Overland Terrace Healthcare & Wellness Centre, LP

In the surveyor’s words

From the most serious findings on record at Overland Terrace Healthcare & Wellness Centre, LP, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Apr 14, 2023

  Based on interview, and record review, the facility failed to protect the residents' right to be free from physical abuse and sexual abuse for two of five sampled residents (Residents 2 and 3) by failing to: 1. Protect Resident 3 who was threatened by his roommate (Resident 1) on 3/2/2023 with a butter knife. 2. Ensure Resident 1 was not found in Resident 2's bedroom on 3/7/2023 on top of Resident 2, who was developmentally delayed (someone who have not gained the developmental skills expected of him or her, compared to others of the same age) and whose incontinence briefs and pants were observed at her ankle. Resident 1's private part (the genital organs of the male) was observed exposed. 3. […]

• No harm, potential for more than minimal, patternF812Jun 5, 2026

  Based 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. […]

• No harm, potential for more than minimal, patternF557Mar 6, 2025

  Based 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. Findings: During a record review, Resident 11's medical record indicated Resident 11 was originally admitted to the facility on [DATE] with diagnoses that muscle weakness, falling, depression (persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities.), cognitive communication deficit (disorder that affect a person's ability to communicate.), and anxiety (excessive and… […]

• No harm, potential for more than minimal, patternF584Mar 6, 2025

  Based 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]. […]

• No harm, potential for more than minimal, patternF609Mar 6, 2025

  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. […]