The Meadows On Sunset Post Acute
The Meadows on Sunset Post Acute in LOS ANGELES, CA — inspection on January 3, 2025.
Found 27 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 a review of the facility's recent policy and procedure (P&P) titled Accommodation of Needs, last reviewed on 12/4/2024, the P&P indicated the resident/patient (hereinafter patient) has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
During a concurrent observation and interview on 12/31/2024 at 10:30 a.m. with the Administrator (Adm), the Adm verified Resident 402's right floor mat was damaged, and the top cover was stripped of at least 3 inches and the foam exposed.
The Adm stated residents should be provided with a safe, clean, and homelike environment while residing in the facility.
The Adm stated the staff should have notified the maintenance department to change the floor mat as the damaged floor mat does not provide a safe, clean, comfortable, and homelike environment for the resident while in the facility which can affect their well-being.
During a review of the facility's policy and procedure (P&P) titled, Accommodation of Needs, last reviewed 12/4/2024, the P&P indicated the resident has the right to a safe, clean, comfortable, and homelike environment including, but not limited to, receiving treatment and support for daily living safely.
The P&P further indicated: - The facility's physical environment and staff behaviors should be directed toward assisting the resident in maintaining and/or achieving independent functioning, dignity, and wellbeing to the extent possible in accordance with the patient's own needs and preferences. - The facility ensures that the resident receive care and services safely and that the physical layout of the facility maximizes patient independence and does not pose a safety risk.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
restraint.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
discharged at the time of discharge.
Knowing the setting to which the individual was discharged helps
minimal harm orders for documentation of the discharge location.
Select the two-digit code that corresponds to the resident's discharge status.
Code 01: for home/community discharge to a private home, apartment,
illness or intellectual disability, the PASARR must be completed prior to admission.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
provide effective and person-centered care of the resident that meet professional standards of quality
- 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.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
timetables to meet the resident's medical, physical, mental, and psychosocial needs shall be
in the resident's functional status and/or functional levels.
The comprehensive CP includes the
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.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
lipodystrophy and localized cutaneious amyloidosis.
The manufacturer's guideline further indicated a
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
During an interview with the DON, on 1/3/2025, at 2:40 p.m., the DON stated smoking material should
resident.
The DON stated if the residents refuse and are noncompliant with storing their smoking materials, the facility will have a care plan and conduct an assessment to store the smoking material safely at the bedside.
The DON further stated it is important to secure smoking material safely for fire safety and prevent other residents from taking the smoking material and potentially putting themselves at risk for harm.
During a review of the facility's P&P titled, Smoking, last reviewed 12/4/2024, the P&P indicated the interdisciplinary team (IDT) will develop an individualized plan for safe storage, use of smoking materials, assistance and required supervision, if necessary for residents who smoke.
The P&P further indicated it will be documented on the Resident Smoking Evaluation, the resident's plan of care, and discussed with the resident and responsible party at resident care conference meetings.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
During an interview on 1/3/2024 at 3 p.m. with the Director of Nursing (DON), the DON stated the practice for urinary catheter care is the placement of a securement device.
There should be no kinks or loops.
The drainage bag should not touch the floor and should be placed below the bladder.
The DON stated the staff should have applied a catheter securement device and repositioned the bag to prevent the loop or kink while hanging on the side of the bed.
The DON stated not applying the securement device can cause prevent accidental pulling or trauma, and the urine would be unable to flow freely with the presence of loop or kink on the tubing which may lead to development of UTI or recurrent UTIs on Resident 129.
During a review of the facility's policy and procedure (P&P) titled, Catheter: Indwelling Urinary - Care of, last reviewed 12/4/2024, the P&P indicated to secure catheter tubing with catheter securement device to keep the drainage bag below the level of the patient's bladder and off the floor.
