Federal inspection record · CMS data as of October 1, 2026
Heritage Gardens Rehabilitation and Healthcare
2135 N Denton Dr, Carrollton, TX · (972) 242-0666
- Cited for abuse (CMS abuse icon)
- Certified beds
- 150
- Residents per day
- 69
- Ownership
- For-Profit
- Chain
- The Ensign Group
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- February 11, 1993
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.
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Staffing
★★★★★−1 star
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
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Quality measures
★★★★★+1 star
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
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Overall
★★★★★2 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Texas homes
Heritage Gardens Rehabilitation and Healthcare carries 51 inspection points. That is fewer than 66% 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
25 health citations on record since 2023. 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 (1)
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G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Everything else, by area of care
Quality of Life and Care6E
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- E
Provide medically-related social services to help each resident achieve the highest possible quality of life.
- D
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
- D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- 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.
Freedom from Abuse, Neglect, and Exploitation3D
- D
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- D
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
- D
Respond appropriately to all alleged violations.
Infection Control3E
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
Resident Rights2E
- D
Keep residents' personal and medical records private and confidential.
- E
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Resident Assessment and Care Planning2D
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Pharmacy Service2D
- 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.
Nursing and Physician Services2E
- E
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
- E
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.
Nutrition and Dietary2F
- E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
- F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Environmental2E
- E
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
- D
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Inspection history
2026-01-15
9 health deficiencies · 1 fire-safety deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (3 deficiencies)
2024-11-06
8 health deficiencies · 5 fire-safety deficiencies
Top issue: Infection Control (2 deficiencies)
2023-10-05
8 health deficiencies · 7 fire-safety deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
4
Nursing time per resident, per day
Each resident here gets about 3 h 13 min of nursing staff time a day, 25 min of it from a registered nurse.
This home
3 h 13 min
Texas average
3 h 25 min
U.S. average
3 h 54 min
- Registered nurse
- Licensed practical nurse
- Nurse aide
Turnover: 60% of nursing staff and 0% of registered nurses left in the past year, along with 2 administrators.
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
$38,840 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-07-08 | Fine | $38,840 |
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 days0.6 pts worse | 2.6 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.9 pts better | 1.1 | 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 injury1.2 pts better | 2.0% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms1.9 pts better | 0.4% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.2 pts better | 2.7% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication0.4 pts better | 17.4% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication7.6 pts better | 2.2% | 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 worsened4.7 pts better | 8.2% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased7.7 pts worse | 23.5% | 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 infection0.4 pts better | 0.4% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence2.6 pts worse | 15.1% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.7 pts worse | 4.4% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine11.3 pts better | 100.0% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit7.7 pts better | 4.5% | 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 vaccine14.6 pts better | 100.0% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission7.4 pts better | 18.1% | 25.5% | 23.4% |
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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 |
| Ctr Partnership LP | Adp Of The SNF · Organization | 0% | 104 facilities |
| Ensign Services Inc | Adp Of The SNF · Organization | 0% | 299 facilities |
| Hernandez, Miguel | Managing Control - Governing Body · Individual | 0% | 4 facilities |
| Hernandez, Miguel | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Hernandez, Miguel | Adp Of The SNF · Individual | 0% | 4 facilities |
| Josey Ranch Healthcare Holdings LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Keetch, Chad | Corporate Officer · Individual | 0% | 301 facilities |
| Paterson, Morley | Managing Control - Governing Body · Individual | 0% | 2 facilities |
| Paterson, Morley | Operational/Managerial Control · Individual | 0% | 2 facilities |
| Paterson, Morley | Adp Of The SNF · Individual | 0% | 2 facilities |
| Savoy Healthcare, Inc. | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Savoy Healthcare, Inc. | Adp Of The SNF · Organization | 0% | 1 facilities |
| Taylor, Stephen | Corporate Officer · Individual | 0% | 22 facilities |
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Fire safety
13 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke10F
- D
Install an approved automatic sprinkler system.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- F
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Install corridor and hallway doors that block smoke.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- D
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Gas, Vacuum, and Electrical Systems2F
- E
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
- F
Have generator or other power source capable of supplying service within 10 seconds.
Egress1E
- E
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.
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Other homes nearby
-
Carrollton Health and Rehabilitation Center
Carrollton, TX · The Ensign Group
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 2 h 58 min
- Fines
- $19,185
-
Sandy Lake Rehabilitation And Care Center
Coppell, TX · Fundamental Healthcare
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 9 min
- Fines
- $23,677
-
The Madison on Marsh
Carrollton, TX · Cantex Continuing Care
★★★★★- Worst citation, 3 yrs
- J
- Nursing / resident / day
- 3 h 21 min
- Fines
- $8,473