Cycle 1
Health 2024-12-05 · Fire 2024-12-05
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Denison, TX
Woodlands Place Rehabilitation Suites
4-star overall rating with 3-star inspections with $109,954 in total fines with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
5600 Woodlands Trail, Denison, TX
(903) 462-1200
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
133
Certified beds
Average residents
85
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Fundamental Healthcare
Operator or chain grouping
Approved since
2015-11-23
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
69 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 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
0.55
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.87
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.87
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.29
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.42
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.30
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.07
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.53
CMS adjusted RN staffing hours
Adjusted total hours
3.15
CMS adjusted total nurse staffing hours
Case-mix index
1.43
Higher values indicate more complex resident acuity
RN turnover
30%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
48%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,979
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.84% · Performance 23.83% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.87
Baseline 5.09% · Performance 6.98% · Measure score 2.87 · Achievement 2.87 · Improvement 0
Total nurse turnover
3.55
Baseline 72.45% · Performance 53.19% · Measure score 3.55 · Achievement 2.57 · Improvement 3.55
Adjusted total nurse staffing
0.96
Baseline 3.57 hours · Performance 3.35 hours · Measure score 0.96 · Achievement 0.96 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.96% |
10.72%
1.2 pts worse
|
No Different than the National Rate · Eligible stays 339 · Observed rate 14.16% · Lower 95% interval 9.56% |
| Discharge to community | 60.3% |
50.57%
9.7 pts better
|
Better than the National Rate · Eligible stays 280 · Observed rate 51.79% · Lower 95% interval 54.19% |
| Medicare spending per beneficiary | 1.02 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 197 · Denominator 197 |
| Falls with major injury | 1.02% |
0.77%
0.2 pts worse
|
Numerator 2 · Denominator 197 |
| Discharge self-care score | 46.72% |
53.69%
7 pts worse
|
Numerator 64 · Denominator 137 |
| Discharge mobility score | 46.72% |
50.94%
4.2 pts worse
|
Numerator 64 · Denominator 137 |
| Pressure ulcers or injuries, new or worsened | 1.52% |
2.29%
0.8 pts better
|
Numerator 3 · Denominator 197 · Adjusted rate 2.06% |
| Healthcare-associated infections requiring hospitalization | 6.98% |
7.12%
0.1 pts better
|
No Different than the National Rate · Eligible stays 222 · Observed rate 7.66% · Lower 95% interval 4.66% |
| Staff COVID-19 vaccination coverage | 8.25% |
8.2%
0.1 pts better
|
Numerator 8 · Denominator 97 |
| Staff flu vaccination coverage | 92.78% |
42%
50.8 pts better
|
Numerator 90 · Denominator 97 |
| Discharge function score | 59.12% |
56.45%
2.7 pts better
|
Numerator 81 · Denominator 137 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 160 · Denominator 160 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 22.37% |
25.2%
2.8 pts worse
|
Numerator 17 · Denominator 76 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.9
0.6 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.5 · Observed 2.3 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.2 |
2.1
0.9 pts better
|
1.8
0.6 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.1 · Expected 1.5 · 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 | 3.0% |
3.3%
0.3 pts better
|
3.3%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 4.3% · Q3 4.7% · Q4 1.6% · 4Q avg 3.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
2.7%
2.9 pts worse
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 4.7% · Q3 4.8% · Q4 9.8% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 1.8% |
3.3%
1.5 pts better
|
5.4%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 3.6% · Q3 0.0% · Q4 1.8% · 4Q avg 1.8% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.7% |
18.9%
2.2 pts better
|
19.6%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.0% · Q2 17.2% · Q3 16.7% · Q4 17.9% · 4Q avg 16.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.5% |
10.8%
9.3 pts better
|
16.7%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.1% · Q3 2.2% · Q4 0.0% · 4Q avg 1.5% · 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 | 7.1% |
15.4%
8.3 pts better
|
16.3%
9.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q4 4.6% · 4Q avg 7.1% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 5.9% |
16.1%
10.2 pts better
|
14.9%
9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q2 7.1% · Q3 1.9% · Q4 9.1% · 4Q avg 5.9% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.2% |
0.8%
0.4 pts worse
|
1.7%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.0% · Q2 1.5% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.6% |
15.0%
2.4 pts better
|
19.8%
7.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 17.9% · Q3 7.3% · Q4 8.4% · 4Q avg 12.6% |
