The Homestead of Denison

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA A, CNA B, and RN C used the required PPE for Resident #1, who was on EBP due to his tube feeding, foley catheter, and open wound, while performing wound care on 07/19/26. This failure could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #4 and Resident #54) of 5 residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #4's care plan reflected changes with oxygen being continuous to PRN and failed to reflect Resident #4's non-compliance with wearing her oxygen.2. The facility failed to ensure Resident #54's care plan reflected Resident #54 changing the oxygen settings from the physician's ordered 4lpm. This failure could put Residents at risk of receiving unnecessary treatments, not receiving care or services and further decline of their physical health. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who needed respiratory care were provided with such care, consistent with professional standards of practice and the comprehensive person-centered care plan, for two of four residents (Resident #4 and #54) reviewed for quality of care. The facility failed to ensure the supplemental oxygen was provided at the physician ordered rate for Residents #4 and #54. This failure could place residents who received oxygen therapy at risk of oxygen toxicity.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in that: The facility dietary staff failed to ensure temperatures were taken of all hot and cold foods before serving them to residents during lunch meal service on 3/24/26. The facility dietary staff failed to ensure the potato salad was at the proper holding temperature for lunch service on 3/24/26. The facility dietary staff failed to ensure all seasonings used for food preparation were not past the used by date. 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 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 (Resident #2) of 5 residents reviewed for ADLs. The facility failed to ensure Resident #2 had his fingernails trimmed on both hands on 03/24/2026. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life. Record Review of Resident #2's Quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male with initial admission date of 11/20/2020 to the facility. His pertinent diagnoses 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 (Med Cart Hall 400) of 2 medication carts reviewed for pharmacy services in that: The facility failed to ensure LVN F responsible for Nurses Cart Hall 400, removed medications in unsecure containers from the Nurses Cart. This failure could affect residents resulting in diminished effectiveness, and not receiving the therapeutic benefits of the medications, and place residents at risk of not having the medication available due to possible drug diversion. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 resident (Resident #71) of 3 observed for infection control. The facility failed to ensure CNA D changed gloves and completed hand hygiene during incontinent care for Resident #71 on 3/25/26. These failures could place residents at risk for infection and cross contamination of pathogens and illness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for one of seven residents (Resident #1) reviewed for abuse. The facility failed to protect Resident #1 from physical abuse by CNA A on 03/30/25, which resulted in Resident #1 sustaining a head injury and contusion to her forehead. The noncompliance was identified as Past Noncompliance IJ. The noncompliance began on 03/30/25 at 6:40 p.m. and ended on 03/31/25. The facility had corrected the noncompliance before the incident investigation began on 07/15/2025. This failure could place residents at risk of serious abuse, injury and harm.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, 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 and freezer were dated or labeled. 2. The facility failed to use proper hand hygiene while handling and serving food to the residents. 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. Findings Include: Observation of refrigerator 1 and interview with Dietary Manager on 12/10/24 revealed: At 8:40am an 8oz Cool Whip container with no open date or date received. At 8:46am an 46oz container of Ready Care thickened sweetened tea with about 2 ounces left dated 10/31/24. [...]

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 #9) of 6 residents reviewed for ADL's. The facility failed to ensure Resident #9 had her fingernails trimmed and cleaned. These failures 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 provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for 2 medication carts (Nurses medication cart Hall 600, and Nurses medication cart 300/400 halls) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure medications in unsecured containers were immediately removed from stock. These failures 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: Record review and observation on 12/10/24 at 10:34 AM of the Nurses Medication Cart Hall 600, with LVN D revealed the blister pack for Resident #12's acetaminophen codeine. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure quality of laboratory services to meet applicable requirements for laboratories by using expired glucometer control solution for 1 medication cart (Nurses medication cart Hall 600) of 3 medication carts reviewed for pharmacy services. The facility failed to ensure an expired glucose control solutions (a liquid used to test the accuracy of a blood glucose meter and test strips) was removed from the nurses medication cart hall 600. This failure could affect diabetic residents resulting in diminished effectiveness, and not receiving the correct reading of the blood glucose level.

Inspectors wroteBased on interview and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices for one of twenty-four residents (Resident #165) reviewed for medical records. LVN F and RT G failed to document physician notification about the Resident #165's trach dislodgement and change of condition on [DATE]. The noncompliance was identified as PNC from [DATE] to [DATE]. The facility had corrected the noncompliance before the survey began on [DATE]. This failure placed residents at risk for inaccurate medical records.

