Overland Terrace Healthcare & Wellness Centre, LP

Inspectors wroteBased on interview and record review, the facility failed to ensure the policy for pressure ulcer/injury (localized, pressure-related damage to the skin and/or underlying tissue usually over a bony prominence) care assessment and treatment was followed, for one of three sampled residents (Resident 1) by failing to:Identify and document the pressure ulcer upon re-admission to the facility. Document a change of condition once the pressure ulcer was identified. Contact the resident's responsible party upon identification of a new pressure ulcer. Implement a low air-loss mattress (pressure ulcer intervention) in a timely manner after pressure ulcer was identified. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed ensure staff followed infection prevention policies and procedures for Enhanced Barrier Precautions (use of personal protective equipment, PPE [gloves, gown, mask and goggles or face shield] when providing wound care to a resident where EBP was indicated for one of three sampled residents (Resident 2). This deficient practice had the potential to result in exposure or transmission of infections to other residents and/or staff. [...]

Inspectors wroteBased on observation and interview, the facility failed to:1. Ensure kitchen staff labeled all foods stored in the freezer with the correct food name, date of food delivery, date the food container was opened, and best by date. 2. Ensure staff did not pick up a meal ticket off the floor then placed the contaminated (something has been made impure, unclean, or dangerous by contact with or the addition of a harmful, foreign, or undesirable substance) meal ticket on one of six residents' (Resident 12) food trays then walked towards the dining room to serve the food tray to Resident 12 with the contaminated meal ticket still on the food tray. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that staff treated residents with respect and dignity and did not calling the residents feeders for seven of seven sampled residents (Residents 2, 3, 20, 56, 57, 58 and 84) who needed assistance with feeding. This deficient practice had the potential for Residents 2, 3, 20, 56, 57, 58 and 84 not attain and maintain the highest practicable physical, mental and psychosocial well-being and also suffer lowered self esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure that three of five residents (Resident 1, Resident 43, and Resident 61) who had severe cognitive (the mental ability to make decisions of daily living), did not sign the consent forms for Influenza (flu - illness caused by a virus that infect nose, throat and lungs), Pneumonia Immunization (immunization that protects against bacteria that causes pneumonia [infection of lungs)] and Corona Virus disease 2019 (COVID 19- is a highly contagious illness that affect lungs and then entire body) according to the facility's policies and procedures titled Resident Rights - Quality of Life reviewed on 1/2026, and P-NP67 Informed Consent effective date 1/30/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide television (TV) remote control for two of two sampled residents (Resident 7 and 62). This deficient practice resulted in Resident 7 feeling frustrated and complained of inability to watch TV and and feeling bored., and Resident 62 complaining of not having a TV remote for a long time and did not keep getting up to change the TV channel.

Inspectors wroteBased on observation, interviews and record review, the facility failed to protect the residents' rights to privacy and confidentiality of records when Licensed Vocational Nurses (LVN) 1 and LVN 5 left two of two residents' (Resident 8 and Resident 11) personal and medical information displayed on the computer screen unattended. This deficient practice of violating the residents' rights to privacy and confidentiality of records had the potential to cause psychological and financial harm to Resident 8 and Resident 11.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the toilet bowl was clean and sanitary for one of three sampled residents (Resident 79). This deficient practice placed Resident 79 at risk for infections, lowered self esteem, and embarrassment.

