SFF Candidate CCRC

Overview

Address
205 N Bonnie Brae, Denton, TX 76201
Phone
9403734766
Certified beds
106
Avg daily residents
82 (78% of beds filled)
Ownership
For-profit corporation
Provider type
Medicare and Medicaid
Medicare/Medicaid since
2002-12-03
Setting
Urban
1 /5
CMS Overall Rating

CMS 5-Star Ratings

CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.

Overall Rating
Composite of Health Inspection, Staffing, and Quality Measures.
1/5
Health Inspection
Based on the three most recent standard surveys, with more weight on recent results.
1/5
Staffing
Weighted combination of RN and total nurse staffing hours per resident per day, case-mix adjusted.
2/5
Quality Measures
15 resident-level quality measures split between long-stay and short-stay (post-acute) residents.
3/5
Quality Measures breakdown
Long-Stay Quality Measures 3/5
Short-Stay Quality Measures 3/5

Staffing & Workforce

Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.

Role Reported Case-mix expected Adjusted Federal floor
Total nurse
All nursing staff combined: RN + LPN + Aide
2.99 3.33 3.46 ≥ 3.48 Below floor
Registered Nurse (RN)
Licensed RN hours. Strongest driver of clinical outcomes.
0.36 0.58 0.42 ≥ 0.55 Below floor
Licensed Practical Nurse (LPN)
LPN/LVN hours. Often handles medication administration.
0.62 0.74 0.72
Nurse aide
CNA hours. Bulk of direct resident care — bathing, feeding, mobility.
2.00 2.01 2.32
Licensed (RN + LPN)
Combined licensed nurse coverage.
0.99
Physical therapist
Rehabilitation therapist hours — important for post-acute / rehab admissions.
0.07

Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.

Weekend staffing

Total nurse (weekend)
2.54
hrs / resident / day
RN (weekend)
0.28
hrs / resident / day
Total nurse (adjusted, weekend)
2.94
hrs / resident / day

Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.

Staff turnover

Total nursing staff turnover
44.6%
annual
RN turnover
55.6%
annual
Administrators departed
0
last 12 months

Resident acuity

Nursing Case-Mix Index
1.18
higher acuity than avg
Case-Mix Index Ratio
0.86
facility / state ratio

Health Inspections

CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.

Cycle Date Total defs. Standard Complaint Deficiency score Revisits Total score
Cycle 1 (most recent) 2024-11-27 18 6 15 534 1 534
Cycle 2/3 (prior) 2023-10-05 23 14 13 253 1 253
Total weighted health score
463.8
lower is better
Infection-control citations
0
last cycle

Deficiencies (43)

Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).

36 D/E/F Actual harm — potential for minor
7 J/K/L Immediate jeopardy
Tag Description Scope/Severity Survey date Corrected
0583 Keep residents' personal and medical records private and confidential. E 2025-12-05 2025-12-06
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2025-11-26 2025-11-27
0761 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. E 2025-11-26 2025-11-27
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. K 2025-07-30 2025-07-31
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. K 2025-07-30 2025-07-31
0880 Provide and implement an infection prevention and control program. D 2025-07-30 2025-07-31
0558 Reasonably accommodate the needs and preferences of each resident. D 2025-05-20 2025-05-21
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2025-05-20 2025-05-21
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2025-04-27 2025-04-28
0677 Provide care and assistance to perform activities of daily living for any resident who is unable. D 2025-04-27 2025-04-28
0690 Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. D 2025-04-27 2025-04-28
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. J 2025-04-21 2025-03-07
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2024-11-27 2024-11-28
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. D 2024-11-27 2024-11-28
0880 Provide and implement an infection prevention and control program. E 2024-11-27 2024-11-28
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. K 2024-11-27 2024-11-28
0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted D 2024-11-27 2024-11-28
0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. K 2024-11-27 2024-11-28
0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. F 2024-06-12 2024-06-14
0604 Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. D 2024-01-31 2024-02-19
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2024-01-31 2024-02-19
0558 Reasonably accommodate the needs and preferences of each resident. D 2023-10-05 2023-10-06
0584 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. E 2023-10-05 2023-10-06
0635 Provide doctor's orders for the resident's immediate care at the time the resident was admitted. D 2023-10-05 2023-10-06
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. D 2023-10-05 2023-10-06
0657 Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. D 2023-10-05 2023-10-06
0660 Plan the resident's discharge to meet the resident's goals and needs. D 2023-10-05 2023-10-06
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2023-10-05 2023-10-06
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2023-10-05 2023-10-06
0727 Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. F 2023-10-05 2023-10-06
0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. E 2023-10-05 2023-10-06
0580 Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. E 2023-10-05 2023-10-06
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. E 2023-10-05 2023-10-06
0760 Ensure that residents are free from significant medication errors. D 2023-10-05 2023-10-06
0880 Provide and implement an infection prevention and control program. E 2023-10-05 2023-10-06
0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. J 2023-08-23 2023-08-24
0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. J 2023-08-23 2023-08-24
0622 Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. D 2023-08-10 2023-08-16
0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. D 2023-08-10 2023-08-16
0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. D 2023-07-24 2023-08-24
0695 Provide safe and appropriate respiratory care for a resident when needed. D 2023-05-01 2023-05-31
0842 Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. D 2022-08-04 2022-08-29
0919 Make sure that a working call system is available in each resident's bathroom and bathing area. D 2022-08-04 2022-08-29

