Health inspection·March 26, 2025

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility staff failed to ensure physician (MD) notification was done for one of nine sampled residents (Resident 1's) change of condition (COC/CIC) by failing to notify MD when Resident 1 had multiple episodes of refusal of basic care. This deficient practice had the potential to result in possible delayed provision of necessary care and services to Resident 1. Cross Referenced F656 Findings: A review of Resident 1's admission Record indicated Resident 1 was originally admitted to the facility on [DATE], and was re-admitted on [DATE] with diagnoses including carcinoma (cancer cells) in the rectum (final section/ part of the lower gastrointestinal tract [GI tract-organ system of the body from the mouth to the anus [part of the GI tract where the stool or feces are being eliminated from the body], colostomy (opening of the large intestine [abdominal area] to the outside of the body for passing of stool and gas) and abnormalities of gait (ambulation) and mobility. A review of Resident 1's Minimum Data Set (MDS - a comprehensive standardized assessment and care-screening tool), dated 12/6/2024, indicated Resident 1 has an intact cognition (mental action or process of acquiring knowledge and understanding) for daily decision-making and needing moderate assistance from staff for activities of daily living (ADL-bed mobility, surface transfer, eating, walk in room, dressing, toileting, and personal hygiene). A review of Resident 1's medical record indicated missing documentation that Resident 1 had multiple episodes of refusals of basic care. 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). 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. CNA 4 also stated that he (CNA 4) notified the charge nurse. (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 8 Event ID: 056195 Printed: 05/15/2026 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 056195 B. Wing A. Building (X3) DATE SURVEY COMPLETED 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 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)