The Meadows on Sunset Post Acute

In the surveyor’s words

From the most serious findings on record at The Meadows on Sunset Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF689Aug 25, 2022

  Based on observation, interview, and record review the facility failed to ensure residents ' safety through effective monitoring, supervision, assessment, and reassessments for three of three sampled residents (Resident 1, Resident 2, and Resident 3), who the facility permitted to go out on pass (OOP) on multiple occasions by failing to: 1. Obtain a Physician ' s Order for residents to go Out on Pass (OOP) under the supervision of a facility staff member. Resident 1 who had moderately impaired cognition (a decline in mental ability to make decisions of daily living), had diagnoses that included psychoactive substance abuse (dependence on substances that, when taken in or administered into one's system, affect mental processes, e.g. […]

• Immediate jeopardy, isolatedF684Oct 10, 2025

  Based on interview and record review, the facility failed to ensure that one of three sampled residents (Resident 1), who had moderately impaired cognition (a noticeable decline in thinking, memory, and judgment that is more significant than normal aging but does not prevent the resident from performing most daily tasks), bed-bound (unable to leave the bed due to illness or weakness), dependent on staff for activities of daily living (ADLs - activities such as bathing, dressing, and toileting a person performs daily), and was receiving Porcine Heparin injection (a powerful anticoagulant [blood thinner] medication used to prevent and treat blood clots that increases the risk of bleeding), was provided the necessary care and services in accordance with professional standards of practice when… […]

• Immediate jeopardy, isolatedF656Aug 9, 2024

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan (is a form that summarizes a person ' s health conditions and current treatments for their care)for one of six sampled residents (Resident 3), who was dependent (helper does all the effort or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff on personal hygiene and diagnosed with muscle weakness (generalized), morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health) and paraplegia (the inability to voluntarily move the lower parts of the body), by failing to: 1. […]

• Immediate jeopardy, isolatedF689Aug 9, 2024

  Based on interview and record review, the facility failed to ensure one of six residents (Resident 3), who was dependent (helper does all the effort or the assistance of 2 or more helpers is required for the resident to complete the activity) on staff on personal hygiene with diagnosis of muscle weakness (generalized), morbid (severe) obesity (abnormal or excessive fat accumulation that presents a risk to health) and paraplegia (the inability to voluntarily move the lower parts of the body), was free from accidents, by failing to: 1. Provide Resident 3 with the needed two-person assistance when Certified Nursing Assistant 1 (CNA 1), with no assistance from another staff, was giving nursing care to Resident 3 on [DATE]. 2. […]

• Immediate jeopardy, isolatedF684Nov 3, 2022

  Based on interview and record review, the facility to ensure one of three sampled residents (Resident 1), who was newly admitted to the facility, was diabetic (a group of diseases that affect how the body uses blood sugar [glucose]) and needed blood sugar level monitoring for insulin (preparation of the protein hormone insulin that is used to treat high blood glucose) administration, received care and treatment to meet Resident 1's needs. The facility failed to ensure: 1. Registered Nurse 1 (RN 1- admitting nurse) thoroughly reviewed the admission inquiry report and General Acute Care Hospital 1 (GACH 1) for Resident 1, during Resident 1's admission process to the facility. 2. RN 1 verified Resident 1's admitting diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . 3. […]