Below average — CMS composite of the measures below.
A standard survey is most likely before around December 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 The Terrace At Denison during CMS and state inspections, most recent first.
Failure to Follow EBP During Resident Care: Staff did not wear PPE or perform hand hygiene as required while providing direct care to two residents on EBP. An LVN cared for a resident with severe cognitive and functional impairment and a feeding tube without washing hands, changing gloves appropriately, or following EBP procedures, and wound care supplies and medications were handled in an unsafe manner. For another resident with dementia, gastric tube use, incontinence, and multiple pressure injuries, CNAs and an RN entered the room without PPE, and the RN performed wound care while changing gloves without hand hygiene and leaving without washing hands. Multiple staff members could not explain the EBP policy or identify residents who required it.
Failure to Provide Ordered Enteral Feeding and Hydration: A resident with severe cognitive impairment, stroke-related diagnoses, and total dependence on staff was found with the enteral feeding and water bags empty while the pump was off and the tube remained connected. An LPN stated the off-going RN had not started the Jevity and water flushes and that she should have initiated them but did not, leaving the resident without nourishment and water for about six hours. The record also showed no initial RD nutritional assessment and no current weight history in the EMR.
A resident with severe cognitive impairment and total dependence on staff for care was found with the call light out of reach, contrary to the care plan and facility policy. Multiple staff members confirmed the call light should have been accessible at all times to ensure the resident could request assistance.
Two residents receiving oxygen therapy did not have their oxygen tubing properly stored in bags when not in use, as required by their care plans and professional standards. Nursing staff confirmed the tubing should have been bagged to prevent contamination, but observations found tubing left exposed on equipment.
A deficiency was identified when a resident was found with a bottle of Milk of Magnesia on her nightstand without a physician's order or authorization to self-administer medication. The medication had been brought in by family members without staff knowledge, and facility policy requires such medications to be secured and not left at the bedside.
The facility failed to ensure residents had reasonable access to telephone use and that relatives could reach residents and staff when the phone system was down for weeks. A severely cognitively impaired resident with dementia and a moderately cognitively impaired resident with COPD, depression, and dysphagia were affected, and multiple residents, an Ombudsman, and staff reported that incoming and outgoing calls were not working. Staff said they were using personal cell phones or an on-call phone to contact families and physicians, but the facility number rang without answer and without voicemail.
A resident with severe cognitive impairment and a recent femur fracture was transferred without a gait belt during one observed transfer, and during another transfer staff used a gait belt but lifted under the arms instead of using proper belt technique. A second resident with severe cognitive impairment had a broken windowsill with exposed wood and nails next to the bed; staff did not report the hazard, and the resident placed a hand in the damaged sill during care.
Inadequate Hair Restraints During Meal Preparation: Two dietary staff were observed during meal service with hair restraints that did not fully cover their hair while plating food, adding condiments, and preparing trays. Both staff said they were unaware their hair was exposed, and the Dietary M stated he expected hair restraints to fully cover all hair; the facility policy required appropriate hair restraints during normal food production hours.
Multiple infection control failures occurred during resident care and meal delivery. An LPN used resident-care equipment on one resident and returned it to the med cart without sanitizing it, and another LPN contaminated a blood pressure cuff, handled a dropped pill, and reused a piston syringe after it fell on the floor. A CNA provided incontinent care to a resident with a urinary catheter without proper EBP PPE or hand hygiene, a treatment nurse failed to perform hand hygiene during wound care, and a CNA delivered meal trays to several residents without sanitizing hands between residents.
A resident with Alzheimer’s disease, CAD, epilepsy, severe cognitive impairment, and total dependence for ADLs was not given proper resident/rep participation in care planning. The facility’s care plan letters invited the RP to attend in person or call with issues, but did not offer a phone option for the care plan meetings themselves. The RP stated she wanted to join by phone but was never given that opportunity, and the SW and DON confirmed the phone option should have been offered.
Failure to care plan falls and pelvic fracture: A resident with dementia, severe cognitive impairment, weakness, unsteadiness, and repeated falls had a care plan that identified fall risk but did not include his actual falls or left pelvic fracture. Records showed multiple falls, including one with a forehead laceration and leg pain requiring hospital transfer, and a later incident where x-rays confirmed a pubic bone fracture. The DON stated the fracture was not on the care plan.
Oxygen Concentrator Set Above Ordered Level: A resident with COPD and continuous O2 orders was observed with the concentrator set at 3 L/min instead of the ordered 2 L/min, and at one point the oxygen was not on her face. An assigned LVN could not find the O2 order in the EMR and had to verify it from the paper chart, while another LVN confirmed the correct order and adjusted the concentrator. Interviews with nursing leadership confirmed the concentrator was expected to match the physician order and be checked each shift.
Medication error rate exceeded the allowed threshold when an LPN failed to administer ordered Digoxin 250 mcg and Ergocalciferol 1.25 mg to a resident during an observed med pass, yet signed both medications out as given on the MAR. The resident had severe cognitive impairment, CAD, HTN, and quadriplegia, and the DON stated staff were expected to follow the six rights of medication administration.
Improper Storage of Topical Medication at Bedside: A resident with moderate cognitive impairment and psoriasis had Clobetasol Propionate cream left on her overbed table without an order for bedside storage. The resident said she kept it there for her psoriasis, could not read the instructions, and used it when needed. The DON stated the resident lacked capacity to manage her own meds and that meds should not have been left in the room; the LVN stated meds were not to be stored at bedside.
Egg salad was served at improper temperatures during lunch service. Residents reported concerns that food was not being served at the right temperatures, and Dietary staff observed pureed egg salad at 51.5 F and regular egg salad at 42.3 F, with no ice under the containers and the food left on the serving line. Staff plated the egg salad without first confirming the temperature, and a test tray later showed the egg salad was slightly warm and tasted warm. An L stated she was not trained on the required food temperatures or what to do if food was not cold enough, while the DM stated egg salad should be served at 41 F or below.
Staff failed to follow infection control protocols for two residents, including not using required PPE during wound care for a resident with wounds and a Foley catheter, and not performing hand hygiene between glove changes during incontinence care for a resident with severe cognitive impairment. These lapses were observed and acknowledged by staff, and were not in accordance with facility policies on Enhanced Barrier Precautions and hand hygiene.