Penalties (4)

Fines issued
4
last 3 years
Total fines
$252,332
Date Type Fine amount
2023-07-24 Fine $8,400
2025-04-21 Fine $10,513
2024-11-27 Fine $34,860
2025-07-30 Fine $198,559

Source: CMS Nursing Home Penalties.

Financial Health (FY 2023)

Payer mix (share of resident days)

Medicare 8.5% Medicaid 66.8% Other 24.7%

Operating performance

Operating Margin
-39.1%
Total Margin
-16.6%
Occupancy Rate
62.8%
Cost per Resident Day
$41

Revenue & costs

Net Patient Revenue
$5.7M
Total Costs
$912K
Net Income
-$1.1M

Balance sheet

Total Assets
-$6K
Total Liabilities
$785K
Fund Balance
-$790K
Current Ratio
0.00

Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.

Ownership & Corporate Structure

Chain: CREATIVE SOLUTIONS IN HEALTHCARE

Chain ID
169
Facilities in chain
149
Legal business name
WEST WHARTON COUNTY HOSPITAL DISTRICT
Chain-average star ratings (for peer context)
Overall
2.7
Health
2.7
Staffing
2.0
QM
3.6

Owner / manager organizations (2)

Organization Role Association
WEST WHARTON COUNTY HOSPITAL DISTRICT 5% OR GREATER DIRECT OWNERSHIP INTEREST since 12/01/2023
DENTON III ENTERPRISES LLC OPERATIONAL/MANAGERIAL CONTROL since 12/01/2023

Owner / manager individuals (6)

Name Role Association
BLAKE, GARY OPERATIONAL/MANAGERIAL CONTROL since 12/01/2023
BLAKE, MALISA OPERATIONAL/MANAGERIAL CONTROL since 12/01/2023
HUGGINS, LINDA CORPORATE DIRECTOR since 12/01/2023
MAK, DAVID CORPORATE OFFICER since 05/17/2021
NARREDDY, NEELIMA CONTRACTED MANAGING EMPLOYEE since 12/01/2023
PARHAM, ANDREW W-2 MANAGING EMPLOYEE since 12/01/2023

Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.

Facility Features

CCRC
Yes
Hospital-based
No
Resident / family council
Resident
Sprinkler systems
Yes
Special focus status
SFF Candidate
Abuse citation flag
No
Methodology & sources

Full methodology →

All Data

Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.

