University Rehabilitation Center
Denton, Denton County, Texas · CCN 675995 · For-profit (LLC) · part of Creative Solutions In Healthcare (149 facilities, chain average 2.1 stars)
CMS rates University Rehabilitation Center 1 of 5 overall as of August 2026. 146 certified beds, 116 residents a day on average. 38 citations on record from the current inspection cycles, 5 at immediate jeopardy; 2 fines totalling $33,117.
CMS’s ratings
The Five-Star Quality Rating System, as CMS publishes it. Where CMS gives no rating, the reason CMS gives is printed instead.
| Overall | ★☆☆☆☆ 1 of 5 |
|---|---|
| Health inspections | ★★☆☆☆ 2 of 5 |
| Staffing | ★☆☆☆☆ 1 of 5 |
| Quality measures | ★★★☆☆ 3 of 5 |
| Quality: long-stay / short-stay | 3 / 3 of 5 |
Staffing
| Total nurse staffing | 3.35828 hours per resident per day |
|---|---|
| Registered nurses | 0.41243 hours per resident per day |
| Weekend total | 2.98292 hours per resident per day |
| Nursing staff turnover | 88.2% (registered nurses 80%) |
| Administrators who left | 4 |
Citations from health inspections
Each is a finding by a state surveyor on the date shown, in CMS’s words. The severity is CMS’s scope-and-severity grid, spelled out: harm on the left, how widespread on the right.
| Survey | Finding | Severity | Status |
|---|---|---|---|
| 2026-04-23 complaint survey |
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Freedom from Abuse, Neglect, and Exploitation Deficiencies · tag F0609 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-24 |
| 2026-04-23 complaint survey |
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 · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-24 |
| 2026-04-23 complaint survey |
Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2026-04-24 |
| 2025-12-11 complaint survey |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-12-12 |
| 2025-09-11 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
J Immediate jeopardy to resident health or safety; isolated | Past Non-Compliance 2025-07-13 |
| 2025-09-11 complaint survey |
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 · tag F0656 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-09-12 |
| 2025-09-11 complaint survey |
Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-09-12 |
| 2025-04-17 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-18 |
| 2025-04-17 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-04-18 |
| 2025-04-17 | Keep residents' personal and medical records private and confidential. Resident Rights Deficiencies · tag F0583 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-18 |
| 2025-04-17 | 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 · tag F0584 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-04-18 |
| 2025-02-26 complaint survey |
Provide appropriate pressure ulcer care and prevent new ulcers from developing. Quality of Life and Care Deficiencies · tag F0686 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2025-02-28 |
| 2025-02-26 complaint survey |
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. Resident Rights Deficiencies · tag F0561 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2024-12-18 |
| 2025-02-26 complaint survey |
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 · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2025-02-28 |
| 2024-12-02 complaint survey |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Quality of Life and Care Deficiencies · tag F0689 |
D No actual harm, with potential for more than minimal harm; isolated | Past Non-Compliance 2024-10-31 |
| 2024-02-28 complaint survey |
Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-28 complaint survey |
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them. Administration Deficiencies · tag F0776 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-28 | 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 · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-28 | Reasonably accommodate the needs and preferences of each resident. Resident Rights Deficiencies · tag F0558 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-28 | 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 · tag F0580 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-28 | PASARR screening for Mental disorders or Intellectual Disabilities Resident Assessment and Care Planning Deficiencies · tag F0645 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-28 | 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 · tag F0656 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-28 | 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 · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-29 |
| 2024-02-28 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Pharmacy Service Deficiencies · tag F0755 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2024-02-29 |
| 2023-11-15 complaint survey |
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 · tag F0842 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-16 |
| 2023-11-15 complaint survey |
Provide and implement an infection prevention and control program. Infection Control Deficiencies · tag F0880 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2023-11-16 |
| 2023-11-15 complaint survey |
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 · tag F0657 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2023-11-16 |
| 2022-12-02 | 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 · tag F0580 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2022-12-23 |
| 2022-12-02 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. Quality of Life and Care Deficiencies · tag F0684 |
J Immediate jeopardy to resident health or safety; isolated | Deficient, Provider has date of correction 2022-12-23 |
| 2022-12-02 | 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 · tag F0584 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-12-23 |
| 2022-12-02 | 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 · tag F0678 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-12-23 |
| 2022-12-02 | 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 · tag F0761 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-12-23 |
| 2022-12-02 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Nutrition and Dietary Deficiencies · tag F0812 |
E No actual harm, with potential for more than minimal harm; pattern | Deficient, Provider has date of correction 2022-12-23 |
| 2022-12-02 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. Resident Assessment and Care Planning Deficiencies · tag F0644 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-12-23 |
| 2022-12-02 | Provide appropriate foot care. Quality of Life and Care Deficiencies · tag F0687 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-12-23 |
| 2022-12-02 | 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 · tag F0690 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-12-23 |
| 2022-12-02 | Provide safe and appropriate respiratory care for a resident when needed. Quality of Life and Care Deficiencies · tag F0695 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-12-23 |
| 2022-12-02 | 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 · tag F0800 |
D No actual harm, with potential for more than minimal harm; isolated | Deficient, Provider has date of correction 2022-12-23 |
Fines and payment denials
| Date | Penalty | Amount |
|---|---|---|
| 2025-09-11 | Fine | $14,316 |
| 2024-02-28 | Fine | $18,801 |
Who owns and runs it
Every owner, officer and manager CMS lists, as filed. These are the names in CMS’s ownership record; anyone named in the ownership record can ask about it on the about page.
| Name | Role | Share | Since |
|---|---|---|---|
| Denton II Enterprises LLC Organization | operational/managerial control | — | 2023-12-01 |
| Huggins, Linda Individual | corporate director | — | 2023-12-01 |
| Mak, David Individual | corporate officer | — | 2021-05-17 |
| Blake, Gary Individual | operational/managerial control | — | 2023-12-01 |
| Blake, Malisa Individual | operational/managerial control | — | 2023-12-01 |
What changed
Nothing has changed in this record since it was first loaded. The next CMS refresh is the next chance.
Tell me when this record changes
One email when the monthly CMS refresh brings a new citation, a fine or payment denial, a rating change, a flag, or a change of ownership for University Rehabilitation Center.
Source: Centers for Medicare & Medicaid Services, Provider Data Catalog (public domain), files dated 2026-08-01. Ratings are CMS’s; citations are state surveyors’ findings; nothing here is estimated or a recommendation. Every nursing home in Denton County.