Above average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Gracewell, An Eventide Community during CMS and state inspections, most recent first.
The facility failed to prepare palatable meals, with residents reporting overcooked and bland food. Observations showed chicken and fish were left in the oven at high temperatures, leading to dry and tough meals. A test tray confirmed the food was overcooked, with mushy vegetables and dry chicken. The Dietary Manager acknowledged the issue, noting the failure to meet the facility's food preparation standards.
The facility failed to verify and document the advanced directives for two residents, leading to discrepancies in their code status. One resident, with intact cognition, had conflicting directives between CPR and DNR without proper documentation or family signatures. Another resident, with severe cognitive deficit, had a care plan indicating DNR while the initial form signed by her niece indicated CPR, lacking proper documentation and family confirmation.
Two residents in an LTC facility experienced delays in the identification and documentation of skin issues. One resident developed an abdominal pressure ulcer that was not documented until it showed signs of infection, despite having a care plan for skin prevention. Another resident had bruising and a skin tear that were not discovered until they had scabbed over. The facility's reliance on CNAs for reporting and lack of scheduled skin assessments contributed to these deficiencies.
A nurse failed to change gloves and perform hand hygiene after repositioning a resident before administering medications via a G-tube. The resident, with severe cognitive impairment and a history of C-diff, was on enhanced barrier precautions. This action violated the facility's hand hygiene policy.
Deficiency in Meal Preparation and Palatability
Penalty
Summary
The facility failed to prepare food that conserved flavor, appearance, and palatability for a lunch meal, affecting the quality of meals served to residents. Observations and interviews revealed that the food, particularly the meat, was often overcooked and burnt, with residents describing it as tough and bland. Specifically, Resident #15 and Resident #45 reported dissatisfaction with the meals, noting the meat was difficult to cut and lacked flavor. During an observation, Staff G, the cook, was seen placing chicken nuggets and fish fillets in the oven, with the chicken reaching a temperature of 180 degrees Fahrenheit and the fish 174 degrees Fahrenheit, yet they were left in the oven, potentially contributing to overcooking. A test tray of sesame chicken, Asian blend vegetables, and fried rice was evaluated after the lunch meal was served, revealing that the sesame sauce had soaked through the breading, leaving the chicken nuggets dry and tough. The vegetables were overcooked to the point of being mushy and indistinguishable in color. Resident #15 confirmed the meal was unsatisfactory, describing the chicken as overcooked and dry, with no sesame sauce, and the vegetables as mushy. The Dietary Manager acknowledged the issue, agreeing that the vegetables were very mushy and not up to the expected standard of providing a palatable meal. The facility's policy on food preparation emphasized the importance of conserving nutritive value, flavor, and palatability, which was not adhered to in this instance.
Failure to Verify and Document Advanced Directives
Penalty
Summary
The facility failed to verify and accurately document the advanced directives for two residents, leading to discrepancies in their code status. Resident #58, who had a BIMS score of 15 indicating intact cognition, initially had a directive for CPR as signed by his sister. However, a physician's order later reflected a DNR status per family wishes, without proper documentation or a signed form from the family. Interviews revealed that Resident #58 expressed a desire for CPR, but the facility did not have adequate documentation to support the change in code status, nor did they have a physician's note deeming him incompetent to make his own decisions. Resident #8, with a BIMS score of 5 indicating severe cognitive deficit, had a care plan indicating a DNR status, while the initial form signed by her niece indicated CPR. The facility's documentation lacked a second form for the change in code status and did not have a signature from the family representative confirming the change. The care conference notes also lacked proper documentation of communication with the family representative, leading to a failure in verifying and maintaining accurate records of the resident's advanced directives.
Failure to Timely Identify and Document Skin Issues
Penalty
Summary
The facility failed to identify and document new skin issues in a timely manner for two residents, leading to deficiencies in care. Resident #29, who had a terminal prognosis and was receiving hospice care, developed an abdominal pressure ulcer that was not documented until it showed signs of infection. Despite having a care plan that included skin prevention protocols and daily skin inspections, the facility did not document the developing skin issue under the right abdominal fold until it had progressed significantly. The wound was first noted in a nursing note on 3/8/24, but lacked detailed documentation of its size and characteristics until 3/18/24, when it was described as an abscess with bloody drainage. Resident #66, who had severely impaired cognition and was on hospice care, was found to have bruising and a skin tear on her lower leg. The facility did not discover or document the skin tear until it had scabbed over. The care plan for Resident #66 included monitoring for excess bruising and bleeding due to the use of aspirin, but the facility failed to identify the skin issues in a timely manner. The bruising and skin tears were reported by a CNA on 10/28/24, but the facility could not explain why they were not discovered sooner. The facility's policy on skin care required immediate assessment and treatment of any areas of skin damage, with direct care staff responsible for daily skin care observations and reporting changes to the charge nurse. However, the facility relied on CNAs to report new skin issues and did not have scheduled full body skin assessments. This lack of proactive monitoring and documentation contributed to the delay in identifying and addressing the skin issues for both residents.
Inadequate Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to practice adequate hand hygiene during the administration of medications via a feeding tube for one resident. The incident involved a registered nurse (RN) who, after assisting in repositioning the resident in bed, did not change her gloves or perform hand hygiene before preparing and administering medications. This action was contrary to the facility's hand hygiene policy, which requires staff to change gloves and perform hand hygiene after touching potentially contaminated surfaces. The resident involved had a severely impaired cognitive status and was totally dependent on staff for various activities of daily living. The resident had a history of C-diff and was on enhanced barrier precautions, receiving all nutrition and hydration through a G-tube due to dysphagia. The nurse manager confirmed that staff were instructed to change gloves and perform hand hygiene after contact with potentially contaminated surfaces, indicating a lapse in following established infection control protocols.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Denison Care Center | 1.3 mi | ★★★★★ | 2 | 0 |
| Dunlap Specialty Care | 17 mi | ★★★★★ | 0 | 0 |
| Odebolt Specialty Care | 20.7 mi | ★★★★★ | 3 | 0 |
| Twilight Acres | 22.1 mi | ★★★★★ | 24 | 0 |
| Willow Dale Wellness Village | 24.5 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.