Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based 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.
Residents Affected - Some
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.
Findings included:
Record Review of facility's Staff schedule for May 11- May 16 reflected the following:
05/11/2024 reflected LVN C, CNA D, and LVN E. There was no RN coverage on Saturday May 11, 2024.
Staffing sheets were requested for 5/1/24 to 5/10/24 but were not provided by the facility at the date and the
time of exit.
Review of CMS PBJ staffing reports reflected the facility triggered for no RN hours for the last 4 quarters
Quarter 1 2024 (October 1 - December 31), Quarter 4 2023 (July 1 - September 30), Quarter 3 2023 (April
1 - June 30), Quarter 2 2023 (January 1 - March 31) since the last licensure survey.
In a phone interview on 5/16/24 at 12:10 PM with LVN C revealed that there was no RN coverage on May
4, May 5, and May 11 when she worked double shifts from 6 am - 2 pm and 2pm -10 pm on those days.
She stated that LVN E was the night shift LVN. She stated she would like to have a registered nurse in the
facility for any emergencies that required RN specific Nursing activities.
In a phone interview on 5/16/24 at 2:25 PM with LVN E revealed she worked the night shift of 5/11/2024.
She was not aware if there was RN coverage for the morning and afternoon shifts on 5/11/2024. She stated
that RN coverage was important to ascertain that any resident who needed RN specific Nursing activities
while in the facility promptly received them.
In an interview on 5/16/24 at 10:54 AM with the DON revealed she started working as the DON on May 1,
2024, at the facility. Prior to that , she worked as a weekend RN supervisor in the facility. The DON stated
that she was the only RN employed by the facility since May 1, 2024. She stated that she did not work in
the facility on 5/4/2024, 5/5/2024 and 5/11/2024 since she was promoted to being the DON. She stated that
she was responsible for creating Nursing schedules and knew the facility
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
455563
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455563
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Denison Nursing and Rehab
601 E Hwy 69
Denison, TX 75021
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
needed 8 hours of RN coverage each day in the facility. She stated that the Corporate Nursing team was
aware there was no RN coverage for the three days in May. She stated LVNs could contact her by phone if
they needed something urgent, but they did not have an RN who came to the facility on weekends since
she was promoted to the DON position. She stated the risk of not having an RN for consecutive 8 hours per
day in the facility was there was no supervisory oversight, and her years of knowledge were helpful for
decision making in terms of emergencies. She stated that the facility was looking for weekend RN coverage
and had posted the position.
In an interview on 5/16/24 at 11:25 AM with the Administrator revealed she started working in the facility in
February 2024. She stated that the previous DON's last day was Thursday May 2, 2024. The current DON
used to cover as a Weekend RN supervisor, but since she was promoted as the DON, there was no RN
coverage for 5/4/24, 5/5/24 and 5/11/24. The Administrator revealed the facility did not have a waiver for RN
coverage. She stated the lack of RN coverage on the weekends could place residents at risk for not getting
the services they require from RNs. She also stated that the DON did not have to fill out any timesheets for
DON so all she had was the staffing sheets.
Attempted Interview with CNA D; called and left voice message for CNA D on 5/16/24 at 9:20 AM and 1:20
PM. CNA D did not return the calls before the date and the time of exit.
Review of facility's policy titled Department Duty Hours, Nursing Services revised April 2006 reflected 1. A
Registered or Licensed Practical/Vocational Nurse is on duty twenty-four hours per day, seven days per
week to supervise the nursing services activities in accordance with physician orders and facility policy. 2. A
Registered Nurse is employed as the Director of Nursing Services .is on duty during the day shift Monday
through Friday. The policy did not reflect about RN coverage on the weekends.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455563
If continuation sheet
Page 2 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455563
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Denison Nursing and Rehab
601 E Hwy 69
Denison, TX 75021
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
Based 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:
Record review and observation on 05/14/24 at 12:24 PM of Nurse Medication Cart Hall 100, with LVN G
revealed missing signatures for Off duty and On duty for 05/01/2024 of the narcotic count sheet.
