Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 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.
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.
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 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 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.
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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) |
|---|---|---|---|---|
| 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 | — | 8 | 0 |
| Southern Pointe Living Center | 6.4 mi | — | 4 | 0 |
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