Below 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 Nursing And Rehab during CMS and state inspections, most recent first.
A resident with stroke-related sequelae, flaccid hemiplegia, paraplegia, and epilepsy required varying levels of assistance with ADLs per a recent MDS, including substantial/maximal help with lower body dressing and footwear and partial/moderate help with upper body dressing, bathing, and toileting hygiene. However, the comprehensive care plan did not include ADLs as a focus of care. The MDS Coordinator, responsible for care plans, acknowledged that ADL goals and interventions were not added after the MDS assessment, citing remote work and internet issues. The Corporate Social Worker and Administrator confirmed that MDS and nursing were responsible for care plan implementation and that ADLs are essential to guide staff. CNAs reported they lacked access to the POC system and were unaware of the resident’s ADL care plan details, instead relying on the resident or the charge nurse for direction, despite facility policy requiring care plans to describe services to maintain the resident’s highest practicable well-being.
A resident with intact cognition but significant physical impairments requiring partial/moderate assistance for bathing did not receive showers according to the posted schedule, and ADLs were not addressed in the care plan. Paper shower records showed only three showers over an extended period despite scheduled shower days, and the resident reported being showered only a few times and feeling unclean. Staff, including CNAs and an LVN, reported lack of POC access, inconsistent use of shower sheets, and limited oversight due to workload, while the Administrator confirmed that showers were expected per resident request or schedule and documented on shower sheets, as required by facility policy.
A resident with heart failure, dementia, and COPD had a UA ordered that later showed positive nitrates and WBCs too numerous to count, consistent with a UTI. Nursing staff obtained the specimen and the lab completed the UA, but the physician was not promptly notified of the abnormal results. Night-shift LVNs reported printing and faxing the results and placing them in a physician binder, while day-shift staff relied on the 24-hour report and text or fax communication, resulting in confusion and lack of timely direct notification. The physician, who expected phone notification for abnormal labs, did not recall receiving a call, and an antibiotic for the UTI was not started until several days after the abnormal UA results, during which time the resident reported burning on urination and a delay in receiving treatment.
Oxygen cylinders were found unsecured in both the oxygen room and CNA room, with staff and the administrator confirming the lack of proper storage and absence of a facility policy on oxygen storage. Observations showed cylinders not placed in racks or secured with chains or straps, despite available space, creating a safety risk.
A resident with dementia and a high risk for wandering was able to elope from the facility by climbing out of a window in an unoccupied room, after staff failed to implement effective supervision and did not follow care plan interventions or facility policy. The resident was found outside, two houses away, and staff were unaware of the absence until a meal was delivered. Several windows were missing screens, and staff had not been in-serviced on elopement procedures following the incident.
The facility did not display the HHSC complaint number or a statement informing residents of their right to file a complaint with the State Survey Agency regarding suspected violations, such as abuse or neglect. An observation confirmed the absence of this required signage, and the Administrator acknowledged not monitoring the postings or ensuring the information was available.
A resident with severe cognitive impairment and a high risk for wandering did not have elopement interventions included in her care plan, despite documented behaviors indicating potential elopement and facility policy requiring such measures. Staff confirmed the omission, and the resident's needs were not fully addressed in the care planning process.
A resident admitted with dementia, diabetes, and heart failure did not have a comprehensive care plan documented in the facility's system, despite policy requiring one within seven days of assessment. Staff interviews confirmed the absence of the care plan, with uncertainty about its deletion or omission, resulting in the resident's needs and services not being formally outlined.
A resident with severe cognitive impairment and total dependence on staff for ADLs was found with long, dirty fingernails, indicating that required nail care was not provided according to the care plan and facility policy. Staff interviews confirmed responsibility for nail care and acknowledged the oversight.
A resident with dementia, diabetes, and heart failure was found alone with a cup of 11 morning medications left unattended on the bedside table. An LVN admitted to leaving the medications while attending to another task and not confirming administration. The DON confirmed this practice was against facility policy, which requires medications to be securely stored and not left at the bedside.
The facility failed to conduct required EMR/NAR checks for a CNA and the DON, as mandated by their policies. The CNA's annual check was missed, and the DON's check was not done upon hire, potentially placing residents at risk of abuse.
A resident with multiple diagnoses returned from hospitalization requiring tube feeding, but the facility failed to update the care plan to reflect this change. Interviews with staff revealed that the DON was responsible for updating care plans but forgot to do so, despite the resident being NPO and receiving tube feeding. The facility's policy mandates care plan updates following significant changes in a resident's condition.
A facility failed to ensure proper treatment for a resident with a gastrostomy tube by not transcribing a bolus feeding order upon the resident's return from the hospital. The resident, with multiple health conditions, was dependent on enteral feeding. Due to a discrepancy in discharge orders and lack of appropriate tubing, LVN A obtained a verbal order for bolus feeding, which was not documented in the electronic MAR. This oversight could affect the resident's nutritional status, as noted by the DON and LVN A.
A medication cart serving rooms 124-143 was found unlocked and unattended, posing a risk of drug diversion. LVN A left the cart unsecured while searching for the ombudsman posting, despite knowing the importance of locking it. Interviews with the ADM and DON confirmed the requirement for carts to be locked when unattended, as per facility policies.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards. Food items in the refrigerator, freezer, and dry storage were not dated or labeled, and Cook B used her gloved hand instead of a scoop to serve fried okra during a lunch meal service, increasing the risk of food contamination.
The facility failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week, on multiple occasions. Interviews and record reviews revealed that LVNs were on duty without RN supervision on specific dates, and the DON confirmed the lack of RN coverage. The facility's policy did not specify weekend RN coverage, contributing to the deficiency.
The facility failed to ensure that controlled drugs were counted at every shift change for Nurses' Medication Cart Hall 100, as evidenced by missing signatures on the narcotic count sheet. This lapse was confirmed through record review, observation, and interviews with LVN G and the DON.
The facility failed to remove 11 expired COVID-19 Antigen self-tests from the medication room. An LVN confirmed the oversight, and the DON acknowledged the risk of inaccurate results and treatment. Facility policy requires outdated medications to be returned or destroyed.
A CNA failed to perform hand hygiene between glove changes while providing incontinence care to a resident with chronic kidney disease, elevated blood pressure, and breast cancer. The CNA admitted to forgetting to carry hand sanitizer, and the DON confirmed the requirement for hand hygiene to prevent infection. This lapse could place residents at risk for infection.
Failure to Include ADL Needs in Comprehensive Care Plan
Penalty
Summary
Surveyors identified a failure to develop and implement a comprehensive, person-centered care plan that included measurable objectives and time frames for activities of daily living (ADLs) for one resident. The resident was an older female with a history of cerebral infarction with sequelae, flaccid hemiplegia of the left dominant side, paraplegia, and epilepsy. Her quarterly MDS dated 03/30/2026 showed a BIMS score of 13, indicating intact cognition, and documented that she required substantial/maximal assistance for lower body dressing and footwear, partial/moderate assistance for upper body dressing, showering/bathing, and toileting hygiene, setup or clean-up assistance for oral hygiene and eating, and supervision for personal hygiene. Despite these documented ADL needs, review of her comprehensive care plan as of 04/28/2026 showed that ADLs were not addressed as a focus of care. During interviews, the MDS Coordinator stated that MDS was responsible for care plans and acknowledged that ADLs were not included in this resident’s care plan, attributing the omission to working remotely and having internet issues. She stated the care plan should have been updated after the 03/30/2026 MDS assessment and that all ADLs reflected in the MDS should have been included. The Corporate Social Worker confirmed that the IDT met weekly and that MDS, as part of nursing, was responsible for implementation of the care plan, and stated she did not know why ADL goals and interventions were missing. The Administrator stated the MDS Coordinator and DON were responsible for the care plan and emphasized that ADLs such as hygiene and showers were important so staff would know how to care for residents. CNAs reported they did not have access to the POC system containing care plans; one CNA stated she was unaware of the resident’s ADL goals and interventions and instead relied on the resident’s directions, while another CNA stated she was not aware of the ADL care plan and had to ask the charge nurse. The facility’s policy on comprehensive care plans stated that the care plan would describe services furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being.
