Overland Terrace Healthcare & Wellness Centre, Lp

F-F689

b. During a record review, Resident 71's admission record indicated was readmitted on [DATE REDACTED], with a diagnoses of history of falling and unspecified Dementia (cause of dementia cannot be determined, often used when a person's cognitive decline is present).

During a record review, Resident 71's MDS- a resident assessment tool dated 2/8/2025, indicated Resident 71's cognition was moderately impaired. The MDS further indicated Resident 71 needed moderate/maximum assistance with ADL (activities of daily living).

During a record review, Resident 71's History and Physical report dated 2/27/2025, indicated Resident 71 has a diagnosis of dementia and does not have the capacity to make medical decisions.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 2 of 3 055504 Department of Health & Human Services Printed: 09/04/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 055504 B. Wing 03/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Overland Terrace Healthcare & Wellness Centre, LP 3515 Overland Avenue Los Angeles, CA 90034

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 During a record review, Resident 71's SBAR form and progress notes dated 2/28/2025, indicated Resident 71 was found on the floor unwitnessed, breathing unlabored, verbally responsive, vital (blood pressure, Level of Harm - Minimal harm or temperature, pulse, respirations) stable. Resident 71 noted with skin open cut in left eyebrow, applied potential for actual harm dressing, and cailed 911 to GACH, not on blood thinner, and family notified and MD (medical doctor).

Residents Affected - Some During a record review, Resident 71's Physician Orders dated 02/28/2025, indicated to transfer Resident 71 to GACH via 911 due to fall causing a cut in skin.

During a record review, Resident 71's GACH After Visit Summary Emergency Department dated 02/28/2025, indicated Resident 71 unwitnessed fall and sustained left eyebrow laceration, and for Resident 71 to return to

the emergency room in 5 days for suture removal.

During an observation and interview on 3/4/2025 at 9:43 am., Resident 71 was noted with dark discoloration under the left eye, and sutures to his left eyebrow. During an interview with Resident 1 he stated he fell in the library and hit his left eye.

During an interview on 03/04/25 at 2:21 pm, Registered Nurse Supervisor (RNS) stated that on 2/28/2025, Resident 71 climbed out of bed, had an unwitnessed fall and sustained an injury the required Resident 71 to be sent to GACH via 911 (Emergency response telephone number) by the paramedics. RNS stated she had to apply pressure to stop the bleeding to Resident 71's left eye and applied steri-strips (thin, adhesive bandages that help close wounds) to Resident 71's left eye prior the paramedics arriving to the facility to transfer Resident 71 to the hospital. RNS stated she did not report the unwitnessed fall with a significant injury to CDPH. RNS stated she notified the Director of nursing and reported the fall with significant injury to

the DON.

During an interview on 03/04/25 at 2:27 pm, the Director of Nursing (DON) stated the RNS reported to DON that Resident 71 fell and was sent to GACH via 911. The DON stated DON did not report the unwitnessed fall with significant injury (left eyebrow laceration) to CDPH because the RNS reported that the injury to Resident 71's left eye was an abrasion. The DON stated DON was aware that RNS steri-strips to Resident 71's left eye and that Resident 71 was transported to GACH via 911. The DON stated DON should have reported the unwitnessed fall with significant injury to CDPH within 24 hours.

During an interview on 03/06/25 at 11:34 am, Administrator stated the DON notified Administrator on the day of the incident (02/28/2025) that Resident 71 fell and was transferred to GACH via 911. Administrator stated

he did not report the unwitnessed fall to CDPH because Resident 71 did not sustain a significant injury. Administrator stated he was aware that the RNS applied steri-strips and transferred Resident 71 to GACH via 911. Administrator stated Administrator does not have any medical training/background and could not define a laceration, and did not consider the bleeding to a Resident 71's left eye and eyebrow and RNS calling 911 for Resident 71 as significant.

During a record review, the facility policy and procedures titled Unusual Occurrence Reporting reviewed and dated 1/25, indicated,

2. Unusual occurrences are reported to the appropriate agency within 24 hours by telephone and then confirmed in writing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 3 055504