West Pico Terrace Healthcare & Wellness Centre LP

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Mar 10, 2023

  Based on interview and record review, for one of three sampled residents (Resident 2), the facility failed to: 1. Provide behavioral management care and continuous 1:1 sitter (one person designated to always remain with the resident while assigned) monitoring and supervision to prevent accident for Resident 2 who was on 5150 hold (a 72-hour long involuntary treatment hold in a hospital or mental health facility) for danger to others and gravely disabled a condition in which a person, as a result of a mental disorder, is unable to provide for his or her basic personal needs for food, clothing, or shelter). 2. […]

• Actual harm, isolatedF689Aug 10, 2022

  Based on interview and record review, the facility failed to ensure one of four sampled residents (Resident 1), who was at risk of falls and was on a low air loss mattress (LALM, an air mattress covered with tiny holes designed to let out air very slowly which helps keep the skin dry and [NAME] away any moisture as well as to relieve pressure), was provided side rails in bed for safety and prevent falls as requested by Resident 1's Responsible Party 1 (RP 1) as Resident 1 was able to move in bed and could roll out of bed. As a result, on 5/17/2022 at 1:30 p.m., two days after admission to the facility for rehabilitation, Resident 1 fell from bed onto the floor, requiring transfer to General Acute Care Hospital 1 (GACH 1) by Emergency Medical Services (EMS, paramedics). […]

• No harm, potential for more than minimal, widespreadF925Oct 24, 2022

  Based on observation, interview, and record review, the facility failed to: 1. Maintain facility ' s premises in a sanitary manner to prevent pests or insects, such as mosquitoes and flies 2. Provide and maintain window screens to two of 13 resident rooms with windows to outside (rooms [ROOM NUMBERS]) that serves as entry points for insects These deficient practices had the potential to place 39 of 39 residents residing in the facility at risk of vector-borne diseases (diseases that result from an infection transmitted to human by insects or rodents) if insects such as mosquitoes and flies spread in the facility. Findings: 1. […]

• No harm, potential for more than minimal, patternF805Apr 17, 2026

  Based on observation, interview and record review, the facility failed to ensure:Four residents on the pureed diet (foods that do not require chewing and are easily swallowed. All food should be smooth and pureed to the consistency of pudding) received bread texture in form that meet their needs and in accordance with international Dysphagia Diet Initiative IDDSI (IDDSI- a framework made up of levels and describes food textures and drink thickness) Level Four (pureed foods and extremely thick drinks) when the texture of the pureed bread was lumpy, not smooth and had small pieces of bread crust present requiring chewing before swallowing.Soft and Bite size diet texture was prepared according to the IDDSI-Level 6 (All foods prepared for are soft and chopped into bite size 1/2 inch x 1/2 inch… […]

• No harm, potential for more than minimal, patternF880Apr 17, 2026

  Based on observation, interview and record review, the facility failed to adhere to infection control practices when certified nursing assistant (CNA) 1 failed to wear a gown while providing direct care to one of five sampled residents (Resident 5). Resident 5 was on enhanced barrier precautions (EBP- are an infection control intervention designed to reduce transmission of multidrug-resistant organisms (MDROs)). This deficient practice had the potential to transmit infectious microorganisms to the other residents in the facility. […]