The facility failed to maintain a clean and homelike environment, resulting in pest infestations and unsanitary conditions. Observations revealed that resident rooms, especially those with feeding tubes, were infested with ants, gnats, and flies due to uncleaned food spills. A resident suffered numerous ant bites, highlighting the facility's inadequate housekeeping and maintenance services. Staff interviews indicated confusion over cleaning responsibilities, and pest control noted ongoing sanitation issues. Residents expressed concerns about the lack of cleaning, particularly on weekends, and the unsanitary state of common areas.
A long-term care facility failed to maintain an effective pest control program, leading to multiple pest infestations affecting residents. One resident suffered 102 ant bites due to ants in her room, which was not adequately cleaned. Other residents' rooms and common areas were also infested with gnats, flies, and ants, with food residue and clutter contributing to the problem. Despite awareness of the issues, facility staff did not take effective action to prevent and control the infestations.
The facility's kitchen failed to meet food safety standards, with issues including ice accumulation in a chest freezer, unlabeled and unsealed food items, and the presence of gnats and flies. The steam table was also found to be dripping, with incomplete repairs. The Dietary Manager was aware of these issues but cited staffing shortages and maintenance delays as contributing factors.
The facility did not conduct required EMR/NAR background checks for seven employees, including an Activity Director, two LVNs, and four CNAs, as mandated by their policies. This oversight was due to a lack of awareness and responsibility within the Human Resources department, potentially placing residents at risk. The checks were eventually completed, revealing no employment bars or license restrictions.
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in addressing their needs. One resident's care plan lacked interventions for ADLs, bowel incontinence, and catheter care, while another's did not address hand contractures and skin integrity. The MDS Coordinator and DON acknowledged these oversights, which were contrary to the facility's care planning policy.
The facility failed to provide necessary ADL care for three residents, resulting in deficiencies in personal hygiene and grooming. A resident with moderate cognitive impairment did not receive scheduled showers, while another with severe health conditions was not adequately bathed or groomed. A third resident with frequent incontinence also missed scheduled showers, leading to poor hygiene. Staff interviews revealed issues with documentation and adherence to the shower schedule.
The facility failed to provide individualized activities for residents with cognitive impairments, leading to a lack of engagement and well-being. A resident with severe cognitive impairment felt bored and unaware of the Activity Director, while another resident with moderate impairment was often upset and redirected rather than engaged in preferred activities. A third resident, also with severe impairment, was primarily engaged in smoking breaks. The Activity Director lacked experience and had not completed all assessments, resulting in insufficient implementation of the facility's activity policy.
The facility failed to properly label and store medications for three residents and in the medication room. A resident had Dakin's Solution stored improperly without a physician's order. Another resident had antifungal powder at her bedside without an order. A third resident's blister pack for sevelamer carbonate was not updated with the correct dosage. Expired medications were found in the medication room. These deficiencies were observed by staff, including LVNs and the DON, highlighting issues in medication management.
A facility failed to maintain proper infection control practices for two residents. An LVN did not perform hand hygiene during wound care and improperly handled multi-use dressing supplies, risking cross-contamination. An agency CNA did not wear appropriate PPE during incontinence care and neglected hand hygiene protocols, potentially spreading infections. Staff interviews revealed gaps in adherence to infection control policies and training.
A resident with conductive hearing loss was not assessed or provided with hearing aids or amplification devices, despite moderate cognitive impairment and minimal hearing difficulty noted in assessments. Facility staff failed to secure a provider accepting Medicaid or pursue alternative solutions, leading to communication issues during care. The facility's policy on assisting residents with hearing care was not followed.
A facility failed to ensure proper use of assistance devices during resident transfers, specifically for a resident with multiple health issues requiring substantial assistance. An NA attempted to transfer the resident without a gait belt, contrary to facility policy, resulting in discomfort for the resident. The NA, working PRN, was aware of the requirement but did not comply, and the facility's training system for new hires had lapsed.
A resident with an indwelling catheter did not receive appropriate care, as a CNA placed the catheter drainage bag on the bed instead of below the bladder, risking backflow and infection. Additionally, the CNA failed to perform hand hygiene after glove removal during care. The resident's care plan lacked specific instructions for catheter care, and staff interviews confirmed awareness of proper procedures.
A facility failed to follow physician-ordered water flushes for a resident with a G-tube, risking tube obstruction and decreased hydration. The resident, who was severely cognitively impaired and dependent on tube feeding, was supposed to receive 60 ml of water flush before and after medication administration. However, an LVN only administered 30 ml, not adhering to the prescribed protocol.
A facility failed to ensure proper post-dialysis care for a resident with chronic kidney disease by not completing required communication sheets. The resident, who received dialysis three times a week, had several missing post-dialysis assessments due to agency staff not being informed about the procedure. This lack of documentation could risk inadequate care.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents who were on Enhanced Barrier Precautions (EBP). Resident #1 was a male admitted with diagnoses including nontraumatic intracerebral hemorrhage, encephalopathy, hypertension, congestive heart failure, and acute respiratory failure. He had severe cognitive impairment, was dependent on staff for all ADLs, and had a care plan indicating he would remain in the facility as a permanent resident. During observation, an LVN entered his room without washing hands or wearing PPE required for EBP, had long artificial nails, could not recall the facility EBP policy or procedure, disconnected the feeding tube from the resident’s gastric port, and draped the tube over the feeding pump pole without capping it. The end of the tube touched the pump pole and the empty Jevity and water bags, contaminating the tip of the feeding tube. The LVN also did not change gloves before adding clear liquid from a previously opened, undated bottle into a water cup and did not wash hands after providing care. Resident #1’s family member stated she was visiting the facility and the resident for the first time since admission and was not aware of EBP or told she needed to gown and glove before entering the room for infection control purposes. The report also noted several medications on a bedside table were crushed and placed in unlabeled clear medicine cups with clear liquid. These observations occurred while the resident was receiving direct care and medication-related activities in the room. Resident #2 was a female admitted with diagnoses including right leg fracture, pressure injuries to both heels, urinary tract infection, metabolic encephalopathy, anxiety disorder, dementia, and major depressive disorder. She had severe cognitive impairment, required moderate assistance and supervision with ADLs, used a wheelchair, was incontinent of bowel and bladder, had a gastric tube, and had multiple pressure injuries. Her care plan identified that she required EBP, with interventions stating staff must use gown and gloves during high-contact care, hand hygiene must be performed when entering and exiting the room, and signage and PPE must be available for staff. During observation, CNAs provided personal care after an incontinence episode without PPE, and an RN entered the room without washing hands or donning PPE for EBP. The RN performed wound care to the left heel, right heel, and sacral wound while changing gloves without hand hygiene and left the room without washing hands. Interviews with multiple staff members, including CNAs, an LVN, housekeeping supervisor, and the DON, reflected they were not recently in-serviced on EBP, could not explain the policy, could not identify residents requiring PPE for high-contact care, and could not name an example of an MDRO associated with EBP.
