Grand Terrace Health Care Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective system wide infection control program for the prevention, control, and investigation of infections and communicable diseases for 14 of 19 sampled residents (Resident 6, 11, 23, 31, 36, 41, 44, 45, 49, 51, 52, 53, 70, and 77), when: 1. For five residents (Resident 6, 23, 77, 41, and 49), the facility staff did not wear an isolation gown (gown-cloth covering protection from neck to below knee) while providing high contact care to residents who are on Enhanced Barrier Precautions (EBP-an infection control intervention that involves wearing gown and gloves during high contact resident care activities). 2. For six residents (Resident 41, 45, 49, 52, 53, and 70), Licensed Vocational Nurse (LVN 1) did not clean the glucometer (a small machine used to check blood glucose) before and after use. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication was stored in accordance to the facility's policy and procedure (P&P) for Storage of medication and Disposal of medication, for one of one medication storage room when one bottle of 30 milliliter (ml-a unit of dosing medication) acetylcysteine (medication that can be used to clear airways) was found inside the refrigerator with an expiration date of February 28, 2026 (four days expired), and readily available for use. This failure had the potential to cause adverse health outcomes from administering expired medication which could negatively affect the vulnerable residents' health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two rooms(room [ROOM NUMBER] and 2) accommodate no more than four residents per room when room [ROOM NUMBER] and 2 had 5 beds in each room. This failure had the potential to place residents housed in room [ROOM NUMBER] and 2 at risk of decreased privacy, increased infection transmission, and limiting the ability of staff to provide safe and individualized care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There were food crumbs, [NAME], and trash under the stove. 2. A tray lined with parchment paper stored condiments (oil, vinegar, soy sauce) had spills. 3. Seven food packages and fruit were found opened and undated inside the kitchen's walk-in refrigerator, freezer, and tray condiments area. 4. One bottle of drink was found inside the walk-in refrigerator which belonged to staff. These failures had the potential to cause foodborne illnesses (any illness resulting from eating contaminated/spoiled foods) to 50 medically compromised residents who receive food served by the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control practices when: 1. A Certified Nurse Assistant (CNA) 1 did not wear appropriate PPE (Personal Protective Equipment - which includes gowns and gloves) during direct care contact with Resident 297 who was on Enhanced Barrier Precaution (EBP - an infection control intervention that involves wearing gown and gloves during high-contact resident care activities). 2. Visitor (V) 1 did not wear appropriate PPE during direct contact with a Resident who was on EBP. 3. V 2 and V 3 did not wear appropriate PPE while inside a resident room on Contact Precautions (CP - an infection control intervention that involves wearing gown and gloves to be avoid direct contact with the patient and indirect contact with the surfaces and objects in the room). 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored properly and securely when: 1. The Intravenous cart (IV cart - mobile cart that carries and stores medications, supplies, and equipment for administering medications through a vein) was left unlocked with key hanging from the cart lock. 2. The IV and medication carts were left unlocked and not under direct observation by authorized staff. 3. Three expired topical (applied to skin) medications were found inside the treatment cart. These had the potential to allow unauthorized access to medications and supplies which could cause undetected misuse, diversion (distribution, abuse, or use of drugs for purposes not intended by the prescriber), and unsafe use of medications intended for 54 residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure timely completion of the Comprehensive admission Minimum Data Set (MDS - a federally mandated resident assessment tool) assessments for one of 17 sampled residents (Resident 350). This deficient practice had the potential to delay the care planning process to meet Resident 350's comprehensive and individualized care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Comprehensive admission Minimum Data Set (MDS - a federally mandated resident assessment tool) assessment was accurately completed per Resident Assessment Instrument (RAI- comprehensive assessment and care planning process used by nursing home) guidelines for one of 17 sampled residents (Resident 351) when: 1. Resident 351's hearing abilities and limitations was not accurately coded. 2. Resident 351's antiplatelet medication (medication to prevent blood clot) was not coded. These deficient practices had the potential for Resident 351 not to receive the necessary care, treatment, and/or services to attain his highest practicable level of functioning.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a baseline care plan that addressed Left Ventricular Assist Device (LVAD - a device implanted in the chest that helps to pump blood from the lower chambers of the heart to the rest of the body) for one of 17 sampled residents (Resident 297). This deficient practice had the potential for not receiving necessary care and treatment related to resident's medical, physical, mental, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the gastrostomy tube (g-tube - a tube inserted through the wall of the abdomen directly into the stomach that can be used to give food and medication to a person) was flushed before and after medication administration as ordered by the physician for one of one observed resident (Resident 12) with g-tube during medication administration observation. This deficient practice posed a risk of not maintaining patency (open or unobstructed) of Resident 12's g-tube which could lead to ungiven medications, hydration, and nutritional feedings to meet Resident 12's needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately monitor two of 17 sampled residents (Residents 350 and 297) for adverse consequences of anticoagulant (used to prevent or treat blood clots) medication therapy. This failure had the potential to result in unidentified care concerns, inconsistent care coordination, and delay of treatment which could adversely affect the health and safety of these residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two rooms (rooms [ROOM NUMBERS]) accommodate no more than four residents per room when rooms [ROOM NUMBERS] had 5 beds in each room. This failure had the potential for the residents housed in rooms [ROOM NUMBERS] to not have the ability to move about freely if the five beds limited their personal space.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents for one of three sampled residents (Resident1). When Resident 1 fell out of bed. This failure contributed to Resident 1 sustaining multiple discoloration to left eye, left forearm and left knee.