Grand Terrace Rehabilitation and Healthcare

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #1) of 3 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected an aggressive behavior he displayed towards a CNA on 5/30/26. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors with all required information for 1 (6/16/26) of 2 days reviewed for nurse staffing information. The facility failed to ensure the current daily staffing information was posted on 6/16/26. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preference for one (Resident #2) of three residents reviewed for call lights. The facility failed to ensure Resident #2's call light was within reach while in bed. This failure could place residents at risk of being unable to obtain assistance or help when needed and in the event of an emergency.

Inspectors wroteBased on interviews, and record review the facility failed to ensure the residents right to be informed of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 3 of 10 residents (Resident #1, Resident #2, and Resident #5) reviewed for consent for antipsychotic medications in that: 1. The facility failed to obtain prior consent based on information of the benefits and risks and options available before the administration of Zyprexa (an antipsychotic) for Resident #37. 2. The facility failed to obtain prior consent based on information of the benefits and risks and options available before the administration of Haldol (an antipsychotic) for Resident #61. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 2 (Resident #1 and Resident #2) of 8 residents reviewed for unnecessary medications. 1. The facility failed to have an adequate indication for the use of the medication Zyprexa (an antipsychotic) for Resident #37 before administering the medication with a black box warning. 2. The facility failed to have an adequate indication for the use of the medication Haldol (an antipsychotic) for Resident #61 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 6 residents (Resident #18 and Resident #46) reviewed for comprehensive person-centered care plans.1. The facility failed to ensure Resident #46's care plan included his code status of full code.2. The facility failed to ensure Resident #18's care plan included she was a 2 person assist for ADLs. These deficient practices could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care in accordance with professional standards of practice for 1 (Resident #1) of 2 residents observed for Quality of Care. The facility failed to ensure that CNA A asked for help when she performed incontinent care and dressed a resident who required 2-person assistance for these tasks. This failure could place residents at risk for potential harm or injury during tasks that require 2-person assistance.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 2 residents (Resident #1) reviewed for medication storage. The facility did not ensure a medication named Normal Saline flush was not stored at the bedside for Resident #1 on 10/3/2025. This failure could place all residents at risk of misuse of medication and decreased quality of life.

Inspectors wroteBased on observations interview, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (1 and 2 hallway cart) of 5 medication carts. The facility failed to ensure that the nurses medication cart for 1 and 2 hallway was secured by a lock when it was left unattended by LVN A. The failure could place residents at risk of injury to other residents if medication left unsecured were consumed.

Inspectors wroteBased on observations, interviews, and record review the facility failed develop a comprehensive person-centered care plan for each resident, consistent with resident needs, that included measurable objectives and time frames to meet residents' physical needs for 1(Resident #66) of 6 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #66. The comprehensive care plan failed to address the antibiotic medication ordered by the physician. This failure could place the residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (room [ROOM NUMBER]) of 5 rooms reviewed for environment. The facility failed to ensure the facility was in good repair as the facility did not repair gaps/holes on the restroom door frame in room [ROOM NUMBER]. This failure could affect all residents, staff, and the public by placing them at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 2 of 8 residents (Resident #54 and Resident #11) reviewed for ADLs. 1. The facility failed to ensure Resident # 54 was provided a shower as scheduled. 2. The facility failed to ensure Resident #11 was provided shower or bed bath as scheduled. These failures could place residents at risk for discomfort, and dignity issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs; and services that were to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for one (Resident #54) of eight residents reviewed for care plans. The facility failed to develop a care plan for slurred speech for Resident # 54. This failure could place residents at risk for not receiving necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision for one Resident (Resident #218) of three residents reviewed for supervision. The facility failed to ensure Resident #218 received two-person assist when providing incontinent care. This failure could place residents at risk for accidents and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 (Resident #267) of 6 residents reviewed for enteral nutrition, in that: The facility failed to appropriately label the formula bag for Resident #267 per the facility's policy. This failure could affect residents receiving enteral nutrition/hydration and place them at risk of health complications and decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections, for one resident (Resident #126) observed for incontinent care, in that: CNA C did not use one wipe per swipe on the perineal and buttock area during incontinent care on Resident #126. CNA C did not change her gloves during incontinent care for Resident #126. CNA C did not wash her hands before leaving Resident #126's room after performing incontinent care. These failures could place residents at risk for infections and cross contamination.