La Brea Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at La Brea Rehabilitation Center, in the surveyor’s own words.

• Actual harm, isolatedF689Dec 17, 2025

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), who was assessed as high risk for falls and dependent in Activities of Daily Living (ADLs), did not experience multiple falls, one resulting in injury, by failing to: 1. Initiate an individualized plan of care upon admission on [DATE] when Resident 1 was identified as having a high fall risk. 2. Update the care plan and interventions when Resident 1 had an unwitnessed fall on 11/16/2025. 3. Ensure staff adhered to the facility's policy and procedure titled Falls - Clinical Protocol (revised 12/2024), which requires staff and physicians to identify and implement interventions to prevent falls and mitigate clinically significant consequences. 4. […]

• Actual harm, isolatedF697May 23, 2024

  Based on observation, interview, and record review, the facility failed to manage pain on the hands, legs, and stomach for one of three sampled residents (Resident 436) by failing to: 1. Address the Resident 436's request for adequate pain management, 2. Evaluate the effectiveness of the resident's pain medication, 3. Notify the resident's physician that pain management intervention was unsuccessful and for consultation. This failure resulted in Resident 436's to continue experiencing severe, unrelieved and uncontrolled pain from 5/11/2024 to 5/22/2024. Resident was unable to walk due to leg pain, felt her pain was stressful, could not perform usual activities (decline in performing daily activities). […]

• Actual harm, isolatedF689Nov 21, 2023

  Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1) received the care and supervision to prevent falls as evidenced by: -Failing to correctly assess Resident 1 as indicated on the Fall Risk Assessment and identify Resident 1 was at high risk for falls. -Failing to care plan for Resident 1's non-compliance with the front wheel walker and the resident's refusal of staff assistance with ambulation. As a result, on 11/7/2023, Resident 1 fell and sustained a hematoma (an abnormal collection of blood outside of the blood vessel) to the head and a femoral neck fracture (broken upper thigh bone) and an impacted subcapital right femoral neck fracture (break in the upper thigh bone). […]

• Actual harm, isolatedF622Aug 22, 2023

  Based on interview and record review, the facility failed to permit one of two sampled (Resident 1) to remain in the facility and not transfer or discharge her unless the transfer / discharge was necessary and appropriate. The facility failed to: -Ensure the reason for discharging Resident 1 was because of one of the following: the resident's welfare and the resident's needs could not be met in the facility; her care needs could not be met at the facility, her health had improved and no longer needed the services provided by the facility, for the safety of individuals in the facility due to Resident 1's clinical or behavioral status, because of Resident 1's lack of payment, or because the facility ceased operation. […]

• Actual harm, isolatedF623Aug 22, 2023

  Based on interview and record review, for one of two sampled residents (Resident 1) the facility failed to ensure: -Resident 1 or the responsible party was notified at least 30 days before the resident was transferred or discharged or as soon as practicable before the discharge and the reasons for the move in writing and in a manner the resident understands. A review of the Notice of Transfer / Discharge form dated 8/1/2023 indicated Resident 1 was self-responsible and the effective date of discharge was 8/1/2023 to the resident's home address. The reason for discharge was, because your health has improved sufficiently so that you no longer require services provided by this facility. […]