Grace Care Center of Henrietta

Inspectors wroteA complaint investigation was conducted on 03/4/26 for intakes #1073184, 1073358. Census 21. Abbreviations/AcronymsNone used. Based on observations and interviews, the facility failed to dispose of garbage and refuse properly for 2 (Dumpsters #1 and #2) of 2 dumpsters located outside of the facility. The facility failed to prevent two of the facility's dumpsters located outside of the facility, lids were closed when not in use and trash was not on the ground from overflow of the dumpsters being full. These failures could place residents at risk of decreased quality of life due to an exterior environment which could attract pests, rodents, and other animals.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records on each resident, in accordance with accepted professional health information management standards and practices, that are complete and accurately documented for 4 of 4 residents (Residents #1, #2, #4, and #7) whose records were reviewed for blood glucose monitoring and insulin administration. The facility failed to ensure insulin administration via insulin pump and blood sugar results were documented as ordered on the Medication Administration Record, dated September 2025, for Residents #1, #2, #4, and #7. These failures could place residents at risk for inaccurate clinical health records.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services.1. The facility failed to ensure Paper towels were available for drying hands at the handwashing sink.2. The facility failed to ensure food was covered and not stored room temperature on the stove top and a shelf above the stove top.3. The facility failed to ensure the residential style chest freezer did not have thick frost build-up on its interior side surfaces.4. The facility failed to ensure opened food item packages were placed in sealed containers and were labeled and dated with a use by date in the refrigerator.5. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation did involve abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 1 of 16 residents (Resident #2) reviewed for abuse or neglect. The facility failed to report to the State Survey Agency allegations of abuse after Resident #2 said CNA B was rough and used profanity. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 3 residents (Resident #18) reviewed for care plans. 1. The facility failed to ensure a care plan was developed to address Resident #18's hospitalizations on 2/27/25-3/04/25, 4/24/25-5/05/25, and 5/28/25-6/09/25 related to urinary tract infection. 2. The facility failed to ensure a care plan was developed to address Resident #18's admission to Hospice care services on 7/03/25. 3. [...]

Inspectors wroteBased 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 03/14/25 at 3:52 pm. The IJ template was provided to the facility on 3/14/25 at 3:52pm. [...]

Inspectors wroteBased 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 12/20/2024. 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 03/14/25 at 3:52 pm. The IJ template was provided to the facility on 3/14/25 at 3:52pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to handle, store, process, and transport linens in accordance with accepted national standards in order to produce hygienically clean laundry and prevent the spread of infection to the extent possiblefor 1 of 1 washing machines observed for infection control practices. The facility failed to make sure the washing machine had hot water and chemicals to sanitize and clean linens and clothing for residents. This failure could affect the residents in the facility by placing them at risk of possible unsanitary conditions and run the risk of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, for 1 of 7 (Resident #1) residents reviewed for resident rights. The facility failed to provide Resident #1 hospice care per resident's request. This failure placed residents at risk of their rights to make choices about their life being disregarded.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a working telephone for the residents to use. The facility failed to pay their phone vendor and phone services were terminated on 02/07/25. This failure could leave residents without the contact from their family/representative which could make them feel isolated.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 4 (Resident # 1, Resident #2, Resident #9, Resident #11) of 14 residents reviewed for Quality of Care. The facility failed to ensure Residents #2, #9, and #11 made it to their scheduled doctor appointments for follow up and other scheduled appointments. The facility failed to provide needed care and services in accordance with Resident #1's preferences to attain hospice services. This failure could affect the ability for residents to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 7 (Resident #1) residents reviewed for pain. The facility failed to manage Resident #1's pain at an acceptable level per her preference until hospice services could be obtained. It took the facility 8-days to arrange hospice services. This deficient practice could place residents at risk of increased pain, discomfort, being unable to perform daily activities, psychological effects, and a diminished quality of life.

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (January 2025, February 2025, and March 2025) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 28 of 47 days. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for 12 of 12 residents (Resident's #1, #2, #3, #4, #5, #6, #7, #8, #9, #11, #15, #16) during medication pass. A: Resident #7 and Resident #5 did not receive medications at 8:00 am medication pass. B: CMA F administered Resident's #2, #3, #4, #6, #8, #9, #11, #15, #16 medications greater than one hour after the scheduled administration time on [DATE]. C: CMA F operated outside of her scope of practice by administering an initial dose of a narcotic to Resident #1 and assessed Resident #1's pain. These failures could place residents at risk for adverse outcomes to resident care and/or services and may also include the potential for physical and psychosocial harm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 7 (Resident's #2, #3, #5, #6, #7, #8, #9) of 11 residents reviewed for medication errors. 1. CMA F failed to administer Resident #2's 7:30 am blood pressure medications on 03/05/25 of Amlodipine Besylate 10mg, hydrochlorothiazide 50mg, Metoprolol Succinate 25mg, hydralazine HCI 10mg after 11:00 am. 2. CMA F failed to administer Resident #3's 7:00 am blood pressure medications on 03/05/25 of Amlodipine Besylate 5mg, Lisinopril 40mg, Metoprolol Succinate 25mg until after 11:00 am. 3. CMA F failed to administer Resident #5's 8:00 am blood pressure medications on 03/05/25 of Lisinopril 5mg, Carvedilol 6.25mg, Verapamil HCI 180mg, Hydralazine HCI 25mg, clonidine HCI 0.1mg until after 11:00 am. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to follow menus for one of one facility. The facility failed to follow their menus prepared in advance daily for 11 meals dated 2/10/25 -3/13/25. This failure could affect the residents by the menus failing to meet the residents' choices and dietary needs.

Inspectors wroteBased on interview and record review, the facility failed to implement appropriate plans of action to correct identified quality deficiencies and to regularly review and analyze data, including data collected under the QAPI program and act on available data to make improvements for one of one facility. The facility failed to follow their Plan of Correction (POC) dated 1/3/25 in utilizing a pool of RNs from neighboring/sister communities to ensure RN coverage at least 8 consecutive hours/day 7 days/week for 28 days since the dated POC. The facility failed to follow their POC to review weekly RN coverage in SOC (Standard of Care meeting) by the Administrator and DON to ensure appropriate RN coverage is arranged and provided by the facility or services of facilities or RN telehealth audio and visual capabilities were arranged. [...]

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months (October 2024, November 2024, December 2024) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 34 days of 92 days in October 2024, November 2024, and December 2024. This failure could place residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to handle, store, process, and transport linens so as to prevent the spread of infection for 1 of 1 laundry carts observed for infection control practices. The facility failed to ensure clean laundry was protected from dust and contamination while being transported to resident's rooms. This failure could place residents at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies and review and update the assessment at least annually for 1 of 1 facility reviewed for facility assessment. The facility failed to update a facility-wide assessment to determine what resources was necessary to care for its residents competently during both day-to-day operations and emergencies. This failure could place residents at risk for not receiving necessary care and services required.

Inspectors wroteBased on observation, interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property for 4 of 5 (LVN A, CNA E, CNA F, and CNA G) employee's files reviewed for abuse protocol. A. The facility failed to complete criminal background, EMR and NAR check on CNA E before her employment date of 10/12/24. B. The facility failed to complete criminal background, EMR and NAR checks on CNA F before his employment date. C. The facility failed to complete criminal background, EMR and NAR checks on CNA G before her employment date. D. The facility failed to complete criminal background and EMR checks on LVN A before her employment date. This failure could place residents at risk for abuse, neglect, and exploitation.

Inspectors wroteBased on interview and record review, the facility failed to provide training to their staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention for 5 of 5 (DON, LVN A, CNA E, CNA F, and CNA G) employees reviewed. The facility failed to ensure abuse training including activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, procedures for reporting incidents of abuse, neglect, exploitation, or the misappropriation of resident property, dementia management and resident abuse prevention was provided to the DON, LVN A, CNA E, CNA F, and CNA G. [...]

Inspectors wroteBased on interview and record review, the facility failed to manage the personal funds of the residents deposited with the facility for 1 of 3 (Resident #6) residents reviewed for personal funds. The facility failed to ensure Resident #6's personal funds were properly managed. This failure could place residents whose funds were managed by the facility at risk of not receiving funds deposited with the facility and not having their rights and preferences honored.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents and hazards. 1. The facility failed to maintain proper functioning of sit-to-stand mechanical lift. This failure could place residents at risk of accidents when using mechanical lift for transfers.

Inspectors wroteBased on interview, and record review, the facility failed to consult with the resident's physician, or the resident's representatives regarding a change in condition for one Resident (Resident #1) of 3 residents reviewed for notification of changes. The facility did not notify or consult with Resident #1's Physician , or resident representative regarding a burn incident on May 10, 2024, due to spilling coffee on herself. Physician was notified on May 13, 2024 and resident representative was notified on May 14, 2024. This failure could affect residents by causing their physician and representative to be unaware of changes in residents' condition.

