Above average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Grand Terrace Health Care Center during CMS and state inspections, most recent first.
Multiple infection control failures were observed involving residents on EBP and residents receiving IV and catheter care. Staff provided high-contact care without gowns, glucometers were not cleaned before or after blood sugar checks, PPE carts and precaution posters were missing outside several rooms, IV tubing lacked required labeling, a Foley tube touched the floor, and an RN did not clean PICC connectors with alcohol before giving IV meds. The DON and DSD/IP confirmed the expected practices and that the facility policies were not followed.
Expired Medication Left in Storage Refrigerator: A medication storage room contained one bottle of acetylcysteine in the refrigerator that had expired and remained readily available for use. The MDS nurse verified the bottle had been opened and was past its 96-hour expiration, while the DSD/IP and DON acknowledged that expired medication should be discarded and that facility P&P for storage and disposal of medication were not followed.
Excess Residents in Two Shared Rooms: The facility failed to ensure two rooms held no more than four residents each, as both rooms had 5 beds despite a waiver being discussed by the Admin. During the survey, the rooms were observed to be free of clutter and wheelchair accessible, and the Maintenance Director confirmed the room measurements and bed counts. Staff stated there were no care issues, safety hazards, or resident complaints related to the rooms having more than four residents.
The facility failed to maintain sanitary conditions in the kitchen, with food crumbs and grime under the stove, spills in the condiment area, and opened, undated food packages in the refrigerator and freezer. Additionally, a staff member's drink was improperly stored in the kitchen refrigerator, violating facility policy.
The facility failed to maintain infection control practices, with staff, visitors, and contractors not wearing appropriate PPE during interactions with residents on Enhanced Barrier Precautions (EBP) and Contact Precautions (CP). A CNA and a RNS did not wear required PPE during direct care activities, and visitors were observed without PPE in resident rooms. Contract phlebotomists and an LVN also neglected proper infection control measures, leading to potential cross-contamination risks.
The facility failed to securely store medications, with IV and medication carts left unlocked and unattended, and expired topical medications found in the treatment cart. Staff acknowledged the importance of locking carts to prevent unauthorized access, and the facility's policy requires secure storage of medications.
A facility failed to complete a resident's Comprehensive Admission MDS Assessment within the required 14 days, as confirmed by the MDS Nurse and DON. The assessment was six days overdue, potentially delaying the care planning process. The facility's policy and CMS guidelines were not followed.
A resident's Comprehensive Admission MDS assessment was inaccurately completed, failing to correctly code the resident's hearing difficulties and daily antiplatelet medication use. The resident reported hearing issues and used hearing aids, yet the MDS coded hearing ability as adequate. Additionally, the resident's daily aspirin use was not recorded in the MDS, despite evidence from the MAR. These inaccuracies were acknowledged by the MDS Nurse and highlighted by the DON as contrary to facility policy and RAI guidelines.
A facility failed to create a baseline care plan for a resident with a Left Ventricular Assist Device (LVAD) within 48 hours of admission. The resident, who was observed with the LVAD connected to a machine, emphasized the importance of monitoring the device. Interviews with staff confirmed the absence of a care plan, despite facility policy requiring one to address cardiovascular functions and risks.
A facility failed to follow physician's orders for a resident with a g-tube by not flushing the tube with the prescribed amount of water before and after medication administration. An LVN administered medications without the required pre-flush and used an incorrect amount of water for the post-flush, as confirmed by the E-MAR and the Director of Nursing.
The facility failed to monitor two residents for adverse effects of anticoagulant therapy, resulting in unmonitored skin discolorations and lack of documentation. Despite the facility's policy requiring monitoring for signs of bleeding, this was not implemented for the residents, leading to a deficiency.
The facility was found non-compliant with regulations as two rooms contained five beds each, exceeding the allowed capacity of four residents per room. The Administrator confirmed the need for a waiver for rooms with more than four beds. Despite this, the rooms were not crowded, posed no safety hazards, and residents did not complain about space issues. The survey team recommended approval of the room waiver request.
