West Pico Terrace Healthcare & Wellness Centre Lp
WEST PICO TERRACE HEALTHCARE & WELLNESS CENTRE LP in LOS ANGELES, CA — inspection on February 9, 2025.
Found 18 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During record review, Resident 29's electronic medical record and paper medical record as of [DATE], there are no ADHD recorded in the chart.
During a concurrent interview and record review with Social Services Director Interim (SSDI) on [DATE] at 3:04 p.m., SSDI reviewed Resident 3's medical record and stated and confirmed, the POLST is incomplete and it does not have information if Resident 3 is a Full Code (if a person's heart stopped beating or breathing, the person will allow all medical measures to be taken to maintain and resuscitate life) or DNR (do not resuscitate- a medical order written by a doctor to instruct health care providers NOT to do cardiopulmonary resuscitation (CPR) if breathing stops or the heart stops beating). SSDI 1 also reviewed Resident 29's ADA form and stated and confirmed, Resident 29 has an AHCD but there was no indication if the facility followed up and requested the copy.
During an interview with Director of Nursing (DON) on [DATE] at 6:10 p.m., DON stated, facility should have followed up with the actual copy of residents' AHCD they formulated one so they can honor their wishes. DON further stated, the POLST must be completed with information if they are Full Code or DNR.
During record review, the facility's policy and procedure (P&P) titled, Advance Directive, reviewed on [DATE] indicated, The Facility will respect a resident's advance directive and will comply with the resident's wishes expressed in an advance directive .
Upon admission, the admission Staff or designee will obtain a copy of a resident's advance directive. If the resident has an Advance Directive, the facility shall obtain a copy of the document and place it in the resident's medical record.
During record review, the facility's P&P titled, Physician Orders for Life-Sustaining Treatment (POLST), reviewed [DATE], the P&P indicated, A completed and signed POLST form is a legal physician order that is immediately actionable .
Completion of a POLST form will reflect a process of careful decision making by the resident, the resident's legally recognized health care decision maker if the resident lacks decision making capacity, and the attending physician, physician assistance or nurse practitioner, regarding the resident's medical condition and known treatment preferences.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
During record review, the admission Record indicated Resident 10 was originally admitted to the facility on [DATE] and was readmitted on [DATE] with diagnoses including cerebral infarction (lack of blood flow resulting in severe damage to some of the brain tissue), Parkinson's disease (a chronic brain disorder that causes movement problems, and can also affect mental health, sleep, and pain), Type II Diabetes Mellitus (DM-a disorder characterized by difficulty in blood sugar control and poor wound healing) and muscle wasting and atrophy (characterized by a significant shortening of the muscle fibers and a loss of overall muscle mass).
During record review, the Minimum Data Set (MDS - resident assessment tool) dated 2/6/2025, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact.
The MDS indicated Resident 10 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During the initial tour of the facility and observation of Resident 10 on 2/7/2025 at 6:23 p.m., Resident 10 was observed in bed, lying on a bed with a bilateral (both) siderails up. Resident 10 was observed asking staff for assistance on opening food container.
During record review of Resident 10's Order Summary Report as of 2/9/2025, indicated there was no physician order for the use of bilateral bed siderails.
During record review of Resident 10's Care Plan (CP) as of 2/9/2025, indicated there are no CP developed for the use of bilateral siderails.
During an interview with Director of Nursing (DON) on 2/9/2025 at 6:14 p.m., DON stated, the bed side rails are used as an enabler. DON stated there should be a physician's order and CP for the use of bed siderails as it limits resident movements and can be a restraint.
During record review of the facility's policy and procedures (P&P) titled, Bed Rails, reviewed on 6/20/2024, the P&P indicated, A bed rail is an assistive device and must be used in accordance with the following regulations: . are classified as a physical restrain when bed rails are used to limit a Resident's freedom of movement . A detailed order by a healthcare provider is required before any restrains can be utilized.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
During an interview with on 2/09/25 at 5:59 PM, the Director of Nursing (DON) stated, the policy is to inform the resident of their right to a bed hold upon transfer.
During record review, the facility's policy and procedures (P&P) titled, Bed Hold, revised 7/2017, indicated, the facility notifies the resident and/or representative, in writing, of the bed hold option, any time the resident is transferred to an acute care hospital or request therapeutic leave.
During record review, the facility's P&P titled, Discharge and Transfer of Residents, revised 2/2018, indicated, the purpose of the policy was to ensure that discharge planning is complete and appropriate and that necessary information is communicated to the continuing care provider.
The P&P also indicated upon transfer to the acute hospital the resident/resident representative will be given an opportunity to execute a bed hold.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
During record review, Resident 23's admission Record indicated the facility admitted Resident 23 on 7/3/2023 with diagnoses including dementia (loss of memory, language, problem-solving and other thinking abilities that are severe enough), personal history of transient ischemic attack (TIA - a temporary blockage of blood flow to the brain) and cerebral vascular accident (CVA- Stroke) without residuals, and hypertension (HTN - elevated blood pressure).