The P&P further indicated to position catheter for straight drainage and keep catheter and tubing free from kinks, and allow slack in catheter so that movement does not create tension.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
During a concurrent observation and interview on 12/31/2024, at 10:58 a.m., with Licensed Vocational Nurse 3 (LVN 3), while inside Resident 104's room, Resident 104's feeding tube was observed to be disconnected and hanging on the feeding pump pole (a vertical pole that can hold a feeding pump and its power cord) without a cap to cover the tip of the tube feeding. LVN 3 stated the feeding tube tip should be covered with a cap when disconnected to the resident to prevent gastrointestinal infection to set in on the resident.
During an interview on 1/3/2025, at 9:30 a.m., with Registered Nurse 2 (RN 2), RN 2 stated the tube feeding should not be disconnected to the resident for stopping the feeding. RN 2 stated the tube feeding only gets disconnected when the resident needed to get a bath or going for ambulation. RN 2 stated if the tube feeding should be disconnected from the resident, it has to be capped to prevent infection to the resident.
During an interview on 1/3/2025, at 2:55 p.m., with the Director of Nursing (DON), the DON stated the feeding tube should not be disconnected to the resident when stopping the feeding.
The DON stated when the resident needed to be disconnected from the tube feeding, such as during bathing or ambulating the resident, the feeding tube tip should be covered with a cap to prevent infection to the resident.
The DON stated leaving the feeding tube tip open without any cover on exposes the tip for entry of harmful organisms such as bacteria.
During a review of the facility's recent policy and procedure (P&P) titled Enteral Feeding: Administration by Pump, last reviewed on 12/4/2024, the P&P indicated to disconnect feeding according to ordered scheduled (e.g., Bolus scheduled, intermittent schedule, cyclic schedule, downtime for continuous schedule). -Close clamp on administration set and disconnect from enteral tube. -Cover end of administration set with a plug or cap.
During a review of the facility's recent policy and procedure (P&P) titled Infection Prevention and Control Program Description, last reviewed on 12/4/2024, the P&P indicated the infection prevention and control program (IPCP) is a set of comprehensive processes that addresses preventing, identifying, reporting, investigating and controlling of infections and communicable diseases for patients/residents (hereinafter patient), staff, volunteers, visitors, and other individuals providing services under a contractual agreement.
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.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
During a review of the undated facility-provided Sanitizing Cap 1 (SC 1) (Disinfecting Cap Strip for Needleless Connectors) user information, undated, the user information indicated SC 1 Disinfecting cap is intended for use on needleless connectors only as a disinfecting cleaner prior to I.V.
Access and to act as a cover between line accesses.
The cap will disinfect the needleless connector one (1) minute after application and protect from contamination between accesses for up to seven (7) days if not removed.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
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.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
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.
- 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 (5) quantity of the medication remaining (6) signature of nurse administering medication.
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According to prescriber's orders
- The Center will consider factors indicating errors in medication administration including, but not
limited to: 2.1 Medication administered not in accordance with prescriber's order.
Examples include, but are not limited to: 2.1.1 Incorrect dose 2.1.2 Incorrect medication
- 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.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
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[TRUNCA
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
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.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
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.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
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: - 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 ensure that the patient's needs are met 24 hours per day. - Delineation of the hospice's responsibilities including nursing care and all other hospice services that are 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.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
reviewed 12/4/2024, the P&P indicated the Infection Prevention and Control Program (IPCP) is a set
other individuals providing services.
The IPCP has been developed to provide staff with technical
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.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
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.
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The Meadows on Sunset Post Acute 5154 Sunset Blvd Los Angeles, CA 90027
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.
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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.
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NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Brier Oak on Sunset 5154 Sunset Blvd Los Angeles, CA 90027
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.
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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 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
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.
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 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
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.
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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 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
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:
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 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
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], and readmitted the resident on [DATE], 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], 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], 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] 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] 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] Insulin Glargine SQ Solution 100 unit/ml (Insulin Glargine).
Inject 50 unit SQ at bedtime for DM.
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 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
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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.