Inspectors wroteBased on interview and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 3 (Resident #1) residents reviewed for clinical records in that: The facility did not maintain accurate and current nursing progress notes on 5/10/24, 5/11/24, 5/12/24, and 5/13/24 related to an incident that occurred to Resident #1 on 05/10/2024 regarding a coffee burn. This failure could place residents at risk for improper documentation.

Inspectors wroteBased on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses or the facility's resident population in accordance with the facility assessment for 1 of 1 (the Dietary Supervisor) reviewed for dietary manager The facility failed to ensure the Dietary Supervisor completed an approved dietary manager training course. This failure could place the residents at risk for compromised nutritional status, weight loss, and compromised health conditions and not being accurately assessed for nutritional status, needs, and preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in one of one kitchen, in that: The facility failed to store foods in the nonperishable food storage room that were sealed and labeled with an opened date. The facility failed to store foods in the refrigerator and freezer that were sealed and labeled with an identifier and/or opened date. These failures could place residents at risk for decline in nutritional health status and foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for 1 of 2 residents (Resident #16) reviewed for urinary catheters in that: The facility failed to ensure that Resident #16's urinary catheter type and size was documented in the Physician order. The facility failed to ensure Resident #16's urinary catheter was irrigated as ordered. The facility failed to ensure Resident #16's urinary catheter care, every shift as ordered was completed. The facility failed to ensure Resident #16's urinary catheter output every shift as ordered was completed. This deficient practice could affect residents who had urinary catheters and could result in trauma or urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 2 of 3 months (October, November) reviewed for nursing services. The facility failed to provide Registered Nurse (RN) coverage for 8 consecutive hours on 2 days in October 10/1/2023, 10/15/2023, and 1 day in November 11/19/2023. This failure placed could place the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were provided a nourishing, palatable well-balanced diet that meets daily nutritional and special dietary needs for 1 of 36 (Resident #6) resident reviewed for needs and preferences. The facility failed to ensure Resident #6 received a Carbohydrate controlled diet with added protein powder to his food three times a day as ordered. This failure placed residents at risk of not having their needs met resulting in delayed healing of pressure ulcer.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 2 residents (Resident #16) whose care was reviewed in that: Resident #16's indwelling urinary catheter bag was not covered. These deficient practices could affect residents who had indwelling urinary catheters by contributing to poor self-esteem, lack of information, and unmet needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure personal privacy by securing signed consents for the use of security cameras for 1 of 2 (Resident #28) residents reviewed for privacy. The facility had operational security cameras in a resident's room without obtaining consents from the resident who occupied the room. This failure could place residents at risk of embarrassment, and reduction of the self-esteem and self-worth by not being provided desired privacy during personal care or meetings with family or physicians.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 2 residents (#5 and #30) reviewed for respiratory care. A. The facility failed to ensure oxygen tubing for Residents #5 were changed weekly. B. The facility failed to ensure Resident #5's nebulizer mask was dated or kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of significant medication errors in accordance to accepted professional standards and principles for 1 of 6 residents (Resident #14) reviewed for medication administration accuracy. The facility failed to administer Resident #14's insulin as ordered by their physician. This failure could place residents receiving insulin at risk for adverse consequences by not receiving therapeutic dosages of their medications as ordered by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were secured on 1 of 2 (Medication Cart A) medication carts and 1 of 1 medication rooms reviewed for pharmacy services. The facility did not ensure medications carts and mediation storage room were secured and locked. This failure could place the residents at risk of a drug diversion.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 of 12 (Resident #16) residents reviewed for clinical records in that: The facility did not maintain accurate and current nursing progress notes related to catheter care for Resident #16. The facility did not maintain accurate and current medication records for Resident #16. This failure could place residents at risk for improper documentation.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain a general training program to ensure staff were trained for 4 of 10 (RN B, LVN C, CNA D, CNA E) reviewed for general training. The facility failed to ensure all staff were trained for communication. The facility failed to ensure all staff were trained for QAPI. The facility failed to ensure all staff were trained for Behavioral Health. The facility failed to ensure all staff were trained for HIV. The facility failed to ensure all staff were trained for Restraint Reduction. The facility failed to ensure all staff were trained for Falls. These failures could place residents at risk of at receiving care from incompetent/untrained staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the actual hours worked by the licensed and unlicensed nursing (RN, LVN and CNA) staff directly responsible for resident care per shift daily. The daily nursing staffing information was posted but did not include the total numbers of actual hours worked for RNs, LVNs, and CNAs. The facility's failure could affect the residents and/or visitors to the facility who may desire to know how many nursing staff were present and on duty and the actual hours worked per each shift daily.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 2 of 10 (RN B, CNA E) reviewed for communication training. The facility failed to ensure all direct care staff were trained on communication. This failure could place residents at risk at receiving care from incompetent/untrained staff.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 2 of 10 (RN B, CNA D) reviewed for Quality Assurance and Performance Improvement(QAPI) training. The facility failed to ensure all staff were trained for QAPI. This failure placed residents at risk of at receiving care from incompetent/untrained staff.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain a training program to ensure staff were trained for 3 of 10 (RN B, CNA D, CNA E) reviewed for behavioral health training. The facility failed to ensure all staff were trained for Behavioral Health. This failure could place residents at risk at receiving care from of incompetent/untrained staff.

