Denison Care Center
Inspection Findings
F-Tag F0684
F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
Director of Nursing (ADON) stated if a resident falls on the floor and is found lying in the prone position she would check their ROM. Staff E stated if the assessment showed any changes with ROM or any decrease
in ROM she would not move the resident and would just call 911. Staff E stated if there was a lot of blood around the head she would not move the resident and just call 911. Staff E stated the reason she would not move a resident lying prone with a head injury is because the resident could have spinal injury. On 10/23/25 at 12:07 PM the Administrator stated she would not want a resident moved if found bleeding from the head, decreased sensations in extremities, or change in extremities ROM. On 10/23/25 at 10:54 AM the Director of Nursing (DON) explained if a resident is found face down she expected an assessment of the resident.
The DON stated in the situation with Resident #1 blood was on the floor. The DON stated she would have shipped the resident to the emergency room immediately. The DON stated during her investigation she did not find any concerns with Resident #1's transfer to the emergency room immediately. The DON stated she was glad that they did not move Resident #1. The DON stated what Staff A said to her was that they could not move the resident because of her position. The DON stated Staff A assumed the blood was coming from Resident #1's nose. The DON acknowledged if a resident is found with blood present face down, they should not be moved and sent directly to the emergency room. Review of policy dated 2021 and revised 3/18 titled, Assessing Falls and Their Causes directed if a resident had just fallen, or is found on the floor without a witness to the event, evaluate for possible injuries to the head, neck, spine and extremities. Obtain and record vital signs as soon as it is safe to do so. If there was evidence of injury, provide appropriate first aid and/or obtain medical treatment immediately.
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Printed: 04/13/2026 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
B. Wing
A. Building
(X3) DATE SURVEY COMPLETED
10/23/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Denison Care Center
1202 Ridge Road Denison, IA 51442
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-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
DON stated taking the resident to pass snacks, sitting with Resident #1 at the table, sitting with her behind
the nurse's station or keeping her in line of sight was part of the job. The DON stated the staff know to do
these redirections without having them in the care plan. The DON stated she would have expected the care plan to reflect the interventions prior to the fall on 10/9/25. The DON stated her expectation was that staff that were not nursing staff would stay with the resident and alert the appropriate staff if Resident #1 was attempting to stand on her own. Stated she would have expected the Staff D to stay with Resident #1 until nursing staff were notified. Review of the Care Plan, dated 6/9/24, revealed a Focus area to address [Name redacted] has impaired cognitive function r/t Dementia. Interventions included, in part: Provide one-to-one or line-of-sight supervision as clinically indicated to ensure resident safety. Date Initiated: 10/15/25. On 10/23/25 at 12:07 PM, the Administrator stated any staff that observed Resident #1 to be agitated or self-transferring should have stayed with the resident for her safety. Review of policy dated 2001 revised 3/22 titled, Care Plans, Comprehensive Person-Centered documented the care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.
Care plan interventions are chosen only after data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their cause, and relevant clinical decision making. When possible, interventions address the underlying source(s) of the problem area(s), not just symptoms or triggers. Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change. Review of policy dated 2021 and revised 3/18 titled, Assessing Falls and Their Causes documented when a resident falls, the following information should be recorded in the resident's medical record: completion of a falls risk assessment and appropriate interventions taken to prevent future falls.
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If continuation sheet
Denison Care Center in Denison, IA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Denison, IA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Denison Care Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.