Denison Nursing and Rehab

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet the resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident #1) reviewed for care plans in that:The facility failed to include interventions for ADLs in Resident #1's care plan. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #1) reviewed for personal hygiene. The facility failed to provide Resident #1 with scheduled showers between 03/24/2026 and 04/28/2026. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections. [...]

Inspectors wroteBased on interview and record review the facility failed to promptly notify the ordering physician regarding laboratory results outside of clinical reference range for 1 of 3 residents (Resident #1) reviewed for laboratory services. The facility did not ensure the physician was promptly notified when Resident #1's urinalysis results completed on 01/29/26 indicated a urinary tract infection, resulting in a delay in treatment until 02/04/26. This failure could place residents at risk of not receiving lab services as ordered and not providing timely treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for three of four quarters for 2025 (Quarters 1, 2, and 3) reviewed for sufficient nursing staff. Based on observation, interview, and record review, the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, for three of four quarters for 2025 (Quarters 1, 2, and 3) reviewed for sufficient nursing staff. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 28 days out of 365 days reviewed. Based on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 28 days out of 365 days reviewed. The facility failed to have an RN for 8 consecutive hours 7 days a week for 28 days out of 365 days reviewed from April 1, 2024 through March 31, 2025. These failures could place all residents at risk for their clinical needs not being met.

Inspectors wroteBased on record review and interviews, the facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for its residents competently during day-to-day operations and review and update the assessment at least annually for 1 of 1 facility reviewed annual assessment. Based on record review and interviews, the facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for its residents competently during day-to-day operations and review and update the assessment at least annually for 1 of 1 facility reviewed annual assessment. The facility did not have a completed Facility Assessment. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for 1 of 1 reviewed for resident council meeting. Based on observation, interview, and record review the facility failed to provide a resident or family group, if one exists, with private space; and take reasonable steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for 1 of 1 resident groups reviewed for resident council meeting. The facility failed to provide a private space for resident council meetings. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #3 and Resident #16) of 3 residents reviewed for infection control. Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 (Resident #3 and Resident #16) of 3 residents reviewed for infection control. The facility failed to ensure LVN B disinfected the blood pressure cuff in between blood pressure checks for Residents #3 and #16. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #2 and Resident #24) of 6 residents reviewed for ADLs. Based on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #2 and Resident #24) of 6 residents reviewed for ADLs. The facility failed to ensure: - Resident #2 had her fingernails cleaned and trimmed on 6/30/25. - Resident #24 had her fingernails trimmed 6/30/25. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #22) of one resident reviewed for catheter care. Based on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #22) of one resident reviewed for catheter care. The facility failed to ensure Resident #22 had a physician's order for a Foley catheter on 06/30/25. This failure could place residents at risk for the development and/or worsening of urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 (Women's Hall Medication Cart and Men's Hall Medication Cart) of 3 carts reviewed for pharmacy services. The facility failed to ensure:- the Men's Hall Medication Cart did not have 1 insulin pen for Resident #22 with an expired open date and 1 insulin pen for Resident #10 with an expired open date. - LVN E responsible for Women's Hall Medication Cart, counted controlled drugs every shift change. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. Based on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen. 1. The facility failed to date 11 bags of broccoli stored in the original packages in the freezer. This failure could place residents who at risk for food-borne illness and food contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment for residents, staff, and the public for one (oxygen room) of one oxygen room and one (CNA room) of one CNA room observed for oxygen storage safety. The facility failed to securely store oxygen cylinders in the facility's only oxygen room and only CNA room on 06/06/25. These failures could affect the residents by placing them at risk of injury due to oxygen cylinders becoming unsecured and becoming a hazard.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one of two (Resident #1) residents reviewed for elopement: The facility failed to prevent Resident #1's elopement through a window in an unoccupied room on [DATE] which resulted in resident being found two houses from the facility and facility staff being unaware that he had eloped. These failures resulted in an Immediate Jeopardy (IJ) on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no harm with a scope identified as isolated. These failures negatively affected the residents and placed all residents at risk of injury or harm by not having a safe and secure facility.

