Grace Care Center Of Henrietta

Penalties

• Apr 25, 2025 — Payment Denial · payment denial 5 days
• Apr 25, 2025 — Fine ($190,510)
• Mar 8, 2024 — Fine ($13,627)

Inspection findings

1. Mar 5, 2026 Health · 1 finding
   • Not serious Scope/severity C Complaint

     F0814 Nutrition and Dietary Deficiencies

     Dispose of garbage and refuse properly.

     Corrected Apr 1, 2026 · CMS health inspection

2. Nov 18, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Nov 19, 2025 · CMS health inspection

3. Jul 30, 2025 Health · 12 findings
   • Not serious Scope/severity D

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0657 Resident Assessment and Care Planning Deficiencies

     Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Aug 30, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0222 Egress Deficiencies

     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.

     Corrected Aug 26, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Aug 1, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0324 Smoke Deficiencies

     Provide properly protected cooking facilities.

     Corrected Aug 30, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0345 Smoke Deficiencies

     Have approved installation, maintenance and testing program for fire alarm systems.

     Corrected Aug 5, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Aug 22, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Aug 30, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Aug 30, 2025 · CMS fire safety

   • Not serious Scope/severity F

     K0712 Miscellaneous Deficiencies

     Have simulated fire drills held at unexpected times.

     Corrected Aug 1, 2025 · CMS fire safety

4. Apr 25, 2025 Health · 12 findings
   • Not serious Scope/severity E Complaint

     F0561 Resident Rights Deficiencies

     Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0576 Resident Rights Deficiencies

     Ensure residents have reasonable access to and privacy in their use of communication methods.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0697 Quality of Life and Care Deficiencies

     Provide safe, appropriate pain management for a resident who requires such services.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0727 Nursing and Physician Services Deficiencies

     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.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0803 Nutrition and Dietary Deficiencies

     Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

     Corrected May 20, 2025 · CMS health inspection

   • Serious Scope/severity L Complaint

     F0835 Administration Deficiencies

     Administer the facility in a manner that enables it to use its resources effectively and efficiently.

     Corrected May 20, 2025 · CMS health inspection

   • Serious Scope/severity L Complaint

     F0837 Administration Deficiencies

     Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0867 Administration Deficiencies

     Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

     Corrected May 20, 2025 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 20, 2025 · CMS health inspection

5. Jan 3, 2025 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0727 Nursing and Physician Services Deficiencies

     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.

     Corrected Jan 27, 2025 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jan 27, 2025 · CMS health inspection

6. Oct 25, 2024 Health · 6 findings
   • Not serious Scope/severity D Complaint

     F0567 Resident Rights Deficiencies

     Honor the resident's right to manage his or her financial affairs.

     Corrected Nov 10, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Nov 10, 2024 · CMS health inspection

   • Serious Scope/severity H Complaint

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Nov 10, 2024 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Nov 10, 2024 · CMS health inspection

   • Not serious Scope/severity F Complaint

     F0838 Administration Deficiencies

     Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

     Corrected Nov 10, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0943 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

     Corrected Nov 10, 2024 · CMS health inspection

7. Jun 7, 2024 Health · 2 findings
   • Not serious Scope/severity E Complaint

     F0580 Resident Rights Deficiencies

     Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

     Corrected Jul 5, 2024 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Jul 5, 2024 · CMS health inspection

8. May 1, 2024 Health · 21 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0727 Nursing and Physician Services Deficiencies

     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.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity C

     F0732 Nursing and Physician Services Deficiencies

     Post nurse staffing information every day.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     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.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0800 Nutrition and Dietary Deficiencies

     Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0801 Nutrition and Dietary Deficiencies

     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.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0940 Administration Deficiencies

     Develop, implement, and/or maintain an effective training program for all new and existing staff members.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity B

     F0941 Administration Deficiencies

     Develop, implement, and/or maintain an effective training program that includes effective communications for direct care staff members.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity B

     F0944 Administration Deficiencies

     Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity B

     F0949 Administration Deficiencies

     Provide behavior health training consistent with the requirements and as determined by a facility assessment.