Failure to Provide Ordered Enteral Feeding and Hydration
Penalty
Summary
The facility failed to protect a resident from neglect when enteral feeding and water ordered by the physician were not started as scheduled for a resident who was dependent on staff for all ADLs and unable to swallow orally. The resident had a history that included nontraumatic intracerebral hemorrhage, encephalopathy, hypertension, congestive heart failure, and acute respiratory failure. The resident’s MDS reflected severe cognitive impairment and dependence on staff for care. The physician orders required Jevity 1.5 at 50 mL/hr for 22 hours with water flushes at 50 mL/hr via feeding pump, with the pump down for 2 hours for ADLs. During observation, the resident was found in bed with the enteral feeding and water bags completely empty while the tubing remained connected to the resident. The feeding pump was turned off. The resident could not participate in conversation due to mental status. The record review also found no initial nutritional assessment by a Registered Dietitian and no current weight history in the EMR. Standards of care in the report stated that a dietitian must collaborate with the physician to calculate calories, fluid needs, protein, and other nutrition and hydration components for residents requiring enteral feeding, and that residents should be weighed weekly for four weeks after admission and then monthly. The LVN who provided care stated that the off-going RN had not hung a new Jevity formula bag or water flush bag before leaving the night shift, and that she should have started the feeding and water when she began her shift but did not. She stated this left the resident without nourishment and water for approximately six hours and that her inaction would be considered neglect. During the medication pass, the LVN did not wash her hands, did not use PPE required for enhanced barrier precautions, preset crushed medications in unlabeled cups, did not recall what medication was in each cup, and later administered medications with residual medication remaining in the cups. She also disconnected and reconnected the feeding tube without capping the end, and reconnected the contaminated tube tip back into the resident’s gastric port while no Jevity or water flush was hung to run per orders.
Failure to Ensure Call Light Accessibility for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident's call light system was accessible, as required by the resident's care plan and facility policy. The resident in question was an elderly male with a history of atherosclerotic heart disease, diabetes mellitus, severely impaired cognition, and was dependent on staff for self-care and mobility. The resident's care plan specifically included an intervention to keep the call light within reach at all times due to his immobility, chronic pain, incontinence, and decreased cognition. On the date of observation, the resident was found lying in bed asleep with the call light hanging behind the nightstand, out of his reach. Staff interviews confirmed that the call light should have been accessible to the resident at all times, and that it was important for resident safety and communication. The facility's policy also required that each resident be provided with a means to call staff directly for assistance from their bed. Multiple staff members, including the LVN, CNA, Administrator, DON, and ADON, acknowledged that the call light was not in compliance with expectations during the incident.
Failure to Properly Store Oxygen Tubing for Residents Receiving Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents who required oxygen therapy. For one resident with COPD and end stage renal disease, observations revealed that oxygen tubing connected to a portable tank on the resident's wheelchair was not stored in a bag as required by the care plan and professional standards. The resident confirmed that the tubing was usually kept in a bag, but at the time of observation, it was looped around the wheelchair handle and left exposed. A nurse acknowledged that the tubing should have been bagged and stated it was important for infection control. For another resident with COPD and diabetes, oxygen tubing connected to an oxygen concentrator was observed draped over the top of the concentrator and not stored in a bag when not in use. Due to the resident's cognitive impairment, he was unable to answer questions about the tubing. Nursing staff confirmed that the tubing should have been bagged to prevent bacterial contamination. The facility's policy addressed the frequency of changing oxygen tubing but did not specify storage requirements when not in use.
Medication Storage Deficiency: Unsecured Medication at Bedside
Penalty
Summary
A deficiency occurred when a bottle of Milk of Magnesia, a liquid medication, was found on the nightstand next to a resident's bed. The resident, an older female with osteoarthritis and a history of repeated falls, was cognitively intact but did not have a physician's order to self-administer medication, nor was there documentation in her care plan authorizing self-administration. The medication was not listed in the resident's physician orders, and there was no indication that staff were aware of its presence prior to the surveyor's observation. Interviews revealed that the medication had been brought in by the resident's family without notifying facility staff. The resident stated she kept the medication at her bedside for occasional use, including applying it to her mouth for discomfort. Facility staff, including an LVN, DON, and ADON, confirmed that medications should not be kept at the bedside unless there is a physician's order and an assessment for self-administration. The facility's policy requires unauthorized medications found at the bedside to be turned over to nursing staff.
Failure to Maintain Working Resident and Family Phone Access
Penalty
Summary
The facility failed to ensure residents had reasonable access to and privacy in their use of the telephone for 7 of 12 residents reviewed for resident rights. Surveyors found that the facility’s phone system was not working for making and receiving calls for several weeks, affecting Resident #30, Resident #50, and other residents. The facility also failed to ensure relatives of Resident #30 had a working phone number to reach the resident and facility staff. Resident #50 was a severely cognitively impaired male with diagnoses including dementia, psychotic disorder, dysphagia, and personality change due to a known physiological condition. His most recent MDS showed a BIMS score of 5 and behaviors of inattention, disorganized thinking, and physical behavioral symptoms directed toward other residents. His relative stated she had not been able to get through to the facility by phone for several days, could not call Resident #50, and could not reach staff at the facility number after being notified by an anonymous number that he had gone to the hospital and later returned. Resident #30 was a moderately cognitively impaired male with diagnoses including pancreatitis, dysphagia, COPD, and depression. His quarterly MDS showed a BIMS score of 11 and that he needed partial assistance with some ADLs. He reported that a relative had been trying to call the facility several times a day for several weeks without success. In a confidential group interview, 5 residents stated there had been a big issue with the phone lines not working for several weeks, including both outgoing and incoming calls. The Ombudsman also reported receiving a complaint from a family member who could not reach a resident, and surveyor calls to the facility number rang without answer and without a way to leave a message. Staff interviews confirmed the phone problems had been ongoing for about 3 to 4 weeks and that staff were using personal cell phones or an on-call phone to contact residents, relatives, and physicians.
