Overland Terrace Unreported Fall Injury Violation LA
LOS ANGELES, CA - State inspectors cited Overland Terrace Healthcare & Wellness Centre after discovering the facility failed to report a serious fall that sent a dementia patient to the emergency room with a head injury requiring sutures.
Unreported Emergency Room Transfer
The violation centered on a February 28, 2025 incident involving a 71-year-old resident with dementia and a history of falls. According to inspection records, the resident climbed out of bed and experienced an unwitnessed fall that resulted in a significant laceration to his left eyebrow. The injury was severe enough that nursing staff had to apply pressure to stop the bleeding and used adhesive bandages to close the wound before paramedics arrived to transport the resident to Greater Los Angeles Community Hospital via emergency services.
Hospital records confirmed the resident sustained a left eyebrow laceration from the unwitnessed fall and required sutures. Medical staff scheduled the resident to return to the emergency department five days later for suture removal. When inspectors observed the resident several days after the incident, he displayed dark discoloration under his left eye and visible sutures on his eyebrow.
Breakdown in Communication and Reporting
The inspection revealed a concerning pattern of miscommunication among facility leadership regarding the severity of the injury. The Registered Nurse Supervisor, who responded to the incident and applied emergency care, acknowledged to inspectors that she failed to report the unwitnessed fall with significant injury to the California Department of Public Health (CDPH). She stated she only notified the Director of Nursing about the incident.
The Director of Nursing admitted during interviews that she was aware of all the details: the fall, the eyebrow laceration, the emergency room transport via 911, and the application of medical adhesive strips. However, she claimed she did not report the incident to state authorities because the nurse supervisor had described the injury as merely an "abrasion" rather than a laceration. The Director of Nursing later acknowledged that she should have reported the unwitnessed fall with significant injury to CDPH within 24 hours, as required by regulations.
Administrator's Medical Knowledge Gap
Perhaps most concerning was the administrator's response during the inspection interview. The administrator confirmed receiving notification about the fall and emergency transport on the day of the incident but stated he did not report it to CDPH because he believed the resident had not sustained a "significant injury." Despite being aware that nursing staff had applied emergency wound care and called 911 for transport, the administrator revealed he lacked basic medical knowledge, stating he had no medical training and could not define what constitutes a laceration.
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 30, 2026 · Our methodology
OVERLAND TERRACE HEALTHCARE & WELLNESS CENTRE, LP in LOS ANGELES, CA was cited for violations during a health inspection on March 6, 2025.
Hospital records confirmed the resident sustained a left eyebrow laceration from the unwitnessed fall and required sutures.
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.