Inspectors wroteBased on interview and record review, the facility failed to ensure the QAA committee developed and implemented appropriate plans of action to correct identified quality deficiencies for change of condition concerns. The QAA committee failed to discuss and review Resident #165's change of condition after Resident #165 expired at the facility on [DATE] to determine any quality deficiencies at QAPI meeting in [DATE]. This failure could place residents at risk of quality of care concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 8 residents (Resident #54) reviewed for infection control. The facility failed to ensure LVN D used the required PPE for Resident #54, who was on enhanced barrier precautions due to his tube feeding and foley catheter, while administering resident medication through tube feeding on 12/10/24. This failure could place the resident at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two of 12 residents (Resident #1 and Resident #2) observed for infection control. 1. The facility failed to ensure that CNA A changed her gloves and performed hand hygiene while providing incontinence care to Resident #1 and transport dirty linens in a plastic bag on 11/05/24. 2. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinence care to Resident #2 and remove her gloves before leaving the room on 11/06/24. These failures could place the residents at risk of cross-contamination and development of infection.

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 and establish policies and procedures to investigate any such allegations for one of seven residents (Resident #1) reviewed for abuse and neglect. The facility failed to follow their policy for abuse and neglect by not reporting an allegation of abuse within 2 hours when Resident #1 alleged his spouse caused him to be sick on 11/24/23. This failure could place residents at risk for not having their allegations of abuse and neglect investigated.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services were state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one of seven residents (Resident #1) reviewed for abuse and neglect. [...]

Inspectors wroteBased on interview and record review the facility failed to have physician orders for the resident's immediate care, at the time each resident was admitted for one of three residents (Resident #1) reviewed for admission Physician Orders. 1. The facility failed to have Physician orders to check residual prior to medication administration. 2. The facility failed to have physician ordered which indicated the proper use of Resident #1's Gastrojejunostomy tube for feeding and medication administration upon his admission to the facility on [DATE]. These failures could place residents at risk of nausea, vomiting and diarrhea.

Inspectors wroteBased on interview, and record review the facility failed to ensure the resident environment was free of accidents and hazards as was possible for one resident (Resident #33) of four residents reviewed for accidents and hazards, in that: CNA A, CNA B, CNA C and LVN D failed to lift Resident #33 with a mechanical lift twice on 01/05/23, which resulted in the resident having a broken leg. The noncompliance was identified as PNC. The IJ began on 01/05/23, and ended on 07/26/23. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of severe injury.

Inspectors wroteBased on interview, and record review the facility failed to ensure a Registered Nurse was on duty in the facility for a minimum of eight consecutive hours a day, seven days a week, for five (05/13/23, 05/27/23, 05/28/23, 06/24/23, and 06/25/23) of 90 days reviewed. The facility failed to have RN coverage on 05/13/23, 05/27/23, 05/28/23, 06/24/23, and 06/25/23. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care. Review of the CMS PBJ Staffing Data Report, a report reflecting data self-reported to CMS by the facility, dated 11/01/23, reflected the facility had not reported RN coverage hours for 05/13/23, 05/27/23, 05/28/23, 06/24/23, and 06/25/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for two (Medication Room A and B) of two medication rooms reviewed for medication storage. The facility failed to store or dispose of medications no longer in use. This failure places residents at risk for incorrect administration of medications due to medications not being stored/disposed of appropriately.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the facility's only kitchen reviewed for kitchen sanitation. The facility failed to properly close an opened and partially used shelf stable food item. This failure could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for two (Medication Rooms A and B) of two medication rooms reviewed for environment. Facility failed to maintain storage and preparation areas in a clean, safe, and sanitary manner in medications room A and medication room B. This failure places facility staff to not follow proper infection prevention practices for hand washing and cross contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for two of (Halls 300 and 400) of six halls. The facility failed to keep the environment free of flies and gnats. This failure could affect by placing them at risk for the potential spread of infection, food-borne illness, bites, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide one of ten residents (Resident #63) food in a form to meet their needs. The facility failed to process the pureed diet for a correct, pudding-like consistency for Resident #63. This failure could place residents at risk of dietary and nutritional needs not being met.

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 one of 14 residents (Resident #28) reviewed for resident call system. The facility failed to ensure Resident #28 had an accessible and working call light. This failure could place residents in the facility at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care, in a manner and in an environment that promotes the maintenance or enhancement of their quality of life, recognizing each resident's individuality. The facility failed to protect and promote the rights of the resident for 1 (Resident #2) of 6 residents observed for dignity. The facility failed to ensure Agency CNA B provided Resident #1 with privacy during a bed bath and brief change. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth.