LOS ANGELES, CA - State health inspectors documented multiple safety and care violations at Overland Terrace Healthcare & Wellness Centre during a March 2025 inspection, including failure to report a serious fall injury, improper infection control practices, and inadequate medication storage procedures.
Unreported Fall Results in Emergency Hospitalization
Overland Terrace faced citations after facility administrators failed to report an unwitnessed fall that resulted in significant injury to a resident with dementia and a documented history of falling. On February 28, 2025, Resident 71 climbed out of bed and fell, sustaining a laceration to the left eyebrow that required emergency intervention.
The Registered Nurse Supervisor applied pressure to control bleeding and used adhesive strips to close the wound before paramedics transported the resident to a general acute care hospital via 911. Emergency department records indicated the resident required seven sutures and imaging studies including CT scans of the head, neck, and facial areas. Medical staff instructed the facility to return the resident in five days for suture removal.
Despite the severity of the injury and emergency hospitalization, facility leadership did not report the incident to the California Department of Public Health within the required 24-hour timeframe. During interviews with inspectors, the Director of Nursing acknowledged awareness that the nurse supervisor had applied adhesive strips and that the resident was transported by ambulance, yet stated the incident was not reported because it was characterized as an "abrasion" rather than a laceration.
The facility administrator similarly failed to report the incident, telling inspectors he lacked medical training and could not define a laceration. He stated he did not consider the bleeding wound requiring emergency transport as "significant," despite having no medical background to make such clinical determinations.
Pattern of Falls Without Adequate Prevention
Records revealed this incident was part of an ongoing pattern. Resident 71 had fallen five times within four months at the facility, with documented falls on October 26, 2024, December 1, 2024, December 24, 2024, December 27, 2024, and the injury-causing fall on February 28, 2025.
The resident's medical record indicated diagnoses of dementia and fall history, with moderate cognitive impairment requiring substantial assistance with daily activities. Despite care plans stating the resident should "remain safe" and "be free of falls," the facility's fall risk evaluations contained inconsistencies and incomplete scoring that should trigger high-risk prevention protocols.
Unwitnessed falls in residents with cognitive impairment represent particularly serious safety concerns. When residents cannot reliably report what happened or whether they experienced injury, facilities must implement enhanced monitoring and environmental modifications. Falls can indicate underlying medical changes, medication side effects, or inadequate supervision during high-risk activities like transfers and mobility.
The failure to accurately assess fall risk and implement effective prevention measures placed this resident at continued danger. Each subsequent fall increases the likelihood of serious injury, including fractures, head trauma, and internal bleeding—complications that can prove fatal in elderly populations with multiple chronic conditions.
Infection Control Failures During Resident Care
Inspectors observed direct violations of infection prevention protocols on March 3, 2025, when a certified nursing assistant provided care to a resident placed on enhanced barrier precautions without using required personal protective equipment. Enhanced barrier precautions involve gowns and gloves during high-contact care activities for residents colonized or infected with multidrug-resistant organisms—bacteria that have developed resistance to multiple antibiotic classes.
The resident's room displayed posted signage clearly indicating enhanced precaution requirements, yet the nursing assistant entered and provided activities of daily living care without donning protective equipment. When questioned, the assistant acknowledged being aware of the infection control requirements but stated the room lacked supplies.
This practice breakdown creates direct transmission pathways for dangerous pathogens. Healthcare workers who have physical contact with infected residents without barrier protection can carry organisms on their hands and clothing to other residents, staff members, and environmental surfaces throughout the facility. Multidrug-resistant organisms cause infections that are difficult or impossible to treat with standard antibiotics, leading to prolonged illness, treatment failures, and increased mortality rates.
The facility's Infection Prevention Nurse confirmed that adequate supplies were available in accessible locations near resident rooms, indicating the violation resulted from staff non-compliance rather than resource limitations. Proper infection control requires consistent adherence to protocols by all staff members during every patient encounter—a single breach can initiate transmission chains affecting multiple residents.
Environmental Sanitation Deficiencies
Inspectors documented unsanitary conditions in a shared bathroom serving two resident rooms, including dried material by the light switch and fecal matter on a bedside commode. These conditions violate fundamental sanitation standards and create additional infection risks.
Fecal contamination represents a particularly serious hazard, as human waste contains high concentrations of bacteria, viruses, and parasites that cause gastrointestinal infections, urinary tract infections, and skin infections. Pathogens from fecal matter can survive on surfaces for extended periods and transfer to residents, staff, and visitors through hand contact.
Proper environmental cleaning requires regular scheduled cleaning, immediate remediation of visible contamination, and verification that high-touch surfaces remain sanitary between uses. Shared bathrooms demand particular attention, as multiple residents contact the same surfaces throughout the day.
Medication Storage and Access Violations
The facility failed to maintain proper medication storage and security when inspectors discovered unlabeled, expired medication in a resident's food bag stored in the general refrigerator on March 1, 2025. The medications were accessible without staff supervision, creating risks for unauthorized self-administration and consumption of expired products.
Medications stored in refrigerated areas designated for food violate pharmaceutical storage requirements and infection control standards. This practice places medications outside the locked, climate-controlled environments required for stability and prevents nursing staff from monitoring administration schedules and dosages.
When residents access medications without professional oversight, several dangers emerge. Residents with cognitive impairment may not remember whether they already took scheduled doses, leading to accidental overdoses. Medications taken at incorrect times may not provide intended therapeutic effects or may interact negatively with food or other medications. Expired medications may have degraded potency or developed harmful breakdown products.