Inspectors wroteBased on interview and record review, the facility failed to document the assessment, observation and communication entries on the nursing progress notes for two of the five residents (Residents 1 and 9). Resident 1 had a behavior of throwing feces on the floor. This deficient practice had the potential to negatively affect the plan of care and delivery/provision of necessary care and services for Resident 1 and Resident 9. 1. During a record review of Resident 1's admission Record (face sheet - a document containing demographic and diagnostic information) indicated the facility admitted Resident 1 on 5/20/2020 and was re-admitted on [DATE] with the following medical diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan for one of four sampled residents (Resident 1) in accordance with the facility policy and procedures (P&P) titled Person-Centered Care Planning with a revision date of 1/2026, by failing to initiate a baseline care plan within 48 hours after the resident was readmitted to the facility on [DATE]. This deficient practice had the potential to negatively affect the delivery of necessary care and services needed for Resident 1 immediately upon admission.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain proper weight settings for the low air loss mattress (LALM-mattress designed to treat and prevent pressure ulcers) for three of five sampled residents (Resident 3, Resident 19 and Resident 57). This deficient practice had the potential for Resident 3, Resident 19 and Resident 57's pressure injuries to worsen or to develop new pressure injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that enteral feed tubing (a flexible tube for delivering nutrient-rich liquid formula directly into the stomach or small intestine) was labeled with the date and time when hung up for one of one sampled resident (Resident 43). This deficient practice had potential for Resident 43 to suffer abdominal discomfort and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of one sampled residents (Resident 77) who received dialysis (process of removing waste products and excess fluid from the body) treatment received care in accordance with standards of practice, by failing to:1. Complete Post Dialysis Assessment following Resident 77 returning from dialysis treatment.2. Implement the physician's order for fluid restriction of 1200 cubic centimeters (cc-unit of measurement) a day. These deficient practices had the potential to result in harm to the resident which could include edema or unchecked bleeding.

Inspectors wroteBased on observation, interview and record review, the facility failed to observe infection control measures for three of four sampled residents (Resident 3, Resident 12, and Resident 79) by failing to ensure: 1. Resident 3's urinals (a container used to collect urine closed parentheses were labeled with the residents names and room numbers. 2. Ensure staff did not pick up a meal ticket off the floor then placed the contaminated (something has been made impure, unclean, or dangerous by contact with or the addition of a harmful, foreign, or undesirable substance) meal ticket on one of six residents' (Resident 12) food trays then walked towards the dining room to serve the food tray to Resident 12 with the contaminated meal ticket still on the food tray. 3. Ensure the toilet bowl in one of one resident (Resident 79) was clean and sanitary (clean and free from germs). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of one staff (Licensed Vocational Nurse (LVN) 7) completed Elder Abuse Mandated Reporter training according to the facility's policy and procedures (P&P) titled, Training Requirements dated reviewed, January 2026. had proof in the personnel file of the necessary training to care for residents in a safe and secure manner. This deficient practice had the potential for LVN 7 not to be able to identify and report suspected/allegation of abuse and placed the residents in the facility at increased risk for abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement their policy regarding reporting resident to resident's allegation of physical abuse and to submit a conclusion report of investigation within five days or in accordance with state or federal law for two of six sampled residents (Resident 1 and Resident 2). This resulted in a delay of an onsite inspection by the Department of Public Health to ensure the residents' allegation of abuse was investigated which can also lead to a delay in prevention of further physical abuse for Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1) received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with Order Summary Report for psychological/psychiatrist consult follow-up treatment dated 9/23/2025 and the facility's policy and procedures titled Behavior Management reviewed on 1/2025, when:1. Resident 1's exhibited episodes of aggressive behavior towards Resident 4 (roommate) and became extremely agitated, disruptive, thrashing arms, uncontrolled screaming, and yelling on 9/23/2026 at 9:30 am., and used curse words, derogatory names, and racial slurs directed at Resident 4 and Resident 4's family members.2. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat two out of 20 residents (Residents 11 and 45) with respect, dignity and, care by failing to provide person-centered care in a manner that promotes and supports the Residents quality of life. This deficient practice had the potential to negatively affect the Residents' 11 and 45 physical, mental and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean, sanitary, and homelike environment for residents in the facility by failing to: 1. Maintain residents' room temperature between 71 and 81 degree Fahrenheit (° F) as required by the Federal regulation for one of three sampled residents (Resident 70) and five of five rooms checked during a facility tour. This deficient practice resulted in Resident 70 stating of being cold and feeling uncomfortable making it hard for the resident to sleep. 2. Provide a clean, sanitary and in good repair environment in one jack and [NAME] bathroom (a shared bathroom situated between two bedrooms, featuring at least two entrances (one from each bedroom),) for residents in rooms [ROOM NUMBERS]. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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], 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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 03/2025. These failures had the potential for the residents to consume expired food and spoiled foods that could result in food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to observe infection control 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on interview and record review, the facility failed to provide outside services as required by the 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interviews and record review, the facility failed to follow their own Policy and Procedure (P&P) by failing to conduct and complete a personal property inventory for one of the three sampled residents (Resident 1). This deficient practice had the potential to leave personal property to be unaccounted for and easily be missed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of three sampled residents (Resident 1), received the necessary, care, treatment and services to maintain activities of daily living (ADLs) This deficient practice resulted in lack of mobility and incontinent care for Resident 1 and the potential for Resident 1 to decline in her abilities to achieve her highest practicable well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one of three sampled residents (Resident 1), received care and treatment according to the professional standards of practice to meet the resident's physical and psychosocial needs: This deficient practice had the potential to increase discomfort and developing pressure injury (injury to skin underlying tissue resulting from prolonged pressure on parts of a body, skin) and psychosocial decline of Resident 1.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of two residents (Resident 1) received care and services necessary to prevent accidents and falls, by failing to accurately assess Resident 1's fall risk upon admission on [DATE]. This deficient practice placed Resident 1 at an increased risk for to not receiving care and services necessary to prevent accidents and falls.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure two of six sampled residents ' (Residents 4 and 6) intravenous (IV, a small tube introduced via a needle into a vein to receive medications and nutrition]) sites were properly secured, labeled and changed per physician ' s orders and the facility ' s policy and procedures. This failure resulted in Resident 4 ' s IV site not being changed as ordered by physician every 48 hours, and Resident 4 and Resident 6 ' s IV sites being improperly labeled as per policy.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure one of six sampled residents ' (Resident 3) physician order for gastrostomy (G-tube, is a tube that is placed directly into the stomach through an abdominal wall incision for administration of food, fluids, and medications) tube feeding were followed. This failure resulted in Resident 3 not receiving the correct amount of formula via g-tube from 3/14/24 at 10 pm until 3/15/24 at 10 am (12 hours at 70 milliliters [ml, metric unit of measurement for liquids] an hour equals 840 ml total).

