The Homestead of Denison

In the surveyor’s words

From the most serious findings on record at The Homestead of Denison, in the surveyor’s own words.

• Immediate jeopardy, patternF689Nov 10, 2023

  48122 Based 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. […]

• Immediate jeopardy, isolatedF600Jul 16, 2025

  Based 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. […]

• Actual harm, patternF689Jul 30, 2021

  Based on observation, interview, and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for three (Residents #21, #28, and #33) of six residents reviewed for transfers. 1. NA G and CNA F failed to transfer Resident #21 safely when they failed to use a gait belt and lifted the resident under his armpits when transferring him from the bed to the wheelchair. 2. CNA P failed to transfer Resident #33 safely when she attempted to transfer the resident from the bed to the wheelchair with one staff instead of 2 as indicated in her care plan. The resident fell and suffered a left femur (leg) fracture. 3. […]

• No harm, potential for more than minimal, widespreadF812Jan 3, 2025

  Based 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. […]

• No harm, potential for more than minimal, widespreadF727Nov 10, 2023

  Based 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. […]