Inspectors wroteBased 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 [DATE] with a diagnosis of hypotension (abnormally low blood pressure) due to drugs. An Immediate Jeopardy was identified on 03/07/2024. The Immediate Jeopardy Template was provided to the Administrator on 03/07/2024 at 5:15 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 1 of 1 resident (Resident #1) was immediately reported to the State Survey Agency. 1. Resident #1 was administered the morning medications for another resident, which included three different blood pressure medications, on [DATE] at approximately 10:20 AM. 2. Resident #1 became unresponsive on [DATE] at 11:15 AM and was transported by ambulance to the local hospital emergency room. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement care plans for necessary treatments and conditions for one of four residents (Resident #1) reviewed for Comprehensive Care Plans. The facility failed to address Resident #1's preference for privacy and to not have staff with him while he was using the bathroom. This failure could place residents at risk of not receiving care that is thoughtful, planned, and relevant to their condition(s) which could lead to complications in resident health and quality of life and care.

Inspectors wroteBased on observations, interviews, and record reviews , the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 2 residents (Residents #1) whose records were reviewed for assessments. The facility failed to recognize and re-assess Resident #1 after a significant weight loss and a decline in ADL function. This failure placed residents at risk for not developing interventions to meet their needs for care assistance and treatments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to accurately assess each resident's status for 1 of 3 (Resident #1) reviewed for assessment accuracy in that: Resident #1's MDS assessment records, after admission, was not coded yes for weight Loss of 5% or more in the last month or loss of 10% or more in last 6 months. This failure could place residents at risk of not receiving the proper care and services due to inaccurate records.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment and failed to ensure the interdisciplinary team reviewed and revised the comprehensive care plan after each assessment including both the comprehensive assessment and quarterly review assessments for 9 (Resident #1, #2, #5, #6, #9, #11 , #18 #22, and #23) of 11 residents who were reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive care plan within seven days for Resident #1, #5, #9, #18 and #23. 2. The interdisciplinary team failed to review and revise the plan of care for Residents #1 #2, #5, #6, #9, #11, #18, #22, and #23. These failures could affect residents by placing them at risk for not having their individual needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 3 of 3 residents (#1, #5 and #11) reviewed for respiratory care. A. The facility failed to ensure oxygen tubing for Residents #1, #5, and #11 were changed weekly. B. The facility failed to ensure Resident #11's nasal cannula was kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed in that, raw hamburger was stored in the freezer above other foods. This failure by the facility could place residents in the facility at risk of acquiring food borne illnesses and a decline in health status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident with a pressure ulcer received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 out of 1 resident (Resident #9) reviewed for pressure ulcers. The facility failed to provide wound care services for Resident #9 on the date of 03/13/2023 as ordered by the resident's physician. This failure could lead to an increased and unnecessary risk of complications including worsening of existing wounds, development of new wounds, and infection. Findings Included: Record review of Resident #9's Face Sheet, dated 03/15/2023, revealed a [AGE] year-old male, admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Residents #6) reviewed for unnecessary medications. Resident #6 had an order and administered Seroquel (an antipsychotic medication) for a diagnosis of behaviors, which was not an appropriate indication for use. This failure placed residents at risk for being over medicated or experiencing undesirable side effects and could cause a physical or psychosocial decline in health status.