Grand Terrace Health Care Center

Name: Grand Terrace Health Care Center
Address: 12000 Mount Vernon Ave, Grand Terrace, CA, 92313, US
Telephone: 9098255221

12000 Mount Vernon Ave, Grand Terrace, CA 92313 · San Bernardino County · 59 certified beds · avg 52 residents/day · certified since Jun 1, 1973

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

5/5

Health inspection rating (on-site)

Serious findings on record

Fines, last 3 years

3.96

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★★★★5/5 · CMS overall rating: 5/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

All citations in the current public record (27)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Mar 5, 2026	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Mar 5, 2026	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Mar 5, 2026	B · Minimal risk, repeated	The facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.
Nov 22, 2024	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Nov 22, 2024	F · Potential for harm, facility-wide	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Nov 22, 2024	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Nov 22, 2024	D · Potential for harm, one-off	The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that.
Nov 22, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Nov 22, 2024	D · Potential for harm, one-off	The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable.
Nov 22, 2024	D · Potential for harm, one-off	The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes.
Nov 22, 2024	D · Potential for harm, one-off	The facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Nov 22, 2024	B · Minimal risk, repeated	The facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.
Oct 14, 2024	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 7, 2023	F · Potential for harm, facility-wide	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not provide or obtain laboratory tests when a doctor ordered them, or did not promptly report the results back to the doctor who ordered them.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not provide food that accounts for each resident's allergies, intolerances, and personal preferences, or did not offer appealing alternatives.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Apr 7, 2023	D · Potential for harm, one-off	The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Apr 7, 2023	B · Minimal risk, repeated	The facility had resident rooms holding more people than allowed — no more than 4 residents per room, and no more than 2 per room in buildings constructed after November 28, 2016.

Inspection trend by year

Citations from standard inspections decreased between the last two inspection cycles (9 → 3).

Year	Citations	Worst severity that year
2023	14	F
2024	10	F
2026	3	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

No fines or payment denials in the published 3-year window.

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	California avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.96	4.31	3.95	bottom 38% in California; top 41% in the U.S.
Registered Nurse hours	0.40	0.61	0.69	bottom 33% in California; bottom 22% in the U.S.
Weekend total nurse staffing	3.52	3.90	3.50	bottom 32% in California; top 41% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.31	0.51	0.48	bottom 38% in California; bottom 35% in the U.S.
Total nursing staff turnover (%)	32.4	36.7	45.8	top 38% in California; top 19% in the U.S.
RN turnover (%)	28.6	38.1	42.9	top 33% in California; top 26% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 4.69, RN 0.48, weekend 4.16. Staffing rating: 4/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 5/5 · long-stay residents: 5/5 · short-stay residents: 4/5

Who owns this facility

For profit - Corporation

Owner / manager	Type	Role	Stake	Since
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	11/08/2022
Fitch, Craig	Individual	Corporate Officer	NOT APPLICABLE	11/08/2022
Haroldsen, Brian	Individual	Operational/Managerial Control	NOT APPLICABLE	02/01/2023
Sato, Ami	Individual	Corporate Officer	NOT APPLICABLE	09/09/2024
Scott, Matthew	Individual	Corporate Officer	NOT APPLICABLE	02/01/2023
Sharobiem, Andro	Individual	ADP of the SNF	NOT APPLICABLE	10/02/2024
The Ensign Group INC	Organization	Limited Partnership Interest	NOT APPLICABLE	02/01/2023
Willits, Adam	Individual	Corporate Director	NOT APPLICABLE	02/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"How many residents share each room, and what options are there for more privacy?"
"What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"How soon after admission is a full assessment completed, and how are the findings shared with the family?"
"Who completes resident assessments here, and how do you check them for accuracy?"
"What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection
Meadows Ridge Care Center	1.0 mi	Colton, CA	★★★★☆	4/5
The Canyons Post-Acute	1.3 mi	Colton, CA	★★☆☆☆	2/5
Heritage Gardens Health Care Center	3.5 mi	Loma Linda, CA	★★★★☆	3/5
Loma Linda Post Acute	3.6 mi	Loma Linda, CA	★★★★☆	4/5
Rialto Post Acute Center	4.3 mi	Rialto, CA	★★☆☆☆	2/5
Asistencia Villa Healthcare Center	4.7 mi	Redlands, CA	★★☆☆☆	3/5
Totally Kids Rehabilitation Hospital - D/P SNF	4.7 mi	Loma Linda, CA	★★★★★	4/5
The Grove Care and Wellness	4.9 mi	Riverside, CA	★★★★★	4/5
Brookside Healthcare Center	5.7 mi	Redlands, CA	★★★☆☆	3/5
Riverside Behavioral Healthcare Center	6.1 mi	Riverside, CA	★★★★★	4/5

Compare this facility with the 3 closest →

All facilities in Grand Terrace →

Facility data as of CMS processing date 2026-08-01. CCN 055129.

The Care File

Visit checklist — Grand Terrace Health Care Center

12000 Mount Vernon Ave, Grand Terrace, CA 92313 · 9098255221

Health inspection rating 5/5 · CMS overall 5/5· Fines (3y): $0

Questions for the administrator:

☐ "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "How many residents share each room, and what options are there for more privacy?"
☐ "What did your most recent kitchen inspection find, and can I see how food is stored and prepared?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "How soon after admission is a full assessment completed, and how are the findings shared with the family?"
☐ "Who completes resident assessments here, and how do you check them for accuracy?"
☐ "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 055129 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)