The Meadows On Sunset Post Acute

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

review on 10/10/2025 at 2:33 p.m., with the Director of Nursing (DON), Resident 1's Care Plans dated 9/26/2025 was reviewed. The DON stated there was no care plan created to address Resident 1's refusal to have blood drawn for CBC STAT. The DON stated that Resident 1 should have a care plan for refusal of blood to be drawn for CBC STAT to identify interventions to address Resident 1's refusal.During a review of

the facility policy and procedure titled, Care Plan - Baseline, last review date of 9/11/2025, the policy and procedure indicated, A baseline care plan each resident that includes the 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 by the Interdisciplinary Team (IDT).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Notes, dated 12/5/2025 to 12/9/2025, were reviewed. The IP stated during the review of Resident 6's progress notes there was no monitoring after Resident 6's change in condition on 12/8/2025 morning shift, and 12/9/2025 night shift. The IP stated it was important to monitor Resident 6's condition to make sure Resident 6's skin condition will not get worse and to make sure that there was no delay of care for Resident 6.During an interview with the Director of Nursing (DON) on 12/10/2025 at 11:51 a.m., the DON stated that

the staff needs to monitor Resident 4, Resident 5, and Resident 6's condition to make sure their condition would not decline. The DON stated it is possible that the physician will not be notified timely for any changes in residents conditions and could cause a delay in providing care. During a review of the facility's policy and procedure (P&P) titled, Change in Condition: Notification of, last reviewed 7/31/2025, the P&P indicated, To provide appropriate and timely information about changes relevant to patient's condition.During a review of the facility's P&P titled, Nursing Documentation, last reviewed 7/31/2025, the P&P indicated, Nursing documentation will follow the guidelines of good communication and be concise, clear, pertinent, and accurate based on the resident's/patient's (hereinafter patient) condition, situation, and complexity. To communicate patient's status and provide complete, comprehensive, and accessible accounting of care and monitoring provided.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

records as approximately 30 cc. RN 2 stated that the 30 cc referred to the amount of stool collected for the occult blood test, not the amount of blood observed. RN 2 stated that according to facility policy, if a COC occurs, staff are required to notify the physician immediately. If there is no callback, the staff must follow up every 15 minutes, up to four times, and if the physician still does not respond, staff must notify the facility's Medical Director but failed to do. During a concurrent interview and record review on 10/3/2025 at 11:42 a.m., with Registered Nurse 5 (RN 5), Resident 1's Laboratory Results Report, dated 9/27/2025, Resident 1's Physician's Order dated 9/26/2025 and Resident 1's Progress Notes (from 9/26/2025 to 9/27/2025) were reviewed. RN 5 stated that the occult blood test result was positive. RN 5 stated that Resident 1's stool sample was collected on 9/26/2025 at 3:00 p.m., received by the laboratory on 9/27/2025 at 8:11 a.m., and the result was reported via the facility's computer system at 11:48 a.m. on 9/27/2025. RN 5 stated that Resident 1's Physician's Order dated 9/26/2025 indicated the occult blood stool test was STAT, meaning the result should have been available within four to six hours of specimen collection. RN 5 stated that the laboratory did not receive Resident 1's stool sample specimen until 9/27/2025 at 8:11 a.m., 17 hours and 11 minutes after collection, and the final result was released on 9/27/2025 at 11:48 a.m., 20 hours and 48 minutes after the stool sample specimen was picked up. RN 5 stated that because the order was STAT, the licensed nurse should have followed up with the laboratory and notified Resident 1's physician (MD 1) when results were delayed. RN 5 also stated that RN 4 entered a late entry on 9/28/2025 at 2:25 p.m. (the day after Resident 1's death) in the Progress Notes for 9/27/2025 at 4:20 p.m., indicating that RN 4 notified NP 1 of the positive