Unsafe Transfers and Unrepaired Room Hazard
Penalty
Summary
The facility failed to ensure adequate supervision and assistive devices were used to prevent accidents for two residents. One deficiency involved a CNA transferring a resident with severe cognitive impairment, a recent right femur fracture, and dependence on two-person assistance without using a gait belt during one observed transfer from the wheelchair to the bed. The resident was described as very unsteady and shaky, and the CNA stated she had been trained on gait belt transfers but had forgotten part of the procedure. During another observed transfer, a gait belt was used, but one CNA placed hands under the resident’s arm while the other placed hands in front of and behind the gait belt, and both CNAs stated they were not supposed to lift residents under the arms because it could cause injury. The resident involved in the transfer observations had an MDS assessment showing severe cognitive impairment, a BIMs score of 4, and dependence on transfers, toileting, and personal hygiene with assistance from two people. The care plan directed extensive two-person assistance for transfers. Staff interviews confirmed the resident had a recent fall and hip fracture and that he sometimes tried to get up without assistance. The DON stated staff were to use gait belts when transferring residents and identified the risk of not following the correct procedure as injury to the resident’s shoulders and arms or a fall. The DOR stated lifting under the arm pits was not acceptable because it increased the risk of falls, fractures, and nerve damage. A second deficiency involved a resident whose windowsill had broken wood and exposed nails across the width of the sill. The resident had severe cognitive impairment, a stroke diagnosis, a seizure disorder, and required substantial assistance with all ADLs. The bed was pushed against the windowsill, and the resident’s arm was observed near the exposed area. During incontinence care, the resident rolled toward the window and placed a hand in the windowsill where the broken wood and exposed nail were located. Staff stated they had not noticed the hazard, and the Maintenance Director and Administrator both stated the windowsill needed immediate repair and posed a risk of injury. A CNA stated the windowsill had been broken for about three months and that she had not reported it because it had been that way when she started working there.
Inadequate Hair Restraints During Meal Preparation
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards when two dietary staff members were observed during lunch meal service with hair restraints that did not fully cover their hair. During the lunch meal preparation and plating process, Dietary [NAME] L had about 2 inches of hair exposed at the back below the restraint and about 1.5 inches of hair exposed on both sides in front. Dietary Aide M was also observed with hair exposed on both sides in front of the ear and a small amount of hair exposed in the back below the restraint while she was placing condiments on plates and silverware and preparing trays for the dining room hall. Both staff members stated they were not aware their hair restraints were not fully covering their hair at the time of the observations. Dietary Aide M stated she had completed a food handler's course and knew hair restraints should fully cover hair during lunch meal service. Dietary [NAME] L stated the restraint must have slipped up and that she knew hair restraints should cover all hair completely. The Dietary Manager stated he expected hair restraints to fully cover all hair for dietary staff and acknowledged he had not recently in-serviced staff on hair restraints. The facility policy on safe food handling stated that anyone working in the kitchen during normal food production hours is expected to wear appropriate hair restraints.
Infection Control Failures During Resident Care and Meal Delivery
Penalty
Summary
The facility failed to maintain infection prevention and control practices during multiple resident care activities and meal tray delivery. During a medication pass, LVN B used a blood pressure cuff, pulse oximeter, and electronic thermometer on a resident with dementia and diabetes, then returned the contaminated equipment to the medication cart without sanitizing it. LVN B stated she was supposed to sanitize the equipment immediately after use and acknowledged that placing it on the cart cross contaminated the cart. During another medication pass, LVN A obtained a resident’s blood pressure, returned the contaminated cuff to the medication cart without sanitizing it, and handled the resident’s medications in a manner that included touching a dropped pill and placing it back into the medication cup. The resident had severe cognitive impairment, coronary artery disease, hypertension, quadriplegia, and received over 51% of total calories through a feeding tube. LVN A also used a piston syringe for g-tube medication administration, dropped it on the floor, rinsed it in the bathroom sink, and returned it for future use. LVN A stated she should have discarded the dropped pill and syringe and acknowledged the actions were cross contamination. The facility also failed to follow enhanced barrier precautions and hand hygiene requirements during direct care. CNA F provided incontinent care to a resident with a urinary catheter and bowel incontinence without performing hand hygiene before entering, without wearing a gown, and without changing gloves or sanitizing hands when moving between tasks and after removing soiled gloves. The resident was severely cognitively impaired and required substantial assistance with activities of daily living. During wound care for another resident with diabetes and viral pneumonia, the Treatment Nurse cleaned a pressure ulcer and applied treatment without changing gloves or performing hand hygiene after the first wound. In addition, CNA I delivered meal trays to residents in the memory care unit and moved from one resident to another without sanitizing or washing hands between tray deliveries. Staff interviews confirmed the expected hand hygiene and PPE practices, and the DON and ADON stated staff were expected to perform hand hygiene before and after care, between glove changes, and between tray deliveries.
Failure to Offer Telephone Participation in Care Plan Meetings
Penalty
Summary
The facility failed to ensure Resident #10’s right to participate in the development and implementation of her person-centered plan of care by not offering her representative the opportunity to join care plan meetings by telephone. Resident #10 was a severely cognitively impaired female with Alzheimer’s disease, coronary artery disease, and epilepsy, and she required substantial to total assistance with activities of daily living. Her face sheet showed she was not her own responsible party and had a representative listed. Record review showed the facility’s care plan conference letters for the past year invited the representative to attend meetings in person or to call if there were issues to discuss, but they did not offer a telephone option for the scheduled care plan meetings. During interview, the representative stated she had been notified of care plan meetings by letter, could not attend in person, and had not been given the opportunity to participate by phone. The social worker confirmed the representative should have been offered the option of phone participation and stated this had not been discussed with her. The DON also stated the representative should have been offered the option of phone participation and that the social worker was responsible for contacting the representative for care plan meetings.