Inspectors wroteBased on observations/interviews/record review, the facility failed to protect the resident's(s') right to be free from resident-to-resident physical abuse by failing ensure the director of nursing (DON) reviewed the general acute care hospital (GACH) admission inquiry for one of three residents (Resident 2). As a result, on 3/1/2024, Resident 2 punched Resident 1 on the face sustaining facial injuries.

Inspectors wroteBased on observations/interviews/record review, the facility failed to ensure the director of nursing (DON) reviewed the general acute care hospital (GACH) admission inquiry for one of three residents (Resident 2) prior to admission. As a result, on 3/1/2024, the facility's marketer reviewed, accepted and admitted Resident 2 to the facility on 2/29/2024.

Inspectors wroteBased on Observation, interview, and record review, the facility failed to provide a safe and hazard free environment ensure three of eight sampled residents (Residents 11, 40, and 47) by failing to ensure. 1. Resident 40 did not keep cigarettes and a lighter at bedside/on oneself. 2. A rollator walker (a device that gives support to maintain balance or stability while walking) and a wheelchair (a manually operated device with wheels that is intended for medical purposes to provide mobility to persons restricted to a seating position) did not impede Resident 11 and resident 47's door from opening completely. This failure resulted had the potential to result in fire resulted injury, accidents, hospitalization, and death to Residents 11, 40, and 47 having an accident while smoking.

Inspectors wroteBased on interview and record review, the facility failed to conduct and documet pain assessment to ensure adequate pain management for one of three sampled residents (Resident 33). This deficient practice had the potential to result in unrelieved or ineffective pain control for the resident receving comfort care.

