LOS ANGELES, CA - State health inspectors discovered fecal matter on bathroom walls, deteriorating facilities, and unreported resident falls during a March 2025 inspection at Overland Terrace Healthcare & Wellness Centre, raising serious concerns about sanitation standards and regulatory compliance at the 3515 Overland Avenue facility.
Fecal Contamination Found in Resident Bathrooms
During the March 6, 2025 inspection, surveyors documented extensive contamination in shared bathroom facilities serving multiple resident rooms. Inspectors observed dried brown smears on bathroom walls near light switches and on bedside commodes, which facility staff confirmed was fecal matter. The contamination was found alongside chipped paint and holes in the walls, creating an environment that violated basic sanitation standards.
When questioned about the conditions, Resident 17 told inspectors that "housekeeping cleans the toilet and floor only every day," indicating that wall surfaces and other areas were not receiving regular attention. The Director of Staff Development acknowledged during the inspection that the presence of fecal matter on walls and equipment "placed residents at risk of contamination with disease causing pathogens micro-organisms that can cause infection."
Fecal contamination in healthcare settings poses significant health risks, particularly for elderly residents with compromised immune systems. Fecal matter contains numerous pathogens including E. coli, norovirus, and C. difficile bacteria. When these contaminants remain on surfaces, they become vectors for disease transmission. Healthcare facilities must maintain rigorous cleaning protocols that include all bathroom surfaces, not just floors and toilets. The presence of dried fecal matter indicates these areas had not been properly cleaned for an extended period, allowing bacterial colonies to establish and multiply.
Cross-contamination occurs when residents touch contaminated surfaces and then touch their faces, food, or wounds. In nursing homes where many residents have open wounds, catheters, or feeding tubes, this contamination pathway becomes particularly dangerous. The risk multiplies when contamination occurs near frequently touched surfaces like light switches, which multiple residents and staff members contact throughout the day.
Critical Falls Go Unreported to State Authorities
The inspection revealed that Overland Terrace failed to report two serious resident falls to the California Department of Public Health within the required 24-hour timeframe, violating both state regulations and the facility's own policies.
On December 23, 2024, Resident 17 experienced an unwitnessed fall in the hallway around 11:35 AM while reaching for items. The fall resulted in a skin tear to the right upper eyebrow, prompting the resident's physician to order an immediate transfer to a general acute care hospital. Hospital records indicated the resident was admitted with complaints of an unwitnessed fall, elevated troponin levels, and left shoulder pain. Troponin elevation often indicates cardiac stress or injury, suggesting the fall may have had cardiovascular implications beyond the visible injuries.
A second unreported incident occurred on February 28, 2025, when Resident 71 sustained an unwitnessed fall at 6:42 PM, resulting in a cut to the left eyebrow that also required hospital transfer for evaluation and treatment.
The failure to report falls within 24 hours prevents timely state investigations that could identify systemic problems contributing to resident injuries. Unwitnessed falls in particular require immediate scrutiny because they may indicate inadequate supervision, environmental hazards, or staffing deficiencies. When facilities delay or fail to report these incidents, patterns of neglect may go undetected for months.
For Resident 17, the situation was particularly concerning given their documented vulnerabilities. Medical records showed the resident had been readmitted to the facility with diagnoses including a history of falling, osteoporosis, cognitive communication deficits, history of traumatic fractures, Alzheimer's disease, and dementia. The resident's assessment indicated severe cognitive impairment and dependence on staff for most daily activities including toileting, bathing, and dressing. The resident was also documented as non-ambulatory, raising questions about how an unwitnessed fall could occur in a hallway.
Medical Implications of Environmental and Reporting Failures
The combination of unsanitary conditions and unreported falls creates a compound risk environment for vulnerable residents. When facilities fail to maintain basic hygiene standards, the risk of infection following any injury increases substantially. A resident who sustains a skin tear or laceration in an environment contaminated with fecal matter faces elevated risk of wound infection, which can lead to sepsis, prolonged hospitalization, or death in elderly populations.
The presence of fecal contamination also suggests broader infection control failures. Proper infection control protocols require systematic cleaning of all surfaces, appropriate use of disinfectants, and regular monitoring to ensure compliance. The discovery of dried fecal matter that had clearly been present for an extended period indicates these protocols were either absent or not being followed. This breakdown in basic infection control measures increases the risk of facility-wide outbreaks of gastrointestinal illnesses, which spread rapidly in congregate care settings.
For residents with cognitive impairments like those documented for Resident 17, environmental hazards pose particular dangers. These residents cannot reliably report unsafe conditions or advocate for themselves when care standards fall below acceptable levels. They may not understand the need to avoid touching contaminated surfaces or may be unable to perform hand hygiene independently after contact with contaminated areas.
Industry Standards and Regulatory Requirements
Federal and state regulations establish clear standards for nursing home cleanliness and incident reporting. Facilities must maintain a safe, sanitary, and comfortable environment that prevents the development and transmission of communicable diseases and infections. This includes daily cleaning of all bathroom surfaces, immediate removal of biological contaminants, and regular deep cleaning to prevent buildup of pathogens.
The facility's own policies, reviewed during the inspection, stated that staff should provide residents with "a safe, clean, comfortable and homelike environment" with particular attention to "cleanliness and order." The infection control policy specifically noted the intention to "help prevent and manage transmission of diseases and infections." The presence of fecal matter on walls directly contradicted these stated standards.
Regarding fall reporting, both federal regulations and California state law require nursing homes to immediately report any incident that causes or has the potential to cause serious injury to a resident. The facility's "Unusual Occurrence Reporting" policy confirmed this requirement, stating that events affecting resident welfare, safety, or health must be reported to appropriate agencies within 24 hours by telephone and confirmed in writing.
Standard fall prevention protocols require comprehensive assessment of residents with fall histories, implementation of individualized interventions, adequate supervision for high-risk residents, and environmental modifications to reduce hazards. For residents with severe cognitive impairment who cannot call for help, continuous supervision or assistive devices should prevent unwitnessed falls in common areas.
Additional Issues Identified
Beyond the primary violations, inspectors documented several related concerns that contributed to the overall breakdown in care quality. The deteriorating physical environment, including chipped paint and holes in bathroom walls, created additional surfaces where bacteria could accumulate and made proper disinfection difficult or impossible. These conditions also suggested deferred maintenance that extended beyond simple cleanliness issues.
The Director of Nursing's acknowledgment during the inspection that acute injuries from falls "should be reported to the appropriate federal and state agencies within 24 hours" confirmed facility leadership understood reporting requirements but failed to ensure compliance. This gap between policy knowledge and implementation points to systemic failures in facility management and oversight.
The inspection findings indicate that housekeeping staff were not properly trained or supervised to maintain required cleanliness standards. The limited cleaning routine described by Resident 17, focusing only on toilets and floors while ignoring walls and other surfaces, suggests either inadequate training, insufficient staffing, or lack of proper cleaning supplies and equipment.
Implications for Resident Safety
These violations reflect fundamental breakdowns in the most basic aspects of nursing home care: maintaining a clean environment and protecting residents from preventable injuries. When facilities cannot manage these foundational responsibilities, residents face cascading risks that compound their existing vulnerabilities.
The elderly nursing home population typically includes individuals with multiple chronic conditions, weakened immune systems, and limited ability to recover from infections or injuries. In this context, environmental contamination and unreported falls represent serious threats to life and health rather than minor regulatory infractions.
For families choosing nursing homes, these findings underscore the importance of careful facility selection and ongoing monitoring. Regular visits, attention to cleanliness and maintenance issues, and prompt reporting of concerns to state agencies can help identify problems before they result in serious harm to residents.
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.
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