Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Denison Care Center during CMS and state inspections, most recent first.
A resident with severe cognitive impairment and a history of self-transfer attempts was left unsupervised in the dining room, despite known fall risks and recent behavioral changes. Due to unclear communication and inconsistent documentation of supervision needs, staff failed to provide adequate oversight, resulting in the resident attempting to stand, falling, and sustaining multiple serious injuries.
A resident with severe cognitive impairment and dependent mobility was found face down, bleeding, and in pain after an unwitnessed fall. Staff attempted to move the resident despite signs of possible head and neck trauma, contrary to facility policy, before EMS arrived and transported the resident to the ER where multiple fractures were diagnosed.
A resident with severe cognitive impairment was transferred to a hospital for surgical repair and later returned, but the facility did not notify the Long-Term Care Ombudsman of the transfer as required. Review of documentation and interviews with staff and family confirmed the omission, and it was noted that the facility lacked a specific policy for Ombudsman notification.
Failure to Provide Adequate Supervision Resulting in Resident Fall and Major Injury
Penalty
Summary
A non-ambulatory resident with severe cognitive impairment, including a BIMS score of 6/15 and diagnoses of non-Alzheimer's dementia, diabetes mellitus, and paroxysmal atrial fibrillation, was dependent on staff for transfers and required a wheelchair for mobility. The resident had a documented history of attempting to self-transfer and had recently exhibited increased behaviors such as agitation, delusions, and attempts to stand unassisted. The care plan identified a risk for falls related to self-transfers, but interventions for supervision were not consistently documented or communicated among staff. On the evening of the incident, the resident was left unsupervised in the dining room after dinner. Multiple staff interviews revealed that there was confusion and lack of clarity regarding the resident's required level of supervision, especially during periods of increased behavioral symptoms. Staff members were either unaware of the specific supervision needs or assumed that others were responsible for monitoring the resident. The nurse on duty was new to the facility and had not been informed of the resident's supervision requirements, while CNAs and other staff did not ensure the resident was not left alone, despite knowledge of her fall risk and recent behavioral changes. As a result, the resident attempted to stand from her wheelchair, fell, and sustained significant injuries including a head injury, nasal fractures, and cervical fractures. The incident was unwitnessed, and staff only became aware after hearing the fall. Documentation and interviews indicated that the expectation for line-of-sight or one-to-one supervision during periods of agitation or self-transfer attempts was not clearly outlined in the care plan or effectively communicated to all staff, including non-nursing personnel. This lack of adequate supervision and failure to ensure a hazard-free environment directly contributed to the resident's fall and subsequent injuries.
Failure to Properly Assess and Intervene After Unwitnessed Fall with Suspected Head and Neck Injury
Penalty
Summary
A resident with severe cognitive impairment, dependent for transfers, and multiple diagnoses including dementia, diabetes, and atrial fibrillation, experienced an unwitnessed fall in the dining room. The resident was found lying face down, bleeding, and in significant pain, with limited ability to move her extremities and unable to move her head. Staff on duty, including a registered nurse and certified nursing assistants, attempted to roll the resident onto her back multiple times but were unsuccessful due to the resident's pain and position. Emergency Medical Services were called, and upon arrival, EMS and staff turned the resident onto her back and transported her to the emergency room, where multiple fractures were diagnosed, including an odontoid fracture, head injury, nasal fracture, and cervical fractures. Staff interviews revealed that the nurse assessed the resident for movement and pain but did not suspect a neck fracture at the time. Despite the presence of blood and the resident's inability to move her head or extremities fully, staff attempted to move the resident before EMS arrived. Facility policy directed staff to evaluate for possible injuries to the head, neck, spine, and extremities after a fall and to provide appropriate first aid or obtain medical treatment immediately if there was evidence of injury. The policy and staff interviews indicated that residents with suspected head or spinal injuries should not be moved and should be sent directly for medical evaluation. The deficiency occurred because staff did not accurately assess the potential for spinal injury and attempted to move the resident despite clear signs of possible head and neck trauma. The actions taken were inconsistent with facility policy and best practices for managing unwitnessed falls with suspected injuries, as confirmed by staff and administrative interviews. The incident highlights a failure to provide appropriate interventions following a significant fall event.
Failure to Notify Ombudsman of Resident Hospital Transfer
Penalty
Summary
The facility failed to notify the Long-Term Care Ombudsman of a resident's transfer to a hospital. Record review showed that a resident with severe cognitive impairment, as indicated by a BIMS score of 5, was hospitalized for surgical repair of the right femur and later reentered the facility. Documentation review confirmed the resident was absent from the facility during the hospital stay, but the facility's Notice of Transfer Form to the Ombudsman did not include this resident. Interviews with the resident's family, Social Services, and the Administrator confirmed the omission and revealed that the facility did not have a policy for reporting such transfers to the Ombudsman, instead relying on state and federal regulations.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Denison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Gracewell, An Eventide Community | 1.3 mi | ★★★★★ | 1 | 0 |
| Dunlap Specialty Care | 18.1 mi | ★★★★★ | 0 | 0 |
| Odebolt Specialty Care | 19.5 mi | ★★★★★ | 3 | 0 |
| Twilight Acres | 20.9 mi | ★★★★★ | 24 | 0 |
| Willow Dale Wellness Village | 23.7 mi | ★★★★★ | 2 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.