Failure to Care Plan Falls and Pelvic Fracture
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for Resident #3 to address his left pelvic fracture and his falls. Resident #3 was an elderly male admitted and readmitted with dementia, generalized muscle weakness, unsteadiness on feet, repeated falls, and lack of coordination. His admission MDS reflected a BIMS score of 2, indicating severe cognitive impairment. The comprehensive care plan last revised 07/18/25 identified him as at risk for falling related to muscle weakness, decreased cognition, and vision problems, but it did not reflect his actual falls or his left pelvic fracture. Incident and accident reports showed multiple falls in July and August 2025, including a witnessed fall in the dining room with a red area on the mid back, an unwitnessed fall with a laceration to the right forehead and pain to the left leg that resulted in transfer to the hospital, and another unwitnessed fall found beside the bed with no injuries noted. A reportable incident investigation also documented that Resident #3 was found on the floor in his room on 08/06/25, and on 08/08/25 he complained of pain to the middle/left side of his buttocks while transferring to a wheelchair and was sent to the hospital, where x-rays showed a fracture of the left superior/inferior pubic bone. The DON stated she was responsible for ensuring the care plan addressed the falls and fracture and acknowledged she could not find the fracture on the care plan.
Oxygen Concentrator Set Above Ordered Level
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident with COPD by not providing oxygen at the physician-ordered setting. Resident #39, an [AGE]-year-old female admitted on 9/11/24, had diagnoses including COPD, a BIMS score of 14, and was documented as receiving oxygen therapy. Her physician order directed oxygen at 2 liters per minute via nasal cannula every shift, and her care plan directed staff to apply oxygen as ordered. On 9/9/25, the resident was observed asleep with the oxygen concentrator turned on at 3 liters per minute and the oxygen not on her face. Later that day, she was observed awake with oxygen via nasal cannula while the concentrator remained set at 3 liters per minute. On 9/10/25, she was again observed asleep with oxygen via nasal cannula and the concentrator set at 3 liters per minute. During interview and observation, an LVN assigned to the resident stated she could not locate an oxygen order in the electronic record and had to call another LVN to verify the order. The second LVN, who had just started his shift, produced the paper order and stated the resident should have been receiving 2 liters per minute continuously. He read the concentrator setting as 3 liters per minute and adjusted it to 2 liters per minute, stating he did not know why it had been set higher and that the concentrator should have been checked during every shift. Interviews with other nursing leadership confirmed the expectation that the concentrator should match the physician order and be checked every shift for residents on continuous oxygen. The facility policy stated oxygen is administered under physician orders.
Medication Error Rate Exceeded Allowed Threshold
Penalty
Summary
The facility failed to ensure that the medication error rate remained below 5 percent. Surveyors calculated a medication error rate of 6.25 percent, based on 2 errors out of 32 opportunities, involving one of six residents reviewed for medication errors and one of three staff reviewed. The errors involved LVN A, who did not administer Resident #14's Digoxin 250 mcg with Digoxin 125 mcg for the ordered total daily dose of 375 mcg, and did not administer Ergocalciferol 1.25 mg as ordered on the medication pass observed on 09/10/25. Resident #14 was a female admitted on 06/15/18 with severe cognitive impairment, coronary artery disease, hypertension, and quadriplegia. Her physician's orders required Digoxin 250 mcg via G-tube daily with Digoxin 125 mcg to equal 375 mcg, and Ergocalciferol 1.25 mg via G-tube every Wednesday. During the observed G-tube medication pass, LVN A administered Digoxin 125 mcg and other medications but did not administer the Digoxin 250 mcg or Ergocalciferol 1.25 mg. The MAR later showed both medications signed out as given by LVN A, and in interview she acknowledged she had not administered them but had signed them off as administered. The DON stated staff were expected to follow the six rights of medication administration.
Improper Storage of Topical Medication at Bedside
Penalty
Summary
The facility failed to ensure that Resident #7’s Clobetasol Propionate external cream 0.05% was labeled and stored in accordance with professional standards. Resident #7 was a [AGE]-year-old female admitted on 10/22/13 with diagnoses including PTSD, CVA, PVD, and hypertension. Her quarterly MDS reflected a BIMS score of 12, indicating moderate cognitive impairment, and she required supervision with bathing and partial to moderate assistance with personal hygiene and dressing. Her care plan identified psoriasis vulgaris with risk for flare-up, infection, and further skin breakdown, and her physician’s order summary listed Clobetasol Propionate external cream 0.05% to be applied topically every 12 hours as needed, with no order allowing bedside medication storage. During observation, a tube of Clobetasol Propionate cream was found on Resident #7’s overbed table in her room, and it remained there on a later observation. The resident stated she kept the medication at bedside for her psoriasis, was unsure who brought it to her, and did not recall the last time she used it. When interviewed, she stated she could not read the instructions on the box and said she just applied it when needed. The DON stated the resident did not have the capacity to manage her own medications and that medications should not have been left in the room. The DON also stated the risk of leaving medications at the bedside was improper use or access by another resident. The LVN stated she had not left the tube in the room and that medications were not to be stored at bedside. The facility policy required all drugs and biologicals to be stored in locked compartments or under direct observation during administration.
Egg Salad Served at Improper Temperature During Lunch
Penalty
Summary
The facility failed to provide egg salad at an appetizing temperature during lunch service. During a confidential group interview with five residents, residents expressed concerns that food was not being served at the right temperatures. An observation at 11:57 AM showed Dietary staff taking the temperature of pureed egg salad at 51.5 degrees Fahrenheit, and at 12:03 PM the egg salad was 42.3 degrees Fahrenheit. There was no ice under the egg salad containers, and the egg salad sandwiches and pureed egg salad were left on the serving line. Dietary staff did not take the food temperature of the egg salad before plating it, but documented temperatures on the log anyway. At 12:08 PM, Dietary staff began plating food, including egg salad, for residents' lunch plates in the dining room. A lunch test tray later showed the last hall resident meal tray served on Hall 3, and the egg salad on the test tray was slightly warm to the touch and tasted warm. In interview, Dietary staff stated she was not trained on the required food temperatures or what to do if temperatures were not cold or hot enough, and said she had placed the egg salad on slider buns and refrigerated them about an hour before serving. The Dietary Manager stated egg salad should be served at 41 degrees Fahrenheit or below, and the food temperature log reflected the regular entree at 42.3 F and the pureed entree at 51.3 F.
