Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Denton Rehabilitation And Nursing Center during CMS and state inspections, most recent first.
A resident with pulmonary edema, sleep apnea, and CHF, ordered for continuous O2 and bedtime CPAP, repeatedly refused CPAP on multiple consecutive night shifts and at times removed O2 by nasal cannula. Nursing staff documented the refusals on the MAR and noted the resident’s complaints of pain, but did not notify the physician, NP, or DON as required by the care plan and facility policy for repeated treatment refusals. On one day, an LVN observed the resident’s O2 saturation at 85%, applied O2, remained with the resident until saturation improved, and verbally informed the NP during rounds, but did not document the low saturation, the intervention, or the NP notification, and charted an inaccurate time. In interviews, the NP, attending physician, and DON reported they had not been notified by nursing of the CPAP refusals, O2 removals, or the low O2 saturation, despite facility policy requiring physician notification for significant changes in condition and refusals of treatment two or more consecutive times.
A resident with pulmonary and cardiac conditions who required continuous O2 and CPAP had multiple undocumented care events. Nursing staff recorded repeated CPAP refusals on the MAR, but did not complete required nursing assessments or progress notes for all refusals and did not document notifying the provider or DON. On one occasion, a nurse identified an O2 saturation of 85%, applied O2, remained with the resident until saturation improved, and verbally informed an NP who assessed the resident, but failed to document the low saturation, interventions, resident response, or provider notification, and also mis-charted the time of the event. These omissions conflicted with the resident’s care plan, physician orders, and facility policy requiring documentation of changes in condition.
A container of germicidal wipes was left in a resident's room, contrary to facility policy requiring such chemicals to be stored securely. The cognitively intact resident, who had a complex medical history, reported that aides had used the wipes to clean items in the room. Multiple staff members confirmed that these wipes should not be left accessible to residents due to potential harm, and no staff could identify who left the container in the room.
A resident with a stage 4 pressure ulcer was found to have two packs of collagen powder, intended for wound care, left unsecured on her bedside table instead of being stored in a locked medication or treatment cart. Staff interviews confirmed that medications should not be left in resident rooms and should be kept in secure storage, but were unaware of how the medication ended up in the room. The facility's policy requiring secure storage of all drugs and biologicals was not followed in this instance.
The facility failed to develop comprehensive care plans for three residents with respiratory needs, including oxygen and CPAP therapy. Despite physician orders and observations of equipment use, the care plans did not reflect these needs, leading to potential unmet respiratory requirements. Staff interviews revealed a lack of awareness and documentation, violating resident rights and facility policy.
The facility failed to properly store respiratory equipment for four residents, leading to potential infection risks. Nebulizer masks and nasal cannulas were found unbagged and improperly placed, contrary to professional standards and facility policy. This affected residents with conditions such as pneumonia, COPD, and acute respiratory failure.
The facility failed to ensure call lights were accessible for two residents, leading to a deficiency in accommodating their needs. One resident, with muscle weakness, had to stand and walk to retrieve his call light, while another, with a history of falls, had her call light stuck behind a side table. Despite staff awareness of the importance of call lights, the facility did not consistently ensure they were within reach, as required by their policy.
A facility failed to update a resident's care plan after the discontinuation of tube feeding, as revealed through observations and interviews. Despite the physician's order to stop the G-tube, the care plan still indicated tube feeding, leading to potential confusion in care. Staff interviews confirmed the care plan should have been updated to reflect the resident's current needs, as per facility policy.
The facility failed to meet professional standards for food service safety by not sealing, labeling, and dating food items in the refrigerator and freezer, and not removing items with frost buildup. The Dietary Manager confirmed these oversights during a walkthrough, and the facility could not provide a safety policy for food storage and labeling.
A CNA in a long-term care facility failed to change gloves and perform hand hygiene during incontinence care for a resident with a history of diarrhea and urinary tract infection. This breach in infection control protocol was acknowledged by the CNA and confirmed by the LVN and DON, highlighting a lapse in following the facility's policy to prevent cross-contamination and infection.
