Overland Terrace Healthcare & Wellness Centre, Lp

F-F584

b. During initial tour on 3/6/25 at 1:40 PM, rooms [ROOM NUMBERS] shared bathroom walls were observed dry hard brown smear was observed on the walls by the light switch and on the bedside BSC that was inside

the residents bathroom.

During a concurrent observation and interview on 3/6/2025 at 1:43PM, Resident 17 was observed ambulating inside room [ROOM NUMBER]. Resident 17 stated the bathroom had poop (fecal matter) on the walls, and that housekeeping cleans the toilet and floor only every day.

During an interview on 3/6/25 at 1:49 PM, Director of Staff Development (DSD) stated housekeeping staff is responsible for cleaning the residents bathrooms. DSD stated the dried hard smear by the light switch, and

the BSC was fecal matter. DSD stated the fecal matter on the walls and BSC placed Residents at risk of contamination with disease causing pathogens micro-organisms that can cause infection and does not reflect good hygiene of a safe, clean, sanitary homelike environment.

During a record review, the facility policy and procedures (P&P) titled Resident rooms and Environment dated 1/2025 indicated, the facility provides residents with a safe, clean, . Facility staff aim . paying close attention to the following: Cleanliness and order .

During a record review, facility (P&P) titled infection control- Policies & Procedures dated 1/2025 indicated,

the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to help prevent and manage transmission of diseased and infections.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 30 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 0912 Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. Level of Harm - Potential for minimal harm 44253

Residents Affected - Some Based on observation, interview, and record review the facility failed to ensure 28 of 39 resident rooms (rooms 131,132, 134, 135,136,137, 139, 140, 142, 143, 144, 146, 148, 150, 154, 202, 203, 204, 205, 208, 209, 210, 211, 216, 220, 221, 222, 228) that the square footage requirements of 80 square feet per resident

this deficient practice had the potential to result in inadequate space for nursing care and privacy and safety of residents.

Findings:

On 3/3/2025, the facility administrator provided a copy of the Client Accommodation Analysis and a facility letter requesting a room waiver. During a record review, the Client Accommodation Analysis indicated 28 resident rooms do not have at least 80 square feet per resident. The room waiver request and the client accommodation analysis indicated the following

Room# No. of Beds Room square fo otage

132 2 144

134 2 144

139 3 216

136 2 144

140 2 144

142 2 144

144 2 144

146 2 144

148 2 144

150 3 216

143 2 144

154 3 228

137 3 216

131 3 216

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 30 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 0912 135 3 216

Level of Harm - Potential for 208 3 216 minimal harm 209 3 216 Residents Affected - Some 205 2 144

204 2 144

210 2 144

211 2 144

203 3 216

202 3 216

216 4 288

220 3 154

221 2 144

222 2 144

228 2 144

The minimum requirement for a 2-, 3- and 4-person bedroom should be at least 160, 240 and 320 square feet respectively per federal regulations.

During multiple observations made from 3/3/2025 to 3/6/2025, both residents and staff had enough space to move about freely inside the rooms. The nursing staff had enough space for safely provide care to the residents with space for beds, side tables, dressers, and resident care equipment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 30 055504

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.

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, temperature, pulse, respirations) stable. Resident 71 noted with skin open cut in left eyebrow, applied dressing, and cailed 911 to GACH, not on blood thinner, and family notified and MD (medical doctor).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 30 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 Physician Orders dated 02/28/2025, indicated to transfer Resident 71 to GACH via 911 due to fall causing a cut in skin. Level of Harm - Minimal harm or potential for actual harm 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 Residents Affected - Some 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 8 of 30 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 0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45528

Residents Affected - Few Based on interview and record review, the facility failed to immediately initiate/develop and implement a baseline care plan for one of five sampled residents (Resident 31) in accordance with the facility's policy and procedures (P&P) titled Comprehensive Person-Centered Care planning, reviewed 1/2025. Resident 31 has

a history of Post Traumatic Stress Disorder (PTSD - a disorder in which a person has difficulty recovering

after experiencing or witnessing a traumatic event).

This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 31.

Findings:

During a record review, Resident 31's Admission Record indicated the facility admitted Resident 31 on 12/17/2024 with diagnoses including PTSD, and hypertension (HTN - high blood pressure).

During a record review, of Resident 31's history and physical (H&P - a physician's examination of the patient) dated 12/17/2024, indicated .history of present illness . PTSD.

During a record review, Resident 31's Minimum Data Set (MDS - a resident assessment tool), dated 12/24/2024, indicated Resident 31 was cognitively intact (when a person has no trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 31 required partial/moderate staff assistance with activities of daily living (ADL - tasks of everyday life).

