Grace Care Center of Henrietta

In the surveyor’s words

From the most serious findings on record at Grace Care Center of Henrietta, in the surveyor’s own words.

• Immediate jeopardy, widespreadF835Apr 25, 2025

  Based on observation, interview, and record review the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for one of one facility reviewed. The facility failed to have sufficient resources to satisfy (pay) debts timely and when they come due. The phone and internet were disconnected, service repair bills/vendors were not paid, and the facility van did not have insurance or current registration tags. The facility failed to provide enough money to purchase the food necessary to follow the menus and to purchase printer supplies. An Immediate Jeopardy was identified on [DATE] at 3:52 pm. […]

• Immediate jeopardy, widespreadF837Apr 25, 2025

  Based on interview and record review the facility failed to ensure the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of the facility and reports to the governing body, in that: The facility had not had an administrator since [DATE]. The governing body failed to provide the facility with enough money to keep up services including telephone service, internet service, food services, van registration/insurance, laundry services, and fire and security services. An Immediate Jeopardy was identified on [DATE] at 3:52 pm. The IJ template was provided to the facility on [DATE] at 3:52pm. […]

• Immediate jeopardy, isolatedF760Mar 8, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 7 residents (Resident #1) reviewed for medication regimen, in that: Resident #1 was administered the morning medications for another resident, which included three different blood pressure medications, a narcotic medication, and a diuretic medication on 2/29/2024 at approximately 10:20 AM. Resident #1 became unresponsive on 2/29/2024 at 11:15 AM and was transported by ambulance to the local hospital emergency room . Resident #1 was admitted to the hospital on 2/29/2024 with a diagnosis of hypotension (abnormally low blood pressure) due to drugs. An Immediate Jeopardy was identified on 03/07/2024. […]

• Actual harm, patternF677Oct 25, 2024

  Based on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 4 of 8 residents (Resident #2, #3, #4 and #7) reviewed for incontinent care, in that: The facility failed to provide bowel and bladder incontinent care for Resident #2 and it resulted in reddened skin on buttocks area. The facility failed to provide bowel and bladder incontinent care for Resident #3 and it resulted in reddened skin on scrotum area. The facility failed to provide bowel and bladder incontinent care for Resident #4 and it resulted in reddened skin and an open area to buttock(coccyx) area. […]

• No harm, potential for more than minimal, widespreadF803Jul 30, 2025

  Based on observation, interview and record review the facility failed to ensure menus were followed for 2 of 2 meals reviewed for Food and Nutrition Services.1. The facility failed to ensure the menu was followed on 07/27/25 and food substitutions were made for the planned lunch menu.2. The facility failed to ensure the menu was followed on 07/28/25 and food substitutions were made for the planned dinner menu. These failures could place residents at risk for weight loss and compromised nutritional health status. The findings include: 1. Record review of the current resident roster, provided 7/27/25, revealed the facility census was 18. Record review of the resident diet order list, printed 7/27/25, revealed all facility residents received oral nutrition. […]