The Meadows On Sunset Post Acute
The Meadows on Sunset Post Acute in LOS ANGELES, CA — inspection on August 9, 2024.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on [DATE] at 4:22 p.m. with the DON stated care plans need to be condition, and it was an interdisciplinary approach (a way of working where staff with different skills and expertise work together towards a common goal).
The DON stated a care plan was used to guide the team that provided care for residents.
The DON stated the care plan should include the specific manufacturer ' s guidelines on the resident ' s LALM because each manufacture ' s guideline was different.
The DON stated if care plans were not resident centered it could staff would not provide the appropriate care to residents.
A review of Med Aire Plus 10 ' Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System User Manual, indicated static button is available to discontinue alternation therapy for patient transfer, caregiving, comfort, or preference.
Static mode is pressed to set the system to static therapy mode.
The system will revert to the previous set alternation mode after 120 minutes.
A review of the current facility-provided policy and procedure titled, Safety of Residents, with last revised date of [DATE] indicated to provide a safe environment for resident and facility staff.
A review of the current facility-provided policy and procedure titled, Care Planning Interdisciplinary Team, with last revised date of [DATE] indicated Interdisciplinary Team is responsible for the development of an individualized comprehensive care plan for each resident. A comprehensive care plan for each resident is developed within seven (7) days of completion of the comprehensive assessment (MDS).
056056 08/09/2024
The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
During a concurrent interview and record review on 8/7/2024 at 3:14 p.m., Resident 3 ' s LALM 1 was the resident was being cared for.
The DON stated for Resident 3, CNA 1 needed to request a LVN or RN to change the setting from 300 lbs to static mode.
During a concurrent interview and record review on 8/7/2024 at 3:14 p.m., Resident 3 ' s LALM 1 was reviewed.
The DON stated when a resident was on LALM (in general), the static mode was used when the resident was being cared for.
The DON stated for Resident 3, CNA 1 needed to request a LVN or RN to change the setting from 300 lbs to static mode.
A review of Med Aire Plus 10 ' Alternating Pressure and Low Air Loss Bariatric Mattress Replacement System User Manual, indicated static button is available to discontinue alternation therapy for patient transfer, caregiving, comfort, or preference.
Static mode is pressed to set the system to static therapy mode.
The system will revert to the previous set alternation mode after 120 minutes.
A review of the current facility-provided policy and procedure titled, Safety of Residents, with last revised date of 7/25/2024 indicated to provide a safe environment for resident and facility staff.
During an interview on [DATE] at 11:15 a.m., Resident 5, who was Resident 3 ' s roommate and who was present when Resident 3 fell , stated on [DATE] at around 10 p.m., one staff (CNA 1) attempted to change Resident 3 ' s incontinent brief. Resident 5 stated the curtain between both beds was closed but she heard Resident 3 fall off the bed. Resident 5 stated the staff (CNA 1) rolled Resident 3 to change her incontinent brief. Resident 5 stated there was only one staff assisting Resident 3. Resident 5 stated Resident 3 ' s bed only had one upper small siderail and Resident 3 ' s bed was at the highest level. Resident 5 stated there were no landing mats (provide cushioned landing surface and reduce the likelihood of injury) next to Resident 3 ' s bed. Resident 5 stated Resident 3 fell on her face, near Resident 5 ' s bed.
056056
Form Approved OMB
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 08/09/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027
During an interview on [DATE] at 11:15 a.m., Resident 5, who was Resident 3 ' s roommate and who was present when Resident 3 fell , stated on [DATE] at around 10 p.m., one staff (CNA 1) attempted to change Resident 3 ' s incontinent brief. Resident 5 stated the curtain between both beds was closed but she heard Resident 3 fall off the bed. Resident 5 stated the staff (CNA 1) rolled Resident 3 to change her incontinent brief. Resident 5 stated there was only one staff assisting Resident 3. Resident 5 stated Resident 3 ' s bed only had one upper small siderail and (provide cushioned landing surface and reduce the likelihood of injury) next to Resident 3 ' s bed. Resident 5 stated Resident 3 fell on her face, near Resident 5 ' s bed.
During an interview on [DATE] at 12:14 p.m. with CNA 1, CNA 1 stated that around 9:30 p.m., on [DATE] she was about to provide care to Resident 3, and while standing on Resident 3 ' s right side, she elevated the resident ' s bed to the level of her waist high. CNA 1 stated she (CNA 1) was six feet tall, and the bed may have been about three feet off the ground. CNA 1 stated Resident 3 was lying on her back, and she rolled Resident 3 onto her left side, placed Resident 3 ' s hand on the handrail with CNA 1 ' s hands on Resident 3 ' s hip. CNA 1 stated she rolled the draw sheet under Resident 3, opened the incontinence brief tab (undergarment designed to absorb urine and it can be fastened at the hip), took the left hand off Resident 3 and Resident 3 let go of the handrail and fell face down. CNA 1 stated she did not request assistance from another staff before performing care and did not change the pressure on Resident 3 ' s LAL.
056056
Form Approved OMB
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 08/09/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027
Frequently Asked Questions
More Reports
Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.