A resident with multiple health issues fell out of bed, sustaining bruises, due to inadequate supervision and delayed implementation of safety measures like bed alarms and floor mats. Initially assessed as low risk for falls, the resident's condition changed, increasing the risk, but necessary precautions were not timely applied.
Infection Control Failures With EBP, Glucometer Cleaning, and IV/Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program for multiple residents on Enhanced Barrier Precautions (EBP). For Resident 6, who had diabetes, pleural effusion, COPD, CHF, and an indwelling Foley catheter, a CNA transferred the resident from bed to wheelchair without wearing a gown, and later another CNA removed linens from the resident’s room without a gown. For Resident 23, who had diabetes, osteomyelitis of the right foot and ankle, and MRSA, a CNA assisted with toileting without a gown. For Resident 77, who had diabetes and an EBP order for a wound, a CNA changed and removed linens from the room without a gown. For Resident 41, who had diabetes, hemiplegia, and dementia, an LVN took a blood glucose reading without a gown. For Resident 49, who had diabetes, CHF, and immunodeficiency, an LVN also took a blood glucose reading without a gown. The facility also failed to ensure glucometers were cleaned before and after use during blood glucose checks. An LVN performed blood glucose checks for Residents 41, 45, 70, 53, 49, and 52 without cleaning the glucometer before use and without cleaning it after use. The LVN confirmed she did not clean the glucometer between residents and stated it should have been cleaned. The facility’s DSD/IP and DON confirmed that nursing staff are expected to clean glucometers before and after use, and the facility policy reviewed by surveyors stated glucometers must be cleaned before use and after each use. The facility also did not have PPE carts or precaution posters in front of several EBP rooms, including those for Residents 6, 23, 77, 36, 51, 11, 31, and 44. Staff confirmed the missing carts and signage, and the DSD/IP and DON stated that signage and PPE should be readily available outside EBP rooms. In addition, Resident 11 had IV tubing hanging without a label showing date, time, and initials, Resident 31’s Foley tubing was observed touching the floor, and RN 1 did not clean the PICC line injection connector with alcohol swabs before administering IV medications to Residents 11 and 31. The DON acknowledged the facility policies were not followed in these instances.
Expired Medication Left in Storage Refrigerator
Penalty
Summary
A medication storage room was observed to contain one 30 mL bottle of acetylcysteine in the refrigerator with an expiration date of February 28, 2026, and the bottle was identified as four days expired and still readily available for use. During the observation and interview, the MDS nurse verified that the pharmacy label indicated the medication expired 96 hours, or four days, after opening, and stated that the bottle had been delivered and opened on February 24, 2026, making it expired and expected to be discarded. The DSD/IP stated that expired medication should be discarded and should not be available in the patient care area. During record review with the DON, the facility’s policies for Storage of medication and Disposal of medication were reviewed, including requirements that outdated medications be immediately removed from stock and disposed of in a timely manner. The DON acknowledged that the policies were not followed and stated that she was not aware the expired medication was still inside the refrigerator and that the facility failed to discard the expired medication.
Excess Residents in Two Shared Rooms
Penalty
Summary
The facility failed to ensure that two resident rooms accommodated no more than four residents per room. During an interview, the Admin stated that the facility had two rooms approved for a waiver to have more than four residents in each room. However, during an environmental tour, the Maintenance Director confirmed that room [ROOM NUMBER] measured 638.45 square feet and room [ROOM NUMBER] measured 644.08 square feet, and each room had 5 beds. The measurements were documented as 127.69 square feet per resident in one room and 128.81 square feet per resident in the other room. Observations showed that each room was occupied by four residents at the time of the survey, and the rooms were described as free of clutter, wheelchair accessible, and without concerns related to the beds or bedside tables. A CNA stated that the rooms were wheelchair accessible and had sufficient space to provide care to all residents, and the Admin and DON stated there had been no issues with care related to the rooms having more than four residents. The report also states that the rooms were not crowded, did not impose safety hazards, and that there were no complaints from the residents occupying the rooms.