Failure to Follow Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program for two residents observed for infection control. For one resident with a history of septicemia, paraplegia, pressure ulcers, and a Foley catheter, a registered nurse did not use the required personal protective equipment (PPE) during wound care. Although Enhanced Barrier Precautions (EBP) signage was posted, there was no PPE available outside or inside the room. The nurse performed hand hygiene and wore gloves but did not don a gown as required for residents with wounds and indwelling devices. The nurse acknowledged the omission and attributed it to the absence of PPE supplies at the point of care. In a separate incident, an agency certified nursing assistant (CNA) failed to perform proper hand hygiene while providing incontinence care to another resident with severe cognitive impairment and total dependence on staff for toileting. The CNA changed gloves multiple times during the care process without performing hand hygiene between glove changes, contrary to facility policy and training. The CNA acknowledged the lapse and recognized the importance of proper hand hygiene in preventing infection. Facility policies reviewed indicated that Enhanced Barrier Precautions require the use of gowns and gloves for residents with wounds or indwelling medical devices, and that PPE should be readily available outside the resident's room. The hand hygiene policy requires staff to perform hand hygiene before and after resident contact, after glove removal, and after contact with soiled items. Both incidents were confirmed through observation, staff interviews, and record review.
Facility Fails to Maintain Sanitary Environment, Leading to Pest Infestations
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for its residents, leading to unsanitary conditions and pest infestations. Observations revealed that several resident rooms, including those of residents with severe cognitive impairments and those dependent on feeding tubes, were infested with ants, gnats, and flies. These pests were attracted by food debris and spills that were not cleaned up, as evidenced by the presence of feeding formula stains on G-tube poles and floors. In one severe case, a resident suffered 102 ant bites due to ants crawling on her body and bed linens, highlighting the facility's failure to provide adequate housekeeping and maintenance services. Interviews with staff and residents indicated a lack of clarity and responsibility regarding cleaning duties. Staff members, including CNAs and nurses, were unsure of who was responsible for cleaning spills and maintaining sanitary conditions in resident rooms. Housekeeping staff acknowledged the presence of pests and the need for more thorough cleaning but cited challenges such as residents hoarding items and the need for stronger cleaning supplies. Additionally, pest control services noted ongoing issues with sanitation and cleanliness, which hindered their ability to effectively address pest problems. The facility's failure to address these issues was further compounded by inadequate communication and follow-up on grievances related to housekeeping. Residents expressed concerns about the lack of cleaning on weekends and the unsanitary conditions in common areas and dining rooms. Despite these complaints, there was no evidence of timely or effective action taken to resolve the issues, resulting in a continued risk of harm to residents due to the unsanitary environment.
Pest Control Deficiency in LTC Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in multiple incidents of pest infestations affecting residents and their living environments. One resident suffered 102 ant bites on various parts of her body, including her chest, neck, shoulder, and arm. The resident, who had severe cognitive impairment and was unable to communicate, was found with ants crawling on her body and bed linens. The room was noted to have G-tube feeding formula spots on the floor and equipment, which were not cleaned, potentially attracting the ants. Despite family members reporting the presence of ants and requesting cleaning, the facility staff did not adequately address the issue. In addition to the ant infestation, other residents' rooms and common areas were found to have pest issues, including gnats, flies, and ants. One resident's room was cluttered and had a strong smell of urine, with gnats swarming around. The resident was known to hoard food and trash, contributing to the pest problem. Another resident's room had flies and gnats, with a sticky residue and food crumbs attracting the pests. The facility's dining room and common areas were also noted to have food residue and crumbs, with residents expressing concerns about the cleanliness and presence of pests. The facility's maintenance and housekeeping staff were aware of the pest issues but failed to take effective action to prevent and control the infestations. The Maintenance Director acknowledged the presence of ants but downplayed their significance, while housekeeping staff were aware of the pest problems but did not consistently clean affected areas. The facility's administration was notified of the pest issues but did not implement adequate measures to address the underlying causes, such as ensuring proper cleaning and maintenance of resident rooms and common areas.
Food Safety and Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in its only kitchen, leading to several deficiencies. Observations revealed significant ice accumulation inside a chest freezer containing turkeys and frozen popsicles, which the Dietary Manager was unaware of due to infrequent checks. Additionally, one of the freezers contained pizza crusts in an unlabeled, undated, and unsealed plastic bag with ice inside, indicating a lack of proper food storage practices. The Dietary Manager acknowledged these lapses, admitting uncertainty about when the pizza crusts were placed in the freezer. Further observations identified the presence of gnats and flies in the kitchen and dry storage areas, with insects landing on counters and near the garbage disposal. The Dietary Manager confirmed awareness of the pest issue, attributing it to warmer weather and open doors during meal times. Additionally, the steam table was observed to be dripping, with containers placed underneath to catch the water. The Dietary Manager noted that the steam table had been leaking for weeks, and although some repairs had been made, parts were still awaited to fully resolve the issue. The Executive Director was unaware of the steam table problem until informed during the survey.
