West Pico Terrace: Restraint, Infection Control Failures - CA
Federal inspectors cited West Pico Terrace Healthcare & Wellness Centre on February 9 for multiple safety and care violations, including the improper use of physical restraints and dangerous infection control practices that mixed COVID-positive and COVID-negative residents in the same room.
Resident 10, who suffered from cerebral infarction and Parkinson's disease but retained cognitive skills for daily decisions, was observed in bed with both side rails raised during the evening inspection on February 7. The resident asked staff for help opening a food container while confined by the rails.
No physician order existed for the bilateral bed rails. No care plan addressed their use.
Director of Nursing staff told inspectors the bed side rails were used as "an enabler" but acknowledged "there should be a physician's order and care plan for the use of bed siderails as it limits resident movements and can be a restraint." The facility's own policy classified bed rails as "a physical restraint when bed rails are used to limit a resident's freedom of movement" and required "a detailed order by a healthcare provider."
The restraint violation was compounded by systematic failures in infection control that placed residents at unnecessary risk during a COVID-19 outbreak.
Resident 4, who tested negative for COVID-19, was housed in the same room as Resident 29, who tested positive on February 6. The arrangement continued for at least three days during the inspection period, despite a Public Health Department letter requiring the facility to "separate" symptomatic individuals from those unaffected.
Registered Nurse 1 confirmed both residents were placed in the same room but found "no documentations to indicate the reason why they did not separate" the COVID-negative and COVID-positive residents. The nurse stated Resident 4 "did not want to move to another room, but there were no documentations for explanation of the risk."
Infection Preventionist staff said Resident 4 refused to move but admitted "there were no documentation that Resident 4 was offered to be moved as her roommate tested positive with COVID-19." The preventionist acknowledged this practice "placed other residents at risk of contracting COVID-19 infection."
Care planning failures extended beyond restraints and infection control.
Resident 6, admitted in November with dementia and hearing loss, never received the audiology consultation ordered by her physician on November 23. Staff had to "go very close to her ear and speak very loud" for the resident to hear, yet no referral was made after 13 weeks.
Social Services Director Interim confirmed "there was no documented evidence that a referral to audiology was made" despite facility policy requiring same-day referrals for specialty services. The delay meant Resident 6 "has a hard time hearing the staff which may lead her to get frustrated," and could cause the resident to "end up feeling depressed."
The facility also failed to develop required baseline care plans within 48 hours of admission for Resident 6, leaving staff without guidance for activity programs tailored to her cognitive and physical abilities.
Medication safety violations put residents at additional risk.
Resident 30's medications were left unattended at his bedside table, including Protonix, fish oil supplements, and bowel medications, despite no physician order permitting self-administration. Licensed Vocational Nurse 3 confirmed this was "not acceptable" and stated the resident "sometimes refuses medications, but it is not acceptable to leave medications for residents to take them whenever they want to."
Respiratory medication storage violated manufacturer guidelines. Resident 43's levalbuterol inhalation solution was opened on January 11 but still in use nearly a month later, despite manufacturer instructions requiring disposal within two weeks of opening the foil pouch and one week after individual vials are removed.
Treatment delays endangered resident health when staff failed to notify physicians about inability to collect ordered urine samples.
Resident 23, who had dementia and became aggressive during care, was ordered to provide a urine sample for infection testing on September 12, 2024. When the resident's combative behavior prevented collection, staff never notified the physician as required by facility policy after three unsuccessful attempts.
The resident was hospitalized three days later for possible urinary tract infection evaluation. Registered Nurse Supervisor 1 warned that untreated UTIs "may lead to sepsis and possibly prolonged hospitalization."
Basic safety measures failed in multiple areas.
Six geriatric chairs completely blocked the exit pathway outside Resident 4's room, despite her complaints to staff about evacuation concerns. Maintenance Supervisor acknowledged the resident's complaint and stated "the exit pathway is not a storage area and it should be clear of any equipment," but had not moved the chairs.
Food safety violations included storing boxed items directly on the kitchen floor, including thickened dairy drinks and a 25-pound bag of sugar. Kitchen staff confirmed items "should be stored at least 6 inches off the floor to prevent contamination."
Respiratory care equipment went unchanged beyond safety timelines. Resident 30's nasal cannula tubing and humidifier bottle had no date labels, preventing staff from knowing when equipment was last changed. Facility policy required weekly changes and proper dating for infection control.
Feeding tube care violated safety protocols when Resident 22's enteral feeding bottle was dated February 6 at 9 AM but still hanging at 6:08 PM the following day. Licensed Vocational Nurse 1 confirmed the 24-hour maximum hang time had been exceeded and warned "leaving the tube feeding hanging for more than 24 hours could lead to infection."
The facility's care plan system broke down repeatedly. Resident 10's care plans were never updated after three hospitalizations in 2024, and Resident 22's feeding care plan showed incorrect infusion rates that didn't match current physician orders.
Documentation failures prevented proper change-of-condition assessments. Resident 23's continued aggressiveness and refusal to allow urine collection never triggered required change-of-condition documentation, despite facility policy requiring such assessments for treatment modifications.
Hospital transfer notifications violated resident rights when Resident 38's family wasn't informed of bed hold options during his February 5 emergency transfer for low blood pressure. The facility's bed hold agreement form remained incomplete in two of three required sections, denying the family knowledge of their right to reserve his bed during hospitalization.
Room size violations affected three resident rooms housing nine people in spaces providing less than the required 80 square feet per resident. The facility requested continued waivers for rooms measuring 217 to 220 square feet but housing three residents each, falling short of the 240 square feet required for triple occupancy.
The inspection documented violations across 14 regulatory areas, from basic safety and medication management to infection control and resident rights. Director of Nursing staff acknowledged that proper care planning ensures "all staff are on the same page on managing resident's plan of care," but the facility's systematic failures left residents vulnerable to preventable harm.
Resident 4 remained confined by the blocked exit pathway she feared would prevent evacuation, while her COVID-negative status offered no protection from prolonged exposure to her COVID-positive roommate in the facility's compromised infection control environment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for West Pico Terrace Healthcare & Wellness Centre Lp from 2025-02-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
WEST PICO TERRACE HEALTHCARE & WELLNESS CENTRE LP in LOS ANGELES, CA was cited for violations during a health inspection on February 9, 2025.
The resident asked staff for help opening a food container while confined by the rails.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.