Failure to Provide and Document Scheduled Showers for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident who required assistance with activities of daily living received scheduled showers to maintain personal hygiene. Record review showed that the resident, an adult female with a history of cerebral infarction with sequelae, flaccid hemiplegia of the left dominant side, paraplegia, and epilepsy, had a BIMS score of 13 indicating intact cognition and required partial/moderate assistance for showering/bathing per the quarterly MDS dated 03/30/2026. Her comprehensive care plan reviewed on 04/28/2026 did not address ADLs as a focus of care. The posted shower schedule listed her shower days as Tuesday, Thursday, and Saturday between 6 a.m. and 6 p.m., but completed shower sheets showed she was only showered on 03/28/2026, 04/14/2026, and 04/22/2026. The resident reported she had only been showered three to four times since admission and could not recall her last shower, stating she had an odor and could smell herself, although she was observed neatly dressed without an odor. Interviews with staff revealed gaps in implementation and documentation of shower care. The Administrator stated residents were to receive showers on request or on scheduled days, and that showers and refusals were documented on paper shower sheets because staff did not have access to the POC system, with nurses responsible for checking daily that showers occurred. CNA A reported the resident was showered or given bed baths but could not recall when and admitted she failed to document on the shower sheets, also noting she did not have access to the electronic medical record for ADL documentation. CNA B stated she had showered the resident once and that CNA A usually provided the showers, and that showers, refusals, and bed baths were to be documented on shower sheets, also without POC access. LVN A stated charge nurses were responsible for overseeing CNAs to ensure residents were showered by checking with CNAs and residents, but she was too busy with her duties to verify when residents were showered. The facility’s policy on Resident Showers, reviewed 02/11/22, stated residents would be provided showers per request or per shower schedule, which was not followed for this resident.
Failure to Promptly Notify Physician of Abnormal UA Results Leading to Delayed UTI Treatment
Penalty
Summary
The deficiency involves the facility’s failure to promptly notify the physician of abnormal laboratory results for a cognitively intact female resident with heart failure, dementia, and COPD. The resident’s quarterly MDS showed she required partial to moderate assistance with ADLs and had bladder and bowel incontinence. On 01/27/26, a verbal order was obtained for a urinalysis with culture and sensitivity if indicated. The urinalysis, completed on 01/29/26, showed positive urine nitrates and white blood cells too numerous to count, findings consistent with a urinary tract infection. Despite these abnormal results, the physician was not promptly notified, and an antibiotic (Macrobid 100 mg twice daily for 10 days) was not started until 02/04/26. The resident reported that she had burning on urination, believed she had a UTI, and stated that after providing a urine specimen it took 5–6 days before she received any medication. She said she was finally feeling a little better and that the urinary burning had stopped while she was still taking the prescribed medication. Nursing staff interviews revealed gaps and delays in the notification process. One LVN stated that the process for labs was to place them on the 24-hour report for follow-up and that, upon receiving results, staff would text or fax the results to the physician. She reported notifying the physician by text on 02/03/26 and was unsure why the physician had not been notified sooner, noting that this occurred during an ice storm when the physician’s office was closed. Another LVN working nights stated that when lab results are uploaded, she prints them and places them in the physician’s binder for day-shift staff to call the physician with results, and she believed she had printed the resident’s lab report on 01/29/26. A third LVN, who worked the weekend of 01/31/26, stated she saw the resident’s lab results and observed there was no documentation in the progress notes or 24-hour report indicating the physician had been notified, so she faxed the results to the physician’s office and returned them to the physician review book. The physician stated his expectation was to be contacted by phone for any abnormal lab results, did not recall receiving a call from the facility, and acknowledged that not being notified could result in a delay in treatment. The facility’s lab and diagnostic test results policy required a nurse to review results, determine urgency, notify the physician by phone, fax, or agent, and document when, how, and to whom the information was provided, with direct voice communication preferred for results requiring immediate notification.
Failure to Securely Store Oxygen Cylinders
Penalty
Summary
The facility failed to provide a safe environment by not securely storing oxygen cylinders in both the only oxygen room and the only CNA room. On observation, a free-standing oxygen cylinder was found in the CNA room without a rack, chain, or strap, and staff confirmed it was unsecured and acknowledged this as a safety risk. Further observation revealed four additional free-standing oxygen cylinders in the oxygen room, also without proper securing devices, despite available space in the rack. The administrator was unaware of the reason for the unsecured cylinders and confirmed that they should be secured to prevent them from falling. Additionally, the facility did not have a policy on oxygen storage. These findings were based on direct observation, staff interviews, and record review.
Failure to Prevent Resident Elopement Due to Inadequate Supervision and Environmental Safeguards
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision to prevent accidents, specifically failing to prevent the elopement of a resident identified as high risk for wandering. The resident, a man with multiple diagnoses including dementia, epilepsy, hemiplegia, and a history of elopement risk, was able to leave the facility undetected by climbing out of a window in an unoccupied room. The resident's care plan noted his risk for elopement and included interventions to identify wandering patterns and intervene as appropriate, but these interventions were not effectively implemented. The resident had previously expressed a desire to leave and had demonstrated agitation and exit-seeking behavior, yet staff did not put additional elopement interventions in place prior to the incident. On the day of the incident, the resident was last seen after a smoke break and was later found missing during routine rounds. Staff discovered the resident's wheelchair in front of a window in an adjoining unoccupied room, with the window closed and the screen removed. The resident was found outside, two houses away from the facility, and reported that he had climbed out the window to go to a family member's house. Staff were unaware of the resident's absence until they attempted to deliver his dinner tray, and the facility did not immediately notify law enforcement, as the resident was missing for only a short period. Interviews revealed that staff had not been in-serviced on elopement procedures following the incident, and the administrator was not fully aware of the details of residents' elopement risk assessments. Further observations identified that several windows in the facility were missing screens, and the maintenance director was unsure if replacements had been ordered. The facility's policies required care plans for residents at risk of elopement and outlined emergency procedures for missing residents, including notification of law enforcement, but these were not followed. The lack of effective supervision, failure to implement care plan interventions, and inadequate physical safeguards such as window screens contributed to the resident's ability to elope undetected, resulting in an Immediate Jeopardy situation.
Failure to Post Required Complaint Information for Residents
Penalty
Summary
The facility failed to post the required Health and Human Services Commission (HHSC) complaint number and a statement informing residents of their right to file a complaint with the State Survey Agency regarding suspected violations of state or federal regulations, including abuse, neglect, exploitation, and misappropriation of property. On 05/14/25, an observation throughout the facility revealed that this information was not posted in any location. During an interview, the Administrator confirmed that the postings were not present and admitted to not paying attention to what was displayed on the facility walls. The Administrator was unable to provide a reason for the absence of the required signage and acknowledged the importance of such postings for residents to know how to report concerns about staff.
Failure to Update Care Plan for Elopement Risk
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting interventions for elopement risk. A review of the resident's records showed that she was a woman with multiple diagnoses, including dementia and severe cognitive impairment, as evidenced by a BIMS score of 3. The resident required extensive assistance with activities of daily living and was assessed as high risk for wandering, with an elopement risk assessment score of 14. Despite these findings, her care plan did not include any strategies or interventions related to elopement risk. Further documentation revealed that the resident had expressed a desire to leave the facility and was observed gathering her belongings, indicating potential elopement behavior. Interviews with facility staff confirmed that the care plan lacked elopement interventions, and the facility's own policy required such risks to be addressed in the care plan. The Director of Nursing was unavailable for comment, and the MDS Coordinator acknowledged the omission. This failure to update the care plan could result in the resident not receiving necessary care and services to address her elopement risk.
Failure to Develop and Implement Comprehensive Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who was admitted with diagnoses of dementia, diabetes mellitus, and heart failure. The resident's admission Minimum Data Set (MDS) assessment indicated moderate cognitive intactness, yet a review of the care plan system (PCC) revealed that no care plan was present for the resident as of the date of the survey. Interviews with the Director of Nursing (DON) and the MDS coordinator confirmed that a care plan should have been in place, with the MDS coordinator stating that the care plan was completed but may have been deleted from the system. The DON acknowledged that the care plan was necessary to ensure appropriate services and care were provided. Facility policy requires that a comprehensive care plan be developed within seven days of completion of the resident assessment (MDS). Despite this policy, the required care plan was not available in the system for the resident, and staff were unable to account for its absence. This lack of a documented care plan meant that the resident's individualized needs and services were not formally outlined or accessible to the care team.
Failure to Provide Nail Care for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for a resident who was totally dependent on staff for personal care. The resident, a male with severe cognitive impairment due to dementia and other medical conditions, was observed to have long fingernails with visible brown matter underneath. Despite being unable to perform self-care, his fingernails had not been trimmed or cleaned as required by his care plan, which specified that nail care should be performed on bath days and as needed. Interviews with staff confirmed that both CNAs and charge nurses were responsible for nail care, except in cases of diabetes where only nurses should perform the task. Staff acknowledged that the resident's nails were long and dirty, and recognized the associated risks. The facility's policy emphasized the importance of nail care for cleanliness and infection prevention, but this was not followed for the resident in question, as evidenced by the observations and staff statements.
Unattended Resident Medications Left at Bedside
Penalty
Summary
A deficiency occurred when a resident's morning medications, including Allopurinol, Aspirin, Glimepiride, Isosorbide, Metoprolol, Nifedipine, Plavix, Potassium, Torsemide, Calcium Carbonate with Vitamin D, and Gabapentin, were left unattended on the bedside table. The resident, who has diagnoses of dementia, diabetes mellitus, and heart failure, was observed alone in his room with a medication cup containing 11 tablets. The resident stated that the nurse had left the medications for him to take. During an interview, the LVN acknowledged that she had given the medications to the resident but left the room to open the facility door and forgot to return to ensure the medications were taken. The DON confirmed that medications should not be left unattended or at the bedside and that nurses are trained to ensure residents swallow their medications before leaving the room. Facility policy requires all drugs and biologicals to be stored in a safe, secure, and orderly manner.
Failure to Conduct Required Background Checks for Staff
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. Specifically, the facility did not conduct the required Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) checks for two employees, a Certified Nursing Assistant (CNA) and the Director of Nursing (DON). The CNA's annual EMR/NAR check was not conducted for October 2024, and the DON's EMR/NAR check was not conducted upon hire, as required by the facility's policies. The facility's policy mandates that background checks, including EMR/NAR checks, be conducted upon hire and annually to ensure that employees are employable and to prevent abuse. However, the Administrator (ADM) responsible for these checks admitted to not performing them as required. This oversight could place residents at risk of abuse and receiving care from staff who may not be employable. The ADM acknowledged the importance of these checks in preventing abuse and ensuring the employability of staff.
Failure to Update Care Plan for Tube Feeding
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which accurately reflected the resident's current tube feeding status. The resident, a male with multiple diagnoses including pneumonia, acute respiratory failure, dementia, Alzheimer's disease, dysphagia, and autistic disorder, was admitted to the facility and later experienced a significant change in condition, necessitating hospitalization. Upon returning to the facility, the resident required tube feeding, but the care plan was not updated to reflect this change, despite the resident being NPO and receiving nutritional needs via tube feeding. Interviews with facility staff, including the Administrator (ADM) and Director of Nursing (DON), revealed that the DON was responsible for updating care plans but failed to do so for this resident. The DON admitted to forgetting to update the care plan to reflect the resident's tube feeding status, acknowledging the importance of keeping care plans current to ensure appropriate care and services. The facility's policy requires care plans to be reviewed and revised when there is a significant change in a resident's condition, which was not adhered to in this case.
Failure to Transcribe Bolus Feeding Order for Resident with Gastrostomy Tube
Penalty
Summary
The facility failed to ensure that a resident who was fed by gastrostomy tube received the appropriate treatment and services to prevent complications of enteral feeding. This deficiency involved a resident who was readmitted to the facility after a hospital stay. Upon return, the resident's bolus feeding order was not transcribed by LVN A, the admitting nurse, which led to the absence of documentation for the resident's bolus feeding on the electronic Medication Administration Record (MAR) for two days. The resident, a male with multiple diagnoses including pneumonia, acute respiratory failure, dementia, Alzheimer's disease, dysphagia, and autistic disorder, was dependent on a gastrostomy tube for nutrition. Upon readmission, there was a discrepancy between the verbal hospital discharge report and the actual discharge paperwork regarding the tube feeding orders. The facility did not have the appropriate tubing for the resident's feeding pump, prompting LVN A to obtain a verbal order for bolus feeding from Dr. B. However, this order was not transcribed into the electronic physician orders or recorded on the MAR. Interviews with the Director of Nursing (DON) and LVN A revealed that the failure to transcribe the bolus feeding order could result in the resident receiving an incorrect tube feeding rate, potentially affecting the resident's nutritional status. The facility's policy requires that all orders, including verbal ones, be transcribed immediately to ensure accurate documentation and care. The deficiency was identified during a review of the resident's care plan and progress notes, which lacked documentation of the bolus feeding order and its administration.
Medication Cart Security Breach
Penalty
Summary
The facility failed to adhere to State and Federal laws regarding the secure storage of drugs and biologicals, as observed with medication cart E, which serves rooms 124-143. On the morning of March 4th, the cart was found unlocked and unattended for approximately two minutes at the nursing station near a resident in a wheelchair. LVN A, responsible for the cart, was not in the hallway or within sight of the cart during this time. Upon returning, LVN A acknowledged the cart was unlocked and admitted to being away from it while searching for the ombudsman posting, despite knowing the importance of keeping the cart locked to prevent drug diversion and theft. Interviews with the facility's administration, including the ADM and DON, confirmed that medication carts should be locked when unattended to ensure medication security. The facility's policies, revised in February 2023, April 2007, and November 2020, clearly state that all medications and biologicals must be stored in locked compartments, and medication carts must be secured during medication passes and when not in use. The failure to lock the medication cart as per these policies could lead to unauthorized access to medications, posing a risk of theft or drug diversion.
Failure to Follow Food Safety Standards
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, food items in the facility's refrigerator, freezer, and dry storage were not dated or labeled. Observations revealed that a packet of chicken pot pie filling and liquid egg yolks in the refrigerator, a loaf of bread and six hamburger buns in the dry storage, and six hamburger patties and bread in the freezer were all undated and unlabeled. This lack of proper labeling and dating could lead to the use of older items first, increasing the risk of food-borne illness among residents who consume these items. Additionally, during a lunch meal service, Cook B did not use sterile technique while serving food. Cook B was observed using her gloved hand to scoop fried okra onto a resident's plate instead of using a scoop or spoon. In an interview, Cook B acknowledged the mistake and the importance of using utensils to prevent food contamination. The Food Service Manager confirmed that all kitchen staff, including herself, were responsible for dating and labeling items and emphasized the importance of using utensils to serve food to minimize the risk of food contamination and infection.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide registered nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week, as required. Specifically, there was no RN coverage on May 4, May 5, and May 11, 2024. This deficiency was identified through interviews and record reviews, which revealed that licensed vocational nurses (LVNs) were on duty during these days without the supervisory oversight of an RN. The Director of Nursing (DON) confirmed that she was the only RN employed by the facility since May 1, 2024, and did not work on the days in question. The DON acknowledged the importance of having RN coverage for emergencies and RN-specific nursing activities, and stated that the facility was actively seeking weekend RN coverage. The facility's staffing sheets and CMS PBJ staffing reports further corroborated the lack of RN coverage on the specified dates and previous quarters. Interviews with LVNs working on the days without RN coverage highlighted their concerns about the absence of an RN for supervisory and emergency purposes. The DON and the facility administrator both confirmed the lack of RN coverage and acknowledged the potential risks to residents. The facility's policy on nursing services did not specify RN coverage requirements for weekends, which contributed to the oversight. Attempts to interview a certified nursing assistant (CNA) who worked on one of the days in question were unsuccessful. The facility did not provide staffing sheets for the requested dates of May 1 to May 10, 2024, further complicating the assessment of RN coverage compliance.
Failure to Count Controlled Drugs at Shift Change
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for Nurses' Medication Cart Hall 100. Specifically, LVN G, who was responsible for this medication cart, did not count controlled drugs at every shift change. This was evidenced by missing signatures for both off-duty and on-duty nurses on the narcotic count sheet for a specific date. This lapse in procedure was confirmed through record review and observation, as well as interviews with LVN G and the Director of Nursing (DON). During an interview, LVN G acknowledged that nurses and medication aides should have signed the narcotic sheet after counting the narcotics. The DON also confirmed that she expected nurses to sign the narcotic count sheet at the beginning and end of their shifts after completing the count with the incoming and off-going nurse. The facility's policy on controlled substances, revised in November 2022, mandates that controlled substances are counted upon delivery and that both the nurse receiving the medication and the person delivering it must count the controlled substances together and sign the designated record. The failure to adhere to this policy could not be substantiated as the narcotic count sheets were not signed, indicating a potential risk for drug diversion.
Expired COVID-19 Antigen Self-Tests Found in Medication Room
Penalty
Summary
The facility failed to label drugs and biologicals in accordance with currently accepted professional principles, specifically by not removing 11 expired COVID-19 Antigen self-tests from the medication room. During an observation, an LVN confirmed the presence of the expired tests and acknowledged that they had not noticed them before. The Director of Nursing (DON) also confirmed that nurses are responsible for checking for expired medications and acknowledged the risk of using expired tests, which could lead to inaccurate results and treatment. The facility's policy on Medication Labeling and Storage, revised in February 2023, states that outdated or deteriorated medications or biologicals should be returned or destroyed as per the dispensing pharmacy's instructions.
Failure to Perform Hand Hygiene During Incontinence Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of infection for one resident observed for infection control. Specifically, a CNA did not perform hand hygiene between changing gloves while providing incontinence care to a resident. The resident, an elderly female with chronic kidney disease, elevated blood pressure, and breast cancer, required extensive assistance with toileting hygiene. During the observed care, the CNA cleaned the resident's pubic and buttocks areas, removed her gloves, and re-gloved without performing hand hygiene, which is against the facility's policy and infection control protocols. In an interview, the CNA admitted to forgetting to carry hand sanitizer and acknowledged the importance of hand hygiene in preventing the spread of infection. The Director of Nursing (DON) confirmed that staff are required to perform hand hygiene before and after care, as well as between glove changes, to prevent contamination. The facility's policy on hand hygiene, reviewed in August 2019, also mandates the use of an alcohol-based hand rub after removing gloves. This lapse in protocol could place residents at risk for infection.
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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) |
|---|---|---|---|---|
| Woodlands Place Rehabilitation Suites | 1.5 mi | ★★★★★ | 14 | 0 |
| The Terrace At Denison | 2.2 mi | ★★★★★ | 23 | 0 |
| Beacon Hill | 2.2 mi | ★★★★★ | 10 | 0 |
| The Homestead Of Denison | 2.3 mi | ★★★★★ | 9 | 0 |
| Avir At Sherman | 5.8 mi | ★★★★★ | 5 | 0 |
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