During a concurrent interview and concurrent record review with Licensed Vocational Nurse (LVN ) 2 on 3/5/2025, at 8:28 AM, Resident 31's electronic medical chart was reviewed. LVN 2 stated Resident 31 has a history of PTSD. LVN 2 stated Resident 31 was admitted to the facility on [DATE REDACTED] and the PTSD diagnosis was entered on 12/17/2024. LVN 2 stated she did not see a care plan for PTSD, and further stated there should be a care plan for it. LVN 2 stated that a care plan is used to target a specific issue, goals are set specifically for that issue and interventions are purposefully in place for the identified issue and then reassess to see if the interventions were effective or not depending on the issue, this reassessment can be done sooner but at the most no later than 90 days. LVN 2 stated care plans should be initiated on admission. LVN 2 stated a PTSD care plan is important so that staff will know the behaviors that may trigger Resident 31's PTSD and therefore be on top of those behaviors to prevent any further issues. LVN 2 stated depending

on the trigger causing the PTSD, the resident may experience an escalation of the issue, which may cause harm to the resident themselves or someone else especially if there is no care plan to address those behaviors.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 30 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 0655 During an interview on 3/6/2025, at 10:15 AM, the Director of Nursing (DON) stated a care plan is inclusive of interventions that the facility will do for a resident and the guidelines utilized in taking care of the resident's Level of Harm - Minimal harm or issues that have been identified so that the facility knows how to intervene. The DON stated the care plan potential for actual harm should be completed upon admission or the day after. The DON stated PTSD diagnosis requires a care plan of course as resident may have anxiety and facility needs to be able to know how to intervene and manage Residents Affected - Few the resident's behavior. The DON stated if the residents is not managed the behavior may persist, may also lead to possible violent behavior towards other residents, staff and a possibility of the resident becoming a danger to themselves.

During a record review, the facility's P&P, Comprehensive Person-Centered Care Planning, revised 1/2025, indicated, Purpose: To ensure that a comprehensive person-centered care plan is developed for each resident .

1. Baseline Care plan .

b. The baseline care plan will be developed and implemented, using necessary combination of problem specific care plans, within 48 hours of the resident admission .

c. The baseline care plan must reflect the resident's stated goals and objectives and include interventions that address his or her needs.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 30 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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45037

Residents Affected - Some Based on observation, interview, and record review, the facility failed to protect one of two sampled residents (Resident 71) from repeated falls. Resident 71 fell on [DATE REDACTED], 12/1/2024, 12/20/2024, and 12/27/2024.

As a result, on 2/28/2025, Resident 71 fell again in the facility and sustained a cut (laceration) to the left eyebrow and first aid administered. On 2/28/2025, Resident 71 was transferred via 911 (emergency response number) to a general acute care hospital (GACH) for further evaluation and care.

Findings:

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, the facility fall list indicated Resident 71 fell 5 times in the facility on 10/26/2024, 12/1/2024, 12/24/2024, 12/27/2024, and 2/28/2025.

During a record review, Resident 71's Fall Risk Evaluation dated 10/24/2024 at 11:51 pm., indicated Resident 71 had not fallen in the past 3 months. The fall risk assessment did not indicate the total score (If

the total score is 10 or greater, the resident should be considered at HIGH RISK for potential falls. Prevention protocol should be initiated immediately and documented on the care plan, and did not indicate if Resident 71 was a high risk for/fall risk.

During a record review, Resident 71's Health Status (s/p- after) Note dated 12/4/2024 at 6:16 pm., indicated

the facility was monitoring Resident 71 s/p fall (date/time not indicated). Resident 71 was able to move upper and lower extremities without discomfort, No slurred speech noted .

During a record review, Resident 71's Health Status Note dated 12/30/2024 at 1:10 pm., indicated the facility was monitoring Resident 71 following unwitnessed fall (date/time not indicated). The Health Status Note indicated Resident 71 was in the dining room and was trying to get out of his wheelchair multiple times and staff encouraged Resident to not get out of wheelchair. Resident tried getting up and slipped on the floor. Redness noted on right side of rib cage and no complaints of pain of discomfort .

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 indicated Resident 71 depended on staff to shower/bathe.

The MDS indicated Resident 71 required partial moderate assistance to substantial/maximal assistance with

a The MDS further indicated Resident 71 needed moderate/maximum assistance with activities of daily living (ADL- eating, oral hygiene, toileting, upper body and lower body dressing, putting on/off footwear, and personal hygiene). The MDS indicated Resident 71 did not walk, however, Resident 71 required partial/moderate assistance with rolling from left to right and return to lying on the back. The MDS indicated Resident 71 required a manual wheelchair for mobility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 30 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 0689 During a record review, Resident 71's Care Plan with a focus on Bed against the wall initiated on 2/24/2025, indicated a goals included that Resident 71 will not have any injuries . x 90 days. Level of Harm - Minimal harm or potential for actual harm During a record review, Resident 71's Care Plan with a focus on Documented Safety Concerns initiated on 2/27/2025, indicated a goal included that Resident 71 will remain safe. The care plan interventions included Residents Affected - Some the facility will perform safety risk evaluations(s) on admission, as needed (necessary-PRN) and upon changes in condition for Resident 71.

During a record review, Resident 71's Care Plan with a focus on Risk for Falls initiated on 2/27/2025, indicated a goal included that Resident 71 will be free of falls. The care plan interventions included to evaluate Resident 71 for falls on admission and PRN

During a record review, Resident 71's History and Physical report dated 2/27/2025, indicated Resident 71 had a diagnosis of dementia and did not have the capacity to make medical decisions, and safety strategies to reduce . falls and injuries initiated as necessary . to initiate fall risk precautions if Resident 1 is a fall risk.

