Grand Terrace Rehabilitation and Healthcare

In the surveyor’s words

From the most serious findings on record at Grand Terrace Rehabilitation and Healthcare, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF677Aug 31, 2023

  Based 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. […]

• No harm, potential for more than minimal, patternF656Mar 18, 2021

  Based on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered plan of care for 4 of 16 residents (Resident #1, Resident #6, Resident #43 and Resident # 38) reviewed for comprehensive care plans, in that: 1) The comprehensive care plan for Resident #1 did not address the Advance Directives for Full Code. 2) The comprehensive care plan for Resident #6 did not address the Advance Directives for DNR. 3) The comprehensive care plan for Resident #43 did not address the Advance Directives for Full Code. […]

• No harm, potential for more than minimal, isolatedF656Jun 17, 2026

  Based 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. […]

• No harm, potential for more than minimal, isolatedF558May 8, 2026

  Based 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.Findings included:Record review of Resident #2's Face Sheet dated 05/08/26 revealed an [AGE] year-old male with an admission initial date of 08/21/24, diagnoses included Type 2 Diabetes Mellitus with Hyperglycemia (high blood sugar levels), Chronic Respiratory Failure with Hypercapnia (high levels of… […]

• No harm, potential for more than minimal, isolatedF552Feb 19, 2026

  Based 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. […]