La Brea Rehabilitation Center: Pressure Ulcer Care Failure - CA
The finding came during a March 2025 inspection of La Brea Rehabilitation Center, a nursing facility at 505 N. La Brea Avenue. Federal inspectors cited the facility for failing to provide care consistent with the resident's needs and professional standards of care.
The resident, identified in inspection records only as Resident 4, had been admitted to the facility with paraplegia, diabetes, and osteomyelitis, a serious infection of the bone. His assessment indicated he was moderately impaired in cognitive decision-making and required one or two staff members to assist him with basic daily activities, including moving in bed, transfers, dressing, and personal hygiene. He weighed 149 pounds as of March 2024.
A physician had ordered a low air loss mattress, known as an LAL mattress, for the treatment and management of his pressure ulcer. The order was documented in November 2024. The mattress works by continuously circulating air to reduce sustained pressure against the skin, a critical function for someone who cannot reposition himself and already has damaged tissue.
When inspectors observed the mattress on the morning of March 25, 2025, it was set to 200 pounds.
The treatment nurse present during that observation confirmed it immediately. She stated the mattress was supposed to be calibrated to the resident's actual weight, not 200 pounds. The Director of Staff Development, interviewed that same afternoon, said the same thing: the setting should be based on the resident's weight.
There is no ambiguity in what the wrong setting means for this resident. Pressure ulcers form when sustained pressure cuts off blood flow to tissue, causing it to break down. LAL mattresses are designed to counteract that process precisely, but only when calibrated correctly. Set too high, the mattress firms up, defeating its purpose. For a man with paraplegia who cannot feel the warning signals that would prompt a person to shift position, and who is already managing an open wound and a bone infection, the margin for error is narrow.
The inspection report does not say how long the mattress had been set incorrectly. The physician's order was dated November 13, 2024. Inspectors arrived in late March 2025. That is more than four months during which the order was in place and, based on what inspectors observed, not being followed.
The facility's own written guidelines, reviewed in December 2024, stated that anyone at risk for developing pressure ulcers should be placed on a redistribution support surface. Resident 4 was not just at risk. He already had a pressure ulcer. He had a physician's order specifically addressing it. And the device meant to carry out that order was not working as intended.
Inspectors classified the violation as causing minimal harm or potential for actual harm, the lower end of the federal harm scale. The deficiency affected one of three residents whose records were reviewed during the inspection.
The inspection report does not describe the current state of Resident 4's wound, whether it had worsened during the period the mattress was miscalibrated, or what the facility did after inspectors flagged the problem on March 25. It does not say whether anyone had checked the mattress setting during the routine shift monitoring the physician had also ordered.
What it does say is that when an inspector and a treatment nurse stood in Resident 4's room together and looked at the number on the mattress, the nurse confirmed on the spot that it was wrong.
Resident 4 remains in the facility, paralyzed from the waist down, unable to move himself off a surface that was not, until that moment, doing what his doctor ordered it to do.
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: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
LA BREA REHABILITATION CENTER in LOS ANGELES, CA was cited for violations during a health inspection on March 26, 2025.
The finding came during a March 2025 inspection of La Brea Rehabilitation Center, a nursing facility at 505 N.
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.