Federal inspection record · CMS data as of October 1, 2026
Carrollton Health and Rehabilitation Center
1618 Kirby Rd, Carrollton, TX · (972) 245-1573
- Certified beds
- 120
- Residents per day
- 82
- Ownership
- Government
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- May 9, 2003
1
How this home got 2 stars
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
-
Staffing
★★★★★no change
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
2
Where it sits among Texas homes
Carrollton Health and Rehabilitation Center carries 139 inspection points. That is fewer than 21% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
39 health citations on record since 2024. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (2)
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care10E
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
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
Provide safe and appropriate respiratory care for a resident when needed.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide safe and appropriate respiratory care for a resident when needed.
- E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Pharmacy Service10E
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure medication error rates are not 5 percent or greater.
- E
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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
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
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Ensure medication error rates are not 5 percent or greater.
- D
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
- D
Ensure that residents are free from significant medication errors.
- D
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.
Resident Rights5E
- E
Keep residents' personal and medical records private and confidential.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Keep residents' personal and medical records private and confidential.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
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.
Infection Control3E
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Resident Assessment and Care Planning3D
- D
Ensure each resident receives an accurate assessment.
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- D
Ensure each resident receives an accurate assessment.
Administration2F
- F
Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.
- E
Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.
Nutrition and Dietary2E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Environmental2E
- D
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- E
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspection history
2026-06-25
25 health deficiencies · 2 fire-safety deficiencies
Top issue: Quality of Life and Care (8 deficiencies)
2025-05-06
6 health deficiencies · 2 fire-safety deficiencies
Top issue: Pharmacy Service (2 deficiencies)
2024-04-11
8 health deficiencies · 3 fire-safety deficiencies
Top issue: Pharmacy Service (3 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 2 h 58 min of nursing staff time a day, 43 min of it from a registered nurse.
This home
2 h 58 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Reported hours from payroll data the home submits to CMS, divided by its daily resident count. Not adjusted for how sick residents are.
5
Fines and payment denials
$19,185 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-01-14 | Fine | $10,358 |
| 2024-03-20 | Fine | $8,827 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days1.2 pts worse | 3.2 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days1.5 pts worse | 3.5 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine3.6 pts better | 100.0% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine3 pts better | 100.0% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury0.8 pts better | 2.4% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.3 pts better | 0.0% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.8 pts worse | 3.7% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.7 pts better | 17.1% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication9.8 pts better | 0.0% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrainedAbout the same | 0.0% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened0.8 pts worse | 13.7% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased11.8 pts worse | 27.6% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.3 pts better | 0.0% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.8 pts better | 0.0% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence3.4 pts worse | 15.9% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers2.1 pts better | 1.6% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine10.8 pts better | 99.5% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit3.5 pts better | 8.7% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.4 pts better | 0.0% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine0.1 pts better | 85.5% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission0.2 pts better | 25.3% | 25.5% | 23.4% |
·
Who owns and runs it
17 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Eastland Memorial Hospital District | 5% Or Greater Direct Ownership Interest · Organization | 100% | 34 facilities |
| Burnam, Soon | Corporate Officer · Individual | 0% | 353 facilities |
| Caretrust Gp LLC | Adp Of The SNF · Organization | 0% | 95 facilities |
| Caretrust Reit Inc | Adp Of The SNF · Organization | 0% | 102 facilities |
| Carrollton Heights Healthcare, Inc. | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Carrollton Heights Healthcare, Inc. | Adp Of The SNF · Organization | 0% | 1 facilities |
| Coil, Ryan | Managing Control - Governing Body · Individual | 0% | 4 facilities |
| Coil, Ryan | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Coil, Ryan | Adp Of The SNF · Individual | 0% | 4 facilities |
| Ctr Partnership LP | Adp Of The SNF · Organization | 0% | 104 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Taylor, Stephen | Corporate Officer · Individual | 0% | 22 facilities |
| Trinity Mill Holdings LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Ward, Charles | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Ward, Charles | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Ward, Charles | Adp Of The SNF · Individual | 0% | 2 facilities |
·
Fire safety
7 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke3F
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Services3C
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
- C
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Egress1E
- E
Keep aisles, corridors, and exits free of obstruction in case of emergency.
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Other homes nearby
-
Heritage Gardens Rehabilitation and Healthcare
Carrollton, TX · The Ensign Group · Abuse icon
★★★★★- Worst citation, 3 yrs
- G
- Nursing / resident / day
- 3 h 13 min
- Fines
- $38,840
-
Brentwood Place Four
Dallas, TX · Opco Skilled Management
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 3 h 8 min
- Fines
- $0
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Brentwood Place One
Dallas, TX · Opco Skilled Management
★★★★★- Worst citation, 3 yrs
- E
- Nursing / resident / day
- 2 h 17 min
- Fines
- $0