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Complaint Investigation

La Brea Rehabilitation Center

March 26, 2025 · Los Angeles, CA · 505 N. La Brea Avenue
Citations 6
CMS Rating 1/5
Beds 141
Provider ID 056195
Healthcare Facility
La Brea Rehabilitation Center
Los Angeles, CA  ·  View full profile →
Source Document
Official CMS Inspection Report (Medicare.gov)
Downloaded from CMS/Medicare.gov. Reflects what state inspectors documented and does not include the facility's plan of correction, which is submitted separately. Facilities may have taken corrective actions since this report was released.
Inspection Summary

LA BREA REHABILITATION CENTER in LOS ANGELES, CA — inspection on March 26, 2025.

Found 6 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

Inspection Findings

FF0580
Immediately tell the resident, the resident's doctor, and a family member of situations

During an interview with the Quality Assurance Nurse (QAN), on 3/25/2025 at 3:13 p.m., QAN stated

COC/CIC documentation must be done for any refusals of care.

A review of the facility's policy and procedures (P&P), titled, Change in Resident's Condition or Status, reviewed on 12/2024, P&P indicated that facility promptly notifies the resident, his or her attending physician and the resident representative of changes in the resident's medical/mental condition and/or status.

056195 03/26/2025

LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036

Person-Centered reviewed on 12/2024, the P&P indicated that interdisciplinary team reviews and

056195 03/26/2025

LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036

During a concurrent observation and interview with the Treatment Nurse 1 (TX1) on 3/25/2025 at 10:31 a.m., observed Resident 4's LAL mattress was currently set at weight 200 lbs. TX1 stated and validated that Resident 4's LAL mattress was supposed to be set according to Resident 4's current weight, not at 200 lbs.

During an interview with the Director of Staff Development (DSD) on 3/25/2025 at 2:52 p.m., DSD stated that LAL mattress should be set based on resident's weight.

A review of the facility's policy and procedures (P&P), titled, Support Surface Guidelines reviewed on 12/2024, P&P indicated that Any individual at risk for developing pressure ulcers should be placed on a redistribution support surface.

056195 03/26/2025

LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036

Administration, reviewed on 12/2024, P&P indicated that Administration of medication must be

During an interview with Certified Nursing Assistant 3 (CNA 3), on 3/25/2025 at 12:59 p.m., CNA3 stated that Resident 1 had been refusing basic care. CNA 3 also stated that she (CNA 3) notified the charge nurse via Stop and Watch (a warning tool that identify any change while caring for a resident).

During an interview with CNA 4 on 3/25/2025 at 1:13 p.m., CNA 4 stated that Resident 1 had also been refusing basic care during the night shift. CNA4 also stated that he (CNA 4) notified the charge nurse.

During an interview with the Director of Staff Development (DSD), on 3/25/2025 at 2:52 p.m., DSD stated and validated that Resident 1 had multiple episodes of refusals of care. DSD also stated that 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.

056195

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056195 B.

Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036

During an interview with Certified Nursing Assistant 3 (CNA 3) on 3/25/2025 at 12:59 p.m., CNA 3 stated that Resident 1 had been refusing basic care. CNA 3 also stated that she (CNA3) notified the charge nurse via Stop and Watch (a warning tool that identify any change while caring for a resident).

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

056195

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 056195 B.

Wing 03/26/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

LA Brea Rehabilitation Center 505 N. LA Brea Avenue Los Angeles, CA 90036

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in LOS ANGELES, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from LA BREA REHABILITATION CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


More Reports

About This Inspection Report

Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.

Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.

Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.