Cycle 1
Health 2025-09-19 · Fire 2025-09-19
13 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
Denton, TX
Denton Village by PureHealth
2-star overall rating with 2-star inspections with abuse icon flag with $83,355 in total fines with 13 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
2500 Hinkle Dr, Denton, TX
(940) 383-2651
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
88
Certified beds
Average residents
55
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Purehealth
Operator or chain grouping
Approved since
1986-02-13
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
8 facilities
Chain averages 3 overall / 3 health / 4 staffing / 5 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
1.01
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.16
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
4.40
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
2.18
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.93
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
1.14
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.22
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.99
CMS adjusted RN staffing hours
Adjusted total hours
4.28
CMS adjusted total nurse staffing hours
Case-mix index
1.41
Higher values indicate more complex resident acuity
RN turnover
36%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
41%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
6,721
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
31.90
Composite VBP score used to determine payment impact.
Payment multiplier
0.9868
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 17.82% · Performance 23.86% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
3.41
Baseline 4.88% · Performance 6.82% · Measure score 3.41 · Achievement 3.41 · Improvement 0
Total nurse turnover
4.71
Baseline 40.00% · Performance 44.44% · Measure score 4.71 · Achievement 4.71 · Improvement 0
Adjusted total nurse staffing
4.65
Baseline 3.72 hours · Performance 4.4 hours · Measure score 4.65 · Achievement 4.65 · Improvement 2.8
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.41% |
10.72%
0.7 pts worse
|
No Different than the National Rate · Eligible stays 230 · Observed rate 10.43% · Lower 95% interval 8.21% |
| Discharge to community | 60.14% |
50.57%
9.6 pts better
|
Better than the National Rate · Eligible stays 209 · Observed rate 58.37% · Lower 95% interval 53.06% |
| Medicare spending per beneficiary | 0.93 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 82.14% |
95.27%
13.1 pts worse
|
Numerator 115 · Denominator 140 |
| Falls with major injury | 0.71% |
0.77%
0.1 pts better
|
Numerator 1 · Denominator 140 |
| Discharge self-care score | 48.11% |
53.69%
5.6 pts worse
|
Numerator 51 · Denominator 106 |
| Discharge mobility score | 51.89% |
50.94%
1 pts better
|
Numerator 55 · Denominator 106 |
| Pressure ulcers or injuries, new or worsened | 0.71% |
2.29%
1.6 pts better
|
Numerator 1 · Denominator 140 · Adjusted rate 0.89% |
| Healthcare-associated infections requiring hospitalization | 6.82% |
7.12%
0.3 pts better
|
No Different than the National Rate · Eligible stays 117 · Observed rate 5.13% · Lower 95% interval 4.2% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 134 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 64.15% |
56.45%
7.7 pts better
|
Numerator 68 · Denominator 106 |
| Transfer of health information to provider | 73.26% |
95.95%
22.7 pts worse
|
Numerator 63 · Denominator 86 |
| Transfer of health information to patient | 88.89% |
96.28%
7.4 pts worse
|
Numerator 40 · Denominator 45 |
| Resident COVID-19 vaccinations up to date | 15% |
25.2%
10.2 pts worse
|
Numerator 12 · Denominator 80 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 3.3 |
2.1
1.2 pts worse
|
1.9
1.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 3.3 · Observed 2.2 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 5.2% |
3.3%
1.9 pts worse
|
3.3%
1.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 3.0% · Q3 5.9% · Q4 9.4% · 4Q avg 5.2% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 4.1% |
3.3%
0.8 pts worse
|
5.4%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 3.7% · Q4 14.3% · 4Q avg 4.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.5% |
18.9%
1.4 pts better
|
19.6%
2.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 15.4% · Q3 17.9% · Q4 28.6% · 4Q avg 17.5% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.6% |
10.8%
7.2 pts better
|
16.7%
13.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.2% · Q2 4.3% · Q3 5.0% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 17.7% |
15.4%
2.3 pts worse
|
16.3%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 17.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.3% |
16.1%
0.2 pts worse
|
14.9%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 18.5% · Q2 16.0% · Q3 23.1% · Q4 5.0% · 4Q avg 16.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.4% |
0.5%
0.9 pts worse
|
1.0%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.6% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.8% |
0.8%
About the same
|
1.7%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.8% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
15.0%
10.4 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.4% · Q2 34.2% · Q3 21.1% · Q4 21.4% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
4.2%
1.1 pts worse
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.5% · Q3 4.9% · Q4 9.8% · 4Q avg 5.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