     Corrected Jun 1, 2024 · CMS health inspection

   • Not serious Scope/severity D

     K0222 Egress Deficiencies

     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.

     Corrected Jun 14, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Jun 14, 2024 · CMS fire safety

   • Not serious Scope/severity F

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Jun 14, 2024 · CMS fire safety

   • Not serious Scope/severity D

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Jun 14, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected May 16, 2024 · CMS fire safety

9. Mar 8, 2024 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0609 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

     Corrected Mar 28, 2024 · CMS health inspection

   • Serious Scope/severity J Complaint

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected Mar 28, 2024 · CMS health inspection

10. Feb 9, 2024 Health · 1 finding
    • Not serious Scope/severity D Complaint

      F0656 Resident Assessment and Care Planning Deficiencies

      Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

      Corrected Mar 1, 2024 · CMS health inspection

11. Sep 6, 2023 Health · 2 findings
    • Not serious Scope/severity D Complaint

      F0637 Resident Assessment and Care Planning Deficiencies

      Assess the resident when there is a significant change in condition

      Corrected Oct 6, 2023 · CMS health inspection

    • Not serious Scope/severity D Complaint

      F0641 Resident Assessment and Care Planning Deficiencies

      Ensure each resident receives an accurate assessment.

      Corrected Oct 6, 2023 · CMS health inspection

12. Mar 15, 2023 Health · 8 findings
    • Not serious Scope/severity E

      F0657 Resident Assessment and Care Planning Deficiencies

      Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

      Corrected Apr 13, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0686 Quality of Life and Care Deficiencies

      Provide appropriate pressure ulcer care and prevent new ulcers from developing.

      Corrected Apr 13, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0695 Quality of Life and Care Deficiencies

      Provide safe and appropriate respiratory care for a resident when needed.

      Corrected Apr 13, 2023 · CMS health inspection

    • Not serious Scope/severity D

      F0758 Pharmacy Service Deficiencies

      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.

      Corrected Apr 13, 2023 · CMS health inspection

    • Not serious Scope/severity E

      F0812 Nutrition and Dietary Deficiencies

      Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

      Corrected Apr 13, 2023 · CMS health inspection

    • Not serious Scope/severity E

      K0211 Egress Deficiencies

      Keep aisles, corridors, and exits free of obstruction in case of emergency.

      Corrected Apr 28, 2023 · CMS fire safety

    • Not serious Scope/severity C

      K0353 Smoke Deficiencies

      Inspect, test, and maintain automatic sprinkler systems.

      Corrected Apr 28, 2023 · CMS fire safety

    • Not serious Scope/severity C

      K0521 Services Deficiencies

      Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

      Corrected Apr 28, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• LAPIN, ZACHARY — operational/managerial control, NOT APPLICABLE, since 10/01/2024
• LAPIN, ZACHARY — adp of the snf, NOT APPLICABLE, since 10/01/2024
• LAPIN, ZACHARY — direct ownership interest, NOT APPLICABLE, since 10/01/2024
• MEEKINS, GREG — managing control - governing body, NOT APPLICABLE, since 10/01/2024
• MEEKINS, GREG — corporate director, NOT APPLICABLE, since 09/01/2014
• EXTENDED CARE AT HENRIETTA LLC — direct ownership interest, NOT APPLICABLE, since 10/01/2024
• EXTENDED CARE AT HENRIETTA LLC — operational/managerial control, NOT APPLICABLE, since 10/01/2024
• EXTENDED CARE AT HENRIETTA LLC — adp of the snf, NOT APPLICABLE, since 01/27/2025
• HENRIETTA PROPCO LLC — adp of the snf, NOT APPLICABLE, since 10/01/2024
• NOCONA HOSPITAL DISTRICT — 5% or greater indirect ownership interest, since 09/01/2014
• NOCONA HOSPITAL DISTRICT — adp of the snf, NOT APPLICABLE, since 01/27/2025