Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Overland Terrace Healthcare & Wellness Centre, Lp during CMS and state inspections, most recent first.
The facility failed to follow its abuse policy when two residents were involved in an incident in which one cognitively impaired, functionally dependent resident reported being yelled at and hit in the face by a roommate who had returned from pass yelling, unsteady, and smelling of alcohol. An LVN later found the allegedly intoxicated resident on top of the other resident and observed a black eye, but the RN documented the event as an accidental elbow contact despite not witnessing it and acknowledged she did not further investigate. The Administrator later observed the injury but the facility did not initiate and complete the required abuse investigation or make the mandated notifications and written reports to authorities within the time frames specified in its policy and applicable law.
A resident with multiple behavioral health diagnoses, including PTSD and major depressive disorder, repeatedly exhibited extreme agitation, verbal and physical aggression, and used racial slurs toward a roommate and the roommate’s family. Despite documented incidents and ongoing complaints, the facility’s interventions were limited and did not effectively address the resident’s behavioral health needs, resulting in continued risk and negative psychosocial impact on others.
Two residents with multiple medical and cognitive conditions experienced disrespectful and non-person-centered care during an overnight shift, including delayed responses to call lights, lack of staff introductions, and rude interactions when requesting incontinence care. Staff interviews denied inappropriate conduct, but facility policy and the DON confirmed expectations for respectful and dignified care.
The facility did not maintain required room temperatures, with several rooms found below the federally mandated range, resulting in a resident feeling cold and uncomfortable. Additionally, a shared bathroom was observed to have chipped paint, holes, and dried fecal matter on the walls and bedside commode, with staff confirming inadequate cleaning and risk of contamination.
A resident with dementia and a history of falls experienced multiple unwitnessed falls, including one resulting in a laceration requiring hospital transfer. Despite repeated incidents, fall risk assessments were incomplete, care plan interventions were delayed, and recommended increased supervision was not implemented. Staff interviews revealed gaps in injury reporting and understanding of policy requirements.
A resident's expired medication was found stored in a food bag inside the residents' refrigerator, an area not designated for medication storage. The Dietary Supervisor and LVN confirmed that licensed nurses are responsible for checking all food and bags stored in the refrigerator, and facility policy requires medications to be stored in locked or designated areas accessible only to authorized personnel. Other medication storage areas were found compliant.
A dietary staff member was observed preparing a meal without following the prescribed recipe, specifically by not measuring black pepper as required. The staff member admitted to not using measuring utensils, and the dietary supervisor confirmed that all cooks are expected to follow recipes. The facility's menu and recipe documentation supported that the meal in question was served to all residents.
Surveyors found that the facility did not properly store, label, or date various food items in the kitchen and residents' food storage areas, with several containers missing expiration or use-by dates. Additionally, the residents' refrigerator and freezer temperatures were not maintained or recorded as required, and the Dietary Supervisor was unaware of their responsibility for these tasks, contrary to facility policy.
Staff failed to use required PPE while providing care to a resident on enhanced barrier precautions, and a shared bathroom used by two residents was found with dried fecal matter on the wall and bedside commode. Despite facility policies and available supplies, these lapses in infection control and environmental cleanliness were confirmed by staff interviews and direct observation.
Two residents with cognitive impairment and a history of falls experienced unwitnessed falls resulting in injuries that required transfer to a general acute care hospital. Despite facility policy requiring reporting of such incidents to CDPH within 24 hours, staff did not report the events due to misinterpretation of injury severity and lack of understanding of reporting requirements.
A resident with PTSD and hypertension was admitted without a baseline care plan being developed or implemented within 48 hours, as required by facility policy. Staff interviews and record reviews confirmed that no care plan addressing PTSD was created at admission, despite the diagnosis being documented. Facility policy mandates timely care planning to address residents' needs, which was not followed in this case.
A resident with an indwelling urinary catheter and multiple urological conditions was observed with the catheter drainage bag positioned above the bladder, contrary to care plan and physician orders. Staff confirmed the improper placement was due to the wheelchair lacking an appropriate attachment, and acknowledged the risk for infection. Facility policy required the drainage bag to be below the bladder, but this was not followed, resulting in a deficiency related to UTI prevention.