The Licensed Vocational Nurse interviewed confirmed that nursing staff hold responsibility for checking all items placed in the resident refrigerator before storage, indicating this represented a nursing practice failure rather than an isolated incident. Proper medication management requires secure storage, regular expiration date monitoring, and controlled administration by licensed personnel who document each dose.
Inadequate Care Planning for Mental Health Conditions
The facility admitted a resident with Post Traumatic Stress Disorder on December 17, 2024, but failed to develop a baseline care plan addressing this condition within the required 48-hour timeframe. Care plans serve as individualized roadmaps that identify specific resident needs, establish goals, and detail interventions staff should implement.
For psychiatric conditions like PTSD, care plans help staff recognize behavioral triggers, implement de-escalation techniques, and provide appropriate environmental modifications. Without documented guidance, staff members may inadvertently trigger traumatic responses or fail to recognize escalating symptoms that require intervention.
PTSD can manifest through anxiety, flashbacks, hypervigilance, and aggressive reactions to perceived threats. In group living environments, unmanaged symptoms can affect not only the individual resident but also roommates and others in shared spaces. Staff trained on individual triggers and effective interventions can prevent behavioral crises and maintain therapeutic environments.
The Director of Nursing acknowledged that PTSD requires care planning so staff understand which behaviors may trigger symptoms and can implement preventive interventions. Without this planning, symptoms may escalate to levels requiring crisis intervention, emergency medications, or hospitalization—outcomes that proper planning aims to prevent.
Food Service and Safety Concerns
Inspectors identified multiple food service violations that compromised nutritional safety for all 81 facility residents. Kitchen staff were observed preparing meals without following standardized recipes and measurement requirements, potentially creating inconsistent seasoning levels that could affect residents with dietary restrictions or sensitivities.
Additional violations included expired and unlabeled food items in kitchen storage areas, and failure to monitor and document temperatures for the resident food refrigerator and freezer. Temperature control represents a critical food safety measure, as improper temperatures allow rapid bacterial growth that causes foodborne illness.
Refrigerators must maintain temperatures at or below 41°F, while freezers must stay below 0°F. The resident refrigerator measured 43°F during inspection—a temperature that falls within the "danger zone" where bacteria multiply rapidly. Without daily temperature monitoring, staff cannot identify equipment malfunctions before spoilage occurs.
Delayed Dental Referrals
A resident admitted February 6, 2025, with no natural teeth or dentures received a physician's order for dental consultation on the admission date, yet had not been referred to a dentist nearly one month later on March 4, 2025. The lack of teeth directly impacts nutrition, as residents cannot properly chew regular-texture foods.
The Social Services Director acknowledged the dental referral should have occurred within the first week of admission, particularly given the resident's complete tooth loss. Delayed dental care can contribute to weight loss, malnutrition, and decreased quality of life. Residents without properly fitted dentures often avoid nutritious foods that require chewing, leading to inadequate protein and nutrient intake.
Tube Feeding Equipment Violations
For a resident receiving nutrition through a feeding tube, staff failed to label feeding equipment with dates and times, and did not change feeding sets according to the required 24-hour schedule. The feeding syringe and tubing set showed no labels indicating when they were last changed, while the water bag was labeled February 28—several days before the March 3 inspection.
Tube feeding equipment that remains in use beyond recommended timeframes develops bacterial contamination that can cause serious gastrointestinal infections. The warm, moist, nutrient-rich environment inside feeding tubes provides ideal conditions for bacterial growth. Contaminated feeding equipment introduces bacteria directly into the stomach, bypassing the mouth's natural defense mechanisms.
The Treatment Nurse confirmed that unchanged equipment could lead to bacterial colonization causing nausea, vomiting, diarrhea, and fever—symptoms that can rapidly cause dehydration and electrolyte imbalances in tube-fed residents who cannot consume oral fluids to compensate for losses.
Catheter Care Deficiencies
Inspectors observed improper positioning of an indwelling urinary catheter drainage bag above the resident's bladder level on March 4, 2025. The catheter tubing looped downward then back upward to enter the drainage bag, preventing proper urine flow and creating backflow risk.
Urinary drainage bags must always remain below bladder level to allow gravity-assisted drainage and prevent urine from flowing backward into the bladder. When urine flows backward, it carries bacteria from the collection bag into the bladder, significantly increasing urinary tract infection risk.
The resident had diagnoses including chronic kidney disease and benign prostatic hyperplasia with a history of frequent urinary tract infections—conditions that make proper catheter management essential. The Licensed Vocational Nurse acknowledged the improper positioning and stated the wheelchair lacked appropriate attachments for correct bag placement, indicating an equipment rather than knowledge deficit.
Additional Issues Identified
Beyond the major violations, inspectors documented that fall risk assessments contained incomplete scoring that should determine whether residents require high-risk prevention protocols. The facility's policy requires unusual occurrences including unwitnessed falls with suspected abuse or neglect to be reported to appropriate agencies within 24 hours, yet leadership demonstrated inadequate understanding of reporting requirements and injury significance thresholds.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Overland Terrace Healthcare & Wellness Centre, Lp from 2025-03-06 including all violations, facility responses, and corrective action plans.
💬 Join the Discussion
Comments are moderated. Please keep discussions respectful and relevant to nursing home care quality.