During record review of Resident 23's Minimum Data Set (MDS - resident assessment tool) dated 1/10/2025, indicated Resident 23 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 23 required extensive staff assistance with activities of daily living (ADL -tasks of everyday life).
During a concurrent interview and record review, on 2/9/2025, at 8:45 a.m., with Registered Nurse Supervisor 1 (RNS 1), Resident 23's electronic chart was reviewed. RNS 1 stated there was no documented evidence that a COC was completed for Resident 23 on 9/15/2025. RNS 1 stated A COC is done to see if there is any new or continuous change in the resident's condition and since residents 23 continued to have aggressiveness, combativeness and continuously refused to allow staff to collect the urine sample ordered by the physician, a COC documentation should have been done. RNS 1 stated lack of completion of the coc leads to lack of recommendations needed on how to deal with the changes.
During an interview, on 2/9/2025, at 4:04 p.m., with the Director of Nursing (DON), the DON stated that a COC is done to so residents can be monitored, and the Interdisciplinary team can be involved in providing resident with the care needed and if not done no one will know or monitor what is going on.
During record review of the facility's P&P, titled, Change of Condition Notification reviewed 6/20/2024, indicated, Purpose: To ensure residents, family, legal representatives, and physicians are informed of changes in the resident's condition in a timely manner .
A. A need to alter treatment significantly (e.g. based on labs/x-ray results, a need to discontinue an existing form of treatment due to change of condition).
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
During an interview, on 2/9/2025, at 4:14 p.m., with Director of Nursing (DON), DON stated base line care plans are supposed to be initiated within 48 hours of admission which includes a personalized activity care plan for the team to know how to take care of the resident. DON stated potential adverse outcome of not having an activity care plan is that the staff may not know the type of activities the Resident prefers and may lead resident to be sad and depressed (sadness, hopeless and loss of interest).
During record review, the facility's policy and procedures, titled, Comprehensive Person-Centered Care Planning revised 11/2018, indicated, Purpose: To ensure that a comprehensive person-centered care plan is developed for each resident .
- 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.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
Planning, reviewed on 6/20/2024, the P&P indicated, Is it the policy of this facility to provide
obtain or maintain the highest physical, mental, and psychosocial well-being .
The comprehensive
condition.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
healthcare professionals from different disciplines [nurses, social worker, therapist, physician, etc.]
will also be reviewed and revised at the following times:
i. onset of new problems; ii. change of condition; iii. in preparation for discharge; iv. to address changes in behavior and care; v. other times as appropriate or necessary.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
the urine sample was supposed to be collected as soon as possible when the order was received.
The
resident is suspected of having a UTI.
The DON further stated if a UTI was left untreated, it could lead
A review of the facility's policy and procedures (P&P), titled, Refusal of Treatment revised 1/1/2012, the P&P indicated, Procedure .
IV.
The attending Physician will be notified of refusal of treatment in a time frame determined by the resident's condition and potential serious consequences of the refusal.
VI.
When the residents refusal brings about a significant change in the resident's condition, a reassessment is made, and new information is incorporated into the residents care plan.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
During an interview with the Director of Nursing (DON), on 2/9/2025, at 4:14 p.m., the DON stated that
social services then notifies the audiologist of the order right away.
The SSDI then puts the resident on the audiology or ancillary list and the resident will be seen when the audiologist comes into the facility.
The DON further stated if the audiologist was not notified of the referral order, there will be a delay in the care and the evaluation of the resident.
The DON further stated delaying the evaluation of Resident 6 would ultimately affect the overall communication with the resident, and the resident may end up feeling depressed (sadness, hopeless).
A review of the facility's policy and procedures (P&P), titled, Referral to Outside Services revised 12/1/2013, the P&P indicated, 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 .
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
Purpose: To provide a safe and hazard free environment .
Any facility staff member who identifies an
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
According to the National Library of Medicine liquid ready to hang (RTH) formulas offer increased hang times of up to 48 hours.
However, most closed containers are discarded after 24 hours due to current manufacturer recommendations to change enteral feeding sets every 24 hours and to spike each closed container only once https://pmc.ncbi.nlm.nih.gov/articles/PMC7519612/#:~:text=Sterile%20liquid%20RTH%20formulas%20offer,each%20closed%20container%20only%20once.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
resident needs .
The humidifier and tubing should be changed no more than seven days and labeled
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
During a concurrent observation and interview with Resident 30 on 2/7/2025 at 6:03 p.m., a medication cup full of medications was observed at Resident 30's bedside table. Resident 30 stated, the medications were protonix (used to treat heartburn and certain other conditions caused by too much acid in the stomach), fish oil supplements (protect the heart, ease inflammation, improve mental health, and lengthen life) vitamins and medications for his bowels.
