Grand Terrace Health Care Center

Location & what’s nearby

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Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.

Quality measures — how residents actually fare

Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.

Short-stay rehab — if you are coming here from a hospital

Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.

54.6% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — which CMS reads as no different from the national rate. This is CMS’s risk-adjusted rate over 175 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.

Met the expected recovery: 82.0% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 50 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.

Therapy staffing: this home’s payroll records show 0.90 therapist hours per resident per day in 2026Q1 — more than 96% of the 13,892 homes that report any therapy hours at all.

Weekend therapy: weekend therapy hours are 1% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.

This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.

Staffing

How full it usually is: this home is certified for 59 beds and averages 51.5 residents a day — about 87% occupied, or roughly 8 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.

Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.69 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.48 is below the 0.55-hour RN benchmark and nurse-aide staffing of 2.75 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.

Weekend coverage: total nurse staffing is 4.16 hrs/resident/day on weekends vs 4.90 on weekdays — 15% thinner on weekends. RN hours go from 0.54 to 0.31 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)

This home’s total nursing-staff turnover of 32% is below the national median of 45%.

Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.

Inspection trend

Deficiencies are fewer than at the previous inspection — improving. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.

Inspection deficiencies

State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.

Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.

27 citations, most serious first. The 10 most serious are shown; the remaining 17 are one tap away and print in full.

• Potential for harm · Fcited before2026-03-05 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. 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. For eight residents (Resident 6, 23, 77, 36, 51, 11, 31, and 44), the facility staff did not provide Personal Protective Equipment…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2026-03-05 · tag F0755 — failed to provide safe pharmacy services — isolated
  Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings: During a concurrent observation and interview on [DATE], at 5:30 AM, with Minimum Data Set (a detail assessment of the resident) nurse (MDS), the facility medication storage room was observed and found one bottle of 30 ml acetylcysteine. MDS verified and stated that the pharmacy indicated on the medication label that the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-11-22 · tag F0812 — failed to store, cook, and serve food safely — widespread
  Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. During an initial observation tour of the kitchen and interview with Dietary Aide (DA), on November 18, 2024, at 8:05 AM, food crumbs, black grime, and trash were found on the floor under the kitchen stove. The DA stated areas in the kitchen should be kept clean…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Nutrition and Dietary Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Fcited before2024-11-22 · tag F0880 — failed to prevent and control infections — widespread
  Provide and implement an infection prevention and control program.
  What the surveyor found here — an excerpt from the official record, may be distressing

  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. 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. Contract Phlebotomist (CPH) 1 and CPH 2 did not complete hand hygiene and did not wear appropriate PPE when completing a blood draw on a resident on EBP. 5. A Registered Nurse Supervisor (RNS) 1 did not wear the required PPE while flushing the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Infection Control Deficiencies · Deficient, Provider has date of correction
• Potential for harm · E2024-11-22 · tag F0761 — failed to label and store drugs safely — pattern
  Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: 1. During an initial tour observation on November 18, 2024, at 11:54 AM, in the facility hallway in front of rooms [ROOM NUMBERS], the IV cart was observed unlocked and unattended. The cart lock was not…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-22 · tag F0636 — isolated
  Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: During an initial screening observation on November 18, 2024, at 11:42 AM, inside resident's room, Resident 350 was lying on her bed, awake, and covered with blanket. Resident 350 was observed with scattered purplish brown discolorations on both forearms. A review of Resident 350's admission Record (document which contains demographic and medical information) indicated she was admitted to the facility on [DATE]. During a concurrent interview and record review with the MDS Nurse (MDSN) on November 20, 2024, at 9:48 AM, the MDSN reviewed Resident 350's Comprehensive admission MDS Assessment with an Assessment Reference…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · Dcited before2024-11-22 · tag F0641 — isolated
  Ensure each resident receives an accurate assessment.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: 1. During a concurrent observation and interview with Resident 351, on November 20, 2024, at 2:54 PM, inside the resident's room, Resident 351 was leaning forward toward the Surveyor and stated he had hearing difficulties for three years now and used hearing aids. Resident…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-22 · tag F0655 — isolated
  Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: During an initial tour observation, in Resident 297's room, on November 18, 2024, at 8:26 AM, Resident 297 was lying in bed, awake, and verbally responsive. Resident 297 was noted with an LVAD connected to the machine on the bedside. During an interview with Resident 297, on November 18, 2024, at 8:49 AM, Resident 297 stated that LVAD was a battery-operated machine with a tubing connected to resident's heart to help pump the blood to the rest of the body. Resident 297 also stated that it was very important to check the…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Resident Assessment and Care Planning Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-22 · tag F0693 — failed to provide proper feeding-tube care — isolated
  Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: During medication pass observation and concurrent interview with Licensed Vocational Nurse (LVN) 2, on November 20, 2024, at 11:02 AM, in Resident 12's room, LVN 2 did not flush the g-tube with water before administering the medications to Resident 12. LVN 2 proceeded to administer the medications and flushed the g-tube with 15 milliliter (ml - unit of measurement)…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Quality of Life and Care Deficiencies · Deficient, Provider has date of correction
• Potential for harm · D2024-11-22 · tag F0757 — failed to avoid unnecessary drugs — isolated
  Ensure each resident’s drug regimen must be free from unnecessary drugs.
  What the surveyor found here — an excerpt from the official record, may be distressing

  NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. Findings: 1. During an initial tour observation on November 18, 2024, at 11:42 AM, inside resident's room, Resident 350 was lying on her bed, awake, and covered with a blanket. Resident 350 was observed with scattered purplish brown discolorations on both forearms. Resident 350 was unable to explain how she got those skin discolorations. A review of Resident 350's admission Record (document which contains demographic and medical information) indicated Resident 350 was admitted to the facility on [DATE] with diagnoses of unspecified atrial fibrillation (irregular and rapid…

  This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

  Pharmacy Service Deficiencies · Deficient, Provider has date of correction

“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.

Fines & penalties

No federal fines in the current CMS record.

Part of a chain

This home belongs to THE ENSIGN GROUP — 342 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →

A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.

Who owns this facility

The source lists no ownership percentage for any party here — PECOS records a share only for equity interests, not for board or management roles.

1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.

Follow the money — this home’s finances

Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.

This home reported $887K paid to related parties — landlords or management companies under common ownership — equal to about 10% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals.

Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.

Cost & finances

Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.

What families pay in CA