LA Brea Rehab: Medication Safety Failures - CA
The nurse gave scheduled 9 a.m. medications on time but didn't document them until 12:32 p.m., when inspectors observed her sitting at the nursing station preparing to sign medication administration records for residents who had already received their drugs hours earlier.
"RN2 stated that she was supposed to sign the MAR right after administering the medication given to the resident," according to the inspection report. The facility's own policy requires that "administration of medication must be documented immediately after it is given."
The delayed documentation affected residents receiving critical medications including blood thinners, heart medications, and anti-seizure drugs. One resident received seven different medications through a feeding tube, including Lasix for fluid retention and Keppra for seizure control. Another got blood clot prevention medication Eliquis twice daily.
The Quality Assurance Nurse told inspectors the practice was "unacceptable."
Inspectors also discovered a cancer patient with rectal carcinoma and a colostomy had been repeatedly refusing basic care, but staff failed to create a required care plan to address the refusals. The resident needed moderate assistance with daily activities and had intact mental capacity to make decisions.
Multiple nursing assistants reported the refusals to charge nurses during both day and night shifts using the facility's "Stop and Watch" warning system. But no care plan materialized.
"When a resident refuses any care, the CNAs should notify the charge nurse and charge nurse must report to the MD and document via COC/CIC and start a care plan so they are able to monitor the resident's issue and plan a solution to assist the resident," the Director of Staff Development explained to inspectors.
The facility's own policy states that care plans must be updated when there are changes in a resident's condition, and refusals should be documented according to established protocols.
A third violation involved improper setup of a pressure-relieving mattress for a paralyzed diabetic resident with a bone infection. The resident weighed 149 pounds but staff had set the low air loss mattress for someone weighing 200 pounds.
The Treatment Nurse acknowledged the error during inspection, confirming the mattress "was supposed to be set according to Resident 4's current weight, not at 200 lbs."
The resident had paraplegia and needed assistance from one or two staff members for all daily activities. His medical assessment indicated he was at high risk for developing pressure ulcers and currently had an existing pressure ulcer requiring treatment.
A physician had specifically ordered the specialized mattress therapy for "treatment and management of pressure ulcer" with monitoring every shift. The facility's policy requires that individuals at risk for pressure ulcers be placed on redistribution support surfaces.
The Director of Staff Development confirmed that "LAL mattress should be set based on resident's weight."
All three violations received citations for minimal harm or potential for actual harm. The medication documentation failure affected "some" residents, while the missing care plan and mattress setup problems each affected "few" residents.
The 505 N. La Brea Avenue facility serves residents with complex medical conditions including cancer, diabetes, heart failure, multiple sclerosis, and paralysis. Many require feeding tubes, specialized equipment, and assistance with basic daily activities.
Federal inspectors completed their investigation on March 26, 2025, documenting systematic failures in medication safety protocols, care planning for residents who refuse treatment, and proper use of medical equipment designed to prevent serious complications.
The medication timing violations particularly concerned inspectors because accurate documentation is essential for preventing dangerous drug interactions, missed doses, and medication errors that can harm vulnerable residents dependent on multiple daily medications for life-threatening conditions.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for La Brea Rehabilitation Center from 2025-03-26 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
LA BREA REHABILITATION CENTER in LOS ANGELES, CA was cited for violations during a health inspection on March 26, 2025.
The nurse gave scheduled 9 a.m.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.