Deficiencies in Kitchen Sanitation and Food Storage
Penalty
Summary
The facility failed to maintain safe and sanitary food preparation and storage practices in the kitchen, as observed during a survey. Food crumbs, black grime, and trash were found under the kitchen stove, indicating a lack of regular cleaning. The Dietary Aide (DA) acknowledged that the kitchen should be kept clean, and the Dietary Services Supervisor (DSS) confirmed that the facility's policy required routine cleaning of floors. The Registered Dietitian (RD) also stated that kitchen floors should be kept clean to prevent contamination. Additionally, a tray lined with parchment paper used to store condiments such as oil, vinegar, and soy sauce had spills, which were not cleaned regularly. The DA confirmed that the area should be free of crumbs and spills to prevent bacterial growth. The DSS and RD both acknowledged that the facility's policy required all utensils, counters, and equipment to be kept clean, and the FDA Federal Food Code mandates that nonfood-contact surfaces be free of debris to prevent microorganism growth. The survey also found several opened and undated food packages in the walk-in refrigerator and freezer, including vegetable oil, milk, soy sauce, honey mustard, Worcestershire sauce, watermelon, and hotdog buns. The DSS confirmed that the facility's policy required all food items to be labeled and dated for safety. The RD stated that undated food packages should be discarded as their safety could not be assured. Furthermore, an open bottle of tea drink belonging to staff was found in the walk-in refrigerator, contrary to the facility's policy that prohibits staff food in the kitchen refrigerator. The RD acknowledged that staff food should not be stored in the kitchen's refrigerator.
Infection Control Lapses in PPE Usage
Penalty
Summary
The facility failed to maintain proper infection control practices, as evidenced by multiple instances of staff, visitors, and contractors not wearing appropriate personal protective equipment (PPE) during interactions with residents on Enhanced Barrier Precautions (EBP) and Contact Precautions (CP). A Certified Nurse Assistant (CNA) did not wear gloves and a gown while providing direct care to a resident with a Left Ventricular Assist Device (LVAD), despite the resident being on EBP. Similarly, a Registered Nurse Supervisor (RNS) did not wear the required PPE while flushing a Peripherally Inserted Central Catheter (PICC) line for another resident on EBP. Visitors also failed to adhere to PPE protocols. One visitor did not wear gloves or a gown while touching a resident's gown and beddings in a room where EBP was in place. Two other visitors were observed in a resident's room on CP without any PPE, despite the facility's policy requiring gowns and gloves for such interactions. The facility did not enforce these requirements, leading to potential cross-contamination and infection risks. Additionally, contract phlebotomists did not perform hand hygiene or wear appropriate PPE while conducting a blood draw on a resident on EBP. A Licensed Vocational Nurse (LVN) also failed to disinfect a blood pressure cuff before and after use during medication administration. These lapses in infection control practices were confirmed through interviews with staff and a review of the facility's policies, highlighting a systemic issue in adhering to established infection prevention protocols.
Medication Storage Deficiencies
Penalty
Summary
The facility failed to ensure the proper and secure storage of medications, as observed during a survey. On November 18, 2024, an IV cart was found unlocked and unattended in the facility hallway, with the key hanging from the lock. This was acknowledged by the Treatment Nurse and the Registered Nurse Supervisor, who both stated that the cart should be locked when not in use to prevent unauthorized access. The Director of Nursing also confirmed that the cart should be locked when out of staff's sight to ensure safety. Further observations on November 20, 2024, revealed that both the IV and medication carts were left unlocked and unattended during medication administration. The Registered Nurse Supervisor and a Licensed Vocational Nurse were observed leaving the carts unlocked while administering medications to residents. Both staff members acknowledged the importance of locking the carts to prevent unauthorized access by residents, staff, and visitors. The facility's policy requires medication carts to be locked or attended by authorized personnel. Additionally, expired topical medications were found in the treatment cart during a storage observation on November 20, 2024. These included Aspercreme Lidocaine Pain Relief Spray, Antiseptic Skin Cleanser, and Hydrogen Peroxide, all of which were past their expiration dates. The Treatment Nurse and the Director of Nursing stated that expired medications should be discarded to prevent cross-contamination and should not be available for resident use. The facility's policy mandates the immediate removal and disposal of outdated or deteriorated medications.
