La Brea Rehabilitation Center
Inspection Findings
F-Tag F0604
F 0604 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
padded, often wheeled chair designed to help seniors or individuals with limited mobility) at the foot of his bed against the wall and was asleep. Resident 3 did not arouse a call of his name and a gentle shake.
Resident was noted to have bruises and scab to both arms and legs During an interview with Family Member (FM) 1 on 9/11/2025 at 1:55 pm, FM 1 stated that facility staff ad called her to get her consent about applying a restraint for Resident 3 because he was too aggressive and striking staff and was attempting to get up and had fallen on multiple occasions. FM 1 stated that she (FM 1) gave the facility consent to apply the restraint and had observed Resident 3 during one of her visits to the facility. FM 1 stated that the restraint was tied around Resident 3 abdomen and secured to his (Resident 3) bed. FM 1 stated that Resident 3 was unable to remove the restraint.During a concurrent observation and interview of Resident 3's medication bubble packs (blister pack/multi-dose pack, is a sealed card that organizes medications by dose, date, and time. Each dose is contained in its own transparent, plastic bubble or compartment, which is sealed with a foil or paper backing) with the Director of Nursing (DON) on 9/11/2025 at 3:35 pm, the DON confirmed that there were two bubble packs one marked for evening which contained 3 Haldol tablets and a bedtime one which contained 2 Haldol tablets. The DON confirmed that there was no physician's order for the Haldol and that Resident 3 should not have had the Haldol among his medications.
The DON stated that Resident 3 had returned from General Acute Care Hospital with an order for Haldol on 8/18/2025 which should have been discontinued on 9/1/2025. The DON stated that only active medications are kept in the medication cart meaning that those medications are being administered to the resident.
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
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Printed: 04/13/2026 Form Approved OMB No. 0938-0391
Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
09/11/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
LA Brea Rehabilitation Center
505 N. LA Brea Avenue Los Angeles, CA 90036
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)
F-Tag F0656
F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
were no floor mats on either side of Resident 3's bed. 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.
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LA BREA REHABILITATION CENTER in LOS ANGELES, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
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.