Cycle 1
Health 2024-11-06 · Fire 2024-11-06
8 health deficiencies
Top issue: Infection Control (2 deficiencies)
5 fire-safety deficiencies
Top issue: Smoke (4 deficiencies)
Carrollton, TX
Heritage Gardens Rehabilitation and Healthcare
1-star overall rating with 2-star inspections with abuse icon flag with $38,243 in total fines with 8 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
2135 N Denton Dr, Carrollton, TX
(972) 242-0666
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
150
Certified beds
Average residents
78
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1993-02-11
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.28
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.04
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.00
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.32
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.32
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.81
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.22
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.21
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.27
CMS adjusted RN staffing hours
Adjusted total hours
3.27
CMS adjusted total nurse staffing hours
Case-mix index
1.39
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
42%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,960
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
18.50
Composite VBP score used to determine payment impact.
Payment multiplier
0.9820
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.85
Baseline 20.25% · Performance 20.57% · Measure score 1.85 · Achievement 1.85 · Improvement 0
Healthcare-associated infections
0
Baseline 7.53% · Performance 7.72% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
5.03
Baseline 54.90% · Performance 43.14% · Measure score 5.03 · Achievement 5.03 · Improvement 3.42
Adjusted total nurse staffing
0.52
Baseline 2.94 hours · Performance 3.23 hours · Measure score 0.52 · Achievement 0.52 · Improvement 0.51
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.82% |
10.72%
2.1 pts worse
|
No Different than the National Rate · Eligible stays 103 · Observed rate 21.36% · Lower 95% interval 9.61% |
| Discharge to community | 32.45% |
50.57%
18.1 pts worse
|
Worse than the National Rate · Eligible stays 68 · Observed rate 19.12% · Lower 95% interval 23.03% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 95.77% |
95.27%
0.5 pts better
|
Numerator 68 · Denominator 71 |
| Falls with major injury | 1.41% |
0.77%
0.6 pts worse
|
Numerator 1 · Denominator 71 |
| Discharge self-care score | 38.24% |
53.69%
15.4 pts worse
|
Numerator 13 · Denominator 34 |
| Discharge mobility score | 29.41% |
50.94%
21.5 pts worse
|
Numerator 10 · Denominator 34 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 71 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.72% |
7.12%
0.6 pts worse
|
No Different than the National Rate · Eligible stays 48 · Observed rate 12.5% · Lower 95% interval 4.42% |
| Staff COVID-19 vaccination coverage | 33.33% |
8.2%
25.1 pts better
|
Numerator 42 · Denominator 126 |
| Staff flu vaccination coverage | 69.51% |
42%
27.5 pts better
|
Numerator 114 · Denominator 164 |
| Discharge function score | 44.12% |
56.45%
12.3 pts worse
|
Numerator 15 · Denominator 34 |
| Transfer of health information to provider | 93.94% |
95.95%
2 pts worse
|
Numerator 31 · Denominator 33 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 2.94% |
25.2%
22.3 pts worse
|
Numerator 1 · Denominator 34 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.9 |
2.1
0.8 pts worse
|
1.9
1 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.9 · Observed 4.1 · Expected 2.7 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.8
0.4 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 2.6 · Expected 2.0 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.5% |
97.9%
0.6 pts better
|
95.5%
3 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.5% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.3%
2.9 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.7% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.0% |
2.7%
2.7 pts better
|
11.4%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who lose too much weight | 3.0% |
3.3%
0.3 pts better
|
5.4%
2.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.1% · Q2 0.0% · Q3 0.0% · Q4 4.8% · 4Q avg 3.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
18.9%
1.9 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 19.0% · Q3 16.7% · Q4 15.4% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.5% |
10.8%
10.3 pts better
|
16.7%
16.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 0.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 18.9% |
15.4%
3.5 pts worse
|
16.3%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 15.4% · Q3 12.3% · Q4 17.0% · 4Q avg 18.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 31.5% |
16.1%
15.4 pts worse
|
14.9%
16.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 23.3% · Q2 35.5% · Q3 37.0% · Q4 29.1% · 4Q avg 31.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 12.7% |
15.0%
2.3 pts better
|
19.8%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.9% · Q2 9.3% · Q3 9.0% · Q4 11.6% · 4Q avg 12.7% |
| Percentage of long-stay residents with pressure ulcers | 3.5% |
4.2%
0.7 pts better
|
5.1%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.7% · Q3 2.2% · Q4 6.7% · 4Q avg 3.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 98.2% |
89.7%
8.5 pts better
|
81.7%
16.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 96.3% · Q2 97.5% · Q3 98.9% · Q4 100.0% · 4Q avg 98.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.7% |
12.0%
1.3 pts better
|
12.0%
1.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.7% · Observed 14.8% · Expected 15.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 87.1% |
88.0%
0.9 pts worse
|
79.7%
7.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 87.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 22.3% |
25.9%
3.6 pts better
|
23.9%
1.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 22.3% · Observed 31.1% · Expected 33.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-10-05 · Fire 2023-10-05
6 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-08-17 · Fire 2022-08-17
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2024-11-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-11-06
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2024-11-07
E · Potential for more than minimal harm
2024-11-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-11-08
E · Potential for more than minimal harm
2024-11-06
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2024-11-06
D · Potential for more than minimal harm
2024-11-06
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-11-08
F · Potential for more than minimal harm
2023-10-05
K342 · Smoke Deficiencies
Fire Safety
Have a complete alarm system manually initiated and initiated by fire sprinkler system connection.
Corrected 2023-10-12
F · Potential for more than minimal harm
2023-10-05
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-10-05
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-10-05
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-10-12
E · Potential for more than minimal harm
2023-10-05
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-10-05
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-10-12
D · Potential for more than minimal harm
2023-10-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-12
E · Potential for more than minimal harm
2022-08-17
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2022-09-09
E · Potential for more than minimal harm
2022-08-17
K344 · Smoke Deficiencies
Fire Safety
Have an alternate power supply for its alarm system.
Corrected 2022-09-07
E · Potential for more than minimal harm
2022-08-17
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2022-09-07
C · Minimal harm
2022-08-17
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-08-18
Inspection history
Recent health citations
G · Actual harm
2025-07-08
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-06-26
D · Potential for more than minimal harm
2025-04-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-04-28
E · Potential for more than minimal harm
2025-03-13
F726 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-03-27
E · Potential for more than minimal harm
2024-11-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-06
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-06
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-06
F805 · Nutrition and Dietary Deficiencies
Health
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Corrected 2024-12-06
E · Potential for more than minimal harm
2024-11-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-06
D · Potential for more than minimal harm
2024-03-08
F693 · Quality of Life and Care Deficiencies
Health
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.
Corrected 2024-03-23
D · Potential for more than minimal harm
2024-02-08
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-03-08
D · Potential for more than minimal harm
2024-02-08
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2024-03-08
F · Potential for more than minimal harm
2023-10-05
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-27
E · Potential for more than minimal harm
2023-10-05
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2023-10-25
D · Potential for more than minimal harm
2023-10-05
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2023-10-31
D · Potential for more than minimal harm
2023-10-05
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-10-24
D · Potential for more than minimal harm
2023-04-19
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-19
F635 · Resident Assessment and Care Planning Deficiencies
Health
Provide doctor's orders for the resident's immediate care at the time the resident was admitted.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-05-05
D · Potential for more than minimal harm
2023-04-19
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-05-05
F · Potential for more than minimal harm
2022-08-17
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2022-09-01
Penalties and ownership
What sits behind the stars
$38,243
2025-07-08
Fine
Fine · fine $38,243
Fine
Ownership
Eastland Memorial Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Hernandez, Miguel
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Paterson, Morley
Operational/Managerial Control · Individual
Savoy Healthcare, Inc.
Operational/Managerial Control · Organization
Taylor, Stephen
Corporate Officer · Individual
Nearby options
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#2
Sandy Lake Rehabilitation And Care Center
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2-star overall rating with 2-star inspections with $23,677 in total fines with 16 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
#3
The Madison On Marsh
Carrollton, TX
3-star overall rating with 3-star inspections with $8,473 in total fines with 8 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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