Inspection Reports for Grand Terrace Rehabilitation and Healthcare

The complaint investigation found that CNA A did not request assistance when performing incontinent care and dressing for Resident #1, who required two-person assistance. The resident's responsible party confirmed CNA A was not often assigned and had performed care alone twice. Staff interviews revealed communication gaps and lack of awareness about the care plan requirements.

The facility failed to ensure that CNA A requested help when performing incontinent care and dressing for Resident #1, who required two-person assistance. This failure posed a risk of potential harm or injury to the resident. Interviews and record reviews confirmed that CNA A did not seek assistance despite the care plan requirements.

The facility failed to ensure that drugs and biologicals were stored in locked compartments under proper temperature controls and that only authorized personnel had access to keys for medication storage. Specifically, a Normal Saline flush was found stored at the bedside of Resident #1, which could lead to misuse and adverse reactions.

The facility failed to ensure that the nurses' medication cart for the 1 and 2 hallway was secured by a lock when left unattended by LVN A, posing a risk of injury to residents if medications were accessed improperly. Interviews and observations confirmed the medication cart was left unlocked, contrary to facility policy and staff expectations.

The facility failed to develop a comprehensive person-centered care plan for Resident #66, specifically failing to address the antibiotic medication ordered by the physician. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

The complaint investigation found that the antibiotic order for Resident #66 was overlooked and not included in the care plan due to timing issues over the weekend. Interviews with MDS, ADON, and DON confirmed responsibility for care planning and acknowledged the oversight.

The facility failed to develop a comprehensive person-centered care plan for Resident #66 that included measurable objectives and time frames, particularly omitting the antibiotic medication order. This oversight could place residents at risk of not receiving appropriate interventions to meet their current needs.

The facility failed to maintain the restroom door frame in good repair, leaving two holes unaddressed for an extended period despite staff reporting the issue. The holes were eventually repaired during the inspection day. The failure posed a risk to residents, staff, and the public by diminishing the quality of the environment.

The investigation was complaint-driven, focusing on care plan omissions, failure to provide scheduled personal care, inadequate supervision during care, improper feeding tube management, and infection control breaches.

The facility failed to develop and implement comprehensive care plans addressing residents' needs, ensure scheduled showers and personal hygiene were provided, provide adequate supervision for residents requiring two-person assistance, properly label feeding tube formula bags, and maintain infection prevention protocols during incontinent care.

The complaint investigation found that Resident #47 did not have the splint on his right hand fourth digit as ordered by the physician. Staff interviews revealed lapses in communication and failure to report the missing splint to supervisors. The Director of Nursing and RN consultant confirmed the importance of the splint and noted the absence of a policy for following physician orders.

The facility failed to apply and maintain a splint on Resident #47's right hand fourth digit as ordered by the physician, despite multiple observations and interviews confirming the absence of the splint. Staff acknowledged awareness of the order but failed to ensure compliance, which could delay the resident's recovery and proper healing.