During a record review, Resident 71's Fall Risk Evaluation dated 2/28/2025 at 9:21 pm., indicated Resident 71 had not fallen in the past 3 months (Resident 71 fell on [DATE REDACTED]). The fall risk assessment did not indicate

the total score.

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, temperature, pulse, respirations) stable. Resident 71 noted with skin open cut in left eyebrow, applied dressing, and cailed 911 to GACH, not on blood thinner, and family notified and MD (medical doctor).

During a record review, Resident 71's Health Status Note dated 2/28/2025 at 6:42 pm., indicated Resident 71 had an unwitnessed fall found patient in bed in lowest position in crouching position, alert to his name, breathing unlabored. Resident 71 was noted with an open bleeding skin cut injury to the left upper eyebrow.

The bleeding was controlled by applying pressure, patient [Resident 71] was verbally responsive, moving all extremities, confused, disoriented X4. The left eyebrow cut was cleansed with NS (normal saline - wound care cleaning solution), patted gently, and clean dressing applied which was secured with tape . 911 paramedics was called and Resident 71 to GACH.

During a record review, Resident 71's Care Plan focusing on The has had an actual fall on 2/28/2025 and initiated on 2/28/2025, indicated a goal included that Resident 71 will have less injury related to fall by review date. The care plan further indicated that on 2/28/2025, Resident 71 had an actual fall and sustained an open skin injury to left upper eyebrow related to unsteady gait (manner of walking), and poor safety awareness.

During a record review, Resident 71's Physician Orders dated 2/28/2025, indicated to transfer Resident 71 to GACH via 911 due to fall causing a cut in skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 30 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 0689 During a record review, Resident 71's GACH After Visit Summary Emergency Department notes dated 02/28/2025, indicated Resident 71 had unwitnessed fall and sustained left eyebrow laceration, initial Level of Harm - Minimal harm or encounter. Resident 71 had computed tomography (CT- a medical imaging technique that uses X-rays to potential for actual harm create detailed cross-sectional images of the body) Cervical (neck area), CT head, and CT maxillofacial (relating to the mouth, jaw, face, and neck). The After Visit Summary Emergency Department notes indicated Residents Affected - Some under instructions for Resident 71 to call your doctor or return Immediately to the Emergency Department if you develop new or worsening pain, fever that you cannot control with medication, or if you develop nausea, vomiting or diarrhea that prevents you from keeping down food or medicine, or with any concerns. The After Visit Summary Emergency Department notes indicated Resident 71 to return to the emergency room in 5 days for suture (a stitch or row of stitches holding together the edges of a wound or surgical incision) 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 03/04/2025 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 GACH. RNS stated she notified the Director of nursing and reported the fall with significant injury to the DON.

During an interview on 03/04/2025 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 was aware that RNS steri-strips to Resident 71's left eye and that Resident 71 was transported to GACH via 911.

During an interview on 03/05/25 at 9:19 am, Administrator stated he was not in the facility on 2/28/2025 but

the DON notified Administrator that Resident 71 fell and sustained a laceration to the left eyebrow. Administrator stated Resident 71 fell , had no significant injury to the left eyebrow, and was transported to GACH via 911 because the resident was taking blood thinners.

During an interview on 3/5/2025 at 11:37 am, Resident 71's family member (FM) 1 stated Resident 71 received seven sutures to the left eyebrow after the fell in the facility on 2/28/2025. FM 1 stated FM 1 had suggested to the facility to move Resident 71 closer to the nurse's station to closely monitor the resident when FM 1 was not in the facility. FM 1 stated that FM 1 and FM 2 would go the facility at different times to sit with Resident 71 and to prevent the resident from falling.

During an interview on 03/06/2025 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 cut and bleeding to Resident 71's left eyebrow and the RNS calling 911 was significant.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 30 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 0689 During a record review, the facility policy and procedures titled Fall Management reviewed on 1/2025, indicated, . Purpose: To provide residents a safe environment that minimizes complications associated with Level of Harm - Minimal harm or falls. Policy: The facility will implement a fall management program that supports providing an environment potential for actual harm free from falls hazards. Post fall huddle: E. The Administrator or designee will notify local agencies and law enforcement according to the state and federal regulations when the fall is not witnessed and abuse, neglect Residents Affected - Some or mistreatment is suspected.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 30 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 0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Level of Harm - Minimal harm or potential for actual harm 44253

Residents Affected - Few Based on observation, interview, and record review, the facility staff failed to ensure resident received appropriate treatment and services to prevent a urinary tract infection (UTI- an infection in the bladder/urinary tract) for one of three residents (Resident 12) by failing to ensure resident's indwelling urinary catheter (a hollow tube inserted into the bladder to drain or collect urine) was placed below the level of the bladder at all times.

This deficient practice had the potential to result in urinary tract infections for the resident.

Findings:

During a record review, Resident 12's Admission Record indicated the facility admitted the resident on 4/16/2020 and readmitted the resident on 5/14/2024 with diagnoses including obstructive and reflux uropathy, chronic kidney disease (progressive damage and loss of function in the kidneys) and benign prostatic hyperplasia (BPH - is a condition that occurs when the prostate gland enlarges, potentially slowing or blocking the urine stream).