Failure to Conduct Required Background Checks
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation by not conducting required background screenings for seven employees. These employees included the Activity Director, two Licensed Vocational Nurses (LVNs), and four Certified Nursing Assistants (CNAs). The facility's policy mandates pre-employment background screening and annual checks through the Employee Misconduct Registry (EMR) and Nurse Aide Registry (NAR) to ensure that no individual with a history of abuse, neglect, exploitation, or related misconduct is employed. However, the records revealed that these checks were not performed for the specified employees, potentially placing residents at risk. Interviews with the Human Resources personnel and the Interim Administrator highlighted a lack of awareness and responsibility regarding the execution of these checks. The Human Resources representative, who was new to the facility, was unaware of the EMR and NAR requirements and assumed that the Administrator or the corporation handled these checks. The Interim Administrator expected that these checks were conducted before hiring and annually thereafter, with Human Resources being responsible for ensuring compliance. The failure to perform these checks was confirmed when the facility completed the EMR/NAR checks on a later date, finding no bars to employment or license restrictions for the employees in question.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to ensure that comprehensive care plans were developed and implemented for two residents, which led to deficiencies in addressing their physical, mental, and psychosocial needs. For one resident, the care plan did not include necessary interventions for activities of daily living (ADLs), bowel incontinence, and urinary catheter care. This resident, who had a moderately impaired cognition, required substantial assistance with toileting and was dependent on others for bathing. Despite these needs, the care plan lacked specific interventions, which was confirmed by the MDS Coordinator during an interview. Another resident's care plan failed to address bilateral hand contractures and the necessary interventions to maintain skin integrity. This resident was severely cognitively impaired and had a history of stroke and malnutrition. Observations revealed that the resident's hands were contracted without any supportive devices in place, and attempts to use such devices in the past had caused pain. The MDS Coordinator acknowledged that contractures should have been care planned, and the Director of Nursing admitted that care plans were not comprehensive and had not been updated to reflect current needs. The facility's policy on care planning emphasized the importance of developing person-centered care plans that meet professional standards and address changes in residents' clinical status. However, the failure to include specific interventions in the care plans for these residents indicates a lapse in adhering to this policy. The lack of comprehensive care plans could potentially affect the quality of care provided to the residents, as staff may not be aware of the necessary interventions to address their needs.
Failure to Provide Adequate ADL Care for Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs) for three residents, leading to deficiencies in personal hygiene, grooming, and overall care. Resident #41, a female with moderate cognitive impairment and multiple health issues, did not receive scheduled showers or adequate bed baths. Despite being scheduled for showers three times a week, documentation showed only two showers over a two-month period. Interviews revealed a lack of communication and documentation regarding the resident's refusal of care, with staff failing to notify the charge nurse or document refusals properly. Resident #44, a male with cognitive intactness and severe health conditions including stage 4 pressure ulcers, also did not receive adequate bathing and grooming. Despite being scheduled for showers three times a week, records indicated no showers were provided for several days, and the resident was observed with unshaven facial hair and dirty nails. The lack of proper hygiene care was confirmed by staff interviews, which highlighted issues with documentation and adherence to the shower schedule. Resident #47, a female with moderate cognitive impairment and frequent incontinence, did not receive scheduled showers, resulting in poor personal hygiene. Observations noted long facial hair and dirty nails, with the resident expressing a desire for regular showers. Staff interviews revealed confusion about the shower schedule and a lack of proper documentation, contributing to the failure to provide necessary care. The facility's policy on ADLs was not followed, leading to deficiencies in maintaining residents' hygiene and dignity.
Failure to Provide Individualized Activities for Residents
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to the preferences and needs of residents, specifically for three residents with cognitive impairments. Resident #10, a female with severe cognitive impairment and a history of dementia, heart failure, and major depressive disorder, expressed a desire for activities such as reading, music, and outdoor activities. However, she reported feeling bored and unaware of the Activity Director, indicating a lack of engagement in her preferred activities. Observations confirmed that she spent much of her time in her room without meaningful activities. Resident #12, with moderate cognitive impairment and diagnoses including major depressive disorder and Alzheimer's disease, expressed a preference for being around animals, group activities, and going outside. Despite these preferences, she was often observed upset and crying, with staff redirecting her rather than engaging her in meaningful activities. The Activity Director and staff acknowledged that smoking was her primary activity, and she required frequent redirection, but there was no evidence of her participation in other preferred activities. Resident #43, with severe cognitive impairment and a history of depression and bipolar disorder, also expressed a desire for group activities and outdoor time. Observations showed she was often confused and upset, with staff focusing on taking her outside for smoking breaks. The Activity Director admitted to not having completed all resident assessments and lacked experience in providing activities for residents with dementia. The facility's activity policy emphasized the importance of personalized activities, but the implementation was insufficient, as evidenced by the lack of meaningful engagement for these residents.
Improper Drug Labeling and Storage in LTC Facility
Penalty
Summary
The facility failed to ensure proper labeling and storage of drugs and biologicals for three residents and in the medication room. Resident #44 had a bottle of Dakin's Solution, a bleach-based wound cleanser, stored improperly on his chest of drawers. There was no physician's order for the use of Dakin's Solution in his wound care, and it was not included in the treatment supplies prepared by the DON during a wound care observation. Resident #44 was a cognitively intact male with multiple health issues, including stage 4 pressure ulcers, and required substantial assistance with daily activities. Resident #47, a moderately cognitively impaired female, had a bottle of antifungal powder on her chest of drawers without a physician's order. She stated she was using it for a rash, but did not know who provided it. LVN A confirmed that medications require an order and should not be kept at the resident's bedside. Resident #47 had a history of multiple medications and required assistance with personal hygiene and dressing. Resident #30's blister pack for sevelamer carbonate was not labeled with the correct dosage. The blister pack indicated three tablets three times a day, but the order had changed to two tablets three times a day. This discrepancy was noted by LVN A and Agency LVN C, who placed a change in order sticker on the blister pack. Additionally, the medication room contained expired medications, including flu vaccines and bisacodyl suppositories, which were available for use. LVN B acknowledged the responsibility to check for expired medications, and the DON emphasized the importance of proper medication storage and labeling to prevent errors.
Infection Control Deficiencies in Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during care for two residents. For Resident #41, the facility did not ensure that LVN B performed proper hand hygiene during wound care. LVN B was observed removing gloves and putting on new ones without washing hands or using hand sanitizer, which is a critical step in preventing infection. Additionally, LVN B improperly handled multi-use dressing supplies by taking the entire packet into the resident's room, cutting a piece for use, and then returning the packet to the treatment cart without sanitizing the scissors used, risking cross-contamination. Resident #6 also experienced lapses in infection control practices. Agency CNA E did not wear appropriate personal protective equipment (PPE) during incontinence care, failing to don a gown despite the resident being on enhanced barrier precautions due to wounds. CNA E also neglected hand hygiene protocols, such as changing gloves and washing hands when transitioning from dirty to clean tasks. This included handling soiled gloves to open drawers and leaving the room without performing hand hygiene, which could lead to the spread of infections. Interviews with staff revealed a lack of adherence to infection control policies. LVN B acknowledged the importance of sanitizing equipment and performing hand hygiene but admitted to forgetting these steps. Agency CNA E was unaware of the enhanced barrier precautions and the requirement to wear a gown, indicating a gap in training and communication. The Assistant Director of Nursing (ADON) confirmed the importance of infection control and stated that staff were expected to follow hand hygiene protocols, but acknowledged ongoing re-education efforts. The facility's policies on hand hygiene and equipment use were not consistently followed, contributing to the deficiencies observed.
Failure to Provide Hearing Assistance for Resident
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices for a resident with hearing impairment. The resident, an elderly male with a history of visual loss, chronic obstructive pulmonary disease, adult failure to thrive, and conductive hearing loss, was not assessed for his hearing loss nor provided with any amplification device. His quarterly MDS assessment indicated moderate cognitive impairment and minimal hearing difficulty in some environments, yet his care plan did not address his hearing loss. During an observation, the resident was unable to understand instructions during a transfer due to his hearing impairment, resulting in discomfort. Interviews with facility staff revealed that attempts to secure hearing aids for the resident were unsuccessful, as the social worker had not found a provider accepting Medicaid and had not pursued alternative solutions such as an amplifier or a referral to an ENT specialist. The Assistant Director of Nursing confirmed the resident had not been evaluated for hearing aids. The Interim Administrator acknowledged the need for timely evaluation and intervention for residents with hearing loss, noting the potential for increased confusion and isolation. The facility's policy emphasized the importance of assisting residents with medical, vision, hearing, and dental care, but this was not adhered to in the resident's case.
Failure to Use Gait Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and use of assistance devices during resident transfers, specifically for Resident #13. The resident, a male with visual loss, chronic obstructive pulmonary disease, adult failure to thrive, and conductive hearing loss, required substantial assistance with transfers. During an observation, NA J attempted to transfer Resident #13 from his wheelchair to the bed without using a gait belt, which is against the facility's policy. The resident was unable to assist in the transfer and expressed discomfort during the process. NA J lifted the resident by his armpits and pants, which is not an approved method, and left the resident improperly positioned on the bed, requiring additional assistance to reposition him. The facility's policy mandates the use of gait belts for transfers, but NA J, who was working PRN and had not been in the facility for over two weeks, did not adhere to this policy. Interviews revealed that NA J was aware of the requirement to use a gait belt and the potential risks of not using one. The facility's Director of Rehabilitation acknowledged that the system for training new hires on gait belt use had lapsed due to increased use of agency staff. The facility's policy on gait belts, revised in March 2019, clearly states that gait belts must be used when residents require physical assistance for ambulation or transfers.
Inadequate Catheter and Incontinence Care
Penalty
Summary
The facility failed to provide appropriate care for a resident who was incontinent of bladder, leading to potential risks of urinary tract infections. During an observation, a CNA placed the resident's indwelling Foley catheter drainage bag on the bed, which is against proper protocol as it should be kept below the bladder to prevent backflow of urine and potential infection. Additionally, the CNA did not perform hand hygiene after removing gloves during the resident's incontinent care, which could lead to cross-contamination and increased risk of infection. The resident involved was a female with a moderately impaired cognition, requiring substantial assistance with toileting, and had an indwelling catheter. The resident's care plan did not include specific instructions for activities of daily living, bowel incontinence, or urinary catheter care. Interviews with the CNA and LVN revealed awareness of the proper procedures, yet these were not followed during the care observed. The facility's nursing book also emphasized the importance of keeping the drainage bag below the bladder to prevent catheter-associated urinary tract infections.
Failure to Follow G-Tube Water Flush Protocol
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for a resident with a feeding tube. Specifically, the staff did not follow the physician's orders for water flushes before and after medication administration via the G-tube for a resident. The resident, a severely cognitively impaired female, was dependent on all activities of daily living and received more than half of her total calories through a feeding tube. The physician's orders required flushing the G-tube with 60 ml of water before and after medication administration, but this was not adhered to during an observed medication pass. During the observation, an agency LVN administered medications to the resident through the G-tube but only flushed the tube with 30 ml of water before and after the medication administration, contrary to the prescribed 60 ml. The LVN admitted to not reviewing the physician's orders prior to administering the medication and assumed 30 ml was the standard flush amount. This failure to follow the prescribed water flush protocol could lead to tube obstruction and decreased hydration for the resident. The facility's policy and procedures, as well as the staff education/orientation policies, were not followed in this instance.
Failure to Complete Post-Dialysis Assessments
Penalty
Summary
The facility failed to ensure that residents requiring dialysis received services consistent with professional standards of practice. Specifically, the facility did not review and complete post-dialysis communication sheets for a resident who was dependent on renal dialysis. The resident, a cognitively intact male with type 2 diabetes mellitus and chronic kidney disease, was receiving dialysis three times a week. Despite having a care plan and physician's orders in place, the facility did not complete the necessary post-dialysis assessments on multiple occasions in July and August. Interviews revealed that agency staff, who were not adequately oriented to the facility's procedures, were responsible for the missing documentation. The Assistant Director of Nursing (ADON) confirmed that the missing assessments were due to agency staff not being informed about the requirement to complete post-dialysis communication forms. This oversight in staff orientation led to a lack of monitoring and documentation, which could potentially place residents at risk of inadequate post-dialysis care.
What surveyors are citing around you — mapped
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Illustrative
What surveyors actually found near you
We read the 92 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Denison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Homestead Of Denison | 0.3 mi | ★★★★★ | 9 | 0 |
| Woodlands Place Rehabilitation Suites | 1.3 mi | ★★★★★ | 14 | 0 |
| Denison Nursing And Rehab | 2.2 mi | ★★★★★ | 3 | 0 |
| Beacon Hill | 3.3 mi | ★★★★★ | 10 | 0 |
| Southern Pointe Living Center | 6.4 mi | ★★★★★ | 4 | 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.