A resident with cognitive impairment and multiple medical conditions was found with an unlabeled tube feeding syringe and tubing set, and a water bag labeled with a date several days old. Staff confirmed that tube feeding equipment should be changed and labeled daily, in accordance with facility policy and physician orders, but this was not done.
A resident with dementia, generalized weakness, and diabetes was admitted without natural teeth or dentures and had a physician order for a dental consultation as needed. Despite facility policy requiring prompt referral to outside services, the resident was not referred to a dentist, and staff confirmed the dental consultation was not completed.
A review of facility records and observations revealed that 28 resident rooms did not meet the required minimum square footage per resident, with several multi-occupancy rooms falling below federal standards. Despite this, both residents and staff were observed to have sufficient space to move and provide care safely.
A facility failed to conduct a personal property inventory for a resident upon admission, as required by its policy. The resident, admitted with diabetes, heart failure, and insomnia, reported not receiving an inventory list during her stay. The DON confirmed the oversight, acknowledging that the inventory list was not completed, leaving personal property unaccounted for.
A resident with multiple health issues, including neoplasm of bone and morbid obesity, did not receive adequate care for mobility and incontinence needs. The resident required significant assistance for ADLs, but the care plan did not reflect current limitations, and staff struggled to meet the resident's frequent requests for repositioning and diaper changes. The facility's policies on care planning and incontinence management were not effectively implemented.
A resident with multiple medical conditions, including neoplasm of bone and morbid obesity, did not receive timely assistance for repositioning and diaper changes, leading to discomfort and potential risk of pressure injuries. The care plan failed to address the resident's mobility limitations and preferences, resulting in unmet physical and psychosocial needs. Staff interviews confirmed delays in providing necessary care due to the requirement of multiple staff members for repositioning.
A resident with Parkinson's disease, anoxic brain damage, and a history of falls was inaccurately assessed as low risk for falls upon admission. The facility's fall risk assessment failed to account for the resident's predisposing conditions and medications, leading to a deficiency in providing necessary preventive care. The DON acknowledged the assessment was not correctly coded, which could have resulted in inadequate fall prevention measures.
Failure to Report and Investigate Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to follow its abuse prevention and management policy regarding timely reporting and investigation of a resident-to-resident allegation of physical abuse. Resident 1, who had hemiplegia and hemiparesis following a cerebral infarction affecting the left dominant side, dysphagia, and heart failure, was cognitively moderately impaired and required maximal assistance to dependent for ADLs. On the date of the incident, an SBAR documented that another resident (Resident 2) accidentally bumped into Resident 1’s right face, hitting the right upper cheek, and that Resident 2 was apologetic. However, during an interview, Resident 1 reported that Resident 2 was yelling and arguing, then hit Resident 1 in the face with both fists, and ended up on top of Resident 1’s bed after Resident 1 tried to push the bedside table to push Resident 2 away. Resident 1 stated there were no staff present when this occurred and that he later explained the incident to staff. LVN 1 reported that Resident 2 returned from an out pass yelling, walking wobbly, and smelling of alcohol, and that he assumed Resident 2 had been drinking based on a brown paper bag with a can inside. LVN 1 stated he directed Resident 2 back to his room, where Resident 1 was also present, and then heard a loud crashing sound. Upon entering the room, LVN 1 found Resident 2 on top of Resident 1 and observed that Resident 1 subsequently had a black eye. When questioned, Resident 1 told LVN 1 that Resident 2 fell on top of him and asked that Resident 2 not be allowed to return to the room. LVN 1 stated he did not witness the actual contact and that Resident 2, who was intoxicated, could not clearly explain what had happened. LVN 1 reported the incident to RN 1. RN 1 documented in Resident 2’s progress notes that Resident 2 returned from pass, was yelling and cursing, and that while walking toward his bed, Resident 2 grabbed the bedside table for support and his elbow accidentally touched Resident 1’s right cheek, with staff supporting Resident 2 to prevent a fall. During interview, RN 1 acknowledged she had not witnessed this and that she should not have documented the event as an accidental elbow contact without further investigation. The Administrator later stated he was not in the facility when the incident occurred and that he had just seen Resident 1 with a black eye and needed to further investigate and interview staff and residents. Despite the facility’s written policy requiring the Administrator or designee to immediately initiate an investigation upon receiving an abuse allegation and to notify law enforcement and submit written SOC341 reports to the Ombudsman, law enforcement, and CDPH within two hours, the facility did not implement these reporting and investigative requirements for this resident-to-resident allegation of physical abuse and did not submit a conclusion report of investigation within five days or in accordance with state or federal law.
