East Terrace Rehab: COVID Care Plan Failures - CA
Licensed Vocational Nurse 1 told inspectors during an August 12 interview that Residents 3, 4 and 5's care plans contained no evidence that COVID-19 care plans had been created. The nurse explained that care plans should have been developed to monitor the residents' health and provide interventions for nurses to follow in delivering quality care.
"Care plans indicate interventions the nurses will follow to provide quality resident care," LVN 1 stated. The nurse warned that without proper care plans for COVID-19 infection, "residents will not receive the proper care, and it can cause Resident 3, Resident 4 and Resident 5 possible hospitalization."
The missing care plans violated the facility's own policies. A review of East Terrace's "Persons Centered - Caring Planning" policy, dated May 20, 2025, indicated the facility must develop and implement comprehensive person-centered care plans for each resident. These plans should include measurable objectives and timeframes to meet residents' medical, nursing, mental and psychosocial needs identified in comprehensive assessments.
Registered Nurse 1 confirmed the problem during a 12:30 p.m. interview the same day. The RN stated that Residents 3, 4 and 5 should have had care plans for COVID-19 infection with interventions developed to guide nurses on proper care delivery.
"If nurses fail to develop a care plan, Residents 3, 4 and 5's health can be compromised and could possibly deteriorate," RN 1 told inspectors.
The absence of COVID-specific care plans left nursing staff without clear protocols for monitoring symptoms, managing medications, or determining when medical intervention might be necessary. Care plans typically outline specific steps nurses should take, how often vital signs should be checked, what symptoms to watch for, and when to contact physicians.
Both nurses emphasized that care plans serve as essential tools for ensuring consistent, quality care. LVN 1 noted that nurses should evaluate the effectiveness of interventions outlined in care plans and update them as needed based on residents' changing conditions.
The deficiency affected three residents simultaneously, suggesting a systemic failure in the facility's care planning process for COVID-19 cases. Federal regulations require nursing homes to develop comprehensive care plans that address all of a resident's identified needs, including acute infections like COVID-19.
Without individualized care plans, the three COVID-positive residents faced potential gaps in monitoring and treatment that could lead to serious health complications. The nurses' warnings about possible hospitalization underscored the real-world consequences of the administrative oversight.
The inspection found the violation caused minimal harm or potential for actual harm to the few residents affected. However, the nurses' explicit concerns about deteriorating health and hospitalization highlighted the serious risks posed by inadequate care planning during infectious disease outbreaks.
East Terrace Rehabilitation & Wellness Centre operates at 2415 South Western Avenue in Los Angeles. The facility's failure to create COVID-19 care plans for three infected residents left nursing staff without the guidance needed to provide appropriate monitoring and intervention during their illnesses.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for East Terrace Rehabilitation & Wellness Centre, Lp from 2025-08-12 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
EAST TERRACE REHABILITATION & WELLNESS CENTRE, LP in LOS ANGELES, CA was cited for violations during a health inspection on August 12, 2025.
"Care plans indicate interventions the nurses will follow to provide quality resident care," LVN 1 stated.
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.