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Show 113 rows
Source Metric Value Raw key
Cost Report Cost per Resident Day ($) $41 metrics.cost_per_resident_day
Cost Report Current Ratio 0 metrics.current_ratio
Cost Report fiscal_year 2,023 fiscal_year
Cost Report Medicaid Day Share (%) 66.8% metrics.medicaid_day_share
Cost Report Medicare Day Share (%) 8.5% metrics.medicare_day_share
Cost Report Net Income ($) $-1,121,301 metrics.net_income
Cost Report Net Patient Revenue ($) $5,662,339 metrics.net_patient_revenue
Cost Report Occupancy Rate (%) 62.8% metrics.occupancy_rate
Cost Report Operating Margin (%) -39.1% metrics.operating_margin
Cost Report Total Assets ($) $-5,657 metrics.total_assets
Cost Report Total Costs ($) $912,470 metrics.total_costs
Cost Report Total Fund Balances ($) $-790,271 metrics.fund_balance
Cost Report Total Liabilities ($) $784,614 metrics.total_liabilities
Cost Report Total Margin (%) -16.6% metrics.total_margin
Provider Information Abuse Icon N Abuse Icon
Provider Information Adjusted LPN Staffing Hours per Resident per Day 0.72140 Adjusted LPN Staffing Hours per Resident per Day
Provider Information Adjusted Nurse Aide Staffing Hours per Resident per Day 2.31861 Adjusted Nurse Aide Staffing Hours per Resident per Day
Provider Information Adjusted RN Staffing Hours per Resident per Day 0.42094 Adjusted RN Staffing Hours per Resident per Day
Provider Information Adjusted Total Nurse Staffing Hours per Resident per Day 3.46096 Adjusted Total Nurse Staffing Hours per Resident per Day
Provider Information Adjusted Weekend Total Nurse Staffing Hours per Resident per Day 2.93835 Adjusted Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Administrator turnover footnote Administrator turnover footnote
Provider Information Automatic Sprinkler Systems in All Required Areas Yes Automatic Sprinkler Systems in All Required Areas
Provider Information Average Number of Residents per Day 82.2 Average Number of Residents per Day
Provider Information Average Number of Residents per Day Footnote Average Number of Residents per Day Footnote
Provider Information Case-Mix LPN Staffing Hours per Resident per Day 0.73989 Case-Mix LPN Staffing Hours per Resident per Day
Provider Information Case-Mix Nurse Aide Staffing Hours per Resident per Day 2.01087 Case-Mix Nurse Aide Staffing Hours per Resident per Day
Provider Information Case-Mix RN Staffing Hours per Resident per Day 0.58320 Case-Mix RN Staffing Hours per Resident per Day
Provider Information Case-Mix Total Nurse Staffing Hours per Resident per Day 3.33396 Case-Mix Total Nurse Staffing Hours per Resident per Day
Provider Information Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day 2.93853 Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day
Provider Information Chain Average Health Inspection Rating 2.7 Chain Average Health Inspection Rating
Provider Information Chain Average Overall 5-star Rating 2.7 Chain Average Overall 5-star Rating
Provider Information Chain Average QM Rating 3.6 Chain Average QM Rating
Provider Information Chain Average Staffing Rating 2.0 Chain Average Staffing Rating
Provider Information Chain ID 169 Chain ID
Provider Information Chain Name CREATIVE SOLUTIONS IN HEALTHCARE Chain Name
Provider Information City/Town Denton City/Town
Provider Information CMS Certification Number (CCN) 675939 CMS Certification Number (CCN)
Provider Information Continuing Care Retirement Community Y Continuing Care Retirement Community
Provider Information County/Parish Denton County/Parish
Provider Information Date First Approved to Provide Medicare and Medicaid Services 2002-12-03 Date First Approved to Provide Medicare and Medicaid Services
Provider Information Geocoding Footnote Geocoding Footnote
Provider Information Health Inspection Rating 1 Health Inspection Rating
Provider Information Health Inspection Rating Footnote Health Inspection Rating Footnote
Provider Information Latitude 33.2159 Latitude
Provider Information Legal Business Name WEST WHARTON COUNTY HOSPITAL DISTRICT Legal Business Name
Provider Information Location 205 N Bonnie Brae,Denton,TX,76201 Location
Provider Information Long-Stay QM Rating 3 Long-Stay QM Rating
Provider Information Long-Stay QM Rating Footnote Long-Stay QM Rating Footnote
Provider Information Longitude -97.161 Longitude
Provider Information Most Recent Health Inspection More Than 2 Years Ago N Most Recent Health Inspection More Than 2 Years Ago
Provider Information Number of administrators who have left the nursing home 0 Number of administrators who have left the nursing home
Provider Information Number of Certified Beds 106 Number of Certified Beds
Provider Information Number of Citations from Infection Control Inspections 0 Number of Citations from Infection Control Inspections
Provider Information Number of Facilities in Chain 149 Number of Facilities in Chain
Provider Information Number of Fines 4 Number of Fines
Provider Information Number of Payment Denials 0 Number of Payment Denials
Provider Information Nursing Case-Mix Index 1.18107 Nursing Case-Mix Index
Provider Information Nursing Case-Mix Index Ratio 0.85731 Nursing Case-Mix Index Ratio
Provider Information Overall Rating 1 Overall Rating
