For profit - Limited Liability company · 146 certified beds · CMS number 675995
University Rehabilitation Center, Denton, TX
CMS records 39 health deficiencies at University Rehabilitation Center in Denton, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Apr 17, 2025. The highest severity cited is J (immediate jeopardy to resident health or safety). 5 citations were at the immediate jeopardy level, 1 of them recorded as past non-compliance (fixed before the inspection). CMS lists 2 fines totaling $33,117 in the last three years.
- 39deficiencies, 3 cycles (TX median 25)
- 12in the latest cycle (TX median 8)
- Jhighest severity · Immediate jeopardy
- $33,117fines, last 3 years
- 1CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for University Rehabilitation Center as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and University Rehabilitation Center may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (12 deficiencies)
Standard inspection Apr 17, 2025. CMS counts 12 health deficiencies and 6 fire safety deficiencies in this cycle.
Jul 8, 2026 · Complaint inspection
1 deficiency, highest D
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 9, 2026
Apr 23, 2026 · Complaint inspection
3 deficiencies, highest D
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 24, 2026
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 24, 2026
F609 · Reporting suspected abuse and crimes
Requirement cited (CMS): Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 24, 2026
Dec 11, 2025 · Complaint inspection
1 deficiency, highest D
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 12, 2025
Sep 11, 2025 · Complaint inspection
3 deficiencies, highest J
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 12, 2025
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), Jul 13, 2025
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Sep 12, 2025
Apr 17, 2025 · Standard + complaint inspection
4 deficiencies, highest E
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 18, 2025
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Apr 18, 2025
F584 · Safe, clean, homelike surroundings
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 18, 2025
F583 · Personal privacy and confidential records
Requirement cited (CMS): Keep residents' personal and medical records private and confidential.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Apr 18, 2025
Previous cycle: 13 deficiencies (standard inspection Feb 28, 2024)
Standard inspection Feb 28, 2024. CMS counts 13 health deficiencies and 6 fire safety deficiencies in this cycle.
Feb 26, 2025 · Complaint inspection
3 deficiencies, highest E
F686 · Pressure ulcer prevention and care
Requirement cited (CMS): Provide appropriate pressure ulcer care and prevent new ulcers from developing.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 28, 2025
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 28, 2025
F561 · Making everyday choices
Requirement cited (CMS): Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Past non-compliance (fixed before the inspection), Dec 18, 2024
Dec 2, 2024 · Complaint inspection
1 deficiency, highest D
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Past non-compliance (fixed before the inspection), Oct 31, 2024
Feb 28, 2024 · Standard + complaint inspection
9 deficiencies, highest J
F776 · Radiology and diagnostic services
Requirement cited (CMS): Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Feb 29, 2024
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Feb 29, 2024
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 29, 2024
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 29, 2024
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Feb 29, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 29, 2024
F645 · Pre-admission screening for mental disorder or intellectual disability
Requirement cited (CMS): PASARR screening for Mental disorders or Intellectual Disabilities
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 29, 2024
F580 · Telling residents and families about changes
Requirement cited (CMS): Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 29, 2024
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Feb 29, 2024
Earlier cycle: 14 deficiencies (standard inspection Dec 2, 2022)
Standard inspection Dec 2, 2022. CMS counts 14 health deficiencies and 3 fire safety deficiencies in this cycle.
