The Meadows On Sunset Post Acute

F 0679

Provide activities to meet all resident's needs.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, and record review, the facility failed to implement its activities program for one of seven sampled residents (Resident 2) when on 11/18/2025 at 2 p.m. the resident activity room was observed closed with no activities being held, when the facility activities calendar indicated on 11/18/2025 at 2 p.m., Crossword Club, would be held. This deficient practice had the potential to negatively affect Resident 2. Findings: During a review of Resident 2's admission Record (AR), the AR indicated the facility admitted Resident 2 on 6/1/2022 and readmitted the resident on 1/19/2024 with diagnosis that included essential (primary) hypertension (HTN-high blood pressure), muscle weakness (generalized), and major depressive disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest).

During a review of Resident 2's Minimum Data Set (MDS - a resident assessment tool), dated 10/2/2025,

the MDS indicated Resident 2 had the ability to understand and be understood. During an interview on 11/18/2025 at 1 p.m. with Resident 2, Resident 2 stated was told during the resident council meeting that

the facility would be doing a weekly calendar for the remainder of the month and for December would have

a full calendar of activities. Resident 2 stated the facility still had the October calendar posted in her (Resident 2) room. Resident 2 stated there was no activities today (11/18/2025). Resident 2 stated she would like some sort of activity as she enjoys participating and interacting with all the other residents.

During a concurrent observation and interview on 11/18/2025 at 2 p.m. with Licensed Vocational Nurse (LVN) 2, observed the resident activity room was closed and upon entering the activity room it was empty with no residents and staff noted. LVN 2 stated was not sure who was running the activities but there were no activities and LVN 2 stated did not see anyone in the activity room. During an interview on 11/18/2025 at 4:33 p.m. with Activities Staff (AS) 1, AS 1 stated being the receptionist this morning. AS 1 stated there were no activities at 2 p.m. for the residents today. During an interview on 11/18/2025 at 4:58 p.m. with the Director of Staff Development (DSD), the DSD stated if the facility scheduled activities for residents, but the facility did not do the activities, the facility failed to fulfill residents' expectations. The DSD stated the facility failed to provide the services to the residents and would not be meeting the residents' needs. During a

review of the Facility Policy and Procedure (P&P) titled, Program Design, last reviewed on 7/31/2025, the P&P indicated an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well of each patient, encouraging both independence and interaction in

the community.5. Programs will be scheduled seven days a week. During a review of the Facility P&P titled, Resident's/Patient's Choice, last reviewed on 7/31/2025, the P&P indicated residents have the right to participate or not participate in leisure and recreation of their choosing. 2. Resident will be informed of activities and programs through: 2:1 Posted Calendar

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

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

Facility ID:

If continuation sheet

Event ID:

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

11/18/2025

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 0698 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

immediately with any urgent problem, left upper chest HD catheter, and to monitor external hemodialysis catheter and siter for catheter integrity, excessive redness, swelling, pain at site, sign and symptoms of infection and excessive bleeding from site and report to physician as indicated. During a review of Resident 3's Order Summary dated, 6/29/2025, the Order summary indicated monitor hemodialysis site for sign and symptoms of complication (e.g. bleeding, swelling, pain, drainage, odor, hardness, or redness at site). Notify

the physician and dialysis center immediately with any urgent problem every shift. During a review of Resident 3's Order Summary, dated 7/24/2025, the Order summary indicated hemodialysis on Monday, Wednesday, and Friday at 8 a.m. During a review of Resident 3's MDS, dated [DATE REDACTED], the MDS indicated Resident 2 had the ability to understand and be understood. During a review of Resident 3's HCR dated 11/3/2025, the HCR indicated post dialysis assessment with no vital signs documented and no assessment of access site. During a review of Resident 3's HCR dated 11/14/2025, the HCR indicated post dialysis assessment, no indication of vitals documented and no assessment of access site. During a concurrent

interview and record review on 11/18/2025 at 4:58 p.m. of Resident 1 and Resident 3's HCR with the Director of Staff Development (DSD), the DSD stated dialysis residents have a communication binder and upon returning from dialysis the residents nurse must check vital and the residents' dialysis sites and document on the communication binder upon the residents' return. The DSD reviewed Resident 1's HCR dated 11/10 2025 and 11/17/2025 and the DSD stated the post assessment was not done, can be a potential for the residents to not be stable and the facility would not know, and can be a potential for a delay

in care. The DSD reviewed Resident 3's HCR dated 11/3/2025 and 11/14/2025 and stated the post assessment was also not done. During a review of the Facility Policy and Procedure (P&P) titled, Dialysis: Hemodialysis (HD) Provided by a Certified End Stage Renal Disease (ESRD) Facility, last reviewed on 7/31/2025, the P&P indicated ongoing assessment of the patient's condition and monitoring for complications before and after HD treatment received as a certified ESRD facility. Ongoing assessment and oversight of the patient before and after HD treatments, include monitoring for complications, implementing appropriate interventions, and using appropriate infection control practices; and ongoing communication and collaboration with the certified ESRD facility regarding HD care and services.1.5 After receiving dialysis, Center staff must provide monitoring and documentation of: 1.5.1 The patient's vascular access site to observe for bleeding or other complications. 1.5.2 Vital signs. 1.5.3 post-dialysis complications, symptoms including, but not limited to, dizziness, nausea, vomiting, fatigue, or hypotension.

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

11/18/2025

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

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

the time frames for the rest of the other medications. LVN 2 stated she did not get access for medications till 8 a.m. During an interview on 11/18/2025 at 2:29 p.m. with Resident 6, Resident 6 stated he was waiting for pills has not gotten any medication and is currently has pain of 8 out 10 (0-10 scale, 0 is no pain and 10 is the worst pain imaginable). During an interview on 11/18/2025 at 4:23 p.m. with the Director of Staff Development (DSD), the DSD stated was notified today medications were late and/or not given. The DSD reviewed Resident 4, Resident 5 and Resident 6's medications and stated the medications were late. LVN 2 stated she would notify the doctor of the medication being given late. The DSD stated medications can be given one hour prior of one hour after the ordered time. The DSD stated if medications are not given as prescribed for example if it is for pain the resident can be in pain and can result in a negative reaction for

the resident and their health if the medication is for high blood pressure or high blood sugar. During a

review of the Facility Policy and Procedure (P&P) titled, Medication and Administration-General Guidelines, last reviewed on 7/31/2025, the P&P indicated medications are administered as prescribed in accordance with good nursing principles and practices.2. Medications are administered in accordance with written orders of the attending physician.10. Medications are administered within 60 minutes of scheduled time (1 hour before and 1 hour after), except before or after meal orders, which are administered based on mealtimes. Unless otherwise specified by he prescriber, routine medication are administered according to

the established medication administration schedule for the facility.

Event ID:

Facility ID:

If continuation sheet