Interview on 05/14/2024 at 12:40 PM, LVN G stated nurses and medication aides should have signed the
narcotic sheet after counting the narcotics on 05/01/24. She stated the risk would be potential for drug
diversion.
Interview on 05/16/24 at 8:36 AM, the DON stated she expected nurses to sign the narcotic count sheet at
the beginning and at the end of their shift after they completed count with the incoming and off-going nurse.
The DON stated if the staff was not signing the narcotic count sheets, she was unable to prove they were
counting. The DON stated it was important to ensure a drug diversion did not occur. The DON stated she
was supposed to check the cart randomly for monitoring.
Review of the facility's policy Controlled Substances revised November 2022, reflected the following:
.Controlled substances are counted upon delivery. The nurse receiving the medication, along with the
person delivering the medication, must count the controlled substances together. Both individuals sign the
designated controlled substance record.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455563
If continuation sheet
Page 3 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455563
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Denison Nursing and Rehab
601 E Hwy 69
Denison, TX 75021
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0761
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted
professional principles; and all drugs and biologicals must be stored in locked compartments, separately
locked, compartments for controlled drugs.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
The findings include:
Observation on [DATE] at 12:47 PM of the medication room with LVN G revealed 11 expired COVID-19
Antigen self-tests for infection detection. The COVID-19 Antigen self-tests expired [DATE].
Interview on [DATE] at 12:49 PM, LVN G stated she had not seen the expired COVID-19 Antigen self-tests
and would have removed them immediately . She stated the risk would be to get a wrong result.
Interview on [DATE] at 8:36 AM, the DON stated nurses had to check for expired medication in the carts
and in the medication room. She stated the risk of using an expired COVID-19 Antigen self-test would be
potential for inaccurate result and inaccurate treatment.
Review of the facility's policy Medication Labeling and Storage revised February 2023, reflected the
following: .If the facility has discontinued, outdated or deteriorated medications or biologicals, the
dispensing pharmacy is contacted for instructions regarding returning or destroying these items .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455563
If continuation sheet
Page 4 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455563
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Denison Nursing and Rehab
601 E Hwy 69
Denison, TX 75021
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based 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.
Findings included:
Observation in facility's kitchen refrigerator on 05/14/24 at 9:33 AM revealed one packet of Chicken pot pie
filling and Liquid egg yolks were not dated.
Observation in facility's kitchen's dry storage on 5/14/24 at 9:36 AM revealed a loaf of bread and 6
hamburger buns were not dated or labeled.
Observation in facility's freezer on 5/14/24 at 9:40 AM revealed 6 hamburger patties and bread were not
dated and labeled.
Observation of lunch meal service on 5/14/24 at 12:05 PM revealed that [NAME] B donned gloves while
serving food to residents in the facility kitchen. [NAME] B did not use a scoop to serve fried okra. She
scooped up several pieces of okra with her gloved hand and put them on the resident's plate. The plate was
then delivered to the resident in the dining room.
In an interview with [NAME] B on 5/14/24 at 12:29 PM revealed she did not use a scooper to scoop fried
okra while serving the lunch meal. She stated it was a mistake, and she knew she should always use a
spoon to serve meals unless it was an individually wrapped item. She stated not using sterile utensils to
serve food can increase the risk of food borne illness. [NAME] B stated everyone in the kitchen, including
herself, was responsible for dating and labeling items in the kitchen . She stated it was important to label
and date all food items in the kitchen; so that older items can be used first and decrease the risk of any
food borne illness.
In an interview on 5/14/24 at 12:36 PM with Food Service Manager stated all kitchen staff including cooks
and herself were responsible for dating and labeling items. She stated she had conducted in-services for all
kitchen staff for dating and labeling items in the past and will make sure to in-service them again. She
stated it was important to always use utensils to serve food to residents since the risk of food contamination
and infection would be higher if not done so. She stated her expectation was that all staff follow adequate
kitchen hygiene. She stated the risk of not dating and
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455563
If continuation sheet
Page 5 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455563
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Denison Nursing and Rehab
601 E Hwy 69
Denison, TX 75021
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
labeling food items was possible risk of food borne illness.
Level of Harm - Minimal harm
or potential for actual harm
Record Review of the Facility's Food receiving and storage, revised October 2017, reflected 7.Dry foods
that are stored in bins will be removed from original packaging, labeled, and dated (use by date). Such
foods will be rotated using a first in - first out system. 8. All foods stored in the refrigerator or freezer will be
covered, labeled, and dated (use by date). All facility storage areas will be maintained in an orderly manner
that preserves the condition of food and supplies .
Residents Affected - Many
Review of the Food and Drug Administration Food Code, dated 2022, reflected, .3-302.12 Food Storage
Containers, Identified with Common Name of Food. Except for containers holding food that can be readily
and unmistakably recognized such as dry pasta, working containers holding food, or food ingredients that
are removed from their original packages for use in the food establishment, such as cooking oils, flour,
herbs, potato flakes, salt, spices, and sugar shall be identified with the common name of the food 3-305.11
Food Storage.(B) .refrigerated, ready-to eat time/temperature control for safety food prepared and
packaged by a food processing plant shall be clearly marked, at the time the original container is opened in
a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the
food shall be consumed on the premises, sold, or discarded, based on the temperature and time
combinations specified in (A) of this section and: (1) The day the original container is opened in the food
establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may
not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food
safety
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455563
If continuation sheet
Page 6 of 7
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
455563
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
05/16/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Denison Nursing and Rehab
601 E Hwy 69
Denison, TX 75021
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Residents Affected - Few
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.
Findings include:
A record review of Resident #7's Comprehensive MDS assessment, dated 03/08/2024, reflected Resident
#7 was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including chronic kidney
disease, elevated blood pressure, and breast cancer. Resident #7 had a BIMS score of 13 which indicated
Resident #7's cognition was intact. Resident#7 required extensive assistance of 2-person physical
assistance with toileting hygiene.
In an observation on 05/15/24 at 9:05 AM revealed CNA A and CNA F entered Resident #7's room to
provide incontinence care. Both CNAs washed hands and donned gloves. CNA A cleaned the front pubic
area using wipes. The resident was assisted onto her side. CNA F held resident and CNA A cleaned the
resident's buttocks area using several wipes. CNA A removed her gloves and re-gloved without performing
hand hygiene, and she placed a clean brief under resident. Both CNAs repositioned the resident back on
her back. Both CNAs gathered the dirty clothes and trash, removed their gloves, and washed hands.
In an interview on 05/15/24 at 9:17 AM, CNA A stated she was to wash hands before and after care. CNA A
also stated she was supposed to complete hand hygiene after removing the dirty gloves. CNA A stated she
did not complete hand hygiene between change of gloves because she forgot to carry the hand sanitizer.
CNA A stated she was supposed to complete hand hygiene to prevent the spread of infection.
In an interview on 05/16/24 at 8:36 AM, the DON stated during incontinent care the staff were to complete
hand hygiene before and after care. The DON also stated in between care CNA was to complete hand
hygiene and change gloves because her hands were considered dirty after cleaning the resident. The DON
stated the staff were to complete hand hygiene between change of gloves to prevent the spread of
infection.
Record review of the facility policy reviewed August 2019, titled Hand Hygiene reflected, . This facility
considers hand hygiene the primary means to prevent the spread of infections . Use an alcohol-based hand
rub . for the following situations: . After removing gloves .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455563
If continuation sheet
Page 7 of 7
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Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F761 - Labeling of Drugs and Biologicals
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the May 16, 2024 survey of DENISON NURSING AND REHAB?
This was a inspection survey of DENISON NURSING AND REHAB on May 16, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at DENISON NURSING AND REHAB on May 16, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full tim..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.