During an interview with Licensed Vocational Nurse (LVN 3) on 2/7/2025 at 6:10 p.m., LVN 3 confirmed Resident 30's medications was left at bedside and stated, it is not acceptable to leave medications at bedside. LVN 3 further stated Resident 30 sometimes refuses medications, but it is not acceptable to leave medications for residents to take them whenever they want to.
During an interview with Director of Nursing (DON) on 2/9/2025 at 6:06 p.m., the DON stated, medications should not be left at bedside as other residents may take the medications and may cause accidents and interactions with other medications.
The DON further stated, if residents refuse medications, they need to reoffer and document.
The DON also stated, the manufacturer guidelines must be followed and the inhalation solution must be labeled when it was first opened so they know when the medication needs to be discarded.
A review of the facility's P&P titled, Medication - Administration, reviewed on 6/20/2024, the P&P indicated, Medications may be administered one hour before or after the scheduled medication administration time .
Medications must be given to the resident by the Licensed Nurse preparing the medication . If a resident is refusing to take medication, time of refusal must be documented in the MAR (Medication Administration Record) stating the reason for the refusal.
The Licensed Nurse will attempt to give the medications, make more than one attempts, and if the resident continues to refuse, the refused medications will be destroyed.
Licensed Nurse will notify Medical Doctor (MD) and document in the medical record.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
Licensed Nurse will attempt to give the medications, make more than one attempts, and if the
indicated, The nurse shall place a date opened sticker on the medication and enter the date opened .
The expiration date of the vial or container will be 30 days unless the manufacturer recommends another date or regulations/guidelines require different dating.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
During a concurrent interview and observation in the dry storage on 2/5/25 at 5:32 PM with [NAME] 1 (CK1), the following food items were observed stacked directly on the floor: a.
One box of Thickened dairy drink b.
One box of thickened lemon-flavored water c. 25- pound bag of sugar CK1 stated these food items in boxes were delivered earlier in the day and were not placed on the racks. CK1 stated the boxes should be stored at least 6 inches off the floor to prevent contamination and not to spread infection to the residents.
During an interview on 2/8/25 at 4:02 PM, the Dietary Supervisor (DS1) stated boxes are to be stored 6 inches off the floor for infection control.
During an interview on 2/9/25 at 5:59 PM, the Director of Nursing (DON) stated food in the kitchen is to be stored in sanitary manner.
A review of the facility provided storage guidelines, under Section A- Sanitary Conditions in Storage of Food, indicated shelving should be mounted at least 6 inches from the floor, preferably on castors for ease of cleaning and 18 inches from the ceiling and foods should be stored off the floor.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
During an interview with IPN on 2/9/2024 at 9:16 a.m., IPN stated Resident 30 was no longer on TBP room, and they should have discontinued the order for precaution. IPN stated, she did not discontinue the order timely after physician had ordered to discontinue the TBP room.
A review of the facility's P&P titled, Infection Control- Policies & Procedures, reviewed date 6/20/2024, 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 diseases and infections.
055119 02/09/2025
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
During a concurrent observation and interview on 2/8/2025, at 4:26 p.m., the maintenance Supervisor (MS) used tape measurer to measure the size of the room from the window to the door for the length, then measured from wall to the start of the closet horizontally for the width to determine the room area.
The MS stated, this is how I measure to verify the size of the rooms.
During an interview on 2/8/2025 at 5:52 p.m., the [NAME] President of Operations (VPO) stated the facility submitted a written request for the continued room waiver although the room sizes do not impede resident care.
During record review, the Minimum Data Set (MDS - resident assessment tool) dated 2/6/2025, indicated Resident 10's cognitive (mental action or process of acquiring knowledge and understanding) skills for daily decisions was intact.
The MDS indicated Resident 10 required maximal assistance from staff for activities of daily living (ADLs- routine tasks/activities such as bathing, dressing and toileting a person performs daily to care for themselves).
During the initial tour of the facility and observation of Resident 10 on 2/7/2025 at 6:23 p.m., Resident 10 was observed in bed, lying on a bed with a bilateral (both) siderails up. Resident 10 was observed asking staff for assistance on opening food container.
During record review of Resident 10's Order Summary Report as of 2/9/2025, indicated there was no physician order for the use of bilateral bed siderails.
During record review of Resident 10's Care Plan (CP) as of 2/9/2025, indicated there are no CP developed for the use of bilateral siderails.
During an interview with Director of Nursing (DON) on 2/9/2025 at 6:14 p.m., DON stated, the bed side rails are used as an enabler. DON stated there should be a physician's order and CP for the use of bed siderails as it limits resident movements and can be a restraint.
055119
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 055119 B.
Wing 02/09/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
West Pico Terrace Healthcare & Wellness Centre LP 6070 W.
Pico Boulevard Los Angeles, CA 90035
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.