The resident, who has rectal cancer and a colostomy, had been refusing basic care during both day and night shifts. Two certified nursing assistants told federal inspectors they had notified charge nurses about the refusals using the facility's "Stop and Watch" warning system.
But when inspectors reviewed the resident's medical record in March, they found no documentation of the multiple episodes.
The resident was originally admitted to the facility and later readmitted with diagnoses including rectal carcinoma, colostomy, and mobility problems. A December assessment showed the resident had intact cognition for daily decision-making but needed moderate assistance with activities like bed mobility, transfers, eating, walking, dressing, toileting and personal hygiene.
Certified Nursing Assistant 3 told inspectors during a March 25 interview that the resident "had been refusing basic care" and that she had notified the charge nurse through the facility's warning system.
Another nursing assistant working the night shift confirmed the pattern. Certified Nursing Assistant 4 said the resident "had also been refusing basic care during the night shift" and that he too had notified the charge nurse.
The Director of Staff Development acknowledged the problem during her interview with inspectors. She confirmed that the resident "had multiple episodes of refusals of care and was made aware by the CNAs."
She explained the facility's protocol: "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 so they are able to monitor the resident's issue."
COC/CIC refers to the facility's documentation system for changes in a resident's condition or status.
But none of that documentation happened.
The Quality Assurance Nurse confirmed the missing paperwork during her March 25 interview. She told inspectors there was "missing documentation with Resident 1's refusals of basic care" and acknowledged that "a COC/CIC documentation must be done for any refusals of care."
The facility's own policy, reviewed in December 2024, requires staff to "promptly notify the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and/or status."
Federal inspectors cited the facility for failing to develop and implement a comprehensive care plan based on the resident's individual needs. Specifically, they found staff failed to ensure the resident's episodes of care refusal were incorporated into care planning.
The violation had "the potential to result negative impact on Resident 1's health and safety, as well as the quality of care and services received," according to the inspection report.
For a resident with rectal cancer and a colostomy who needs moderate assistance with basic activities, refusing care presents serious health risks. Without proper documentation and care planning, staff cannot track patterns, identify triggers, or develop strategies to address the refusals.
The nursing assistants had done their jobs by reporting the refusals through the facility's warning system. But the breakdown occurred at the supervisory level, where charge nurses failed to document the episodes or notify the resident's doctor as required by facility policy.
The inspection was conducted in response to a complaint. Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents.
LA Brea Rehabilitation Center, located on North La Brea Avenue, serves residents requiring skilled nursing and rehabilitation services. The facility must now develop a plan to correct the documentation and care planning failures identified during the March inspection.
The case illustrates how communication breakdowns between direct care staff and supervisors can leave vulnerable residents without proper monitoring and intervention, even when frontline workers identify problems and follow reporting protocols.
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
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