Health inspection·May 15, 2025

F 0557 Level of Harm - Minimal harm or potential for actual harm Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. Based on observation, interview, and record review, the facility failed to treat one of three sampled residents (Resident 1) with dignity and respect by failing to safeguard Resident 1 ' s personal belongings. Residents Affected - Few This failure resulted in the loss of Resident 1 ' s shoes which caused his feelings of being upset. Findings: During a review of Resident 1 ' s admission Record, the admission Record indicated the facility admitted the resident on 2/18/2025, and readmitted the resident on 5/7/2025, with diagnoses including dementia (a progressive state of decline in mental abilities), depression (a common mental health condition characterized by persistent feelings of sadness, loss of interest and changes in thoughts, behavior, and physical well-being) and schizophrenia (a mental illness that is characterized by disturbances in thought). During a review of Resident 1 ' s Inventory of Personal Effects, dated 2/18/2025, the Inventory of Personal Effects indicated Resident 1 had one pair of shoes (unidentified description). During a review of Resident 1 ' s History and Physical (H&P) dated 2/21/2025, the H&P indicated the resident had the capacity to make decisions. During a review of Resident 1 ' s Minimum Data Set (MDS, a resident assessment tool) dated 2/25/2025, the MDS indicated the resident had moderate impairment, meaning the individual may need assistance with daily activities or specific tasks due to cognitive (ability to think, understand and reason) decline. The MDS indicated Resident 1 did not have difficulty in normal conversation, social interaction, listening to TV, distinct intelligible words and clear comprehension. During a review of Resident 1 ' s Inventory of Personal Effects, dated 5/7/2025, the Inventory of Personal Effects did not indicate Resident 1 had shoes. During an interview on 5/14/2025 at 11:19 AM with the Certified Nurse Assistant (CNA) 1, CNA 1 stated Resident 1 had a pair of shoes on 5/1/2025. During a concurrent observation and interview on 5/15/2024 at 2:30 PM with CNA 1 in Resident 1 ' s bedroom closet, CNA 1 stated she (CNA1) could not find the resident ' s shoes. During an interview on 5/15/2024 at 2:31 PM with Resident 1, Resident 1 stated that the tennis (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 2 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 05/15/2025 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)