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

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 potential for actual harm

Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from significant medication errors by failing to ensure the physician orders were followed. The facility failed to ensure Resident 1's metoprolol oral tablet (a medication, taken by mouth, used to treat high blood pressure) 25 milligrams (mg - unit of measurement) was not administered for systolic blood pressure (SBP - the pressure in the arteries when the heart beats) of less than 110 or heart rate (HR) of less than 60 beats per minute (bpm) on multiple dates.This deficient practice placed Resident 1 at risk for inadequate blood pressure management which can cause hypotension (low blood pressure) and irregular heartbeat.Findings: During a review of Resident 1's admission Record (undated), the admission Record indicated the facility admitted Resident 1 on 7/22/2025 with diagnoses including metabolic encephalopathy (an alteration in consciousness due to brain dysfunction), type 2 diabetes mellitus (a chronic condition that affects the way the body processes blood sugar [glucose]), and essential hypertension (an abnormally high blood pressure that was not a result of a medical condition). During a review of Resident 1's Physician Orders, dated 7/22/2025, the Physician Orders indicated metoprolol oral tablet 25 mg, to give 0.5 tablet two times a day for hypertension. The Physician Orders indicated to hold metoprolol medication for SBP of less than 110 or HR of less than 60 bpm. During a review of Resident 1's Minimum Data Set (MDS - a resident assessment tool), dated 7/29/2025, the MDS indicated Resident 1's cognition (refers to conscious mental activities including thinking, reasoning, understanding, learning, and remembering) was moderately impaired. During a review of Resident 1's Physician Orders, dated 9/24/2025, the Physician Orders indicated metoprolol oral tablet 25 mg, to give 0.5 tablet two times a day with food for hypertension. The Physician Orders indicated to hold metoprolol medication for SBP of less than 110 or HR of less than 60 bpm. During an interview on 10/6/2025 at 8:45 a.m. and a concurrent record review of Resident 1's Medication Administration Record (MAR), dated 9/1/2025 to 9/30/2025, reviewed with Licensed Vocational Nurse (LVN) 5, LVN stated Resident 1's metoprolol had parameters to hold for SBP of less than 110 or HR of less than 60 bpm. Resident 1's metoprolol was given outside the parameters on the following dates:a. 9/1/2025 at 9 p.m. for HR of 59 bpm.b. 9/4/2025 at 9 p.m. for SBP of 98.c. 9/10/2025 at 9 p.m. for SBP of 108.d. 9/15/2025 at 9 p.m. for SBP of 96.e. 9/16/2025 at 9 p.m. for SBP of 107.f. 9/18/2025 at 9 p.m. for SBP of 102.g. 9/20/2025 at 9 p.m. for SBP of 108.h. 9/23/2025 at 9 p.m. for SBP of 108.i. 9/24/2025 at 9 p.m. for SBP of 108.LVN 5 stated Resident 1's blood pressure had the potential to drop low and cause the resident to experience serious conditions that may lead to death. During an interview on 10/8/2025 at 4 p.m. with the Director of Nursing (DON), the DON stated medications should be administered within the physician order's parameters. The DON stated Resident 1's metoprolol was administered while the resident's SBP or HR were below the ordered medication parameters. The DON stated Resident 1's blood pressure had the potential to drop and cause less tissue perfusion to other organs. The DON stated the facility failed to ensure Resident 1's medication was administered as ordered by the physician. During a

review of the facility-provided policy and procedure (PnP) titled, Medication Administration-General Guidelines, last reviewed on 7/31/2025, the PnP indicated Personnel authorized to administer medications do so only after they have familiarized themselves with the medication. The PnP indicated Medications are administered in accordance with written orders of the attending physician.

Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/10/2025

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 potential for actual harm

Based on observation, interview, and record review, the facility failed to ensure the facility staff were wearing proper personal protective equipment (PPE - equipment worn to minimize exposure to hazards that cause serious workplace injuries and illnesses) when changing resident who were in Enhance Barrier Precautions (EBP - infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs - germs that have become so tough they shrug off most common medicines (antibiotics) designed to kill them, making infections much harder to treat) for one of eight sample residents (Resident 2).This deficient practice had the potential to spread infections and illnesses among residents and staff. Findings: During a review of Resident 2's admission Record, the admission Record indicated the facility admitted Resident 2 on 4/21/2023 with diagnoses including Huntington's Disease (inherited brain disorder where nerve cells progressively break down, causing uncontrollable jerky movement, severe personality changes, impaired judgment, and decline in thinking, memory, and reasoning, eventually leading to inability to walk, talk or care for oneself) and hemiplegia (severe weakness on one side of your body).During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/28/2025, the MDS indicated Resident 2 thought process was intact and was dependent on assistance from staff to complete activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily).During a review of Resident 2's Physician's Orders, dated 5/6/2025, the Physician's Order indicated to provide EBP due to urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) every shift.During a concurrent observation, interview, and record review on 12/10/2025 at 10:53 a.m. with the Infection Prevention (IP) Nurse, observed CNA 1 did not wear a gown while providing care to Resident 2. The facility's policy and procedure (P&P) titled, Enhance Barrier Precautions, dated 11/14/2025, was reviewed. IP Nurse stated that CNA 1 was not wearing gown while changing Resident 2.

The IP Nurse stated that CNA 1 should wear a gown while changing Resident 2. The IP Nurse stated according to the facility's EBP P&P indicated during a high contact with the resident, staff must wear a gown when changing the resident.During an interview on 12/10/2025 at 11:51 a.m. with the Director of Nursing (DON), the DON stated that the staff should wear a gown and gloves when changing residents with EBP because the staff and residents are at high risk of exposure to infection.During a review of the facility P&P titled, Enhance Barrier Precautions, last reviewed 11/14/2025, the P&P indicated, EBP expands on

the use of gown and gloves beyond anticipated blood and body fluid exposures, focusing on use of gown and gloves only during high contact patient care activities that have been demonstrated to result in transfer of MDROs to hands and clothing of healthcare personnel, even if blood and body exposure is not anticipated.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet