Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Cottonwood Nursing & Rehabilitation
DENTON, TX · 60 certified beds · Last Life Safety survey August 14, 2025
CMS Certification Number 675292 · first certified March 1994
Ownership
Operated by CREATIVE SOLUTIONS IN HEALTHCARE · For profit - Corporation
- Ownership changed December 1, 2020 (change of ownership)from COTTONWOOD NURSING AND REHABILITATION LP
Position within TX
16 citations — more than 87% 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 3 citations; the earlier surveys on file 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 (September 2026 to October 2026). Most TX facilities have been surveyed by November 2026. This facility’s last Life Safety survey was August 2025. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,923 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 about three years in Virginia. 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 cited for sprinkler inspection and testing in CMS’s current file are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
4 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 16 Life Safety citations above. The Physical Environment Index
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 | 16 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| May 18, 2023 | 9 |
| July 11, 2024 | 4 |
| August 14, 2025 | 3 |
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. | 3 | 2025-08-14 |
| K-0511 | Have properly installed electrical wiring and gas equipment. | 1 | 2023-05-18 |
| K-0344 | Have an alternate power supply for its alarm system. | 1 | 2025-08-14 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 1 | 2023-05-18 |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | 1 | 2024-07-11 |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | 1 | 2024-07-11 |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | 1 | 2023-05-18 |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | 1 | 2023-05-18 |
What the citations cover
- Smoke Deficiencies 8
- Services Deficiencies 4
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Egress Deficiencies 1
- Other 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 8 |
| Services Deficiencies | 4 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 1 |
| Electrical Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
August 14, 2025 — 3 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0344 | Have an alternate power supply for its alarm system. | Deficient, Provider has date of correction (August 15, 2025) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (August 15, 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 (August 15, 2025) |
July 11, 2024 — 4 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0324 | Provide properly protected cooking facilities. | Deficient, Provider has date of correction (August 21, 2024) |
| K-0352 | Properly install and monitor supervisory attachments on automatic sprinkler systems. | Deficient, Provider has date of correction (August 21, 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 (August 21, 2024) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (August 21, 2024) |
May 18, 2023 — 9 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| 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 (June 30, 2023) |
| 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 30, 2023) |
| K-0331 | Construct fire resistant interior walls. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0362 | Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0511 | Have properly installed electrical wiring and gas equipment. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0521 | Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0901 | Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Deficient, Provider has date of correction (June 30, 2023) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (June 30, 2023) |
Reflects the CMS posting of October 1, 2026. Surveys conducted in the last few months may not appear yet.