A list of the most recent deficiencies for Brier Oak On Sunset. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-12-29 | 2024-01-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2023-12-29 | 2024-01-26 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2023-12-29 | 2024-01-26 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2023-12-29 | 2024-01-26 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-12-29 | 2024-01-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-12-29 | 2024-01-26 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-12-29 | 2024-01-26 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-12-29 | 2024-01-26 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2023-12-29 | 2024-01-26 | N |
| Post nurse staffing information every day. | Health | 2023-12-29 | 2024-01-26 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-12-29 | 2024-01-26 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-12-29 | 2024-01-26 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-12-29 | 2024-01-26 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2023-12-29 | 2024-01-26 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-12-29 | 2024-01-26 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2024-01-04 | 2024-01-26 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2024-01-04 | 2024-01-26 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2024-01-04 | 2024-01-26 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-04 | 2024-01-26 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-04 | 2024-01-26 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-04 | 2024-01-26 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-04 | 2024-01-26 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-04 | 2024-01-26 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-07 | 2023-09-06 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-07 | 2023-09-06 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-08-07 | 2023-09-06 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-07 | 2023-09-06 | Y |
| Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Health | 2023-08-07 | 2023-09-06 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-08-07 | 2023-09-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-22 | 2023-06-21 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-04-06 | 2023-05-02 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-04-06 | 2023-05-02 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-04-06 | 2023-05-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-04-06 | 2023-05-02 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-03-25 | 2023-04-25 | Y |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-04-07 | 2023-04-20 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-01-26 | 2023-02-23 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-03 | 2023-02-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-02-08 | 2023-02-20 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-22 | 2023-02-10 | Y |
| Allow residents to self-administer drugs if determined clinically appropriate. | Health | 2023-01-12 | 2023-02-09 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-01-12 | 2023-02-09 | N |
| The resident has the right to receive notices in a format and a language he or she understands. | Health | 2023-01-12 | 2023-02-09 | N |
| Allow residents to easily view the nursing home's survey results and communicate with advocate agencies. | Health | 2023-01-12 | 2023-02-09 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2023-01-12 | 2023-02-09 | N |
| Ensure each resident receives an accurate assessment. | Health | 2023-01-12 | 2023-02-09 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-01-12 | 2023-02-09 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-12 | 2023-02-09 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-01-12 | 2023-02-09 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-01-12 | 2023-02-09 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-01-12 | 2023-02-09 | N |
| Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. | Health | 2023-01-12 | 2023-02-09 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2023-01-12 | 2023-02-09 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-01-12 | 2023-02-09 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2023-01-12 | 2023-02-09 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-02-09 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-12 | 2023-02-09 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-01-18 | 2023-02-09 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-28 | 2022-12-09 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-03 | 2022-12-07 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-11-03 | 2022-12-07 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-11-03 | 2022-12-07 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-11-03 | 2022-12-07 | Y |
| Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care. | Health | 2022-11-03 | 2022-12-07 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-11-03 | 2022-12-07 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-11-03 | 2022-12-07 | Y |
| Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. | Health | 2022-11-03 | 2022-12-07 | Y |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2022-09-29 | 2022-10-10 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-21 | 2022-10-10 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-09-21 | 2022-10-10 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-22 | 2022-10-07 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-09-20 | 2022-09-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-25 | 2022-09-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-08-23 | 2022-09-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-08-17 | 2022-09-14 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2022-08-17 | 2022-09-14 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-17 | 2022-09-14 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-08-03 | 2022-09-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-08-04 | 2022-08-28 | Y |
| Ensure that each resident is free from medications that restrain them, unless needed for medical treatment. | Health | 2022-08-02 | 2022-08-28 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-08-02 | 2022-08-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-07-16 | 2022-08-15 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-07-02 | 2022-08-05 | Y |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2022-06-24 | 2022-07-29 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-21 | 2022-05-27 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-05-18 | 2022-05-27 | Y |
| Ensure the facility is licensed under applicable State and local law and operates and provides services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards. | Health | 2022-04-25 | 2022-05-05 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-04-05 | 2022-04-13 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-03-04 | 2022-03-16 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-02-12 | 2022-02-28 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-02-12 | 2022-02-28 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-01-17 | 2022-01-31 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-01-04 | 2022-01-28 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-09-30 | 2021-10-13 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-08-07 | 2021-08-18 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-14 | 2021-05-27 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-04-18 | 2021-04-27 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2021-04-13 | 2021-04-23 | Y |
| Address patient/client population and determine types of services needed. | Fire Safety | 2019-09-18 | 2019-10-11 | N |
| Provide rooms that can be unlocked from inside without a key. | Fire Safety | 2019-09-18 | 2019-10-11 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2019-09-18 | 2019-10-11 | N |
| Install proper backup exit lighting. | Fire Safety | 2019-09-18 | 2019-10-11 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-09-18 | 2019-10-11 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-09-18 | 2019-10-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2019-09-18 | 2019-10-11 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-09-18 | 2019-10-11 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-09-18 | 2019-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-09-10 | 2019-10-04 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-09-10 | 2019-10-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-09-10 | 2019-10-04 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-09-10 | 2019-10-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-09-10 | 2019-10-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-09-10 | 2019-10-04 | N |