Failure to Notify Provider of Respiratory Treatment Refusals and Low O2 Saturation
Penalty
Summary
The deficiency involves the facility’s failure to consult with a physician regarding a resident’s change in condition, specifically related to respiratory treatment refusals and low oxygen saturation. The resident was an adult male with pulmonary edema, sleep apnea, and congestive heart failure, admitted with orders for continuous oxygen therapy and CPAP at bedtime. His care plan required oxygen to be administered per physician orders, oxygen saturation to be monitored every shift and as needed, and abnormalities to be reported to the physician. Facility policy required the nurse to notify the attending physician when there was a significant change in condition or a refusal of treatment or medications two or more consecutive times. Record review showed that the resident refused his ordered CPAP on three consecutive nights, as documented on the MAR by an RN, and a nursing note indicated he refused CPAP and chose to sleep with nasal cannula oxygen, with complaints of pain managed by PRN medication. The MDS indicated he required continuous oxygen therapy and CPAP and had moderate cognitive impairment but no documented behavioral symptoms or rejection of care. Despite the repeated refusals of CPAP and the care plan and policy requirements, there was no documentation that the physician, NP, or DON were notified of these refusals. The RN later confirmed in interview that she did not notify the physician or DON of the refusals, although she did notify a family member, and acknowledged she had been trained on documenting and notifying the physician of changes in status. Further, an LVN reported that the resident’s oxygen saturation was 85% on one morning, that she applied oxygen and stayed with him until his saturation rose above 90%, and that the NP was rounding and was told in person and assessed the resident. However, she did not document the low oxygen saturation, the intervention, or the NP notification, and the recorded time of the low saturation was inaccurate due to late charting. The NP and attending physician both stated in interviews that they were not aware, from nursing reports, of the resident’s CPAP refusals, oxygen removals, or the documented low oxygen saturation, and the attending physician stated that she and the NP should have been notified of the low saturation. The DON stated she had not been notified of the refusals or the low oxygen saturation and expected nurses to document findings, intervene, and notify the physician if oxygen saturation remained low. The facility’s policy specified that refusals of treatment two or more consecutive times and significant changes in condition required physician notification, which did not occur in this case.
Failure to Document CPAP Refusals and Low Oxygen Saturation Event
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete and accurate clinical records for one resident with multiple cardiopulmonary conditions, including pulmonary edema, epilepsy, sleep apnea, and congestive heart failure. The resident’s MDS indicated moderate cognitive impairment (BIMS 11), clear communication, no behavioral symptoms, and a need for continuous oxygen therapy and CPAP. The care plan and physician orders required oxygen administration per orders, monitoring of oxygen saturation every shift and as needed with abnormalities reported to the physician, and application of CPAP at bedtime with instructions to notify the provider and DON of refusals. The MAR showed that the resident refused CPAP on three consecutive nights, and a nursing note documented refusal on one of those nights, but there was no documentation that the physician or NP were notified of the refusals as required, nor were nursing assessments or progress notes completed for the refusals on two of those nights. Further, a nurse reported that the resident’s oxygen saturation was 85% on a morning during the review period. She stated she applied oxygen, stayed with the resident until saturation rose above 90%, and verbally informed the NP who then assessed the resident, but she did not document the low saturation, the interventions, the resident’s response, or the NP notification and assessment. She also mis-charted the time of the low oxygen saturation, entering it as mid-afternoon while documenting at the end of her shift and failing to correct it. Review of the progress notes confirmed there was no documentation of the low oxygen saturation event, the resident’s removal of oxygen by nasal cannula, or provider notification. The facility’s policy on change in condition required nurses to record information related to changes in a resident’s medical or mental condition or status in the medical record, which was not followed in these instances.
Germicidal Wipes Left in Resident Room
Penalty
Summary
A deficiency occurred when a container of germicidal wipes was left inside the room of a cognitively intact female resident with a medically complex condition, including a diagnosis of esophageal neoplasm. The wipes were observed on a table near the resident's door, and the resident confirmed that the container had been in the room for some time, with aides using them to clean items in the room. Multiple staff members, including an LVN, CNA, ADON, and DON, acknowledged that germicidal wipes should not be left in resident rooms due to the potential for adverse effects such as skin or eye irritation and possible ingestion, regardless of the resident's cognitive status. Facility policy requires that cleaning supplies and potentially harmful substances be stored away from resident areas and as instructed on product labels. Staff interviews revealed a lack of awareness or oversight regarding the presence of the wipes in the resident's room, and no one could identify who left the container there. The incident demonstrated a failure to ensure the resident's environment was free from accident hazards and toxic chemicals, as required by facility policy and standard practice.
Unsecured Medication Storage in Resident Room
Penalty
Summary
The facility failed to store all drugs and biologicals in locked compartments as required by state and federal laws. During an observation, two packs of collagen powder, which was ordered for wound care, were found on a resident's bedside table rather than in a locked medication or treatment cart. The resident, who was cognitively intact and had a stage 4 pressure ulcer of the lower sacrum, stated she did not know who brought the collagen powder into her room. Multiple staff interviews confirmed that medications, including collagen powder, should not be left in resident rooms and should be stored securely in the nurse's or treatment cart. Staff were unaware of how the medication ended up in the resident's room, and it was noted that hospice staff may have left it there. The facility's policy requires that all drugs and biologicals be stored safely and securely in locked compartments, accessible only to licensed nursing personnel, pharmacy personnel, or authorized staff members. However, the observation and staff interviews revealed that this policy was not followed in the case of the resident with the pressure ulcer, as the collagen powder was left unsecured in the resident's room. This lapse in medication storage protocol was identified during the survey and confirmed through interviews and record review.
Deficiency in Care Planning for Respiratory Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which is a violation of resident rights as outlined in S483.10(c)(2) and S483.10(c)(3). Specifically, the care plans did not include measurable objectives and timeframes to address the residents' medical, nursing, and psychosocial needs identified in their comprehensive assessments. This deficiency was observed in the care plans of three residents who required oxygen administration or CPAP therapy, yet their care plans did not reflect these needs. Resident #14, a female with chronic obstructive pulmonary disease and acute respiratory failure, was observed using an oxygen concentrator, but her care plan did not include oxygen therapy. Similarly, Resident #75, who had severe cognitive impairment and was admitted for respiratory failure, also lacked a care plan for oxygen administration despite having a physician's order for it. Both residents were observed using oxygen equipment, indicating a disconnect between their care needs and the documented care plans. Resident #48, who had chronic respiratory failure, was admitted with a CPAP order but did not have a care plan for its use. The resident expressed discomfort with the CPAP and was not using it, yet there was no care plan addressing this noncompliance. Staff interviews revealed a lack of awareness about the CPAP order and the absence of a care plan, highlighting a failure in communication and documentation. The facility's policy requires care plans to be developed based on resident assessments, but this was not adhered to, resulting in unmet respiratory needs for the residents.
Improper Storage of Respiratory Equipment
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for four residents who required such care. Specifically, the facility did not ensure that nebulizer masks for two residents and nasal cannulas for two other residents were properly stored. This failure was observed during a survey, where it was noted that the respiratory equipment was not bagged when not in use, which could potentially lead to respiratory infections. Resident #77, a male with diagnoses of pneumonia and pneumonitis, was found with his nebulizer mask sitting on a recliner without being bagged. Similarly, Resident #48, a female with chronic respiratory failure and COPD, had her nebulizer mask on a drawer, also not bagged. Both residents had physician orders for respiratory treatments, but the equipment was not stored according to professional standards. Resident #14, a female with COPD and acute respiratory failure, and Resident #75, a female with acute respiratory failure and pneumonia, had nasal cannulas that were not properly stored. Resident #14's nasal cannula was hanging on top of the oxygen concentrator, while Resident #75's nasal cannula was found on the floor. These observations indicate a lack of adherence to the facility's policy on infection prevention related to respiratory therapy equipment.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure the call light system was accessible to two residents, leading to a deficiency in accommodating their needs and preferences. Resident #45, a 53-year-old male with muscle weakness and difficulty walking, was observed unable to locate his call light, which was positioned behind his roommate's side table. Despite being cognitively intact and requiring supervision for various activities, his care plan did not include an intervention to ensure the call light was within reach. During an observation, the resident had to stand and walk to retrieve the call light, indicating a lack of reasonable accommodation for his needs. Similarly, Resident #29, an elderly female with a history of falls and moderate cognitive impairment, was found with her call light inaccessible, stuck behind her roommate's side table. Her care plan included an intervention to ensure the call light was within reach, yet this was not adhered to. The resident had experienced multiple falls in the past, highlighting the importance of having the call light accessible to prevent further incidents. Staff interviews revealed an understanding of the importance of call lights, yet the deficiency persisted. Interviews with staff, including RN E, CNA A, CNA C, the DON, and the Administrator, confirmed the significance of call lights for resident safety and communication. Despite this awareness, the facility did not consistently ensure the call lights were within reach, as evidenced by the observations of the two residents. The facility's policy on answering call lights emphasized the need for accessibility, yet this was not effectively implemented, resulting in the deficiency.
Failure to Update Resident Care Plan Post Tube Feeding Discontinuation
Penalty
Summary
The facility failed to ensure the timeliness and accuracy of a resident's comprehensive care plan, specifically for a resident who had discontinued the use of tube feeding. Despite the physician's order to discontinue the G-tube, the resident's care plan still reflected the use of tube feeding. This discrepancy was identified through observations, interviews, and record reviews, which revealed that the resident was on a mechanically altered diet and not on tube feeding as per the current physician's orders. The care plan had not been updated to reflect the resident's current health condition, leading to potential confusion in the care provided. Interviews with facility staff, including an RN, MDS Nurse, DON, and the Administrator, confirmed that the care plan should have been updated to reflect the resident's current needs and interventions. The staff acknowledged that the failure to update the care plan could result in confusion and missed care. The facility's policy requires that the interdisciplinary team reviews and updates the care plan to ensure it reflects the current care being provided to the resident. However, this process was not followed, leading to the deficiency identified in the report.
Deficiency in Food Storage and Labeling Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen's storage, preparation, distribution, and serving of food. Specifically, dietary staff did not seal, label, and date food items in the refrigerator and freezer, which is a critical step in preventing food contamination. Additionally, items with frost buildup inside their containers were not removed, which could compromise the quality and safety of the food. These practices were confirmed during a walkthrough with the Dietary Manager, who acknowledged the oversight and the potential for freezer burn to render food inedible. The Dietary Manager, who has four years of experience at the facility and extensive experience in the food service industry, confirmed responsibility for kitchen sanitation and proper food storage. Despite this, the facility was unable to provide a copy of its safety policy for food storage and labeling when requested by the survey team. The U.S. Food and Drug Administration (FDA) Code mandates that packaged food be labeled according to specific regulations to protect it from contamination, a standard that was not met in this instance.
Infection Control Breach During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, as evidenced by the actions of a Certified Nursing Assistant (CNA) during incontinence care for a resident. The resident, a cognitively intact female with a history of diarrhea, urinary tract infection, and a rash, was observed receiving care from CNA B. During the procedure, CNA B did not change gloves or perform hand hygiene after cleaning the resident and before handling a new brief, which is a critical step to prevent cross-contamination and infection. The CNA acknowledged the lapse in protocol, recognizing that failing to change gloves and wash hands could lead to the transfer of microorganisms and potential infection. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the correct procedure was not followed, emphasizing the importance of changing gloves and washing hands to prevent contamination. The facility's policy on incontinence care also mandates changing gloves after cleaning the resident, which was not adhered to in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Denton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lake Forest Village By Purehealth | 2 mi | ★★★★★ | 13 | 0 |
| Corinth Rehabilitation Suites On The Parkway | 2 mi | ★★★★★ | 18 | 0 |
| University Rehabilitation Center | 2.8 mi | ★★★★★ | 7 | 1 |
| Rambling Oaks Courtyard Extensive Care Community | 4.8 mi | ★★★★★ | 17 | 0 |
| Vintage Health Care Center | 6.4 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.