During a record review, Resident 12's Risk for UTI care plan, initiated 5/26/2024, indicated the resident had

an indwelling catheter and was at risk for a UTI do to the presence of the catheter. The care plan goal was for the resident was to show no sign or symptom of UTI. The care plan interventions included to position catheter bag and tubing below the level of the bladder and away from the entrance of the door.

During a record review of the Minimum Data Set (MDS - resident assessment tool), dated 2/25/2025, indicated Resident 12's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was moderately impaired. The MDS indicated Resident 12 required partial/moderate assistance from staff for toileting hygiene, showering and lower body dressing. The same MDS also indicated, Resident 12 has an indwelling catheter.

During a record review, Resident 12's Order Summary Report, dated 3/1/2025 indicated on 5/14/2024 the physician ordered the following:

- To change the urinary catheter per schedule and as needed for leaking, occlusion, dislodgement or excessive sedimentation.

- To assess urinary drainage for signs and symptoms of infection, noting cloudiness, colour, sediment, blood , odor and amount of urine output every shift.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 30 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 0690 During a concurrent interview and observation of Resident 12 on 3/4/2025 at 9 AM, Resident 12 was sitting

in a wheelchair inside the resident's room. Resident 12 was observed with a indwelling urinary catheter Level of Harm - Minimal harm or attached to the side of the wheelchair with the drainage catheter bag positioned at the resident's waist. potential for actual harm Resident 12's indwelling urinary catheter tubing was observed looped toward the ground and then back up to enter the drainage bag above the resident's bladder and the urine was not flowing into the urinary drainage Residents Affected - Few bag. Resident 12 stated the catheter is changed at the phsyician's office once a month and was placed because the resident had a history of frequent UTIs.

During a concurrent observation and interview with Licensed Vocational Nurse (LVN) 3 on 3/4/2025 at 9:13 AM, LVN 3 observed Resident 12's indwelling urinary catheter. LVN 3 stated that staff had to place the indwelling urinary catheter was above the resident's bladder because the wheelchair (Resident 12) did not have the attachment to place the indwelling urinary catheter lower than the resident's bladder. LVN 3 stated

the indwelling urinary catheter bag was placed too high, and the urine was not draining in the indwelling urinary catheter drainage bag. LVN 3 stated the indwelling urinary catheter drainage bag should be placed below Resident 12's bladder to prevent backflow and the risk for infection.

During an interview with Director of Nursing (DON) on 3/6/2025 at 12:59 PM, DON stated the urinary drainage bag needs to be below the bladder to prevent infection.

During a record review, the facility policy and procedures (P&P) titled, Indwelling Catheter, reviewed 1/2025, indicated the catheter and collecting tube will be kept free from kinking and the collection bag will be kept below the level of the bladder.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 30 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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm 45528

Residents Affected - Few Based on observation, interview and record review, the facility failed to:

1. Label tube feeding syringe and feeding tube

2. Change tube feeding set for one of five sampled residents (Resident 41).

These deficient practices had the potential to cause infection and/or possible hospitalization .

Findings:

During a record review, Resident 41's Admission Record indicated the facility admitted Resident 41 on 7/10/2024 with diagnoses including encephalopathy (a brain disorder that can cause a change in how the brain functions), generalized weakness (a feeling of weakness in most parts of the body), and adult failure to thrive (a noticeable decline in health).

During a record review, Resident 41's physician order dated 10/9/2024 indicated enteral feed order, every night shift change tubing syringe daily.

During a record review, Resident 41's Minimum Data Set (MDS - a resident assessment tool) dated 12/19/2024, indicated Resident 41 had cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 41 was dependent of staff for activities of daily living.

During an observation on 3/3/2025, at 8:44 AM, in Resident 41's room, a tube feeding syringe was observed hanging from Resident 41's feeding pole. The tube feeding syringe was not labeled with the date or time. Resident 41's tube feeding set was not labelled to indicate when the feeding tube was changed. A feeding water bag was observed hanging on the pole and had a label dated 2/28/2025 and timed 8:54 AM.

During a concurrent observation and interview on 3/3/2025, at 8:55 AM, with Licensed Vocation Nurse/Treatment Nurse (LVN) 1 in Resident 41's room, the tube feeding syringe was observed hanging from Resident 41's feeding pole not labeled with the date or time. Resident 41's tubing set was observed to have no label indicating when it had been changed and the feeding water bag had a label date 2/28/2025, at 8:54 AM, LVN 1 stated, the tube feeding set is all changed at the same time which includes the tubing set, tube feeding bottle and the water bag including spiking a new feeding bottle. LVN 1 stated tube feeding syringe is also changed daily. LVN 1 stated that after the entire set has been changed, the facility staff need to complete the tube feeding label with the resident's name, date, time when it was changed and the tube feeding syringe has to be dated as well. LVN 1 stated that the date on the water bag indicated 2/28/2025, LVN 1 stated she does not think the tubing was changed and that the tubing set needs to be changed to prevent infection. LVN 1 stated, if is not changed, it could lead to bacteria in the resident's stomach which can cause nausea, vomiting, diarrhea, and maybe elevated temperature.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 30 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 0693 During an interview, on 3/6/2025, at 10:28 AM, the Director of Nursing (DON) stated tube feeding set should be changed daily and should be labeled with date, time, name of the resident, the rate of the feeding and the Level of Harm - Minimal harm or water rate at the time the tube feeding set is changed. The DON stated tubing feeding needs to be changed potential for actual harm for infection prevention which may lead to resident having diarrhea, fever, and colic. The DON further stated, I in serviced the staff right away when I heard about it (tube feeding set not being changed), It is not Residents Affected - Few acceptable.