89.7%
2.6 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 95.3% · Q2 92.3% · Q3 94.7% · Q4 87.1% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.5% |
12.0%
0.5 pts better
|
12.0%
0.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.5% · Observed 10.7% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.5% |
1.5%
About the same
|
1.6%
0.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 1.2% · Q2 2.5% · Q3 1.3% · Q4 0.7% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.0% |
88.0%
About the same
|
79.7%
8.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.1% |
25.9%
1.2 pts worse
|
23.9%
3.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.1% · Observed 24.4% · Expected 21.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-22 · Fire 2024-08-22
11 health deficiencies
Top issue: Resident Rights (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-07-20 · Fire 2023-07-20
2 health deficiencies
Top issue: Environmental (1 deficiency)
7 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-19
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-10-10
F · Potential for more than minimal harm
2023-07-20
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-07-20
K133 · Construction Deficiencies
Fire Safety
Install a two-hour-resistant firewall separation.
Corrected 2023-08-31
F · Potential for more than minimal harm
2023-07-20
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-08-31
E · Potential for more than minimal harm
2023-07-20
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-20
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-20
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-08-31
D · Potential for more than minimal harm
2023-07-20
K917 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure electrical receptacles or cover plates have distinctive color or marking.
Corrected 2023-08-31
Inspection history
Recent health citations
K · Immediate jeopardy
2025-11-18
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-11-18
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-11-19
D · Potential for more than minimal harm
2025-11-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-11-19
E · Potential for more than minimal harm
2025-09-19
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-19
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-19
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-19
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-19
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-25
E · Potential for more than minimal harm
2025-09-19
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-19
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-19
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-19
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2025-09-25
D · Potential for more than minimal harm
2025-09-19
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-09-25
E · Potential for more than minimal harm
2024-08-22
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-22
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-22
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-22
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-09-26
E · Potential for more than minimal harm
2024-08-22
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-22
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-22
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-22
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-22
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-09-26
D · Potential for more than minimal harm
2024-08-22
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-09-26
D · Potential for more than minimal harm
2023-07-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-08-22
D · Potential for more than minimal harm
2023-07-20
F908 · Environmental Deficiencies
Health
Keep all essential equipment working safely.
Corrected 2023-08-22
Penalties and ownership
What sits behind the stars
$83,355
2025-09-19
Fine
Fine · fine $83,355
Fine
Ownership
Dv Ops Denton LLC
5% Or Greater Direct Ownership Interest · Organization
Bell, Kevin
5% Or Greater Indirect Ownership Interest · Individual
Bradshaw, Dasa
Operational/Managerial Control · Individual
Bradshaw, Dasa
Corporate Director · Individual
Campion, Robert
5% Or Greater Indirect Ownership Interest · Individual
Campion, Robert
Operational/Managerial Control · Individual
Kccj1 Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Lbei Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Management Mcoa LLC
Operational/Managerial Control · Organization
Narreddy, Neelima
Operational/Managerial Control · Individual
Narreddy, Neelima
Corporate Director · Individual
Overhead Ops Investments Iii LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
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Cottonwood Nursing And Rehabilitation
Denton, TX
2-star overall rating with 3-star inspections with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Vintage Health Care Center
Denton, TX
1-star overall rating with 1-star inspections with Special Focus status with $252,332 in total fines with 18 recent health deficiencies with 8 fire-safety deficiencies in the latest cycle
#3
University Rehabilitation Center
Denton, TX
1-star overall rating with 2-star inspections with $40,446 in total fines with 8 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
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