDACTED] was reviewed with RN 2, RN 2 verified the MAR indicated the insulin lispro, insulin glargine was administered as follows:

- Insulin Lispro Injection Solution 100 unit/ml:

[DATE REDACTED] 4:59 p.m. subcutaneously Abdomen - right upper quadrant (RUQ)

[DATE REDACTED] 8:52 a.m. subcutaneously Abdomen - RUQ

[DATE REDACTED] 12:25 p.m. subcutaneously Abdomen - RUQ

[DATE REDACTED] 3:50 p.m. subcutaneously Abdomen - RUQ

[DATE REDACTED] 4:52 p.m. subcutaneously Abdomen - left lower quadrant (LLQ)

[DATE REDACTED] 8:07 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 1:16 p.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 5:39 p.m. subcutaneously Abdomen - left upper quadrant (LUQ)

[DATE REDACTED] 10:36 a.m. subcutaneously Abdomen - LUQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 74 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 [DATE REDACTED] 8:35 a.m. subcutaneously Abdomen - LLQ

Level of Harm - Minimal harm or [DATE REDACTED] 11:56 a.m. subcutaneously Abdomen - LLQ potential for actual harm [DATE REDACTED] 4:57 p.m. subcutaneously Abdomen - LUQ Residents Affected - Some [DATE REDACTED] 8:44 a.m. subcutaneously Abdomen - LUQ

[DATE REDACTED] 8:18 a.m. subcutaneously Abdomen - right lower quadrant (RLQ)

[DATE REDACTED] 12:15 p.m. subcutaneously Abdomen - RLQ

[DATE REDACTED] 12:28 p.m. subcutaneously Abdomen - RUQ

[DATE REDACTED] 8:42 a.m. subcutaneously Abdomen - RUQ

[DATE REDACTED] 4:52 p.m. subcutaneously Abdomen - RLQ

[DATE REDACTED] 11:07 a.m. subcutaneously Abdomen - RLQ

[DATE REDACTED] 2:25 p.m. subcutaneously Abdomen - RLQ

[DATE REDACTED] 8:47 a.m. subcutaneously Abdomen - RUQ

[DATE REDACTED] 2:16 a.m. subcutaneously Abdomen - RUQ

[DATE REDACTED] 5:14 p.m. subcutaneously Abdomen - LUQ

[DATE REDACTED] 8:19 a.m. subcutaneously Abdomen - LUQ

[DATE REDACTED] 12:25 p.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 4:26 p.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 11:34 a.m. subcutaneously Abdomen - RUQ

[DATE REDACTED] 4:12 p.m. subcutaneously Abdomen - RUQ

[DATE REDACTED] 11:48 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 4:59 p.m. subcutaneously Abdomen - LLQ

- Insulin glargine subcutaneous solution 100 unit/ml:

[DATE REDACTED] 8:22 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 9:14 a.m. subcutaneously Abdomen - LLQ

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 75 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 [DATE REDACTED] 8:24 a.m. subcutaneously Abdomen - RLQ

Level of Harm - Minimal harm or [DATE REDACTED] 9:44 a.m. subcutaneously Abdomen - RLQ potential for actual harm [DATE REDACTED] 9:40 a.m. subcutaneously Abdomen - LLQ Residents Affected - Some [DATE REDACTED]:30 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 8:46 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 9:25 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 10:05 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 9:42 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 10:27 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 8:01 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 11:09 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 9:27 a.m. subcutaneously Abdomen - RLQ

[DATE REDACTED] 8:23 a.m. subcutaneously Abdomen - RLQ

-Resident 402's MAR from ,d+[DATE REDACTED] was reviewed with RN 2, RN 2 verified the MAR indicated the insulin lispro, and heparin were administered as follows:

- Heparin sodium porcine injection solution 5000 unit/ml:

[DATE REDACTED] 1:17 p.m. subcutaneously Arm - right

[DATE REDACTED] 5:24 a.m. subcutaneously Arm - right

[DATE REDACTED] 1:24 p.m. subcutaneously Arm - left

[DATE REDACTED] 10:38 p.m. subcutaneously Arm - left

[DATE REDACTED] 1:22 p.m. subcutaneously Arm - left

[DATE REDACTED] 9:18 p.m. subcutaneously Arm - left

[DATE REDACTED] 1:32 p.m. subcutaneously Abdomen - right lower quadrant (RLQ)

[DATE REDACTED] 11:18 p.m. subcutaneously Abdomen - RLQ

[DATE REDACTED] 2:14 p.m. subcutaneously Abdomen - left lower quadrant (LLQ)

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 76 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 [DATE REDACTED] 5:55 a.m. subcutaneously Abdomen - LLQ

Level of Harm - Minimal harm or [DATE REDACTED] 1:12 p.m. subcutaneously Abdomen - LLQ potential for actual harm [DATE REDACTED] 6:23 a.m. subcutaneously Abdomen - LLQ Residents Affected - Some [DATE REDACTED] 12:57 p.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 9:44 p.m. subcutaneously Abdomen - LLQ

- Insulin lispro injection solution 100 unit/ml:

[DATE REDACTED] 6:25 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 9:53 a.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 12:04 p.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 5:19 p.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 8:32 p.m. subcutaneously Abdomen - LLQ

[DATE REDACTED] 8:59 p.m. subcutaneously Abdomen - LLQ

RN 2 stated the standard of practice is to rotate the administration site of heparin and insulin to prevent the development of lipodystrophy and bruising. RN 2 stated the licensed nurses should have rotated the insulin and heparin sites for Resident 134 and 402 as it placed the residents at risk for complications of not rotating administration sites such as trauma, bruising, and development of lipodystrophy. RN 2 stated not rotating the subcutaneous administration sites can be considered a medication error as it is in accordance with the standards of practice and not following manufacturer's guideline.

During a concurrent interview and record review on [DATE REDACTED], at 9:41 a.m., with RN 2, reviewed Resident 495's Order Summary Report, MAR, and the Tacrolimus Oral Capsule 1mg Administration History. RN 2 stated there were multiple instances on ,d+[DATE REDACTED] that the resident got the medication over an hour of its scheduled administration times. RN 2 stated the Resident 495 is taking Tacrolimus capsule to prevent organ rejection. RN 2 stated the resident had a kidney transplant and administering the Tacrolimus on varying times can potentially lead to organ rejection.

During an interview on [DATE REDACTED], at 2:48 p.m., with the DON, the DON stated the staff should rotate insulin and heparin administration sites to prevent lipodystrophy, malabsorption of the medication, and to prevent bruising on the frequented sites of administration on the resident. The DON stated not rotating insulin and heparin administration site as a medication error.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 77 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 During an interview on [DATE REDACTED] at 2:49 p.m., the DON stated the standards of practice regarding administration of medication subcutaneously is to rotate the administration sites to prevent bruising, pain, Level of Harm - Minimal harm or lipodystrophy, and amyloidosis. The DON stated Resident 134's administration sites for heparin and insulin potential for actual harm should have been rotated by the licensed nurses as it placed the resident at risk for trauma, bruising, lipodystrophy, and amyloidosis to the administration site. The DON stated not following rotating the Residents Affected - Some administration site for any subcutaneous injections can be considered a medication as the practice is not following the standards of nursing practice as well not following the manufacturer's guideline.

During an interview on [DATE REDACTED], at 3:05 p.m., with the DON, the DON stated it was important for the staff to follow the facility's policy and procedure on administering medications specially on the case of Resident 495 to prevent organ rejection.

Review of the facility's policy and procedures (P&P), titled Procedures for All Medications, last reviewed [DATE REDACTED], the P&P indicated To administer medications in a safe and effective manner.

E. Check expiration date on package/container.

F. Read medication label before administering.

N. Once removed from the package or container, unused doses should be disposed of in accordance with th medication destruction policy.

Review of the facility's P&P, titled Discontinued Medications, last reviewed [DATE REDACTED], the P&P indicated When medications are expired .the medicatioins are marked as discontinued or stored in a separate location and later destroyed.

A. If a medication expires .the drug container shall be marked or oterwise identified and shall be stored in a separate location designated solely for this purpose.

B. Medications are removed from the mediation cart or storage area prior to expiration.

Review of the facility's P&P, titled Storage of Medications, last reviewed [DATE REDACTED], the P&P indicated: Medications .are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

M. Outdated .medications .are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

Review of the facility's P&P, titled Medication Errors, last reviewed [DATE REDACTED], the P&P indicated: Medication error means the observed or identified preparation or administration of medications or biologicals which is not in accordance with the prescriber's order; manufacturer's specificatinos (not recommendations) regarding

the preparation and administration of t

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 78 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 43455 Residents Affected - Some Based on observation, interview, and record review the facility failed to:

1. Remove and discard from use two (2) open, expired insulin (a medication used to control high blood sugar levels) Lantus (brand name insulin for glargine, a long-acting insulin) pens stored at room temperature for Resident 63 and 71 in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) observed medications carts (Medication cart 4.)

2. Remove and discard from use one (1) open, expired insulin Humulin 70/30 (brand name combination insulin for isophane human and regular human; an intermediate-acting insulin combined with rapid onset regular insulin) pen stored at room temperature for Resident 141 in accordance with manufacturer's requirements and facility policy and procedures, in one (1) of two (2) observed medications carts (Medication cart 4.)

3. Remove and discard from use one (1) open Aplisol (also known as Tubersol - medication used to diagnose tuberculosis [infection in the lungs]) vial for facility stock, in accordance with manufacturer's requirements and facility policy and procedures in one (1) of two (2) inspected medication room (Medication Room Station 3.)

4. Remove and discard from use one (1) open, expired insulin Humulin 70/30 pen stored in the refrigerator for Resident 141 in accordance with manufacturer's requirements, in one (1) of two (2) observed medication room (Medication Room Station 3.)

5. Remove and discard from use one (1) expired emergency medication kit (storage container for emergency use medications) for facility stock in accordance with facility policy and procedures, one (1) of two (2) inspected medication room (Medication Room Station 3.)

These failures increased the risk that Resident 63, 71 141 and other residents in the facility could receive medication that had become ineffective or toxic due to inadequate storage, labeling and monitoring, experience medication adverse consequences resulting in the negative impact to residents' health and well-being possibly leading to health complications, hospitalization , or death.

Findings:

During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 1, on 12/31/2024 at 11:16 a.m., in Medication Cart 4, the following were found:

1. One (1) open insulin Lantus Solostar pen (an injection device containing Lantus) for Resident 63 was found stored at room temperature with a label indicating that use at room temperature began on 11/21/2024, and to discard unused portion after 28 days.

The manufacturer's product labeling indicated open Lantus Solostar insulin pens should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening pen.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 79 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 2. One (1) open insulin Lantus Solostar pen for Resident 71 was found stored at room temperature with a label indicating that use at room temperature began on 11/28/2024, and to discard unused portion after 28 Level of Harm - Minimal harm or days. potential for actual harm

The manufacturer's product labeling indicated open Lantus Solostar insulin pens should be stored at room Residents Affected - Some temperature below 86 degrees Fahrenheit and used or discarded within 28 days of opening pen.

3. One (1) open insulin Humulin 70/30 Kwikpen (an injection device containing Humulin 70/30) for Resident 141 was found stored at room temperature with a label indicating that use at room temperature began on 12/16/2024, and to discard unused medication after 10 days.

The manufacturer's product labeling indicated open Humulin 70/30 Kwikpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 10 days of opening pen. LVN 1 stated that insulin Lantus Solostar pen for Resident 63 was opened on 11/21/2024 and expired on 12/19/2024, Lantus Solostar pen for Resident 71 was opened on 11/28/2024 and expired on 12/26/2024 and needed to be removed from the medication cart 28 days after opening and replaced with a new pen from pharmacy immediately. LVN 1 stated Humulin 70/30 Kwikpen for Resident 141 was opened on 12/16/2024 and expired on 12/26/2024 and needed to be removed from the medication cart 28 days after opening and replaced with a new pen from pharmacy immediately. LVN 1 stated several licensed nurses administered several doses of expired Lantus to Resident 63 from 12/20/2024 to 12/30/2024, to Resident 71 from 12/27/2024 to 12/30/2024 and Humulin 70/30 to Resident 141 from 12/27/2024 to 12/30/2024. LVN 1 stated that administering expired insulin has lost its potency (strength) will not be effective in keeping the blood sugar levels stable and can harm Resident 63, 71 and 141 by causing hyperglycemia (increased/high blood sugar levels) and diabetic ketoacidosis ([DKA] - a condition that develops when the body doesn't have enough insulin resulting in the buildup of acid in the blood to levels that can be life threatening,) leading to hospitalization and death.

During a concurrent observation and interview, on 12/31/2024 at 11:37 a.m., with LVN 1, in Medication Room Station 3, the following medications were found either expired and not discarded, or stored contrary to their respective manufacturer's specifications and facility policies and procedures:

1. One (1) open Aplisol multi-dose vial for facility stock was found stored in the refrigerator with a label indicating use began on 11/25/2024.

The manufacturer's product storage and labeling indicated Aplisol vials should be stored in the refrigerator between 36 and 46 degrees Fahrenheit and used or discarded from use within 30 days of opening the vial.

2. One (1) unopened expired emergency medication kit labeled with an expiration date of 12/2024.

The pharmacy label and facility policy indicated expired emergency medication kits should not be used and discarded by the indicated expiration date.

3. One (1) open insulin Humulin 70/30 Kwikpen (an injection device containing Humulin 70/30) for Resident 141 was found stored at room temperature with a label indicating that use at room temperature began on 12/11/2024, and to discard unused medication after 10 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 80 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 The manufacturer's product labeling indicated open Humulin 70/30 Kwikpen should be stored at room temperature below 86 degrees Fahrenheit and used or discarded within 10 days of opening pen. Level of Harm - Minimal harm or potential for actual harm LVN 1 stated one (1) Aplisol vial stored in the refrigerator in Medication Room Station 3 was opened on 11/25/2024 and expired on 12/25/2024, one (1) insulin Humulin 70/30 Kwikpen stored in the refrigerator in Residents Affected - Some Medication Room Station 3 for Resident 141 was opened on 12/11/2024 and expired on 12/21/2024, and one (1) emergency medication kit stored at room temperature in Medication Room Station 3 was unopened and expired on 12/24/2024. LVN 1 stated the expired medications needed to be removed from the refrigerator and placed in the expired medication bin to be disposed of and not accidentally used for residents, and the expired emergency kit needed to be replaced with a new one from pharmacy before December 2024. LVN 1 stated administering expired Aplisol to residents may result in inaccurate results (either false negative or false positive) and therefore lead to providing the incorrect treatment to the residents. LVN 1 stated that expired insulin has lost its potency and will not be effective in keeping the blood sugar levels stable and when used in error can harm Resident 141 by causing hyperglycemia and DKA, leading to hospitalization and death. LVN 1 stated emergency medications are needed in emergency situations and used from the emergency kits. LVN 1 stated giving residents expired medications from the emergency kits during emergency situations will only make the emergent situation worse for residents.

During an interview on 12/31/2024 at 2:28 p.m., with the Director of Nursing (DON,) the DON stated that expired medications needed to be removed from use in medication carts and medication rooms and placed

in the expired medication bin to be disposed of and not accidentally used for residents. The DON stated insulin Lantus Solostar pen for Resident 63 and 71 and Humulin 70/30 kwikpen for Resident 141 in medication cart 4 and Humulin 70/30 kwikpen for Resident 141 in Medication room station 3 refrigerator were expired and needed to be removed from the medication carts and room and replaced with new pens from pharmacy. The DON acknowledged that several LVN's failed to remove the expired insulin from the medication cart and refrigerator. The DON stated administering expired insulin to Resident 63, 71 and 141 will not be effective in controlling the blood sugar levels and can harm Resident 63, 71 and 141 by causing high blood sugar levels, leading to DKA, coma, hospitalization , and death. The DON stated that the emergency medication kit in Medication Room Station 3 expired December of 2024 and should have been replaced with a new one from pharmacy. The DON stated medication storage areas should be checked daily for expired medications and expired medication removed from those areas. The DON stated that the facility failed to remove expired emergency medication kit from Medication Room Station 3. DON stated administering expired medications from the emergency kit during emergency situations will make the emergent situation worse for residents. The DON stated that one (1) Aplisol vial was opened on 11/25/2024 and stored in the medication refrigerator for facility stock use. The DON stated multi-dose vials usually expire 28 days after opening the vials and should be discarded beyond that date to prevent accidental use. The DON stated the Aplisol vial was expired and needed to be removed from the medication room and be discarded to prevent accidental use. The DON stated using Aplisol vials beyond the expiration date in error may potentially provide inaccurate results for tuberculosis (a contagious bacterial disease that's usually spread through the air when someone with tuberculosis coughs, sneezes, or spits) leading to inaccurate treatment for residents.

During a review of the facility's policy and procedures (P&P), titled Procedures for All Medications, last reviewed 12/4/2024, the P&P indicated To administer medications in a safe and effective manner.

E. Check expiration date on package/container.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 81 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 N. Once removed from the package or container, unused doses should be disposed of in accordance with

the medication destruction policy. Level of Harm - Minimal harm or potential for actual harm During a review of the facility's P&P, titled Discontinued Medications, last reviewed 12/4/2024, the P&P indicated When medications are expired .the medications are marked as discontinued or stored in a separate Residents Affected - Some location and later destroyed.

A. If a medication expires .the drug container shall be marked or otherwise identified and shall be stored in a separate location designated solely for this purpose.

B. Medications are removed from the medication cart or storage area prior to expiration.

During a review of the facility's P&P, titled Storage of Medications, last reviewed 12/4/2024, the P&P indicated: Medications .are stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier.

M. Outdated .medications .are immediately removed from stock, disposed of according to procedures for medication disposal, and reordered from the pharmacy if a current order exists.

During a review of the facility's P&P, titled Emergency Pharmacy Service and Emergency Kits, last reviewed 12/4/2024, the P&P indicated:

G. The emergency supply is maintained

O. The kits are checked by a pharmacist at least monthly.

During a review of facility's P&P, titled Guide for Special Handling of Medications, dated June 2023, the P&P listed the following:

Multiple dose vials for injection - Discard 28 days after opening.

Tubersol, Aplisol - Store in refrigerator. Discard 30 days after opening.

Insulin products - Refer to the Insulin Storage Guideline reference sheet.

During a review of facility's P&P, titled Insulin Storage, undated, the P&P listed to store the following:

Humulin 70/30 pen opened at room temperate for 10 days

Lantus Solostar (glargine) opened at room temperature for 28 days.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 82 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0814 Dispose of garbage and refuse properly.

Level of Harm - Minimal harm or 43418 potential for actual harm Based on observation, interview, and record review, the facility failed to dispose garbage and refuse properly Residents Affected - Some when the garbage dumpsters located in the facility parking lot were overflowing with garbage.

This deficient practice had the potential to attract pests and possibly spread infection to 138 out of 138 facility residents.

Findings:

During an observation on 1/2/2025, at 7:15 a.m., in the facility parking lot, the lids of two black dumpster bins were left open with bags of garbage stacked over opening of the bin.

During an observation on 1/2/2025, at 7:41 a.m., in the facility parking lot, the lids of two black dumpster bins were left open with bags of garbage stacked over opening of the bin.

During an observation on 1/3/2025, at 7:31 a.m., in the facility parking lot, the lid of a black dumpster bin was resting on top bags of garbage. The dumpster lid was unable to completely close.

During an interview with the Housekeeping Supervisor (HSKS), on 1/3/2025, at 1:50 p.m., the HSKS stated garbage from the facility is thrown out into the dumpsters in the parking lot. The HSKS stated the garbage container should be always closed because leaving it open can attract flies and pests which can lead to the spread of infection.

During an interview with the Maintenance Supervisor (MS), on 1/3/2025, at 2:19 p.m., the MS stated the garbage dumpsters in the facility parking lot should be kept closed. The MS stated the dumpster contains garbage from both the facility and the facility kitchen. The MS stated if the garbage dumpster bins are not kept closed, there is a potential that the garbage can attract pests which can lead to the spread of infection.

During an interview with the Director of Nursing (DON), on 1/3/2025, at 2:40 p.m., the DON stated the dumpsters in the facility parking lot should be closed. The DON stated leaving the dumpster open can potentially invite pests to come to the facility, rips open the bags of garbage, and be a source of infection.

The DON further stated leaving the garbage dumpsters open does not look appealing and can negatively affect the appearance of the environment.

During a review of the facility's policy and procedure (P&P) titled, Waste Management, last reviewed 12/4/2024, the P&P indicated to dispose of all regulated or potentially regulated waste and to close and dispose regulated waste according to state and federal regulations.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 83 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm 43988

Residents Affected - Few Based on interview and record review, the facility failed to arrange provisions of hospice services (a program designed to provide a caring environment for meeting the physical and emotional needs of the terminally ill)

in a consistent manner for one of one sampled resident (Resident 11) investigated during review of hospice services by failing to:

1. Ensure the hospice staff including the registered nurse (RN), licensed vocational nurse (LVN), and hospice aide (HA), provided nursing and visitation notes to the facility.

2. Ensure the calendar of visits from 9/23/2024 to the most current visits was provided by Hospice Provider 1 (HP 1).

These deficient practices had the potential to negatively affect the residents' physical comfort and psychosocial well-being and had the potential to result in the delay or lack of necessary hospice care and services.

Findings:

During a review of Resident 11's Admission Record, the Admission Record indicated the facility admitted the resident on 9/12/2024 with diagnoses including hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following intracerebral hemorrhage (a type of stroke that occurs when a blood vessel in the brain bursts) affecting right dominant side; unsteadiness on feet; and generalized muscle weakness.

During a review of Resident 11's History and Physical (H&P) dated 9/14/2024, the H&P indicated Resident 11 had fluctuating capacity to understand and make decisions.

During a review of Resident 11's Order Summary Report, the Order Summary Report indicated a physician's order dated 9/23/2024 to admit Resident 11 in the facility under the care of HP 1 for routine level of care with

a primary diagnosis of cerebral infarction (also known as stroke, loss of blood flow to apart of the brain).

During a review of Resident 11's hospice binder for the Plan of Care (POC) Summary, the POC Summary indicated the following:

- 9/23/2024: HA - to visit patient two times (2x) a week to perform ADL care and assistance as assigned by RN and following POC.

- 9/23/2024: Skilled Nurse to visit patient 2x per week plus 1 as needed visit for symptoms management and changes in patient's condition.

- 12/19/2024: Please increase frequency of HA to three times (3x) a week to start 12/22/2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 84 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 During a review of Resident 11's Minimum Data Set (MDS - a resident assessment tool) dated 10/3/2024,

the MDS indicated Resident 11 had an intact cognition (mental action or process of acquiring knowledge and Level of Harm - Minimal harm or understanding) and was independent with eating; required substantial/maximal assistance with toileting, potential for actual harm bathing, and lower body dressing; partial/moderate assistance with all other activities of daily living (ADLs - basic tasks that must be accomplished every day for an individual to thrive). Residents Affected - Few

During a concurrent interview and record review on 1/3/2025 at 11:48 a.m. with the Social Services Director (SSD), Resident 11's hospice binder including the calendar of visits from 9/23/2024 to 1/3/2025, sign in and out sheets for the RN, LVN, and HA from 9/23/2024 to 1/3/2025, POC Summary, and progress notes were reviewed. The SSD stated she is the designated facility representative to coordinate with the hospice providers. The SSD verified:

- The calendar of visits indicated HP 1 RN was scheduled to visit Resident 11 on 11/4/2024 and the HP 1 HA was scheduled to visit on 12/23/2024 and 1/2/2025. The SSD verified the RN did not sign in on 11/4/2024 and the HA on 12/23/2024 and 1/2025. The SSD verified the POC summary indicated RN visits 2x a week and HA visits 3x a week. The SSD stated HP 1 RN and HA should have visited Resident 11 on 11/4/2024, 12/23/2024, and 1/2/2024 according to the calendar of visits to ensure Resident 11's needs were assessed and met to prevent delay in the provision of care the resident needs.

- The SSD verified there were no HP 1 RN/LVN and HA notes in Resident 11's clinical record. The SSD stated she was not sure, but she knows HP 1 do not place their progress notes in the binder. The SSD stated the Medical Records Director (MRD) audits the clinical records to ensure it was readily available for all staff so we would be aware of what services were provided to Resident 11 while HP 1 RN and HA were in

the facility and to ensure Resident 11 receives the necessary care the resident needs.

During an interview on 1/3/2024 at 12:13 p.m., the MRD stated HP 1 did not provide or place the progress notes for Resident 11 in the hospice binder. The MRD stated per HP 1, the hospice binder would be thick if

the notes were placed in the binder. The MRD stated he can scan and upload the progress notes on Resident 11's electronic health record (EHR). The MRD stated the progress notes should have been readily available so the staff would be aware of what care was provided to the resident.

During an interview on 1/3/2025 at 3 p.m., the Director of Nursing (DON) hospice providers have a schedule of visits provided to the facility and should be followed accordingly. the DON stated if HP 1 staff are not able to visit as scheduled, it should be indicated in the notes or in the calendar. The DON stated the RN/LVN and HA notes were supposed to be part of the resident's medical record. The DON stated the progress notes can be scanned and uploaded in the EHR. The DON stated the HP 1 RN should have visited Resident 11 as scheduled on 11/4/2024 and the HA on 12/23/2024 and 1/2/2025 to ensure Resident 11's needs and services required were met. The DON stated the RN/LVN and HA notes should have been readily available

in Resident 11's medical record regardless if it was paper or in the EHR. The staff would be aware of the services provided to the resident by HP 1 staff as not knowing places Resident 11 at risk for a delay in the provision of care and services needed.

During a review of the facility's policy and procedure (P&P) titled, Hospice, last reviewed 12/4/2024, the P&P indicated the Administrator (Adm) will ensure that the hospice services meet professional standards and principles that apply to individuals providing services in the facility and to the timeliness of services. The P&P further indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 85 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 - The Adm will obtain a written agreement with each hospice that includes a communication process, including the method for documenting the communication between the facility and the hospice provider to Level of Harm - Minimal harm or ensure that the patient's needs are met 24 hours per day. potential for actual harm - Delineation of the hospice's responsibilities including nursing care and all other hospice services that are Residents Affected - Few necessary for the care of the patient's terminal illness and related conditions.

During a review of the facility's agreement with HP 1 dated 8/14/2024, the agreement indicated:

- All required documentation shall be submitted within five (5) days of service being provided.

- All healthcare professionals including nurses and HAs shall submit a progress note with a signed time sheet within the specified time frame.

- Submitted documentation shall include any instructions given to and left with the patient. Within the specified time frame skilled nursing facilities shall document accurately in the patient chart in the facility record.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 86 of 92 056056 Department of Health & Human Services Printed: 09/11/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 056056 B. Wing 01/03/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or 44244 potential for actual harm Based on observation, interview, and record review the facility failed to maintain an infection prevention and Residents Affected - Some control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections by failing to:

1.Ensure the Housekeeping Supervisor (HSKS) did not place two pillows from the ground on top of clean linens, observed during the Infection Control task.

2. Ensure the resident's right floor mat did not have any damage on the top exposing the foam for one (1) of 1 sampled resident (Resident 402).

These failures had the potential to spread infections and illnesses among residents and staff.

Cross-reference