Provider Information Overall Rating Footnote Overall Rating Footnote
Provider Information Ownership Type For profit - Corporation Ownership Type
Provider Information Physical Therapist Staffing Footnote Physical Therapist Staffing Footnote
Provider Information Processing Date 2026-03-01 Processing Date
Provider Information Provider Address 205 N Bonnie Brae Provider Address
Provider Information Provider Changed Ownership in Last 12 Months N Provider Changed Ownership in Last 12 Months
Provider Information Provider Name Vintage Health Care Center Provider Name
Provider Information Provider Resides in Hospital N Provider Resides in Hospital
Provider Information Provider SSA County Code 410 Provider SSA County Code
Provider Information Provider Type Medicare and Medicaid Provider Type
Provider Information QM Rating 3 QM Rating
Provider Information QM Rating Footnote QM Rating Footnote
Provider Information Rating Cycle 1 Health Deficiency Score 534 Rating Cycle 1 Health Deficiency Score
Provider Information Rating Cycle 1 Health Revisit Score 0 Rating Cycle 1 Health Revisit Score
Provider Information Rating Cycle 1 Number of Complaint Health Deficiencies 15 Rating Cycle 1 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 1 Number of Health Revisits 1 Rating Cycle 1 Number of Health Revisits
Provider Information Rating Cycle 1 Number of Standard Health Deficiencies 6 Rating Cycle 1 Number of Standard Health Deficiencies
Provider Information Rating Cycle 1 Standard Survey Health Date 2024-11-27 Rating Cycle 1 Standard Survey Health Date
Provider Information Rating Cycle 1 Total Health Score 534 Rating Cycle 1 Total Health Score
Provider Information Rating Cycle 1 Total Number of Health Deficiencies 18 Rating Cycle 1 Total Number of Health Deficiencies
Provider Information Rating Cycle 2 Number of Standard Health Deficiencies 14 Rating Cycle 2 Number of Standard Health Deficiencies
Provider Information Rating Cycle 2 Standard Health Survey Date 2023-10-05 Rating Cycle 2 Standard Health Survey Date
Provider Information Rating Cycle 2/3 Health Deficiency Score 253 Rating Cycle 2/3 Health Deficiency Score
Provider Information Rating Cycle 2/3 Health Revisit Score 0 Rating Cycle 2/3 Health Revisit Score
Provider Information Rating Cycle 2/3 Number of Complaint Health Deficiencies 13 Rating Cycle 2/3 Number of Complaint Health Deficiencies
Provider Information Rating Cycle 2/3 Number of Health Revisits 1 Rating Cycle 2/3 Number of Health Revisits
Provider Information Rating Cycle 2/3 Total Health Score 253 Rating Cycle 2/3 Total Health Score
Provider Information Rating Cycle 2/3 Total Number of Health Deficiencies 23 Rating Cycle 2/3 Total Number of Health Deficiencies
Provider Information Registered Nurse hours per resident per day on the weekend 0.28136 Registered Nurse hours per resident per day on the weekend
Provider Information Registered Nurse turnover 55.6 Registered Nurse turnover
Provider Information Registered Nurse turnover footnote Registered Nurse turnover footnote
Provider Information Reported Licensed Staffing Hours per Resident per Day 0.98643 Reported Licensed Staffing Hours per Resident per Day
Provider Information Reported LPN Staffing Hours per Resident per Day 0.62294 Reported LPN Staffing Hours per Resident per Day
Provider Information Reported Nurse Aide Staffing Hours per Resident per Day 2.00215 Reported Nurse Aide Staffing Hours per Resident per Day
Provider Information Reported Physical Therapist Staffing Hours per Resident Per Day 0.06563 Reported Physical Therapist Staffing Hours per Resident Per Day
Provider Information Reported RN Staffing Hours per Resident per Day 0.36349 Reported RN Staffing Hours per Resident per Day
Provider Information Reported Staffing Footnote Reported Staffing Footnote
Provider Information Reported Total Nurse Staffing Hours per Resident per Day 2.98858 Reported Total Nurse Staffing Hours per Resident per Day
Provider Information Short-Stay QM Rating 3 Short-Stay QM Rating
Provider Information Short-Stay QM Rating Footnote Short-Stay QM Rating Footnote
Provider Information Special Focus Status SFF Candidate Special Focus Status
Provider Information Staffing Rating 2 Staffing Rating
Provider Information Staffing Rating Footnote Staffing Rating Footnote
Provider Information State TX State
Provider Information Telephone Number 9403734766 Telephone Number
Provider Information Total Amount of Fines in Dollars 252332.00 Total Amount of Fines in Dollars
Provider Information Total number of nurse staff hours per resident per day on the weekend 2.53730 Total number of nurse staff hours per resident per day on the weekend
Provider Information Total Number of Penalties 4 Total Number of Penalties
Provider Information Total nursing staff turnover 44.6 Total nursing staff turnover
Provider Information Total nursing staff turnover footnote Total nursing staff turnover footnote
Provider Information Total Weighted Health Survey Score 463.750 Total Weighted Health Survey Score
Provider Information Urban Y Urban
Provider Information With a Resident and Family Council Resident With a Resident and Family Council
Provider Information ZIP Code 76201 ZIP Code