Inspectors wroteBased on interview and record review, the facility failed to implement its policy and procedures to ensure an evaluation was made by the physician within 72 hours of admission for one of 24 sampled residents (Resident 32). This deficient practice had the potential for the resident not receiving necessary care and treatment timely based on the physician's evaluations.

Inspectors wroteBases on observation, interviews, and record reviews, the facility failed to ensure menu was followed to cook vegetables according to their dietary recipes. This deficient practice had the potential not to meet the residents' dietary and nutritional needs.

Inspectors wroteBased on interview and record review, the facility failed to provide activities of daily living (ADL-such as bathing, showering, toileting, and mobility) for two of eight residents (Residents 13 and 68) This failure resulted in Resident 68 feeling angry and also had the potential for Residents 13 and 68 to develop skin infections, skin irritation, and foul odor.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure they have procedures in place to document a resident's choices regarding issues like Cardiopulmonary Resuscitation (CPR - an emergency lifesaving procedure performed when a person breathing and/or heart stops) for one of three sample residents (Resident 12) by failing to ensure the code status ((level of medical interventions a person wishes to have started if their heart or breathing stops) ) documents (Physician order, POLST, and Advance Directives [a legal document that states a person's wishes about receiving medical care if that person is no longer able to make medical decisions because of a serious illness or injury]) were on file and readily available for review in case of a medical emergency for Resident 12. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to change, label, and date nebulizers tubing and mask and store a nebulizer mask set-up bag for one of eight sampled residents. This failure had the potential for contamination of nebulizer mask and use nebulizer tubing with past open dates for Resident 24.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of three facility staff were competent (a measurable pattern of knowledge, skills, abilities, behaviors, and other characteristics that an individual needs to perform work roles or occupational functions successfully) and had the skills set to weigh residents appropriately and accurately. This failure had the potential for inaccurate residents' weight calculation that could result in neglecting necessary and or implementing unwanted medical interventions.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and label food in accordance with professional standards and facility policy to ensure food service safety by failing to: 1. Label food with the resident's name and date received. 2. Discard expired food stored in the resident's refrigerator. Those deficient practices placed residents with compromised health status at risk for foodborne illnesses.

Inspectors wroteBased on interviews, and record reviews the facility failed to implement its' abuse policy and procedures when the facility failed to report to the California Department of Public Health (State Agency) of an alleged abuse of one of three sampled residents (Resident 1). This deficient practice resulted in a delay for an onsite investigation of the alleged abuse and places Resident 1 to continuous verbal and mental abuse from Resident 3.

Inspectors wroteBased on interview and record review, the facility failed to provide medical records requested upon written request on 12/8/24 within two working days per facility's policy and procedures (P&P) titled Resident Access to PHI, for one of three sampled residents (Resident 1). This deficient practice denied Resident 1 and the representative (RP) the right to have access to their medical records as indicated in their P&P.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that meet the care/services based on the resident ' s individual assessed needs for one of two sampled residents (Resident 4) by failing to ensure: 1. Resident 4 ' s right buttock Pressure Ulcer (PU- skin and soft tissue injuries that form because of constant or prolonged pressure exerted on the skin. These ulcers occur at bony areas of the body) was care planned. 2. Resident 4 ' s right first and fifth metatarsal (a group of 5 long bones in the middle of your foot. They connect the back part of your foot to your toes) Arterial Ulcer (a painful, deep sore or wound in the skin of the lower leg or foot. The ulcer doesn't heal as you'd expect an ordinary sore to heal. That's because there isn't enough blood flowing to the area. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals for one of four sampled residents (Resident 4) by failing to: 1. Ensure physician orders were carried out. 2. Initial skin assessment was completed upon admission. This deficient practice had the potential to place Resident 4 and an increased risk for worsening of the Pressure Ulcers (PU- skin and soft tissue injuries that form because of constant or prolonged pressure exerted on the skin. These ulcers occur at bony areas of the body) and/or new PU development.