Inspectors wroteBased on observation and interview, the facility failed to post the Health and Human Services Commission (HHHSC) complaint number and a statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of a state or federal regulation, including but not limited to resident abuse, neglect, exploitation, and misappropriation of property for 1 of 7 mandatory postings. The facility failed on 05/14/2025 to ensure the required posting (signage) of a HHSC complaint number and statement about how a resident may file a complaint with the State Survey agency. This failure placed residents at risk of being unaware of who and how to contact the State Survey Agency and their right to file a complaint with the State Service Agency concerning any suspected violation of state or federal regulation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-center plan that includes services that are furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for one of twenty-eight ( Resident #2) reviewed for care plans. The facility failed to update Resident #2's care plan to reflect elopement risk. These failures could affect residents by placing them at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 1 resident whose care plan was reviewed, in that: The facility failed to develop a comprehensive care plan for Resident #1. This failure could place residents at risk of receiving inadequate individualized care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #2) of 1 resident reviewed for ADL's. The facility failed to ensure Resident#2 had his fingernails trimmed and cleaned. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 1 Resident (Resident#1) reviewed for pharmacy services. The facility failed to ensure Resident#1 did not have his morning medications (Allopurinol, Aspirin, Glimepiride, Isosorbide, metoprolol, Nifedipine, Plavix, Potassium, Torsemide, Calcium Carbonate -Vit D with min, and Gabapentin) left on the bedside table on 04/10/25. These failures could place residents at risk of medication misuse, not receiving physician ordered medications which could result in non-therapeutic treatments or injuries. Findings Included: Record review of Resident # 1's face sheet dated 04/10/25 reflected a [AGE] year-old male with an admission date of 02/25/25. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for two (CNA C and the DON) of five employees reviewed for abuse and neglect. 1. The facility failed to conduct CNA C's Employee Misconduct Registry (EMR)/Nurse Aide Registry (NAR) check annually. 2. The facility failed to conduct the DON's Employee Misconduct Registry (EMR)/Nurse Aide Registry (NAR) check upon hire. These failures could place residents at risk for abuse and receiving care from unemployable staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents whose care plans were reviewed, in that: The facility failed to revise Resident #1's care plan to accurately reflected current tube feeding status as of 02/27/25. These failures could place residents at risk of receiving inadequate individualized care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident who was fed by gastrostomy tube received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #1) of one resident reviewed for gastrostomy tube feedings. LVN A failed to transcribe Resident #1's bolus feeding order upon hospital return on 02/27/25. This failure could place residents who received gastrostomy tube feedings at risk for not receiving the intended therapeutic benefit as ordered.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for one (cart E, cart for rooms 124-143) of two medication carts reviewed. LVN A failed to lock medication cart E (cart for rooms 124-143) on 03/04/25. This failure could place residents at risk for possible drug diversions.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: 1. The facility failed to ensure food items in the facility refrigerator, freezer and dry storage were dated or labeled. 2. The facility failed to ensure [NAME] B used sterile technique during lunch meal service on 5/14/24. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness if consumed, and food contamination.

Inspectors wroteBased on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 3 of 7 days reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 5/4/2024, 5/5/2024, 5/11/2024 in May 2024. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Nurses' Medication Cart Hall 100) of 2 carts reviewed for pharmacy services. The facility failed to ensure LVN G, who was responsible for Nurses' Medication Cart Hall 100, counted controlled drugs every shift change. This failure could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 medication room of 1 reviewed for pharmacy services in that: The facility failed to ensure the medication room did not have 11 expired COVID-19 Antigen self-tests for infection detection. This failure could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to prevent the development and transmission of infection for one of two residents (Resident #7) observed for infection control. Facility failed to ensure CNA A performed hand hygiene while providing incontinence care to Resident # 7. This failure could place the residents at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure appropriate discharge information was documented in the medical record by the physician for one (Resident #1) of two residents reviewed for discharges. The facility failed to ensure documentation was made by the physician for the basis of Resident #1's discharge and/or the specific resident needs that could not be met by the facility. This failure could place residents at risk of being discharged without a safe and effective transition of care, an accurate reason for discharge and inaccurate information communicated to the receiving health care institution or provider.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for five (Resident Rooms 150, 151, 152, 153 and 154) of 19 residents' rooms reviewed for resident call system in that: The facility failed to ensure Resident Rooms 150, 151, 152, 153 and 154 call lights were working properly. This failure could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observations, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #4) of 16 residents reviewed for comprehensive care plans. The facility failed to develop Resident #4's care plan for his preference to bathe himself. This failure placed residents at risk of not receiving individualized care and services to meet their needs.