The discovery at Overland Terrace Healthcare & Wellness Centre came during a March 6 inspection that also revealed 28 of the facility's 39 resident rooms fall short of federal space requirements, cramming residents into quarters as small as 144 square feet for two people.
Resident 17 was walking inside their room when inspectors arrived at 1:43 PM. The resident told inspectors the bathroom had "poop" on the walls and that housekeeping cleaned only the toilet and floor daily.
Six minutes earlier, inspectors had observed the evidence themselves. Hard, dried brown smears covered the bathroom walls near the light switch and on a bedside commode inside the shared bathroom.
The facility's Director of Staff Development confirmed what residents already knew. The dried material was fecal matter, she told inspectors. She acknowledged the contamination placed residents at risk of infection from disease-causing pathogens and failed to provide the safe, clean environment required by federal regulations.
The facility's own infection control policies, updated just two months before the inspection, state the nursing home maintains procedures "to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseased and infections."
Those policies proved meaningless for residents sharing the contaminated bathroom.
The space violations affected nearly three-quarters of the facility's rooms. Federal regulations require at least 80 square feet per resident in shared rooms, but Overland Terrace packed residents into spaces well below that threshold.
Room 216 housed four residents in just 288 square feet, providing each person with 72 square feet. Federal standards require 320 square feet for four-person rooms.
Twenty-seven other rooms violated space requirements, with most two-person rooms measuring just 144 square feet instead of the required 160. Three-person rooms provided 216 square feet rather than the mandated 240.
The facility administrator provided inspectors with documentation acknowledging the space deficiencies. A "Client Accommodation Analysis" and waiver request detailed room-by-room measurements that fell short of federal standards.
Room 220 crammed three residents into 154 square feet. Rooms 131, 135, 137, 139, 150, 202, 203, 208, and 209 each housed three people in 216 square feet.
Despite the cramped conditions, inspectors noted that residents and staff could move about the rooms during their observations from March 3 through March 6. Nursing staff had sufficient space to provide care, with room for beds, side tables, dressers, and resident care equipment.
But the space violations represented a systematic failure to meet basic federal requirements designed to ensure adequate room for nursing care, privacy, and resident safety.
The fecal contamination presented immediate health risks. Disease-causing microorganisms can survive on surfaces for extended periods, particularly in bathroom environments where moisture and warmth create ideal conditions for bacterial growth.
Resident 17's complaint revealed the housekeeping staff's selective cleaning approach. While they addressed the toilet and floor daily, they ignored visible contamination on walls and equipment within the same space.
The Director of Staff Development's acknowledgment that the fecal matter posed infection risks highlighted the facility's awareness of the problem. Yet the contamination remained visible when inspectors arrived, suggesting no immediate action to address the hazard.
The facility's January 2025 policies on "Resident rooms and Environment" promised residents a safe, clean environment with staff paying close attention to "cleanliness and order." The reality inspectors found contradicted those written commitments.
Overland Terrace operates at 3515 Overland Avenue in Los Angeles, serving residents who depend on the facility for daily care and a sanitary living environment. The space violations affect the majority of residents, while the sanitation failures expose vulnerable individuals to preventable health risks.
The inspection findings document a facility struggling with basic requirements for resident care. Cramped living conditions and contaminated bathrooms represent fundamental failures in providing the safe, homelike environment federal regulations require.
For Resident 17, the daily reality meant living with visible fecal contamination while housekeeping staff completed their limited cleaning routine around it.
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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