| Percentage of long-stay residents with pressure ulcers | 3.6% |
4.2%
0.6 pts better
|
5.1%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 5.5% · Q3 3.0% · Q4 4.4% · 4Q avg 3.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.4% |
89.7%
9.7 pts better
|
81.7%
17.7 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.4% · Q2 99.3% · Q3 99.4% · Q4 99.4% · 4Q avg 99.4% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.4% |
12.0%
2.6 pts better
|
12.0%
2.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.4% · Observed 10.1% · Expected 12.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.8% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 94.0% |
88.0%
6 pts better
|
79.7%
14.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 94.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 24.6% |
25.9%
1.3 pts better
|
23.9%
0.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 24.6% · Observed 27.3% · Expected 26.5% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-11-16 · Fire 2023-11-16
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-09-22 · Fire 2022-09-22
5 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-05
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2024-12-06
F · Potential for more than minimal harm
2024-12-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-23
F · Potential for more than minimal harm
2024-12-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-12-10
E · Potential for more than minimal harm
2024-12-05
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2024-12-12
E · Potential for more than minimal harm
2024-12-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-01-06
E · Potential for more than minimal harm
2024-12-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2025-01-05
E · Potential for more than minimal harm
2024-12-05
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-12-06
D · Potential for more than minimal harm
2023-11-16
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-12-16
F · Potential for more than minimal harm
2022-09-22
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2022-10-26
D · Potential for more than minimal harm
2022-09-22
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-10-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-12-23
F551 · Resident Rights Deficiencies
Health
Give the resident's representative the ability to exercise the resident's rights.
Corrected 2025-12-28
D · Potential for more than minimal harm
2025-12-23
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 2026-01-28
G · Actual harm
2025-10-22
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
E · Potential for more than minimal harm
2024-12-05
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 2024-12-12
E · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-12
D · Potential for more than minimal harm
2024-12-05
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 2024-12-12
J · Immediate jeopardy
2024-04-18
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-04-19
J · Immediate jeopardy
2024-04-18
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 2024-04-19
J · Immediate jeopardy
2024-04-18
F777 · Administration Deficiencies
Health
Provide or obtain x-rays/tests when ordered and promptly tell the ordering practitioner of the results.
Corrected 2024-04-19
E · Potential for more than minimal harm
2023-11-16
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2023-12-15
D · Potential for more than minimal harm
2023-11-16
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-11-16
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 2023-12-16
D · Potential for more than minimal harm
2023-11-16
F790 · Quality of Life and Care Deficiencies
Health
Provide routine and 24-hour emergency dental care for each resident.
Corrected 2023-12-16
D · Potential for more than minimal harm
2023-07-11
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-12
D · Potential for more than minimal harm
2023-07-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-07
E · Potential for more than minimal harm
2022-09-22
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 2022-10-21
D · Potential for more than minimal harm
2022-09-22
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2022-10-15
D · Potential for more than minimal harm
2022-09-22
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-09-26
Penalties and ownership
What sits behind the stars
$109,954
2024-04-18
Fine
Fine · fine $109,954
Fine
Ownership
Fannin County Hospital Authority
5% Or Greater Direct Ownership Interest · Organization
Denison Long Term Care, LLC
Operational/Managerial Control · Organization
Garvin, Clifford
Operational/Managerial Control · Individual
Sanderson, Clark
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
The Terrace At Denison
Denison, TX
2-star overall rating with 2-star inspections with $47,097 in total fines with 14 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#2
Denison Nursing And Rehab
Denison, TX
2-star overall rating with 2-star inspections with $8,281 in total fines with 20 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
#3
The Homestead of Denison
Denison, TX
1-star overall rating with 2-star inspections with abuse icon flag with $29,789 in total fines with 8 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
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