Grand Terrace Health Care Center

In the surveyor’s words

From the most serious findings on record at Grand Terrace Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, widespreadF812Jul 15, 2021

  Based on observation, interview, and record review, the facility failed to ensure the ice and water machine, used for resident consumption of ice and drinking water in the facility, was maintained in a clean and sanitary manner, and free from visible contamination indicative of foreign growth matter, for 46 out of 46 residents in the facility. This failure resulted in the residents being exposed to unsanitary and contaminated water and ice used for resident consumption, risking the likelihood of severe health consequences due to foodborne illness upon these vulnerable residents in the facility. Findings: During an interview on July 14, 2021, at 12:57 PM, with the Maintenance Director (Maintenance), the Maintenance stated the facility had only one ice machine. […]

• Immediate jeopardy, patternF913Sep 16, 2021

  Based on observations, interviews, and record reviews, the facility failed to ensure that resident rooms had direct access to an exit corridor when four of four Resident rooms (rooms 15, 17, 19 and 21) in the red zone (rooms with confirmed COVID -19 a contagious virus) had been drilled shut. This had the potential to result in three residents (Resident 1, Resident 2 and Resident 3) who were dependent on staff, being trapped in their rooms in the event of a fire, causing severe [CONDITION(S)], permanent disability or even death. Findings: During an observation on September 16, 2021, at 9:20 AM, four Resident rooms, (Room 15, Room 17, Room 19 and Room 21) were noted to have doors that had been drilled closed with a screw. […]

• No harm, potential for more than minimal, widespreadF880Mar 5, 2026

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Nov 22, 2024

  Based 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. Findings: 1. […]

• No harm, potential for more than minimal, widespreadF880Nov 22, 2024

  Based 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. […]