Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
DENISON NURSING AND REHAB
DENISON, TX · 71 certified beds · Last Life Safety survey July 2, 2025
CMS Certification Number 455563 · first certified October 1985
Ownership
Independently operated (no chain recorded by CMS) · For profit - Limited Liability company
- Ownership changed March 1, 2021 (change of ownership)from DENISON NURSING AND REHABILITATION LP
Position within TX
17 citations — more than 91% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 4 citations; the earlier surveys in the window averaged 6.5. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
Past the typical window (August 2026 to September 2026). Most TX facilities have been surveyed by September 2026. This facility’s last Life Safety survey was July 2025. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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1 inspection-and-testing tag has been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Emergency preparedness
3 of the 17 citations on file are Emergency Preparedness E-tags. E-tags are cited under 42 CFR §483.73 and concern the emergency plan, training, drills, communications and supplies. Nationally about half of certified facilities have at least one. The Emergency Preparedness Index
Physical environment (health survey)
5 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 17 Life Safety citations above. The Physical Environment Index
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 17 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| February 16, 2023 | 10 |
| May 16, 2024 | 3 |
| July 2, 2025 | 4 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | 2 | 2025-07-02 |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | 2 | 2025-07-02 |
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | 1 | 2023-02-16 |
| E-0020 | Establish policies and procedures including evacuation. | 1 | 2023-02-16 |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | 1 | 2023-02-16 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2023-02-16 |
| K-0363 | Install corridor and hallway doors that block smoke. | 1 | 2023-02-16 |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | 1 | 2023-02-16 |
What the citations cover
- Smoke Deficiencies 4
- Services Deficiencies 3
- Miscellaneous Deficiencies 3
- Emergency Preparedness Deficiencies 3
- Other 4
| Category | Citations |
|---|---|
| Smoke Deficiencies | 4 |
| Services Deficiencies | 3 |
| Miscellaneous Deficiencies | 3 |
| Emergency Preparedness Deficiencies | 3 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 2 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
July 2, 2025 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0211 | Keep aisles, corridors, and exits free of obstruction in case of emergency. | Deficient, Provider has date of correction (August 7, 2025) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (July 25, 2025) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (July 31, 2025) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (July 25, 2025) |
May 16, 2024 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (June 10, 2024) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 10, 2024) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (May 17, 2024) |
February 16, 2023 — 10 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| E-0004 | Develop and maintain an Emergency Preparedness Program (EP). | Deficient, Provider has date of correction (March 13, 2023) |
| E-0006 | Conduct risk assessment and an All-Hazards approach. | Deficient, Provider has date of correction (March 13, 2023) |
| E-0020 | Establish policies and procedures including evacuation. | Deficient, Provider has date of correction (March 13, 2023) |
| K-0222 | 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. | Deficient, Provider has date of correction (February 27, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (March 1, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (February 20, 2023) |
| K-0712 | Have simulated fire drills held at unexpected times. | Deficient, Provider has date of correction (March 13, 2023) |
| K-0741 | Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Deficient, Provider has date of correction (March 10, 2023) |
| K-0916 | Have a battery powered remote alarm panel in a location accessible by operating personnel. | Deficient, Provider has date of correction (February 27, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (March 13, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.