La Brea Rehabilitation Center: Care Refusal Failures - CA
The gap surfaced during a March 2025 federal inspection of the facility at 505 N. La Brea Avenue. Inspectors flagged the deficiency as causing minimal harm or potential for actual harm, and noted that only a few residents were affected. But what the inspection record shows is a breakdown in one of the most basic functions a nursing facility performs: making sure a physician knows when a patient is declining to accept care.
The resident at the center of the finding is identified only as Resident 1. The inspection report does not describe what kind of basic care was refused, how many times it was refused, or over what period. What it does document is that the charge nurse failed to report the refusals to the attending physician and failed to create what the facility calls COC/CIC documentation, the internal record used to flag a change in a resident's condition or status so that the care team can monitor what is happening.
The Quality Assurance Nurse confirmed the problem herself.
During an interview on March 25, 2025, at 3:13 p.m., the QAN told inspectors she had reviewed the record and validated that the documentation for Resident 1's care refusals was missing. She also confirmed that COC/CIC documentation is required any time a resident refuses care. The facility's own policy, last reviewed in December 2024, states that it promptly notifies the resident's attending physician and representative of changes in medical or mental condition or status.
The charge nurse, by the QAN's own account, had done neither.
What that means in practice is that a physician responsible for overseeing Resident 1's care was making decisions, or not making them, without knowing that the resident was turning down treatment. Whether that affected the resident's health, the inspection report does not say. The deficiency was categorized at a level suggesting the potential for harm existed, even if actual harm was not documented.
Facilities use COC/CIC reports precisely because care refusals are not trivial. A resident who repeatedly declines basic care may be in pain, may be experiencing a decline in cognitive function, may be depressed, or may have a grievance that staff have not addressed. A physician who receives that information can intervene. A physician who never receives it cannot.
The inspection report does not say how long the documentation gap persisted before inspectors found it. It does not name the charge nurse involved or describe any disciplinary action taken. It notes that the QAN validated the missing records during the interview, which suggests the problem was not discovered internally before the inspection.
La Brea Rehabilitation Center is a licensed skilled nursing facility operating under CMS certification number 056195. The March 26, 2025 inspection was a standard health survey. This deficiency was one of multiple findings listed across eight pages of the inspection statement, though the full scope of the other deficiencies is not reflected in the portion of the report available here.
For Resident 1, the record closes without resolution. Whether the physician was eventually notified, whether the care refusals continued, whether anyone sat down with the resident to understand why basic care was being turned away, none of that appears in what inspectors documented. The file shows a gap where a report should have been, a physician kept in the dark, and a resident whose choices, for whatever reason, went unrecorded and unreported.
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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 7, 2026 · Our methodology
LA BREA REHABILITATION CENTER in LOS ANGELES, CA was cited for violations during a health inspection on March 26, 2025.
The gap surfaced during a March 2025 federal inspection of the 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.