During a record review, the facility policy and procedure titled, Enteral Feeding reviewed 1/2025, indicated, Purpose: To safely administer enteral feeding according to professional standard.

13. Label bag and tubing with date and time hung hang time' is for no more than 24 hours.

15. Change feeding bag and tubing every 24 hours or as required by manufacturers guidelines.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 30 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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45037 Residents Affected - Some Based on observation, interview, and record review the facility failed to label and store medications in a locked compartment for one sampled resident (Resident 27).

This deficient practice had the potential to result in:

1. Resident 27 self medicating without a physician's order.

2. Resident 27 receiving/consuming expired medication.

Findings:

During a concurrent observation, interview, and record review with the facility Dietary Supervisor (DS) on [DATE REDACTED] at 10:06 am, the residents outside food storage refrigerator was observed noted multiple food items without expiration dates on them, expired foods, and expired medication in Resident 27's food bag. DS stated, it is the license nurses responsibility to check the residents outside food items before they store it in

the refrigerator.

During an observation and interview on [DATE REDACTED] at 2:34 PM, of medication cart A with License Vocational Nurse 1 (LVN 1) medication cart noted to be clean. Stated he has been employed with the facility for 1 year. Stated all medications and biologicals are dated and stored properly in the medication rooms and on the medication carts. During an observation of narcotic count for all residents, all narcotics noted to be accurate.

Observation of Medication storage room noted to be clean, good lighting, and well organized. All medications, biologicals, IV, tubing, and oxygen tubing with current dates. There was no medication noted with expiration dates. Stated the resident's refrigerator is not a designated area to store the resident's medications. LVN 1 stated if residents are storing medications in their food bags stored in the resident's refrigerator and is self-administering the medication the resident could accidentally overdose or have a medication interaction to other medications that the residents are taking. LVN 1 stated it is the License Nurses responsibility to check all food and bags being stored in the resident's refrigerator. LVN 1 stated if the resident takes expired medication it could make them very sick.

During an observation, interview, and record review on [DATE REDACTED] at 8:46 AM, with the Director of Nursing (DON). Observation and record review of the binder kept in the DON's office which included the receipts, usage, disposition, of all narcotic medications that are discontinued, or the residents are no longer using the medications. DON stated he destroys the narcotic medications with the pharmacy Consultant monthly and as needed. DON stated the Pharmacy consultant brings water with him to put in the incinerator to dissolve the wasted medication prior to Med Waste Management picking up the incinerator to prevent diversion. Director of Nursing stated the resident's refrigerator is not a designated area to store the resident's medications.

During a record review, the facility policy and procedures titled Medication Storage in the Facility with a

review date of [DATE REDACTED], indicated:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 30 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 0761 Procedure:

Level of Harm - Minimal harm or B. Only license nurses, pharmacy personnel, and those lawfully authorized to administer medications are potential for actual harm allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access. Residents Affected - Some G. Except for those requiring refrigeration, medications intended for internal use are stored in a medication cart or other designated area.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 30 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 0790 Provide routine and 24-hour emergency dental care for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45528 potential for actual harm Based on interview and record review, the facility failed to provide outside services as required by the Residents Affected - Few physician orders in accordance with the facility's policy and procedures (P&P) titled Referral to Outside Services revised 1/2025, by failing to refer one of five sampled residents (Resident 21) to a dentist (a healthcare professional that specializes in caring for teeth, gums, and related oral health problems).

This deficient practice had the potential to negatively affect the delivery of necessary care and services for Resident 21.

Findings:

During a record review, Resident 21's Admission Record indicated the facility admitted Resident 21 on 2/6/2025 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), generalized weakness (a feeling of weakness in most parts of the body), and Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing).

During a record review, the physician order dated 2/6/2025, indicated Dental consultation (a meeting with a dentist to discuss oral health concerns, potential treatment, and to get a comprehensive examination of mouth, teeth, and gums) PRN (PRN as needed) with treatment as indicated.

During a record review, Resident 21's Minimum Data Set (MDS - a resident assessment tool) dated 2/13/2025, indicated Resident 21 had mild cognitive impairment (when a person has trouble remembering, learning new things, concentrating, or making decisions that affect their everyday life). The MDS indicated Resident 21 required extensive staff assistance with activities of daily living (ADL -tasks of everyday life).

The MDS further indicated Resident 21 had no natural teeth or tooth fragments.

During a record review, the Social Services assessment dated [DATE REDACTED], indicated, Ancillary Needs, Devices Used and Sensory Deficits:

1. Ancillary Needs

a. Dental status and referral needs.

Dental: No teeth/No dentures .