Delayed Completion of Comprehensive Admission MDS Assessment
Penalty
Summary
The facility failed to ensure the timely completion of the Comprehensive Admission Minimum Data Set (MDS) assessments for a resident, identified as Resident 350. During an observation, Resident 350 was found in her room with purplish brown discolorations on her forearms. A review of her admission record indicated she was admitted to the facility, but her Comprehensive Admission MDS Assessment, which should have been completed within 14 days of admission, was six days overdue. This delay was confirmed during an interview with the MDS Nurse, who acknowledged that the assessment was not completed on time, contrary to the facility's policy and the Resident Assessment Instrument (RAI) guidelines. Further review and interviews revealed that the Director of Nursing (DON) also acknowledged the delay, stating that she missed signing the assessment by the required date. The facility's policy, which mandates that a comprehensive assessment be conducted within 14 days of admission and signed by a Registered Nurse, was not adhered to. The Centers for Medicare & Medicaid Services' guidelines also require that the MDS completion date be no later than day 14. The failure to complete the assessment in a timely manner had the potential to delay the care planning process for Resident 350.
Inaccurate MDS Assessment for Resident's Hearing and Medication
Penalty
Summary
The facility failed to accurately complete the Comprehensive Admission Minimum Data Set (MDS) assessment for a resident, identified as Resident 351, as per the Resident Assessment Instrument (RAI) guidelines. The first issue was related to the incorrect coding of the resident's hearing abilities. During an observation and interview, the resident expressed having hearing difficulties for three years and using hearing aids, with more pronounced issues in the left ear. This was corroborated by a family member who noted the need for louder speech for the resident to hear better. Despite these observations, the MDS assessment inaccurately coded the resident's hearing ability as adequate, indicating no difficulty in normal conversation, which was later acknowledged as incorrect by the MDS Nurse (MDSN) upon review. The second issue involved the failure to code the resident's antiplatelet medication use accurately. During an initial tour, the resident was observed with reddish-purple discolorations on the forearms, and a review of the resident's records showed a prescription for daily aspirin for cerebrovascular accident prophylaxis. However, the MDS assessment left the section for antiplatelet medication blank, indicating the resident did not receive such medication during the 7-day look-back period, despite evidence from the Medication Administration Record (MAR) showing daily aspirin administration. The MDSN admitted to not following the RAI guidelines for coding medication use. The Director of Nursing (DON) expressed that the expectation was for staff to accurately complete the MDS assessment and adhere to RAI guidelines, as these are crucial for developing the resident's care plan. The facility's policy emphasized the importance of comprehensive and accurate assessments, yet the deficiencies in coding both the resident's hearing abilities and medication use were evident, potentially impacting the resident's care and treatment.
Failure to Develop Baseline Care Plan for Resident with LVAD
Penalty
Summary
The facility failed to develop a baseline care plan for a resident with a Left Ventricular Assist Device (LVAD) within 48 hours of admission, as required by their policy. During an initial observation, the resident was found in their room with the LVAD connected to a machine at the bedside. The resident explained the importance of checking the battery and settings of the LVAD to ensure its proper function. However, a review of the resident's care plan revealed that no plan had been developed to address the LVAD and its associated cardiovascular functions and risks. Interviews with the Registered Nurse Supervisor and the Director of Nursing confirmed the absence of a baseline care plan for the resident's LVAD. Both acknowledged the necessity of such a plan to monitor potential risks and determine appropriate interventions for any issues related to the resident's cardiovascular condition. The facility's policy mandates the development of a comprehensive, person-centered care plan within 48 hours of admission, which was not adhered to in this case.