Nov 15, 2023 · Complaint inspection
3 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Nov 16, 2023
- Found in
- infection control inspection
F842 · Complete, confidential medical records
Requirement cited (CMS): Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Nov 16, 2023
- Found in
- infection control inspection
F657 · Care plan timing and team review
Requirement cited (CMS): Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 16, 2023
- Found in
- infection control inspection
Dec 2, 2022 · Standard inspection
11 deficiencies, highest J
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 23, 2022
F800 · Nourishing, well-balanced diet
Requirement cited (CMS): Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 23, 2022
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 23, 2022
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 23, 2022
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 23, 2022
F687 · Foot care
Requirement cited (CMS): Provide appropriate foot care.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 23, 2022
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Dec 23, 2022
F678 · CPR and basic life support
Requirement cited (CMS): Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 23, 2022
F644 · Coordinating with PASARR screening
Requirement cited (CMS): Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Dec 23, 2022
F584 · Safe, clean, homelike surroundings
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Dec 23, 2022
F580 · Telling residents and families about changes
Requirement cited (CMS): Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Correction date Dec 23, 2022
Tags cited in more than one inspection
12 tags cited on more than one inspection date at University Rehabilitation Center; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F656 Comprehensive person-centered care plan | 3 | Apr 23, 2026; Sep 11, 2025; Feb 28, 2024 |
| F689 Accident prevention and supervision | 3 | Sep 11, 2025 (PNC); Apr 17, 2025; Dec 2, 2024 (PNC) |
| F695 Respiratory and oxygen care | 3 | Apr 23, 2026; Sep 11, 2025; Dec 2, 2022 |
| F580 Telling residents and families about changes | 2 | Feb 28, 2024; Dec 2, 2022 |
| F583 Personal privacy and confidential records | 2 | Jul 8, 2026; Apr 17, 2025 |
| F584 Safe, clean, homelike surroundings | 2 | Apr 17, 2025; Dec 2, 2022 |
| F657 Care plan timing and team review | 2 | Feb 26, 2025; Nov 15, 2023 |
| F684 Quality of care | 2 | Feb 28, 2024; Dec 2, 2022 |
| F690 Bladder, bowel, and catheter care | 2 | Feb 28, 2024; Dec 2, 2022 |
| F755 Pharmacy services and a consultant pharmacist | 2 | Dec 11, 2025; Feb 28, 2024 |
| F761 Drug labeling and secure storage | 2 | Feb 28, 2024; Dec 2, 2022 |
| F812 Food safety and sanitation | 2 | Apr 17, 2025; Dec 2, 2022 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Sep 11, 2025 | Fine | $14,316 |
| Feb 28, 2024 | Fine | $18,801 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- 3.36 h (about the same as the Texas median of 3.27 h)
- RN hours per resident per day
- 0.41 h (above the Texas median of 0.38 h)
- Weekend nurse staff hours per resident per day
- 2.98 h
- Nursing staff turnover
- 88.2% (Texas median 52.1%)
- Administrators who left
- 4
- CMS overall rating
- 1 of 5
- Health inspection rating
- 2 of 5
- Staffing rating
- 1 of 5
- Quality measure rating
- 3 of 5
CMS figures for University Rehabilitation Center, copied as published; Texas medians are ours.
Facility details
- Address
- 2244 Brinker Road, Denton, TX 76208
- Phone
- (940) 289-3268
- County
- Denton
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Limited Liability company
- Chain (CMS)
- Creative Solutions in Healthcare
- Certified beds
- 146
- Average residents per day
- 116.2
- In Medicare/Medicaid since
- Dec 4, 2003
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How are a resident's goals and preferences written into the care plan? (F656, cited 3 times)
- How does the home assess each resident's fall risk and plan to prevent falls? (F689, cited 3 times)
- How are oxygen equipment and breathing treatments managed and checked? (F695, cited 3 times)
- How quickly is the family called if a resident falls or their condition changes? (F580, cited 2 times)
Other nursing homes in Denton and the same chain
- Vintage Health Care Center
Denton · 52 deficiencies - Cottonwood Nursing & Rehabilitation
Denton · 31 deficiencies - Denton Village by PureHealth
Denton · 26 deficiencies - Denton Rehabilitation and Nursing Center
Denton · 24 deficiencies - Lake Forest Village by PureHealth
Denton · 12 deficiencies - Franklin Heights Nursing & Rehabilitation
El Paso · 76 deficiencies - St. Teresa Nursing & Rehab Center
El Paso · 75 deficiencies - Mountain View Health & Rehabilitation
El Paso · 72 deficiencies - Pleasant Springs Healthcare Center
Mount Pleasant · 66 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.