Denison Care Center

In the surveyor’s words

From the most serious findings on record at Denison Care Center, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 20, 2026

  Based on clinical record review, facility investigation review, personnel file review and staff interviews, the facility failed to provide adequate assistance to a resident to prevent a fall that resulted in a fracture for 1 of 3 residents reviewed (Residents #3) and failed to reeducate the staff after a resident had a suicide attempt for 1 of 1 residents reviewed (Resident #14). The facility reported a total census of 30 residents. Findings include: 1. The Minimum Data Set (MDS) assessment dated [DATE] for Resident #3 documented diagnoses of vitamin D deficiency, disorientation and malnutrition. […]

• Actual harm, isolatedF689Oct 23, 2025

  Based on clinical record review, facility policy review, and staff interviews, the facility failed to provide adequate nursing supervision for 1 of 3 residents (Resident #1) reviewed. A non-ambulatory resident with a history of attempting to self-transfer, fell when left unsupervised in the dining room, which resulted in a head injury, nasal fractures and cervical fractures. The facility reported a census of 28. Findings include:Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 with a Brief Interview for Mental Status (BIMS) score of 6 out of 15, which indicated a severe cognitive impairment. The MDS list of diagnoses included non-Alzheimer's dementia, diabetes mellitus and paroxysmal atrial fibrillation (irregular heart rhythm). […]

• No harm, potential for more than minimal, patternF812May 24, 2023

  Based on observation, policy review, and staff interviews the facility failed to follow proper sanitation and food handling practices to prevent the outbreak of foodborne illness. The facility reported a census of 33 residents. Findings include: An initial tour of the kitchen on 5/21/23 at 10:15 AM revealed the following: a. Freezer #3 contained - no thermometer to check its temperature. - an unlabeled and undated bag of frozen pink meat that looked freezer burnt. - an unlabeled, unsealed, and undated bag of frozen strawberries. - an undated frozen ham that appeared freezer burnt b. […]

• No harm, potential for more than minimal, patternF812Dec 22, 2021

  Based on observation, staff interviews, and record reviews, the facility failed to ensure food was stored and prepared under sanitary conditions. The facility failed to ensure appropriate temperatures while washing dishes in the dishwasher to efficiently clean dishes that the residents and staff use for meals. The facility reported a census of 30 residents. Findings include: 1. On 12/20/21 at 9:58 AM noted a white liquid on the salsa bottle in the refrigerator. On 12/20/21 at 11:30 AM Staff A, Cook, noted to have her face mask below nose. On 12/20/21 at 11:31 AM Staff A opened the window and moved her face mask over her nose. Without hand hygiene, Staff A gave a Certified Nurse's Aide a cup. On 12/20/21 at 11:32 AM Staff A adjusted her mask and without hand hygiene Staff A got a plate. […]

• No harm, potential for more than minimal, isolatedF684Oct 23, 2025

  Based on clinical record review, facility policy review and staff interviews, the facility failed to accurately assess and provide appropriate interventions after a resident had an unwitnessed fall for 1 of 3 residents (Resident #1) reviewed. Staff attempted to move Resident #1 after they found her prone (face down), bleeding, and in pain. The facility reported a census of 28 residents.Findings include: Review of the Minimum Data Set (MDS) dated [DATE] revealed Resident #1 had a Brief Interview for Mental Status (BIMS) score of 6 out of 15 which indicated a severe cognitive impairment. The MDS list of diagnoses included non-Alzheimer's dementia, diabetes mellitus, and paroxysmal atrial fibrillation (irregular heart rhythm). […]