Failure to Provide Necessary Behavioral Health Services for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to ensure that a resident with significant behavioral health diagnoses received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. The resident, who had diagnoses including diabetes, hypertension, stroke, PTSD, major depressive disorder, and Cluster B personality disorder, exhibited repeated episodes of extreme agitation, verbal and physical aggression, and use of racial slurs and derogatory language towards a roommate and the roommate’s family members. These behaviors were documented on multiple occasions, including incidents of yelling, screaming, hitting, spitting, and making threatening or abusive remarks, particularly when the resident felt his personal space was encroached upon or when interacting with the roommate’s visitors. Despite the ongoing and escalating behavioral issues, the facility’s interventions were limited to offering room changes, which the resident refused, and implementing care plan interventions such as discussing behaviors with the resident, removing the resident from situations, and arranging for psychiatric and psychological consults as indicated. The care plan was updated to reflect the resident’s behavioral problems and included goals to reduce agitation, but the interventions did not effectively address or mitigate the resident’s aggressive and abusive behaviors. Staff interviews revealed that the resident’s behaviors were well-known, and there was reluctance to move the resident due to anticipated issues with other roommates. The roommate’s family expressed concerns for safety and documented their experiences in a letter to the facility, but the underlying behavioral health needs of the resident were not adequately addressed. The facility’s policy on behavior management required appropriate treatment for residents displaying mental disorders or psychosocial adjustment difficulties, including the use of non-pharmacological interventions before psychoactive medications. However, the documentation and interviews indicate that the facility did not ensure the resident received comprehensive behavioral health care and services as required, resulting in ongoing risk and negative psychosocial impact on the roommate, the roommate’s family, other residents, and staff.
Failure to Provide Respectful, Person-Centered Care to Two Residents
Penalty
Summary
Two residents were not treated with respect, dignity, or person-centered care, as evidenced by their experiences during the overnight shift. One resident, with diagnoses including muscle weakness, depression, and anxiety, reported that a CNA assigned to her care expressed reluctance to provide incontinence care and did not respond when asked if there was an issue. The resident also noted that staff on the overnight shift appeared angry, did not introduce themselves, and failed to greet her when called for assistance with activities of daily living, leading her to feel scared and fear abandonment. Another resident, who had spinal stenosis, muscle weakness, COPD, cognitive impairment, and anxiety disorder, stated that he waited two hours for a call light response during the same shift. When a female nurse finally arrived, she did not introduce herself, addressed him rudely, and stated she had other residents to attend to before leaving the room without providing the requested incontinence care. The resident was unable to identify the staff member because staff wore their badges in a way that obscured their names. Facility records confirmed the staff assignments for the shift in question. Interviews with the involved CNAs denied any inappropriate behavior, but the Director of Nursing confirmed that staff are required to be polite, introduce themselves, and treat residents with dignity and respect. Facility policies reviewed also emphasized the importance of treating residents with kindness, respect, and dignity, and providing care in a person-centered manner.
Failure to Maintain Safe Room Temperatures and Sanitary Resident Bathrooms
Penalty
Summary
The facility failed to maintain a safe, clean, sanitary, and homelike environment for its residents in two key areas. First, the facility did not keep resident room temperatures within the federally required range of 71 to 81 degrees Fahrenheit. During observations, five resident rooms, including one occupied by a resident with Parkinson's disease, anemia, and high blood pressure, were found to have temperatures ranging from 62 to 68 degrees Fahrenheit. The resident reported feeling cold and uncomfortable, which made it difficult to sleep. The DON was unaware of the specific temperature requirements, and facility policy emphasized the importance of comfortable temperatures for residents. Second, the facility did not provide a clean and sanitary environment in a shared bathroom between two resident rooms. Observations revealed chipped paint, holes, and dried brown smears identified as fecal matter on the walls and bedside commode. A resident confirmed the presence of fecal matter and stated that housekeeping only cleaned the toilet and floor daily. The Director of Staff Development acknowledged that the fecal matter placed residents at risk of contamination and did not reflect good hygiene. Facility policies required cleanliness and infection control to maintain a safe and comfortable environment.
Failure to Prevent Repeated Falls and Injury Due to Inadequate Supervision and Assessment
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident with a history of falls and dementia from repeated falls, resulting in injury. The resident experienced multiple falls over several months, including incidents on 10/26/2024, 12/1/2024, 12/24/2024, 12/27/2024, and 2/28/2025. Despite these repeated events, fall risk assessments were either incomplete or did not accurately reflect the resident's fall history, and the total risk scores were not documented. The care plans were updated only after several falls had already occurred, and interventions to address the resident's high risk for falls were not clearly documented or implemented in a timely manner. On 2/28/2025, the resident suffered another unwitnessed fall, resulting in a laceration to the left eyebrow that required first aid and transfer to a general acute care hospital for further evaluation and treatment. Documentation indicated that the resident was found in a crouching position in bed, confused and disoriented, with a bleeding cut above the left eye. The injury was managed by nursing staff, and emergency services were called. The resident's family had previously suggested increased supervision, such as moving the resident closer to the nurse's station, but this was not implemented prior to the incident. Interviews with facility staff revealed gaps in communication and understanding of the significance of the injury. The administrator did not report the unwitnessed fall to the state health department, stating he did not consider the laceration and bleeding to be significant, and was unaware of the medical implications due to lack of clinical training. Facility policy required safety risk evaluations and reporting of unwitnessed falls with significant injury, but these procedures were not consistently followed, contributing to the deficiency.
Improper Storage and Labeling of Medication in Resident's Refrigerator
Penalty
Summary
Facility staff failed to ensure that medications were properly labeled and stored in accordance with professional standards for one resident. During an observation of the residents' outside food storage refrigerator, multiple food items were found without expiration dates, along with expired foods and expired medication in a resident's food bag. The Dietary Supervisor stated that it is the responsibility of licensed nurses to check residents' outside food items before storage. Further interviews and observations confirmed that the resident's refrigerator is not a designated area for medication storage, and that only licensed nurses, pharmacy personnel, and those lawfully authorized are permitted access to medications, which should be stored in locked compartments or designated areas. Additional observations of medication carts and storage rooms showed that all other medications and narcotics were properly stored, dated, and accounted for. However, the presence of expired medication in a resident's food bag within the refrigerator indicated a lapse in following facility policy and procedures regarding medication storage. Both the LVN and DON acknowledged that medications should not be stored in the resident's refrigerator and that it is the licensed nurses' responsibility to check all food and bags being stored there.
Failure to Follow Food Recipe During Meal Preparation
Penalty
Summary
During an observation and interview, a dietary staff member was seen preparing lunch and not following the facility's recipe for ground beef, specifically by pouring black pepper without using measuring utensils. The dietary staff member, who has worked at the facility for eight years, admitted to not following the recipe and acknowledged that not measuring seasonings could result in using too much, which could make residents sick. The dietary supervisor confirmed that all dietary cooks are required to follow recipes and stated that staff had been in-serviced on this requirement two weeks prior. A review of the facility's recipe for Southern Style Pattie indicated that only 1/8 teaspoon of black pepper should be used, and the menu for the day confirmed that this dish was served for lunch to all residents.
Failure to Properly Store, Label, and Monitor Food Items and Temperatures
Penalty
Summary
Surveyors observed that the facility failed to properly store, label, and date food items in both the kitchen and the residents' food storage areas. Multiple food containers, including ground spices, sauces, mayonnaise, and salad dressing, were found without original labels, expiration dates, or use-by dates. Additionally, a review of dietary purchase invoices did not show records for several of these food items, and the Dietary Supervisor confirmed that if residents consume expired foods, it could make them very sick. The Registered Dietician also stated that all food items should be labeled and dated to prevent residents from consuming expired foods. Further observations revealed that the residents' outside food refrigerator and freezer were not maintained at appropriate temperatures, with the freezer above zero degrees and the refrigerator at 43 degrees Fahrenheit. There was no documented evidence that temperatures for these storage units were checked or recorded for the required period. The Dietary Supervisor was unaware of their responsibility to maintain and record these temperatures, despite facility policy stating otherwise. Facility policies also required that perishable food brought in by visitors be labeled, dated, and discarded after specific timeframes, but these procedures were not followed.
Failure to Follow Infection Control Protocols and Maintain Sanitary Environment
Penalty
Summary
Facility staff failed to adhere to infection control measures in two key areas. First, a certified nursing assistant (CNA) was observed providing activities of daily living (ADL) care to a resident on enhanced barrier precautions (EBP) without donning the required personal protective equipment (PPE), despite signage indicating the need for PPE and the availability of supplies nearby. The CNA acknowledged awareness of the requirement but stated that PPE was not present in the room at the time. Interviews with the infection prevention nurse and the director of nursing confirmed that staff are expected to use PPE when caring for residents on EBP, and that PPE is accessible for staff use. Second, the facility failed to maintain a clean and sanitary environment in a shared bathroom used by two residents. Observations revealed a dried, hard brown smear by the light switch and fecal matter on a bedside commode (BSC) inside the bathroom. A resident reported that while housekeeping cleans the toilet and floor daily, the fecal matter on the walls remained. The director of staff development confirmed the presence of fecal matter and acknowledged that housekeeping is responsible for cleaning resident bathrooms. Facility policies reviewed indicated the expectation for maintaining a safe, clean, and sanitary environment, as well as adherence to infection control procedures.
Failure to Timely Report Unwitnessed Falls with Injury
Penalty
Summary
The facility failed to report two separate incidents of unwitnessed falls with injury to the Department of Health Services (CDPH), Licensing and Certification, and the local health officer within twenty-four hours as required by facility policy. In the first incident, a resident with a history of falls, osteoporosis, cognitive impairment, and dementia experienced an unwitnessed fall in the hallway, resulting in a skin tear to the right upper eyebrow. The resident was assessed, provided first aid, and transferred to a general acute care hospital (GACH) for further evaluation. Despite the injury and transfer, the event was not reported to the appropriate authorities within the required timeframe. In the second incident, another resident with a history of falls and unspecified dementia was found on the floor with a cut to the left eyebrow after an unwitnessed fall. The resident required moderate to maximum assistance with activities of daily living and did not have the capacity to make medical decisions. The registered nurse supervisor applied pressure and steri-strips to the wound and called 911 for transfer to GACH. Although the incident involved a significant injury and emergency transfer, it was not reported to CDPH within 24 hours, as required by facility policy. Interviews with facility staff, including the DON and Administrator, revealed a lack of understanding and miscommunication regarding what constitutes a significant injury and the reporting requirements. The DON and Administrator both acknowledged that the incidents should have been reported but failed to do so, citing misinterpretation of the severity of the injuries. Facility policy clearly states that unusual occurrences affecting resident welfare, safety, or health must be reported to the appropriate agency within 24 hours by telephone and confirmed in writing, which was not followed in these cases.
Failure to Initiate Baseline Care Plan for Resident with PTSD Upon Admission
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident with a diagnosis of Post Traumatic Stress Disorder (PTSD) and hypertension. The resident was admitted with a documented history of PTSD, and the diagnosis was entered into the medical record on the day of admission. Despite this, a review of the resident's electronic medical chart revealed that no care plan addressing PTSD was created at the time of admission, as confirmed by a Licensed Vocational Nurse (LVN) during an interview. The LVN acknowledged the absence of a care plan for PTSD and stated that such a plan is necessary to identify triggers and implement interventions to manage the resident's condition. Further interviews with facility staff, including the Director of Nursing (DON), confirmed that the facility's policy requires a care plan to be completed upon admission or the following day, especially for residents with behavioral health diagnoses such as PTSD. The facility's policy on Comprehensive Person-Centered Care Planning specifies that a baseline care plan must be developed and implemented within 48 hours of admission, reflecting the resident's goals and including interventions for identified needs. The lack of a timely care plan for the resident with PTSD constituted a failure to meet these requirements.