During a concurrent interview and record review, on 3/4/2025 at 3:09 A.M., with the Social Services Director (SSD), Resident 21's electronic medical chart was reviewed. The SSD stated Resident 21 was admitted to

the facility on [DATE REDACTED], and according to the assessment that SSD did on 2/27/2025, Resident 21 had no dentures or teeth. The SSD stated Resident 21 had a dental referral order from 2/6/2025 and had not yet been seen by the dentist. The SSD stated Resident dental referral should be done in the first week of the resident being admitted especially since Resident 21 has not teeth which could lead to weight loss.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 30 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 0790 During an interview, on 3/6/2025 at 10:24 A.M., the Director of Nursing (DON) stated the facility's process for dental referral is to put in the referral the day that the order is received from the doctor or order set as issues Level of Harm - Minimal harm or with teeth can affect the residents eating, nutrition, mood, weight loss including loss of self-esteem and potential for actual harm confidence.

Residents Affected - Few During a record review, the facility policy and procedures, titled, Referral to Outside Services revised 1/2025, indicated, Purpose: To provide residents with outside services as required by physician orders or the care plan .

The Director of Social Services coordinates the referral of residents to outside agencies/programs to fulfill resident needs for services not offered by the Facility .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 30 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 0803 Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. Level of Harm - Minimal harm or potential for actual harm 45037

Residents Affected - Some Based on observation, interview, and record review, the facility failed to follow the food recipe when preparing lunch for the residents.

These failures had the potential to result in resident receiving diets that could have made the residents sick for 81 of 81 residents.

Findings:

During an observation and concurrent interview on 03/03/2025 at 9:30 AM, Dietary [NAME] was observed preparing lunch for the residents and not following the recipe. Dietary [NAME] was pouring black pepper into

the ground beef. Dietary [NAME] stated has worked in the facility for 8 years. Dietary [NAME] stated he did not follow the recipe for cooking ground beef. Dietary [NAME] stated if he does not use the measuring utensils and follow the recipes' when preparing meals, he could use too much seasoning that can make the residents sick.

During an interview on 03/03/2025 at 9:36 AM, Dietary Supervisor (DS) stated all the Dietary Cooks are supposed to follow the recipes for all meals when preparing food for the residents. DS stated DS last in-serviced dietary staff on following the recipes two weeks ago.

During a record review, the facility recipe titled Southern Style Pattie indicated Dietary [NAME] is supposed to use 1/8 teaspoon of black pepper.

During a record review, the facility Winter Menu dated 3/3/2025, indicated the facility served Southern Style Pattie, Beef Pattie for lunch.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 30 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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45037

Residents Affected - Some Based on observation, interview, and record review, the facility failed to:

1. Store, label, and date food items stored in the refrigerator, freezer in the kitchen

2. Label and date the residents outside food stored in the resident's refrigerator

3. Check, record, and maintain the appropriate temperatures for the residents' food refrigerator and freezer for ,d+[DATE REDACTED].

These failures had the potential for the residents to consume expired food and spoiled foods that could result

in food borne illnesses.

Findings:

During the initial tour of the kitchen and concurrent interview on [DATE REDACTED] at 7:55 am with the Dietary Supervisor (DS), the following was observed:

1. Ground nut [NAME] and salt did not have the original label and did not have the expiration or used by date

on containers.

2. [NAME] ground pepper did not have use by or expiration date on container.

3. Ground cinnamon no expiration or used by date on container.

4. Pumpkin spice no expiration or used by date on container.

5. Barbeque sauce with an expiration date.

6. Paprika, classic ground pepper no expiration or used by date on container.

7. Large container of mayonnaise no expiration or used by date on container

8. Large container of Italian salad dressing with an expiration date on container.

9. Large container of syrup no expiration or used by date on container.

10. Tomato spice bay leaves no expiration or used by date on container.

The DS stated DS has the invoice with the numbers, used by and delivery dates for the above-mentioned food items.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 30 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 0812 During an interview and concurrent record review with DS on [DATE REDACTED] at 2:59 pm, the facility dietary food purchase invoices dated [DATE REDACTED], [DATE REDACTED] [DATE REDACTED], [DATE REDACTED], and [DATE REDACTED] were reviewed. There was no ground Level of Harm - Minimal harm or nut [NAME], salt, white ground pepper, ground cinnamon, pumpkin spice, barbeque sauce, paprika, classic potential for actual harm ground pepper, mayonnaise, Italian salad dressing, syrup, and tomato spice bay leaves on the invoices or item numbers that matched any of the aforementioned food items. The DS stated, if a resident consumes Residents Affected - Some expired foods, it could make them very sick.

During an interview on [DATE REDACTED] at 9:45 am, the facility Registered Dietician (RD) stated that all food items are supposed to be stored, labeled, should have an expiration date, or used by date. RD stated if food items are not stored, labeled, and have no expiration date or used by date on them, the residents could consume expired foods become them very sick.

During an observation, interview, and concurrent record review on [DATE REDACTED] at 10:06 AM, the following was observed:

1. The residents outside food storage refrigerator freezer temperature was greater than zero degrees.

2. The refrigerator temperature was 43 degrees Fahrenheit.

3. There was no documented evidence that indicated temperatures for the residents' food refrigerator and freezer were checked and recorded for ,d+[DATE REDACTED].

DS stated it is not DS's responsibility to maintain/check/record the temperature for the residents' refrigerator and freezer.

During a concurrent record review DS stated DS was not aware that the facility policy Titled Refrigerator/Freezer Temperature Records

indicated that DS is responsible to maintain the residents outside storage refrigerator. DS stated, if the temperatures are not maintained then the

residents' food can go bad, and if the residents consume the food, they (residents) can get very sick.

During a record review, the facility policy and procedures (P&P) titled Storage of canned and dry goods dated[DATE REDACTED], indicated:

Procedure: 15. No food item that is expired or beyond the best buy date are in stock.

During a record review, the facility P&P titled Refrigerator/Freezer Temperature Records ' with a reviewed date of ,d+[DATE REDACTED], indicated:

Policy: A daily temperature record is to be kept for refrigerated and frozen storage areas.

Procedure:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 30 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 0812 I. The Dietary Manager or designee is to record daily all refrigerator and freezer temperatures on Form A-Refrigerator/Freezer Temperature Log during AM and Level of Harm - Minimal harm or potential for actual harm PM shifts.

Residents Affected - Some 11. The freezer temperature must be below 0 degrees Fahrenheit or below.

111. The refrigerator temperature must be 41 degrees Fahrenheit or below.

IV. Temperatures above these areas are to be reported to the Dietary Manager

immediately.

VI. Corrective action should be taken to correct the temperature, or the items should be removed to another storage area to maintain acceptable temperature.

During a record review, the facility P&P titled Food Brought in by visitors, with a revised

date of ,d+[DATE REDACTED], indicated:

Procedure:

11. Perishable food requiring refrigeration will be discarded after 2 hours at bedside, and if refrigerated it will then be labeled, dated, and discarded after 48 hours.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 30 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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45455 potential for actual harm Based on observation, interview, and record review, the facility staff failed to observe infection control Residents Affected - Some measures by:

1. Failing to put on and use (don) personal protective equipment (PPE-gowns and gloves) while providing Activities of daily leaving (ADL- self-care tasks necessary for daily functioning and maintaining independence) to a one of 20 sampled residents (Resident 15) who was on enhanced barrier precaution (EBP- infection control measures that expand the use of PPE, during high-contact resident care activities to reduce the spread of multidrug-resistant organisms (MDROs - microorganisms, typically bacteria, that have become resistant to multiple classes of antibiotics).

2. Failing to provide and maintain a safe, clean, and sanitary environment in a one jack and [NAME] bathroom (a shared bathroom situated between two bedrooms, featuring at least two entrances (one from each bedroom) for two of two sampled residents rooms (rooms [ROOM NUMBERS]) by failing to ensure there was no dried hard smear by the light switch, and no fecal matter on a bedside commode (BSC).

These deficient practices had the potential for further spread of infection/s and to expose other facility residents and staff to contamination through exposure to disease causing pathogens (germs) from bodily fluids and waste placed resulting in, poor patient outcomes, medical complications, and unnecessary hospitalization .

Findings:

a. During a facility tour on 3/3/25 at 9:28 AM, Certified Nursing Assistant (CNA) 4 was observed providing ADL care to Resident 15 without donning PPE, a sign was posted and observed by room [ROOM NUMBER] entry indicating Resident in 136B was on EBP and staff entering the room to provide care were required to don PPE prior to entering the room to provide ADL care.

During an interview 3/3/2025 at 9:35AM, CNA4 stated CNA4 recently returned to work after a week ago and that Resident 15's room did not have PPE. CNA 4 further stated CNA4 was supposed to don PPE for infection.

During an interview on 3/6/2025 at 12:20PM, infection prevention nurse (IPN) stated staff should don PPE when they have physical contact with a resident on EBP. IPN stated the facility had PPE's sufficient PPEs for all staff and that PPEs are placed in areas close to residents rooms for easy access. IPN stated staff who do not follow enhanced precaution procedures can spread infection to other residents through contamination of their clothing and hands with bodily fluids and waste.

During an interview on 3/6/2025 at 2: 50 PM Director of Nursing (DON) stated staff should put on (don) personal protective equipment (PPE) when providing care to Residents on enhanced precaution to prevent spread of diseases.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 30 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 0880 During a record review, the facility policy and procedures (P&P) titled infection control - Policies and procedures dated 1/2025 indicated, facility's infection control policies and practices are intended to facilitate Level of Harm - Minimal harm or maintaining a safe, sanitary and comfortable environment and to help prevent and manage transmission of potential for actual harm diseases and infections. Facility's infection control policies and procedures apply equally to all facility staff, staff are trained on the infection control policies and procedures upon hire and periodically thereafter Residents Affected - Some including where and how to find and use pertinent procedures and equipment related to infection control.

Cross Reference

F-F880

b. During initial tour on 3/6/25 at 1:40 PM, rooms [ROOM NUMBERS] shared bathroom walls were observed to have chipped paint, holes, dry hard brown smear was observed on the walls by the light switch and on the bedside BSC that was inside the residents bathroom.

During a concurrent observation and interview on 3/6/2025 at 1:43PM, Resident 17 was observed ambulating inside room [ROOM NUMBER]. Resident 17 stated the bathroom has chipped walls, and holes, there is poop (fecal matter) on the walls, and that housekeeping cleans the toilet and floor only every day.