Failure to Follow G-Tube Flushing Protocol
Penalty
Summary
The facility failed to ensure proper care for a resident with a gastrostomy tube (g-tube) by not adhering to the physician's orders for flushing the tube before and after medication administration. During an observation of medication administration, a Licensed Vocational Nurse (LVN) did not flush the g-tube with water before administering medications to the resident. The LVN only flushed the tube with 15 milliliters of water after administering all medications, contrary to the physician's order which required flushing with 30 milliliters of water both before and after medication administration. Upon review of the Electronic Medication Administration Record (E-MAR), it was confirmed that the resident had an order to flush the g-tube with 30 milliliters of water before and after medication administration. The LVN acknowledged the oversight and the incorrect amount of water used. The Director of Nursing confirmed the importance of following the physician's order to maintain the patency of the g-tube. The facility's policy also indicated the necessity of flushing the tube with 30 milliliters of water prior to and after medication administration.
Failure to Monitor Anticoagulant Therapy
Penalty
Summary
The facility failed to adequately monitor two residents for adverse consequences of anticoagulant medication therapy. Resident 350 was observed with purplish brown discolorations on her forearms, and there was no documented evidence of monitoring for anticoagulant side effects in her Medication Administration Record (MAR). The Registered Nurse Supervisor confirmed that there was no order to monitor for side effects, and the Director of Nursing stated that monitoring should have been initiated when the medication was prescribed. Resident 297 was also observed with multiple purplish skin discolorations and reported that the medication Coumadin caused easy bruising. The resident's care plan indicated a need for monitoring and documenting anticoagulant complications, but this was not implemented. The Registered Nurse Supervisor verified the lack of monitoring, and the Director of Nursing acknowledged the absence of monitoring for complications related to anticoagulant therapy. The facility's policy on anticoagulation therapy requires licensed nursing staff to monitor for signs and symptoms of bleeding and document them in the medical record. However, this policy was not followed for Residents 350 and 297, leading to a deficiency in monitoring for adverse effects of anticoagulant medications.
Non-compliance with Resident Room Capacity
Penalty
Summary
The facility failed to comply with the regulatory requirement that resident rooms accommodate no more than four residents per room. During an observation, interview, and record review, it was found that two rooms contained five beds each, exceeding the allowed number of residents per room. The Administrator confirmed that these rooms did not meet the accommodation requirement and acknowledged that a waiver is necessary for any room with more than four beds. Despite the non-compliance, the rooms were not crowded, did not pose safety hazards, and there were no complaints from the residents about space or room issues. The survey team recommended the approval of the room waiver request for the rooms listed in this deficiency.
Inadequate Supervision Leads to Resident Fall and Injuries
Penalty
Summary
The facility failed to provide adequate supervision to prevent avoidable accidents for a resident who fell out of bed, resulting in multiple bruises on the left eye, forearm, and knee. The resident was admitted with several diagnoses, including cardiac arrest, pneumonia, type 2 diabetes, and hypertension. Despite being assessed as low risk for falls initially, a change in condition led to a high-risk assessment. The resident was found on the floor at the foot of the bed, and interventions such as bed alarms and floor mats were implemented only after the fall occurred. Interviews and record reviews revealed that the resident had poor safety awareness and required more supervision due to impaired clarity. Another resident reported that the fallen resident had significant bruising and that floor mats were only placed after the resident's sister requested them. The facility's policy on fall management emphasizes providing an environment free of accident hazards and adequate supervision, which was not adhered to in this case, leading to the resident's fall and subsequent injuries.
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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.
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Nursing homes near Grand Terrace
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Meadows Ridge Care Center | 1 mi | ★★★★★ | 8 | 0 |
| The Canyons Post-acute | 1.3 mi | ★★★★★ | 8 | 0 |
| Heritage Gardens Health Care Center | 3.5 mi | ★★★★★ | 18 | 0 |
| Loma Linda Post Acute | 3.6 mi | ★★★★★ | 0 | 0 |
| Rialto Post Acute Center | 4.3 mi | ★★★★★ | 14 | 1 |
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