Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Cottonwood Nursing And Rehabilitation during CMS and state inspections, most recent first.
Surveyors found that a large maintenance toolbox was left open and unsecured at the end of one resident hall, exposing tools such as a cordless drill, screwdrivers, wrenches, and a hammer while residents, including a wandering resident, were moving about the hall. The Administrator acknowledged the toolbox was in use for repairs but agreed it should not have been left unsecured due to safety concerns, and the Maintenance Director admitted it should have been secured because it posed a trip hazard and the tools could harm a resident. This situation did not comply with the facility’s Resident Rights policy requiring a safe environment and a physical layout that does not pose a safety risk.
Surveyors found that the facility failed to ensure meals were palatable and served at safe, appetizing temperatures for most residents on regular, mechanical, and pureed diets. A resident council president reported ongoing complaints for months that food at all meals was cold, and test trays observed with the Dietary Manager were lukewarm. The Dietary Manager acknowledged she only intermittently verified that cooks checked food temperatures, was not present when temperatures were taken, and could not produce temperature logs for two meals reviewed. A cook stated he took temperatures when food came off the stove, with no verification or clear instruction on when to check, and temperature logs for the reviewed meals were missing from the facility’s logbook.
A resident with acute respiratory failure and a PRN order for 2–4 L/min O2 via nasal cannula was observed in a wheelchair while the nasal cannula, last used during the prior night, was left unbagged on the bed instead of being stored properly. An LVN, the Regional Nurse, and the ADON each acknowledged that nursing staff were responsible for ensuring the nasal cannula was bagged when not in use to prevent contamination and infection, and that this practice did not follow the facility’s oxygen administration guidelines.
A facility failed to maintain an effective infection control program when two CNAs did not adhere to proper hand hygiene during incontinent care for a resident. The resident required a two-person assist and was always incontinent. CNA A and CNA B did not wash or sanitize their hands appropriately between glove changes, leading to a breach in infection control practices. Interviews with staff revealed awareness of the importance of hand hygiene, but protocols were not followed during the observed care.
The facility's kitchen failed to meet professional standards for food safety, with issues in labeling and dating food items, and inadequate cleaning of the ice machine and other equipment. Interviews revealed a lack of awareness and adherence to protocols, posing a risk of food contamination.
The facility failed to develop comprehensive care plans for two residents, one with severe cognitive impairment and smoking habits, and another receiving hospice care and tube feeding. The absence of care plans addressing these needs was observed, highlighting a lack of communication and awareness among staff regarding care plan responsibilities.
A facility failed to provide adequate respiratory care for three residents. One resident on oxygen therapy lacked an 'Oxygen In Use' sign outside his room, posing a fire hazard. Another resident's oxygen mask was improperly stored, increasing the risk of respiratory issues. A third resident's CPAP mask was left exposed, risking contamination and infection. The facility lacked a specific policy for bagging masks, contributing to these deficiencies.
A facility failed to maintain an effective Infection Prevention and Control Program, leading to potential cross-contamination risks. A CNA did not change gloves or sanitize hands during incontinent care, and an LVN did not sanitize a blood pressure cuff between residents. These actions were contrary to the facility's infection control policies, which emphasize hand hygiene and equipment sanitation.
A facility failed to obtain physician's orders and assess a resident for a scoop mattress before its installation, contrary to professional standards and facility policy. The resident, with severe cognitive impairment and a history of falls, was placed on the mattress without prior assessment, which was later acknowledged as an oversight by the DON.
Two residents in the facility were found unable to access their call lights, which were on the floor and out of reach. One resident, a female with hemiparesis, and another, a male with cerebral infarction, both required assistance for personal care and had moderate cognitive impairments. Staff interviews revealed a failure to adhere to the facility's policy of ensuring call lights are accessible, compromising the residents' ability to communicate their needs.
A resident with a gastrostomy tube did not receive proper care as LVN B failed to check the tube's placement and gastric residual before administering medication, contrary to physician's orders. This oversight was confirmed by interviews with LVN B, the DON, and the ADON, highlighting a deficiency in the facility's adherence to its own policies and procedures for enteral feeding.
