Health inspection·January 5, 2024

F000 INITIAL COMMENTS

F000 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE The following reflects the findings of the California Department of Public Health during the investigation of a complaint. Complaint Number: CA00870244 Representing the Department: Health Facilities Evaluator Nurse: 43454 The inspection was limited to the specific complaint investigated and does not represent the findings of a full inspection of the facility. One deficiency was issued for complaint number: CA00870244 (refer to F626).

F626 SS=D Permitting Residents to Return to Facility CFR(s): 483.15(e)(1)(2)

F626 §483.15(e)(1) Permitting residents to return to facility. A facility must establish and follow a written policy on permitting residents to return to the facility after they are hospitalized or placed on therapeutic leave. The policy must provide for the following. (i) A resident, whose hospitalization or therapeutic leave exceeds the bed-hold period under the State plan, returns to the facility to their previous room if available or immediately upon the first availability of a bed in a semiprivate room if the resident(A) Requires the services provided by the facility; and (B) Is eligible for Medicare skilled nursing facility services or Medicaid nursing facility services. (ii) If the facility that determines that a resident who was transferred with an expectation of returning to the facility, cannot return to the LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE 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. FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3IXW11 Facility ID: CA970000021 If continuation sheet 1 of 6 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056195 (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA BREA REHABILITATION CENTER 505 N La Brea Ave Los Angeles, CA 90036 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE facility, the facility must comply with the requirements of paragraph (c) as they apply to discharges. §483.15(e)(2) Readmission to a composite distinct part. When the facility to which a resident returns is a composite distinct part (as defined in § 483.5), the resident must be permitted to return to an available bed in the particular location of the composite distinct part in which he or she resided previously. If a bed is not available in that location at the time of return, the resident must be given the option to return to that location upon the first availability of a bed there. This REQUIREMENT is not met as evidenced by: Based on interview and record review, the facility failed to re admit one of three sampled resident (Resident 1) after hospitalization on 11/9/2023 at a General Acute Care Hospital (GACH) as indicated in the facility's policy and procedure (P&P) titled "Bed-holds and Returns". As a result, Resident 1 remained in GACH 1 since 11/16/2023 and had the potential to cause psychosocial harm. Findings: A review of Resident 1 ' s Admission Record indicated resident was originally admitted to the facility on 8/2/20222 and readmitted on 11/7/2023, with diagnoses including urinary tract infection (UTI- an infection in any part of the urinary system, including the kidney, bladder or urethra), epilepsy (a disorder in which nerve cell activity in the brain is disturbed causing seizures) and major depressive disorder (a mental disorder that have a persistent feeling of loss of pleasure or interest FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3IXW11 Facility ID: CA970000021 If continuation sheet 2 of 6 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056195 (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA BREA REHABILITATION CENTER 505 N La Brea Ave Los Angeles, CA 90036 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE in life). A review of Resident 1 ' s History and Physical, dated 10/29/2023, physician indicated, "resident does not have the capacity to understand and make decisions". A review of Resident 1 ' s Minimum Data Set (MDS-a standardized assessment and care screening tool), dated 9/25/2023 indicated the resident required supervision from staff for activities of daily living (ADLs-bed mobility, transfers, dressing, eating, toilet use, and personal hygiene). A review of Resident 1 ' s care plan for risk for falls related to disease process, revised on 11/8/2023, indicated interventions including, anticipate and meet the resident ' s needs, be sure the resident ' s call light (a device used to notify the nurse that the resident needs assistance) within reach and encourage the resident to use it for assistance as needed. The resident needs prompt response to all requests for assistance" ... A review of Resident 1 ' s Interdisciplinary Team (IDT - a group of dedicated healthcare professionals who work to bring knowledge together to help residents receive the care they need) Record, dated 11/9/2023 indicated, "Resident (1) observed in supine (lying horizontally with the face and torso facing up) position, right side of bed in between the space of bedside tablet and bed ... transfer to hospital for further evaluation." A review of Resident 1 ' s Physician Note from General Acute Care Hospital 1 (GACH 1), dated 11/12/2023, indicated, "Anticipate discharge