The Meadows On Sunset Post Acute
The Meadows on Sunset Post Acute in LOS ANGELES, CA — inspection on January 3, 2025.
Found 6 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 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.
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 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.
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 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.
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, 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