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University Rehabilitation Center
2244 Brinker Road, Denton, TX 76208 · CMS Certification Number (CCN) 675995
At a glance
- CMS overall rating
- ★☆☆☆☆ 1 of 5
- Health inspection citations
- 39 in the last 3 inspection cycles (5 immediate jeopardy, 0 actual harm, 18 from complaints)
- Fire safety citations
- 15
- Fines (last 3 years)
- 2 fines, total $33,117
- Payment denials
- 0
- Most recent standard inspection
- April 17, 2025
- Official record
- Medicare Care Compare page for this facility
Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
CMS star ratings
CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide
| Rating | This facility | Texas average | U.S. average |
|---|---|---|---|
| Overall | ★☆☆☆☆ 1 of 5 | 2.7 | 3 |
| Health inspections | ★★☆☆☆ 2 of 5 | 2.8 | 2.8 |
| Staffing | ★☆☆☆☆ 1 of 5 | 1.9 | 2.9 |
| Quality measures | ★★★☆☆ 3 of 5 | 3.7 | 3.6 |
| Long-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
| Short-stay quality | ★★★☆☆ 3 of 5 | Not published | Not published |
Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Health inspections
| Inspection cycle | Standard survey date | Health citations | From standard survey | From complaints |
|---|---|---|---|---|
| Cycle 1 (most recent) | April 17, 2025 | 12 | 4 | 9 |
| Cycle 2 | February 28, 2024 | 16 | 9 | 9 |
CMS weighted health inspection score: 106.25 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: 3. How to read these citations
39 health citations across 10 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.
July 8, 2026: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 07/09/2026 |
April 23, 2026: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/24/2026 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/24/2026 |
| D | F-0609 | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 04/24/2026 |
December 11, 2025: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 12/12/2025 |
September 11, 2025: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/12/2025 |
| J | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Past Non-Compliance Corrected 07/13/2025 |
| E | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 09/12/2025 |
April 17, 2025: 4 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/18/2025 |
| E | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 04/18/2025 |
| D | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/18/2025 |
| D | F-0583 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 04/18/2025 |
February 26, 2025: 3 citations (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0686 | Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/28/2025 |
| D | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Complaint | Deficient, Provider has date of correction Corrected 02/28/2025 |
| D | F-0561 | Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies | Complaint | Past Non-Compliance Corrected 12/18/2024 |
December 2, 2024: 1 citation (Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| D | F-0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies | Complaint | Past Non-Compliance Corrected 10/31/2024 |
February 28, 2024: 9 citations (Standard + Complaint)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| J | F-0776 | Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Administration Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 02/29/2024 |
| E | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/29/2024 |
| D | F-0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/29/2024 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/29/2024 |
| J | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Standard + Complaint | Deficient, Provider has date of correction Corrected 02/29/2024 |
| D | F-0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/29/2024 |
| D | F-0645 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/29/2024 |
| D | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/29/2024 |
| D | F-0558 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 02/29/2024 |
November 15, 2023: 3 citations (Complaint + Infection control)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0880 | Provide and implement an infection prevention and control program. Infection Control Deficiencies | Complaint + Infection control | Deficient, Provider has date of correction Corrected 11/16/2023 |
| E | F-0842 | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. Resident Assessment and Care Planning Deficiencies | Complaint + Infection control | Deficient, Provider has date of correction Corrected 11/16/2023 |
| D | F-0657 | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. Resident Assessment and Care Planning Deficiencies | Complaint + Infection control | Deficient, Provider has date of correction Corrected 11/16/2023 |
December 2, 2022: 11 citations (Standard)
| Severity | Tag | What was cited | Type | Status |
|---|---|---|---|---|
| E | F-0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
| D | F-0800 | Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. Nutrition and Dietary Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
| E | F-0761 | 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. Pharmacy Service Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
| D | F-0695 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
| D | F-0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
| D | F-0687 | Provide appropriate foot care. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
| J | F-0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
| E | F-0678 | Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Quality of Life and Care Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
| D | F-0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
| E | F-0584 | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
| J | F-0580 | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Resident Rights Deficiencies | Standard | Deficient, Provider has date of correction Corrected 12/23/2022 |
Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Fire safety inspections
15 fire safety citations across 3 inspection dates
| Date | Severity | Tag | What was cited | Status |
|---|---|---|---|---|
| 04/17/2025 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 04/18/2025 |
| 04/17/2025 | F | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 04/18/2025 |
| 04/17/2025 | F | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/18/2025 |
| 04/17/2025 | F | K-0345 | Have approved installation, maintenance and testing program for fire alarm systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/18/2025 |
| 04/17/2025 | F | K-0341 | Install a fire alarm system that can be heard throughout the facility. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/18/2025 |
| 04/17/2025 | F | K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 04/18/2025 |
| 02/28/2024 | F | K-0918 | Have generator or other power source capable of supplying service within 10 seconds. Gas, Vacuum, and Electrical Systems Deficiencies | Deficient, Provider has date of correction Corrected 02/29/2024 |
| 02/28/2024 | F | K-0761 | To conduct inspection, testing and maintenance of fire doors by qualified individuals. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 02/29/2024 |
| 02/28/2024 | F | K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 02/29/2024 |
| 02/28/2024 | F | K-0712 | Have simulated fire drills held at unexpected times. Miscellaneous Deficiencies | Deficient, Provider has date of correction Corrected 02/29/2024 |
| 02/28/2024 | F | K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/29/2024 |
| 02/28/2024 | F | K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 02/29/2024 |
| 12/02/2022 | E | K-0353 | Inspect, test, and maintain automatic sprinkler systems. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/23/2022 |
| 12/02/2022 | E | K-0351 | Install an approved automatic sprinkler system. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/23/2022 |
| 12/02/2022 | F | K-0324 | Provide properly protected cooking facilities. Smoke Deficiencies | Deficient, Provider has date of correction Corrected 12/21/2022 |
Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.
Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Penalties
| Date | Type | Fine amount | Payment denial |
|---|---|---|---|
| September 11, 2025 | Fine | $14,316 | — |
| February 28, 2024 | Fine | $18,801 | — |
Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Staffing
| Measure | This facility | Texas average | U.S. average |
|---|---|---|---|
| Total nurse staff hours per resident per day | 3.36 | 3.39 | 3.86 |
| Registered nurse (RN) hours per resident per day | 0.41 | 0.43 | 0.69 |
| LPN/LVN hours per resident per day | 0.93 | Not published | Not published |
| Nurse aide hours per resident per day | 2.01 | Not published | Not published |
| Total nurse staff hours per resident per day, weekends | 2.98 | Not published | Not published |
| RN hours per resident per day, weekends | 0.46 | Not published | Not published |
| Total nursing staff turnover (%) | 88.2 | 55.3 | 45.8 |
| Registered nurse turnover (%) | 80 | Not published | Not published |
| Administrators who have left | 4 | Not published | Not published |
Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.
Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Facility details
- Legal business name
- West Wharton County Hospital District
- Ownership type
- For profit - Limited Liability company
- Chain
- Creative Solutions in Healthcare (149 facilities)
- Ownership changed in last 12 months
- No
- Certified beds
- 146
- Average residents per day
- 116.2
- Participates in
- Medicare and Medicaid
- Located inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- First approved for Medicare/Medicaid
- December 4, 2003
- County/parish
- Denton
Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Owners and managers reported to CMS
5 ownership and management records
| Name | Role | Type | Ownership % | Since |
|---|---|---|---|---|
| HUGGINS, LINDA | CORPORATE DIRECTOR | Individual | NOT APPLICABLE | undefined undefined, NaN |
| MAK, DAVID | CORPORATE OFFICER | Individual | NOT APPLICABLE | undefined undefined, NaN |
| DENTON II ENTERPRISES LLC | OPERATIONAL/MANAGERIAL CONTROL | Organization | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, GARY | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
| BLAKE, MALISA | OPERATIONAL/MANAGERIAL CONTROL | Individual | NOT APPLICABLE | undefined undefined, NaN |
Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 26, 2026
Check it yourself
- Medicare Care Compare: University Rehabilitation Center. Full inspection reports, quality measures and staffing.
- HHSC long-term care complaint portal (TULIP). The state agency also takes nursing home complaints.
- Ask the facility to show you its most recent inspection report and plan of correction.
Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 26, 2026. Not a ranking or endorsement.