Unsecured Maintenance Toolbox Left Accessible on Resident Hall
Penalty
Summary
Surveyors identified a deficiency related to accident hazards on one of four resident halls (Hall 3). During observation, a large maintenance toolbox was found open and unsecured at the end of Hall 3. The open toolbox contained multiple tools, including a cordless drill, screwdrivers, wrenches, and a hammer. At the same time, residents were observed entering and exiting their rooms, and one resident was noted wandering in the hall near the unsecured toolbox. The facility’s written policy on Resident Rights states that residents have the right to a safe, clean, comfortable, and homelike environment, and that the facility must ensure residents can receive care and services safely and that the physical layout does not pose a safety risk. When the Administrator was shown the unsecured toolbox, she acknowledged that maintenance was using it to make repairs and stated that it should not have been left unsecured because it was a safety concern for residents. In a subsequent interview, the Maintenance Director was informed that his toolbox had been left on the hall unsecured. He confirmed that the Administrator had spoken with him about this and acknowledged that the toolbox needed to be secured because it could be a trip hazard and the tools inside could harm a resident. These observations and interviews demonstrated that the Maintenance Director failed to ensure his toolbox was closed and secure from resident access on Hall 3, resulting in an environment that was not as free from accident hazards as possible, contrary to facility policy.
Failure to Ensure Meals Served at Safe and Appetizing Temperatures
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to ensure that residents’ food and drink were palatable, attractive, and served at safe and appetizing temperatures for 37 of 39 residents on regular, mechanical, or pureed diets. The Resident Council President reported that for the past six months, she and other residents had been complaining during council meetings that the food served at all meals was always cold, and she stated she had communicated these concerns to the Dietary Manager. During an observation with the Dietary Manager, test trays for regular, mechanical, and pureed diets were found to be lukewarm. The Dietary Manager stated she only sometimes checked to ensure the cook was checking food temperatures during preparation, did not do so regularly, and was not present when temperatures were taken. She also stated she received temperature logs from cooks at the end of the day but could not provide temperature logs for the breakfast and lunch meals served on the day of the survey. A cook reported that he had been at the facility for four months and usually took food temperatures when removing items from the stove, with readings well over 165 degrees, but that no one verified his temperature checks and he was never instructed on when to check food temperatures. He stated he simply turned in the temperature information at the end of his shift. Record review of the facility’s temperature logbook showed no temperature logs for the breakfast and lunch meals served to residents on the survey date. The facility’s undated Resident Rights policy stated that residents have a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility.
Improper Storage of Nasal Cannula for Resident on PRN Oxygen
Penalty
Summary
The facility failed to provide respiratory care consistent with professional standards and the resident’s care plan by not properly storing a nasal cannula when not in use. Record review showed that the resident was an adult male with acute respiratory failure with hypoxia and an active diagnosis of respiratory failure, admitted with a physician’s order for oxygen at 2–4 L/min via nasal cannula as needed for acute respiratory failure. The resident’s MDS reflected intact cognition. During an observation in the morning, the resident was seen in his wheelchair in the hallway while his nasal cannula, which he reported using only at night and not since getting out of bed that morning, was found lying unbagged on top of his bed. When the LVN was shown the unbagged nasal cannula, she stated that the night nurse should have bagged it to avoid contamination and confirmed that the resident used oxygen at night and sometimes during the day. She further stated it was the nurse’s responsibility to ensure the nasal cannula was bagged when not in use. The Regional Nurse, when informed of the situation, stated the nasal cannula should have been bagged when not in use and that not bagging it could result in the resident getting an infection, reiterating that it was the nurse’s responsibility. The ADON also stated that the nasal cannula needed to be bagged when not in use to prevent infection and that it was the nurse’s responsibility to ensure this occurred. The facility’s Oxygen Administration policy, dated 10/2010, outlined guidelines for safe oxygen administration, including verifying a physician’s order and reviewing the resident’s care plan, but the observed practice did not align with these standards.