back to skilled nursing facility tomorrow (11/13/2023). During an interview with Admission Director FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3IXW11 Facility ID: CA970000021 If continuation sheet 3 of 6 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056195 (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA BREA REHABILITATION CENTER 505 N La Brea Ave Los Angeles, CA 90036 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE (AD) on 11/16/2023 at 10:27 a.m., AD stated, they received readmission request and clinical record from GACH 1 indicating Resident 1 was ready to be readmitted on 11/13/2023. AD stated, they have beds available for Resident 1 to be readmitted on 11/13/2023. AD stated, the Case Manager from GACH 1 sent over the clinical record on 11/13/2023 which required to be reviewed by the Director of Nursing (DON). AD stated, he sent over the GACH 1 ' s medical record to DON on 11/13/2023 and DON replied to him on 11/14/2023 indicating that before they can readmit Resident 1, they will need safety equipment including padded bedside full rails, low bed, floor mats and soft helmet. AD stated, he notified Maintenance Supervisor (MS) to order the equipment. During an interview with DON on 11/16/2023 at 10:46 a.m., DON stated, she was able to review the GACH 1 ' s Clinical Record on 11/14/2023 in which she had determined to readmit Resident 1 but need safety equipment prior to readmitting which was a full bed side rails, soft helmet, low bed, and floor mat. DON stated, Resident 1 was transferred to GACH 1 for further evaluation after Resident 1 was found on the floor. DON stated, they don ' t have a full bed siderails at the facility and a soft helmet, so she requested more time from GACH 1 to readmit Resident 1. During an interview with MS on 11/16/2023 at 11:11 a.m., MS stated, they don ' t have any bedside full rails in the facility. MS stated he tried to order them from the company that provides them supplies in which he was told that full siderails no longer exist as it is considered a physical restraint (the use of a manual hold to restrict freedom of movement of all or part of a person's body, or to restrict normal access to the person's body) and therefore, no longer available. MS further FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3IXW11 Facility ID: CA970000021 If continuation sheet 4 of 6 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056195 (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA BREA REHABILITATION CENTER 505 N La Brea Ave Los Angeles, CA 90036 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE stated, he even looked on Amazon to order the equipment but did not find any full siderails. MS stated, he was aware the full side bedrails are considered physical restraints. During a follow-up interview with DON on 11/16/2023 at 12:59 p.m., DON stated, they were not able to find a full bed siderails, but soft helmet arrived today. When asked regarding Resident 1 ' s fall risk care plan and intervention, DON stated, Resident 1 ' s needs should be met by providing patient care and staffs assistance to prevent injury if Resident 1 had another fall incident. DON stated, she was aware that a bed full siderails are considered physical restraints. When asked if Resident 1 is on physical restraints, DON stated, "no". When asked if preventing injury during a residents ' fall was being relied upon equipment, DON stated "no". DON further stated, they will readmit Resident 1 today. When asked if Resident 1 should have been readmitted since 11/13/2023 as ordered by the physician, DON did not answer. A review of the facility ' s policy and procedure (P&P) titled, "Bed-Holds and Returns", reviewed on 1/2023 indicated, "The resident will be permitted to return to an available bed in the collation of the facility that he or she previously resided." A review of the facility ' s P&P titled, "Bed Safety and Bed Rails", revised on 1/2023 indicated, "The use of bed rails is prohibited unless the criteria for use of bed rails have been met ... Bed rails are adjustable metal or rigid plastic bars that attach to the bed. They are available in a variety of types, shapes, and sizes ranging from full to one-half, one-quarter, or one-eight lengths." A review of the facility ' s P&P titled, "Use of FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3IXW11 Facility ID: CA970000021 If continuation sheet 5 of 6 PRINTED: 05/13/2026 FORM APPROVED DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION OMB NO. 0938-0391 (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X1) MULTIPLE CONSTRUCTION A. BUILDING: ___________ B. WING: _______________ 056195 (X3) DATE SURVEY COMPLETED 11/16/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE LA BREA REHABILITATION CENTER 505 N La Brea Ave Los Angeles, CA 90036 (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) ID PREFIX TAG PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) (X5) COMPLETE DATE Restraints", revised on 1/2023 indicated, "Restraints shall only be used to treat the resident ' s medical symptom(s) and never for discipline or staff convenience, or for the FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: 3IXW11 Facility ID: CA970000021 If continuation sheet 6 of 6