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain professional standards for food service safety when: 1. The stainless-steel wall backsplash, behind the stove and the steam table, had food splash and white-water splash. 2. There were food crumbs and trash under the stove. The food preparation area drawer was lined with paper and had crumbs underneath. The front drawer had black grime. A tray lined with foil stored condiments (oil, vinegar, soy sauce) had crumbs and spills. A metal pan with clean serving spoons, lined with parchment paper, had crumbs underneath. There were trash and food crumbs under the handwashing sink and condiment shelf. 3. The stainless-steel shelves, storing clean pots and pans, were lined with grip liner and had crumbs underneath. The shelf above the drink dispenser had black grime and dust. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the call light (a device used by a resident to signal their need for assistance from facility staff) was not within reach for two of four residents (Residents 9 and 20) reviewed for call light. This failure had the potential to place Residents 9 and 20 at risk of harm, as residents would be unable to call for help, or alert staff in the event of an incident.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set (MDS- a computerized assessment instrument) Assessments were accurately completed to reflect the resident's status, care, and services in the skin conditions under Section M for two of three residents (Residents 299 and 350) reviewed for Resident Assessment. These failures had the potential to cause inaccuracy in identifying Resident 299's and 350's care and support needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a care plan (a summary of a resident's health conditions, specific care needs, and current treatments) were developed for two of two residents (Resident 9 and 46) reviewed for care planning when: 1. For Resident 9, a care plan was not developed for her behavior of removing her nasal cannula (a pronged device used to administer oxygen). This failure had the potential for Resident 9's oxygen needs not being met. 2. For Resident 46, a care plan was not developed when Resident 46 repeatedly refused weekly weights. This failure has the potential for Resident 46's weight changes not being identified and addressed which could place his health at risk. 3. For Resident 46, a care plan was not developed for his refusal of anti-coagulant medications (used to prevent blood clots). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe environment was maintained for one of two residents (Resident 37) reviewed for accidents when there was no oxygen sign posted outside of Resident 37's room. This failure has the potential to increase the risk of injuries, which could threaten the welfare, health, and safety of Resident 37.

Inspectors wroteBased on observation, interviews and record review, the facility failed to follow the physician's order for urinary catheter (a flexible tube used to empty the bladder and collect urine in a drainage bag) care for one resident (Resident 12) reviewed for urinary catheter. This failure has the potential for Resident 12 to be at risk of Urinary Tract Infection (UTI- clinically detectable condition associated with invasion by disease causing microorganisms of some part of the urinary tract), placing his health and safety to be jeopardized.

Inspectors wroteBased on interview and record review, the facility failed to ensure nursing staff provided adequate monitoring for one of three residents (Resident 451) reviewed for dialysis (process of removing excess water and toxins from the blood by using a machine and an artificial kidney), when Resident 451 was not monitored by the nursing staff after missing two dialysis treatments. This failure had the potential to compromise Resident 451 health due to missed dialysis treatments and increased the risk for complications such as fluid overload (too much fluid in the body).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure laboratory (lab) procedures were implemented for one of two residents (Resident 46) reviewed for anticoagulant (preventing blood clots) medication use when: 1. Resident 46's physician was not notified of abnormal laboratory result. 2. Blood work was missed for one of four sample residents (Resident 46). These failures had the potential for Resident 46 to develop a deep vein thrombosis (DVT - blood clot forming in a deep, large vein) causing life threatening complications such as pulmonary embolism (a sudden blockage in a lung), heart attack, or ischemic stroke (blockage in the brain).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food prepared for residents on a pureed diet (blended to pudding consistency) was palatable for lunch on April 5, 2023, when five of five residents (Residents 6, 9, 14, 24, and 35) on a pureed diet were served pureed cauliflower and peas that was not palatable and did not taste comparable with the cauliflower and peas served to the residents receiving a regular diet (diet with no restrictions). This failure had the potential to cause the Residents 6, 9, 14, 24, and 35 to experience a decrease in food intake which could lead to poor nutrition and health outcomes for these vulnerable residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a food alternative meal that was of similar nutritive value for two of two residents (Residents 101 and 13) reviewed for food alternate meal, when Residents 101 and 13 refused the meal offered on April 4, 2023. This failure had the potential to lead to decrease calorie and nutrient consumption for Residents 101 and 13, who are medically compromised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure accurate documentation for one of two residents (Resident 299) reviewed for pressure ulcer/injury (refers to localized damage to the skin and/or underlying soft tissue usually over a bony prominence or related to a medical or other device) when a Treatment Nurse (TN 1) did not follow the facility policy and procedure for documenting the change of condition for Resident 299. This failure could have potentially caused a delay of healing for Resident 299's wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure their infection control practices were implemented in accordance with their policy and procedure when: 1. Resident 35's nasal canula tubing (NC-tubing that delivers oxygen) did not have a date to indicate when it was changed. 2. In the care area, two staff members were not wearing masks. 3. 17 seat cushions were stored on the floor, across the nurse's station. These failures had the potential to spread infectious disease (disease caused by bacteria, viruses, fungi or parasite) to 52 medically compromised residents and staff in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe environment for one of 23 rooms (room [ROOM NUMBER]), when in room [ROOM NUMBER], a power cord from Bed B was dangling and extending to the power outlet of Bed A. This failure had the potential for the facility staff and residents to trip and fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two rooms (rooms [ROOM NUMBERS]) accommodate no more than four residents per room when rooms [ROOM NUMBERS] had 5 beds in each room. This failure had the potential for the residents housed in room [ROOM NUMBER] and 2 to not have the ability to move about freely if the five beds limited their personal space.