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of two CNAs during the provision of incontinent care to a resident. The resident, a cognitively intact female with a BIMS score of 15, was always incontinent for both bowel and bladder and required a two-person assist during care. During the observed care, CNA A and CNA B did not adhere to proper hand hygiene protocols, which are critical to preventing cross-contamination and infection. CNA A was observed cleaning the resident's perineal area without changing gloves before handling a new brief. CNA B entered the room, donned gloves without washing her hands, and assisted in turning the resident. After cleaning the resident's bottom, CNA B changed her gloves but failed to sanitize her hands before putting on a new pair. Both CNAs continued to handle clean items without proper glove changes or hand sanitization, which is a breach of infection control practices. Interviews with the CNAs, ADON, DON, and Administrator revealed an awareness of the importance of hand hygiene and the facility's policies requiring hand washing and sanitization before and after care, as well as between glove changes. However, the CNAs did not follow these protocols during the observed care, leading to a deficiency in the facility's infection prevention and control program.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their only kitchen. The deficiencies included improper labeling and dating of food items in both the refrigerator and freezer, with several items such as miniature pizzas, a whole ham, a pork butt, and various vegetables either lacking labels or missing expiration dates. Additionally, the facility's ice machine and ice scoop holder were not thoroughly cleaned, with dust, dirt, and rust observed on and inside the machine. The milk dispenser and drink stirrer holder in the dining area were also found to be dusty and dirty. Interviews with the Dietary Manager (DM), Dietician, and Maintenance Director revealed a lack of awareness and adherence to proper food storage and equipment cleaning protocols. The DM and Dietician acknowledged the issues and mentioned that food items were being dated without the year due to vendor practices. The Maintenance Director admitted to cleaning the ice machine only once a month and was unaware of the rust issue. The Administrator expressed expectations for the kitchen to meet required standards and noted improvements with the new DM, but acknowledged the risk of food contamination if the concerns were not addressed.
Failure to Implement Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which is a deficiency in meeting the residents' needs. Resident #16, a female with severe cognitive impairment and a history of smoking, did not have a care plan addressing her smoking habits. Despite being observed independently going to the designated smoking area, her care plan lacked any mention of smoking, which is crucial for ensuring her safety and health needs are met. Similarly, Resident #20, a female with cognitive communication deficit and dysphagia, was receiving hospice care and tube feeding but did not have a care plan addressing these critical aspects of her care. Observations revealed that she was connected to a feeding formula, yet her care plan did not reflect the necessary interventions for tube feeding or hospice care. This oversight could lead to inadequate care and services for her specific medical needs. Interviews with facility staff, including the Senior MDS Case Manager, DON, ADON, and the Social Worker, highlighted a lack of awareness and communication regarding the responsibility for creating and maintaining comprehensive care plans. The staff acknowledged the importance of care plans in guiding resident care and admitted to oversights in ensuring that all residents had complete and detailed care plans tailored to their current conditions.
Deficiencies in Respiratory Care and Equipment Storage
Penalty
Summary
The facility failed to provide adequate respiratory care for three residents, leading to deficiencies in their care. Resident #26, a male with chronic obstructive pulmonary disease and acute respiratory failure, was observed to be on oxygen therapy without an 'Oxygen In Use' sign outside his room. This oversight was acknowledged by LVN B, who stated that the sign is necessary to remind staff and visitors of the potential fire hazard posed by oxygen use. Resident #30, a male with COPD and obstructive sleep disorder, had an oxygen mask that was not properly stored. The mask was found exposed on a stand instead of being placed in a sealed bag, as required. RN M confirmed the improper storage and noted that the failure to bag the mask could lead to respiratory concerns. The responsibility for ensuring proper storage was attributed to the CNAs and nurses. Resident #189, a male with obstructive sleep apnea, had a CPAP mask that was not bagged when not in use. The mask was left exposed on top of the CPAP machine, which could lead to contamination and infection. LVN B and the DON both acknowledged the need for the mask to be bagged to prevent cross-contamination and respiratory infections. The facility lacked a specific policy for bagging masks, which contributed to the oversight.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective Infection Prevention and Control Program, resulting in potential cross-contamination and infection risks for several residents. During an observation, CNA A did not change gloves or perform hand hygiene while providing incontinent care to a resident. Despite initially washing hands and donning PPE, CNA A touched the trash can and handled a new brief without changing gloves or sanitizing hands, which could lead to cross-contamination. Additionally, LVN B did not sanitize the blood pressure cuff between its use on multiple residents. The blood pressure cuff was used on several residents without being cleaned, increasing the risk of transferring infections between residents. LVN B acknowledged forgetting to sanitize the cuff and recognized the potential for infection transfer due to this oversight. Interviews with the DON, ADON, and Administrator confirmed the expectation for staff to sanitize equipment and perform hand hygiene to prevent infections. The facility's policies on perineal care and infection control emphasize the importance of hand hygiene and equipment sanitation, which were not adhered to in these instances.
Failure to Obtain Physician Orders for Scoop Mattress
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices. Specifically, the facility did not obtain physician's orders or assess a resident for a scoop mattress before its installation. This oversight was identified during an observation and interview with RN M, who confirmed that the physician's orders for the scoop mattress were only submitted after the concern was raised. The resident in question was an elderly female with severe cognitive impairment, requiring moderate assistance for activities of daily living, and had a history of dementia, lack of coordination, and repeated falls. The Director of Nursing (DON) acknowledged that the scoop mattress was installed without prior physician assessment or orders, which was an oversight. The facility's policy on physician orders, dated August 2007, mandates that no resident should be placed in physical restraints for convenience or discipline, and that restraints should only be used to treat medical symptoms after assessing for the least restrictive measures. The failure to adhere to this policy could potentially result in physical harm to the resident.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call light systems in the rooms of two residents were accessible, which is a deficiency in accommodating the needs and preferences of residents. Resident #23, a female with a history of cerebrovascular accident and hemiparesis, was found unable to reach her call light, which was on the floor under her bed. This resident, who has moderate cognitive impairment and is dependent on staff for personal care, expressed difficulty in moving and the need for assistance, highlighting the importance of having the call light within reach. Similarly, Resident #26, a male with cerebral infarction and anxiety disorder, was also unable to access his call light, which was observed on the floor. This resident, who requires maximal assistance for personal care and has moderate cognitive impairment, emphasized the necessity of having the call light near his functioning hand due to his dependency on staff for most activities. Both residents were at risk for falls, and their care plans specifically included ensuring the call light was within reach as an intervention. Interviews with staff, including a CNA, LVN, DON, ADON, and the Administrator, revealed a lack of adherence to the facility's policy of ensuring call lights are accessible to residents. Staff acknowledged the importance of call lights for communication and assistance, yet failed to consistently ensure they were within reach, as evidenced by the observations. The facility's policy emphasizes the right of residents to a dignified existence and access to necessary services, which was not upheld in these instances.
Failure in Gastrostomy Tube Management
Penalty
Summary
The facility failed to ensure proper management of a gastrostomy tube for a resident, leading to a deficiency in care. Specifically, LVN B did not check the placement of the gastrostomy tube before administering medication to Resident #20, nor did they check the gastric residual. This oversight occurred despite the physician's orders requiring these checks every shift before feeding and medication administration. Resident #20, a 77-year-old female with a diagnosis of cognitive communication deficit and dysphagia, was observed in bed with a feeding formula hanging from an IV pole, which was not connected to her. LVN B prepared and administered medications via the gastrostomy tube without verifying the tube's placement or checking the residual, which are critical steps to ensure the tube is correctly positioned and the stomach is emptying properly. Interviews with LVN B, the DON, and the ADON confirmed the importance of these checks to prevent potential complications such as aspiration pneumonia. The facility's policy also outlined the necessity of checking tube placement and gastric residuals as part of the procedure for enteral feeding. However, these steps were not followed, resulting in a failure to provide appropriate care for the resident with a feeding tube.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Denton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Denton Village By Purehealth | 0.5 mi | — | 15 | 1 |
| Vintage Health Care Center | 1.9 mi | — | 20 | 0 |
| University Rehabilitation Center | 4.1 mi | — | 7 | 1 |
| Lake Forest Village By Purehealth | 5.3 mi | — | 13 | 0 |
| Denton Rehabilitation And Nursing Center | 6.7 mi | — | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.