Improper Placement of Catheter Drainage Bag Increases UTI Risk
Penalty
Summary
Facility staff failed to ensure proper placement of an indwelling urinary catheter drainage bag for a resident with a history of obstructive and reflux uropathy, chronic kidney disease, and benign prostatic hyperplasia. The resident, who was moderately cognitively impaired and required partial assistance with activities of daily living, had a care plan and physician orders specifying that the catheter drainage bag should be positioned below the level of the bladder to prevent urinary tract infections (UTIs). However, during observation, the drainage bag was found attached to the side of the resident's wheelchair at waist level, with the tubing looped and the bag positioned above the bladder, resulting in urine not draining properly. Staff interviews confirmed that the improper placement was due to the lack of an appropriate attachment on the wheelchair, and both the LVN and DON acknowledged that the drainage bag should be below the bladder to prevent infection. Facility policy also required the catheter and tubing to be free from kinking and the collection bag to be kept below the bladder. The failure to maintain the correct position of the catheter drainage bag constituted a deficiency in providing appropriate care to prevent UTIs.
Failure to Label and Change Tube Feeding Equipment as Required
Penalty
Summary
The facility failed to properly label and change tube feeding equipment for a resident with significant medical needs. Specifically, a tube feeding syringe was observed hanging from the resident's feeding pole without a label indicating the date or time, and the tube feeding set also lacked a label to show when it had last been changed. The water bag attached to the feeding pole was labeled with a date several days prior to the observation, suggesting that the tubing set may not have been changed as required. The resident involved had diagnoses including encephalopathy, generalized weakness, and adult failure to thrive, and was dependent on staff for activities of daily living due to cognitive impairment. During interviews, staff confirmed that the tube feeding set, including the tubing, bottle, and water bag, should be changed daily and labeled with the resident's name, date, and time of change. The facility's policy also required that feeding bags and tubing be labeled and changed every 24 hours. The lack of labeling and failure to change the tube feeding set as required constituted a deviation from both facility policy and physician orders.
Failure to Provide Timely Dental Referral per Physician Order
Penalty
Summary
The facility failed to provide a dental referral for a resident as required by physician orders and facility policy. The resident was admitted with diagnoses including dementia, generalized weakness, and diabetes mellitus, and was noted to have no natural teeth or dentures. A physician order for a dental consultation on an as-needed basis was present from the time of admission, but the referral was not made. The Social Services Director confirmed that the resident had not been seen by a dentist, despite the order and the resident's lack of teeth, which was documented in both the admission record and the social services assessment. The facility's policy requires that referrals to outside services, such as dental care, be coordinated by the Director of Social Services in accordance with physician orders or the care plan. Interviews with facility staff, including the DON and Social Services Director, indicated that the process is to initiate the referral the day the order is received. However, this process was not followed for this resident, resulting in the resident not receiving the required dental consultation.
Resident Room Square Footage Below Regulatory Minimums
Penalty
Summary
The facility failed to ensure that 28 out of 39 resident rooms met the required minimum square footage per resident, as specified by federal regulations. Specifically, rooms designed for two, three, and four residents did not provide at least 80 square feet per resident, with several rooms falling short of the 160, 240, and 320 square foot minimums for 2-, 3-, and 4-person rooms, respectively. This deficiency was identified through observation, interview, and record review, including a Client Accommodation Analysis and a facility letter requesting a room waiver. Despite these findings, observations indicated that both residents and staff had enough space to move about freely and that nursing staff could safely provide care with adequate space for beds, side tables, dressers, and care equipment.
Failure to Conduct Personal Property Inventory
Penalty
Summary
The facility failed to adhere to its own Policy and Procedure (P&P) by not conducting and completing a personal property inventory for a resident upon admission. This oversight was identified during a review of the resident's admission records and confirmed through interviews. The resident, who was admitted with conditions including diabetes mellitus, heart failure, and insomnia, reported that the facility staff did not offer a personal property inventory list during her stay. The Director of Nursing (DON) acknowledged that the inventory list was not completed as required by the facility's policy, which mandates that a personal property inventory be conducted upon admission. The facility's P&P on personal property, reviewed in January 2024, outlines the procedures for safeguarding residents' belongings. It specifies that the Admissions Staff should inform residents or their representatives about marking belongings and updating the inventory list as items are added or removed. Additionally, a Certified Nursing Assistant (CNA) or designee is responsible for conducting the inventory and placing it in the medical record. The failure to complete this process for the resident left personal property unaccounted for, as confirmed by the DON during an interview.