During an interview on 3/6/25 at 1:49 PM, Director of Staff Development (DSD) stated housekeeping staff is responsible for cleaning the residents bathrooms. DSD stated the dried hard smear by the light switch, and

the BSC was fecal matter. DSD stated the fecal matter on the walls and BSC placed Residents at risk of contamination with disease causing pathogens micro-organisms that can cause infection and does not reflect good hygiene of a safe, clean, sanitary homelike environment.

During a record review, the facility policy and procedures (P&P) titled Resident rooms and Environment dated 1/2025 indicated, the facility provides residents with a safe, clean, comfortable and homelike environment. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: Cleanliness and order .

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 30 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 0584 During a record review, facility (P&P) titled infection control- Policies & Procedures dated 1/2025 indicated,

the facility's infection control policies and procedures are intended to facilitate maintaining a safe, sanitary, Level of Harm - Minimal harm or and comfortable environment and to help prevent and manage transmission of diseased and infections. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 30 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 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 45455

Residents Affected - Some Based on interview and record review, the facility failed to report to the Department of Health Services (CDPH), Licensing and Certification and the local health officer an unusual occurrence for two of six sample residents (Residents 17 and 71) an unwitnessed fall with injury within twenty-four (24) hours of confirmed occurrence per facility policy.

On 12/23/2024 at around 11:35 AM, Resident 17 had an unwitnessed fall and sustained a skin tear to the right upper eyebrow. On 12/23/2024 Resident 17 was transfered to a General Acute Care Hospital (GACH) for a higher level of care and evaluation.

On 2/28/2025 at 6:42 PM, Resident 71 had an unwitnessed fall and sustained a cut to the left eyebrow. On 2/28/2025, Resident 71 was transferred to GACH for higher level care and evaluation.

This deficient practice resulted in a delay of an onsite inspection by CDPH to ensure Residents 17 and 71 allegation of an unwitnessed fall with a significant injury was investigated in a timely manner placing the residents at risk for undetected elder neglect and/or abuse.

Findings:

a. During a record review, Resident 17's admission record indicated Resident 17 was originally admitted to

the facility on [DATE REDACTED] and readmitted on [DATE REDACTED], with diagnoses that included history of falling, osteoporosis (a decrease in bone mass and density, leading to increased bone fragility and fracture risk.), cognitive communication deficit (disorder that affect a person's ability to communicate), history of traumatic fracture (a bone break that results from an external force or trauma), Alzheimer's (a progressive, neurodegenerative disorder characterized by the gradual decline of memory, thinking, and other cognitive functions) and dementia (a progressive decline in cognitive functions, such as memory, thinking, reasoning, and problem-solving, that significantly interferes with daily life and activities.),

During a record review, Resident 17's History and Physical report dated 1/2/2025, indicated Resident 17 does not have the capacity to understand and make decisions.

During a record review, Resident 17s Minimum Data Set (MDS - a resident assessment tool) dated 1/6/2025, indicated Resident 17s cognition (the mental action or process of acquiring knowledge and understanding through thought, experience, and the senses) was severely impaired. The MDS indicated Resident 17 partial/moderate assistance with eating, substantial/maximal assistance and oral hygiene and upper body dressing, and was dependent for toileting hygiene, shower/bathing, lower body dressing and putting on/ taking off footwear and was non-ambulatory.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 30 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 17's SBAR (an acronym for Situation-Background-Assessment-Recommendation is a technique used to provide a framework for Level of Harm - Minimal harm or communication between members of the health care team) form and progress notes dated 12/23/2024, potential for actual harm indicated that on 12/23/2025 at around 11:35 AM, Resident 17 had an unwitnessed fall that occurred in the hallway and sustained a skin tear to the right upper eyebrow. Resident 17 was reaching for item(s) at time of Residents Affected - Some the fall. Resident 17 was assessed, provided first aid care, vital signs were within normal limits and neuro checks were initiated. Resident 17's doctor was notified of the fall who ordered to transfer Resident 17 to a General Acute Care Hospital (GACH) for a higher level of care and evaluation.

During a record review, Resident 17s GACH (which records ED/HP?) records dated 12/24/2024, indicated,

the reason/chief complaint for admitting Resident 17 was an unwitnessed fall, elevated troponin and left shoulder pain.

During a record review, Resident 17's GACH head computerized tomography scan (CT scan - a non-invasive imaging procedure that uses X-rays and computer technology to produce detailed images of the body's internal) impressions dated 12/24/2024, indicated Resident 17 did not sustain any fractures.

During an interview on 03/06/2025 at 2:45PM, the Director of Nursing (DON) stated, acute injury due to a fall, should be reported to the appropriate federal and state agencies within 24 hours.

During a record review, the facility policy and procedures (P&P) titled Unusual Occurrence Reporting, reviewed on 01/2025 indicated, the facility reports the following events by phone and in writing to the appropriate state or federal agencies other occurrences that interfere with And affect the welfare, safety or health of residents . The P&P further indicates that, unusual occurrences are reported to the appropriate agency within 24 hours by telephone and the confirmed in writing.

45037

Cross Reference