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Deficiency Records for Grace Care Center of Henrietta
A list of the most recent deficiencies for Grace Care Center of Henrietta. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Grace Care Center of Henrietta. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-06-07 | 2024-07-05 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-07 | 2024-07-05 | Y |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-05-15 | 2024-06-14 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-05-15 | 2024-06-14 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-05-15 | 2024-06-14 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-05-15 | 2024-06-14 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-05-01 | 2024-06-01 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-05-01 | 2024-06-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2024-05-01 | 2024-06-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-05-01 | 2024-06-01 | N |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2024-05-01 | 2024-06-01 | N |
| Post nurse staffing information every day. | Health | 2024-05-01 | 2024-06-01 | N |
| Ensure that residents are free from significant medication errors. | Health | 2024-05-01 | 2024-06-01 | N |
| 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. | Health | 2024-05-01 | 2024-06-01 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2024-05-01 | 2024-06-01 | N |
| Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. | Health | 2024-05-01 | 2024-06-01 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-05-01 | 2024-06-01 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-05-01 | 2024-06-01 | N |
| Develop, implement, and/or maintain an effective training program for all new and existing staff members. | Health | 2024-05-01 | 2024-06-01 | N |
| Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members. | Health | 2024-05-01 | 2024-06-01 | N |
| Conduct mandatory training, for all staff, on the facility?s Quality Assurance and Performance Improvement Program. | Health | 2024-05-01 | 2024-06-01 | N |
| Provide behavior health training consistent with the requirements and as determined by a facility assessment. | Health | 2024-05-01 | 2024-06-01 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2024-05-15 | 2024-05-16 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2024-03-08 | 2024-03-28 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2024-03-08 | 2024-03-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-02-09 | 2024-03-01 | Y |
| Assess the resident when there is a significant change in condition | Health | 2023-09-06 | 2023-10-06 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2023-09-06 | 2023-10-06 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-03-29 | 2023-04-28 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-03-15 | 2023-04-13 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-03-15 | 2023-04-13 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-03-15 | 2023-04-13 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-03-15 | 2023-04-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-03-15 | 2023-04-13 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-08 | 2022-10-15 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-07-08 | 2022-08-07 | Y |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-01-13 | 2022-02-28 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-01-13 | 2022-02-25 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-13 | 2022-02-25 | N |
| 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. | Health | 2022-01-13 | 2022-02-25 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2022-01-13 | 2022-02-25 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-01-13 | 2022-02-25 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-13 | 2022-02-25 | N |
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