Deficient Care for Resident's Mobility and Incontinence Needs
Penalty
Summary
The facility failed to provide necessary care and assistance for a resident, resulting in a lack of mobility and inadequate incontinent care. The resident, who was readmitted with multiple diagnoses including neoplasm of bone, morbid obesity, and muscle weakness, required maximal assistance for lower body dressing and moderate assistance for activities of daily living (ADLs). Despite these needs, the resident's care plan did not reflect current mobility limitations, and interventions were not adequately implemented to prevent episodes of incontinence. Interviews with the resident and staff revealed that the resident frequently requested to be repositioned and have their diaper changed, but these requests were not consistently met in a timely manner. The resident expressed dissatisfaction with the room setup, which hindered their ability to perform tasks independently. Staff acknowledged the challenges in meeting the resident's needs due to the requirement of multiple staff members to assist with repositioning. The facility's policies on person-centered care planning and bowel and bladder training were not effectively followed, contributing to the deficiency in care provided to the resident.
Deficiency in Resident Care and Mobility Support
Penalty
Summary
The facility failed to provide appropriate care and treatment for a resident, identified as Resident 1, to maintain or improve their range of motion and mobility. Resident 1 was readmitted to the facility with multiple diagnoses, including neoplasm of bone, morbid obesity, muscle weakness, and anxiety disorder. The resident required maximal assistance for lower body dressing and moderate assistance for toileting hygiene. Despite these needs, the care plan did not adequately address the resident's current mobility limitations, and the interventions were not effectively implemented to meet the resident's physical and psychosocial needs. Observations and interviews revealed that Resident 1 frequently requested assistance to be repositioned in bed and for diaper changes, but these requests were not consistently met in a timely manner. The resident expressed dissatisfaction with the room setup, which made it difficult to access personal items, and reported delays in receiving assistance. Staff interviews confirmed that repositioning the resident required at least four people, which sometimes led to delays in providing the necessary care. Additionally, the resident's care plan did not reflect the resident's preferences and needs, such as having personal items on the right side of the bed. The facility's policies and procedures for person-centered care planning and bowel and bladder training were not effectively followed, resulting in neglect of the resident's needs. The failure to provide timely and adequate care had the potential to increase the resident's discomfort and risk of developing pressure injuries, as well as contribute to psychosocial decline. The facility's neglect in addressing the resident's needs and preferences was identified as a deficiency in providing care according to professional standards of practice.
Inaccurate Fall Risk Assessment for Resident
Penalty
Summary
The facility failed to accurately assess a resident's fall risk upon admission, which led to a deficiency in providing necessary care and services to prevent accidents and falls. The resident, who was admitted with diagnoses including Parkinson's disease, anoxic brain damage, a history of falling, and diabetes mellitus, was incorrectly assessed as being at low risk for falls. The fall risk assessment did not account for the resident's predisposing conditions such as Parkinson's disease and the use of medications like anti-convulsants, hypoglycemics, and antihypertensives, which should have indicated a higher fall risk. The Director of Nursing acknowledged that the fall risk assessment was not correctly coded, failing to reflect the resident's actual risk factors. This oversight meant that the resident was not identified as being at high risk for falls, which could have led to inadequate preventive measures being implemented. The facility's policy required that fall risk factors be documented and interventions be included in the care plan, regardless of the fall risk evaluation score, but this was not done in this case.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 4,736 citations issued within 25 miles in the last 12 months — including the 30 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Los Angeles
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cheviot Hills Post Acute | 0.1 mi | — | 24 | 0 |
| Southern California Hosp At Culver City D/p Snf | 0.6 mi | — | 9 | 0 |
| Meadowbrook Behavioral Health Center | 1.5 mi | — | 14 | 0 |
| Vista Del Sol Care Center | 1.8 mi | — | 3 | 0 |
| Mar Vista Country Villa Healthcare & Wellness | 1.8 mi | — | 3 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Overland Terrace Healthcare & Wellness Centre, Lp.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.