La Brea Rehabilitation Center
LA BREA REHABILITATION CENTER in LOS ANGELES, CA — inspection on September 11, 2025.
Found 2 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
During a concurrent interview and record review of Resident 3's care plan for actual fall initiated on 8/23/2025 with the DON on 9/11/2025 at 4:15 pm, the DON confirmed that the care plan included an intervention which indicated to apply restraints.
The DON stated that a care plan's intervention guides the staff on what type of care to provide for a resident.
The DON stated that restraints may not be applied as a preventative measure for falls or behavior monitoring unless ordered as a safety measure for the resident.
The DON stated that restraints must have a physician order after careful monitoring.
During a review of the Policy and Procedure (P&P) titled Use of Restraints, revised 12/2024, indicated, Restraints shall only be used for the safety and well-being of the resident(s) and only after other alternatives have been tried unsuccessfully.
Restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls.
The same P&P indicated under policy interpretation the followingi.
Prior to placing a resident in restraints, there shall be a pre-restraining assessment and review to determine the need for restraints.
The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions (programs, devices, referrals, etc.) that may improve the symptoms.ii Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor).
The order shall include the following:a.
The specific reason for the restraint (as it relates to the resident's medical symptom);b.
How the restraint will be used to benefit the resident's medical symptom; andc.
The type of restraint, and period of time for the use of the restraint. iii.
Documentation regarding the use of restraints shall include:a.
Full documentation of the episode leading to the use of the physical restraint.
This includes not only the resident symptoms but also the conditions, circumstances, and environment associated with the episode
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
09/11/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
LA Brea Rehabilitation Center
505 N. LA Brea Avenue Los Angeles, CA 90036
SUMMARY STATEMENT OF DEFICIENCIES
During an interview with the Director of Nursing (DON) on 9/5/2025 at 2:30 pm, the DON stated that Resident 3 was at high risk for falls and had fallen twice since his admission.
She stated that when residents are at a fall risk, the interventions must include frequent visual monitoring, call light within reach, floor mats in place.
The DON confirmed that there was a physician's order to place floor mats besides but that the order was not carried out nor was it included in the care plan.
The DON stated that the facility should have developed an individualized care plan for fall prevention which should have included Resident 3's specific interventions such as floor mats and frequent monitor checks.
The DON stated that care plans help health care staff be uniform in carrying out interventions to prevent falls.
During a review of the Policy and Procedure (P&P) titled Care Plans Comprehensive, revised 12/2024, indicated the following policy statement, An individualized comprehensive care plan that includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychological needs is developed for each resident.
The same P&P policy interpretation and implementations included:Each resident's comprehensive care plan is designed to:a.
Incorporate identified problem areas.b.
Incorporate risk factors associated with identified problems.c.
Build on the resident's strengths.d.
Reflect the resident's expressed wishes regarding care and treatment goals.e.
Reflect treatment goals, timetables and objectives in measurable outcomes.f.
Identify the professional services that are responsible for each element of care.g.
Aid in preventing or reducing declines in the resident's functional status and/or functional levels.h.
Enhance the optimal functioning of the resident by focusing on a rehabilitative program; [NAME].
Reflect currently recognized standards of practice for problem areas and conditions.
Facility ID: