Carrollton Health and Rehabilitation Center

Name: Carrollton Health and Rehabilitation Center
Address: 1618 Kirby Rd, Carrollton, TX, 75006, US
Telephone: 9722451573

1618 Kirby Rd, Carrollton, TX 75006 · Dallas County · 120 certified beds · avg 78 residents/day · certified since May 9, 2003

Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)

2/5

Health inspection rating (on-site)

Serious findings on record

$19,185

Fines, last 3 years

3.18

Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 2/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, one-off · Mar 20, 2024 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.

Corrected: Jan 5, 2024 (Past Non-Compliance)

▲ Actual harm, one-off · Jan 14, 2025 · F-0600 · triggered by a complaint

The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 20, 2024 (Past Non-Compliance)

All citations in the current public record (39)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

Date	Severity	What the facility was cited for
Jun 25, 2026	F · Potential for harm, facility-wide	The facility did not electronically submit complete and accurate staffing information to the government, based on payroll and other verifiable records.
Jun 25, 2026	E · Potential for harm, repeated	The facility did not keep residents' personal and medical information private and confidential.
Jun 25, 2026	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.
Jun 25, 2026	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Jun 25, 2026	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
Jun 25, 2026	E · Potential for harm, repeated	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Jun 25, 2026	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Jun 25, 2026	E · Potential for harm, repeated	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 25, 2026	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Jun 25, 2026	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Jun 25, 2026	D · Potential for harm, one-off	The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 25, 2026	D · Potential for harm, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Jun 25, 2026	D · Potential for harm, one-off	The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections.
Jun 25, 2026	D · Potential for harm, one-off	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it.
Jun 25, 2026	D · Potential for harm, one-off	The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests.
Mar 26, 2026	E · Potential for harm, repeated	The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint
Mar 5, 2026	D · Potential for harm, one-off	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint
Jan 30, 2026	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jan 30, 2026	E · Potential for harm, repeated	The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. · from a complaint
Jan 30, 2026	E · Potential for harm, repeated	The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint
Dec 1, 2025	E · Potential for harm, repeated	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Nov 20, 2025	D · Potential for harm, one-off	The facility did not keep residents' personal and medical information private and confidential. · from a complaint
Nov 20, 2025	D · Potential for harm, one-off	The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Nov 20, 2025	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint
Nov 20, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
May 6, 2025	E · Potential for harm, repeated	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
May 6, 2025	E · Potential for harm, repeated	The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
May 6, 2025	E · Potential for harm, repeated	The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time.
May 6, 2025	E · Potential for harm, repeated	The facility did not provide timely, approved x-ray services or have an agreement with an approved provider to supply them.
May 6, 2025	D · Potential for harm, one-off	The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jan 14, 2025	▲ G · Actual harm, one-off	The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Apr 11, 2024	E · Potential for harm, repeated	The facility did not safely and appropriately administer IV fluids (fluids given through a vein) for residents who needed them.
Apr 11, 2024	D · Potential for harm, one-off	The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Apr 11, 2024	D · Potential for harm, one-off	The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Apr 11, 2024	D · Potential for harm, one-off	The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Apr 11, 2024	D · Potential for harm, one-off	The facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Apr 11, 2024	D · Potential for harm, one-off	The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication.
Apr 11, 2024	D · Potential for harm, one-off	The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Mar 20, 2024	▲ J · Immediate jeopardy, one-off	The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (5 → 15).

Year	Citations	Serious (G–L)	Worst severity that year
2024	8	1	J ▲
2025	11	1	G ▲
2026	20	0	F

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

2 fines totaling $19,185.

Date	Type	Amount / length
Jan 14, 2025	Fine	$10,358
Mar 20, 2024	Fine	$8,827

Nurse staffing (from payroll records, adjusted for how much care residents need)

Measure	This facility	Texas avg	U.S. avg	Where it stands
Total nurse staffing (hours per resident per day)	3.18	3.46	3.95	bottom 37% in Texas; bottom 21% in the U.S.
Registered Nurse hours	0.68	0.44	0.69	top 10% in Texas; top 38% in the U.S.
Weekend total nurse staffing	2.62	3.04	3.50	bottom 23% in Texas; bottom 13% in the U.S.
Weekend RN hours (not acuity-adjusted)	0.66	0.34	0.48	top 5% in Texas; top 19% in the U.S.
Total nursing staff turnover (%)	0.0	55.3	45.8	—
RN turnover (%)	0.0	54.6	42.9	—

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.12, RN 0.67, weekend 2.57. Staffing rating: 2/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 3/5 · long-stay residents: 4/5 · short-stay residents: 3/5

Who owns this facility

Government - Hospital district

Owner / manager	Type	Role	Stake	Since
Eastland Memorial Hospital District	Organization	5% or Greater Direct Ownership Interest	100%	04/01/2017
Burnam, Soon	Individual	Corporate Officer	NOT APPLICABLE	04/01/2017
Caretrust GP LLC	Organization	ADP of the SNF	NOT APPLICABLE	12/01/2006
Caretrust Reit INC	Organization	ADP of the SNF	NOT APPLICABLE	12/01/2006
Carrollton Heights Healthcare, INC.	Organization	Operational/Managerial Control	NOT APPLICABLE	04/01/2017
Carrollton Heights Healthcare, INC.	Organization	ADP of the SNF	NOT APPLICABLE	08/11/2025
Coil, Ryan	Individual	Managing Control - Governing Body	NOT APPLICABLE	08/01/2025
Coil, Ryan	Individual	Operational/Managerial Control	NOT APPLICABLE	08/01/2025
Coil, Ryan	Individual	ADP of the SNF	NOT APPLICABLE	08/01/2025
Ctr Partnership LP	Organization	ADP of the SNF	NOT APPLICABLE	12/01/2006
Ensign Services INC	Organization	ADP of the SNF	NOT APPLICABLE	03/20/2006
Keetch, Chad	Individual	Corporate Officer	NOT APPLICABLE	03/01/2011
Taylor, Stephen	Individual	Corporate Officer	NOT APPLICABLE	07/01/2025
Trinity Mill Holdings LLC	Organization	ADP of the SNF	NOT APPLICABLE	12/01/2006
Ward, Charles	Individual	Managing Control - Governing Body	NOT APPLICABLE	12/01/2023
Ward, Charles	Individual	Operational/Managerial Control	NOT APPLICABLE	12/01/2023
Ward, Charles	Individual	ADP of the SNF	NOT APPLICABLE	12/01/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

"What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
"Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
"How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
"How do you protect residents' privacy, both in their medical records and in day-to-day care?"
"How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
"How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
"What is your current medication error rate, and what have you changed to bring errors down?"
"Can you show me how medications are stored and secured on the units, including controlled drugs?"
"What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
"Can I see the results and plan of correction from your most recent state inspection?"

Nearby facilities (within 20 miles)

Facility	Distance	City	Overall	Inspection	Flags
Heritage Gardens Rehabilitation and Healthcare	1.9 mi	Carrollton, TX	★☆☆☆☆	2/5	abuse
Brentwood Place Three	2.9 mi	Dallas, TX	★☆☆☆☆	2/5
South Dallas Nursing & Rehabilitation	2.9 mi	Dallas, TX	★☆☆☆☆	1/5
Brentwood Place One	2.9 mi	Dallas, TX	★★★★★	5/5
Brentwood Place Two	2.9 mi	Dallas, TX	★★★☆☆	3/5
Brentwood Place Four	2.9 mi	Dallas, TX	★★★☆☆	3/5
The Madison on Marsh	3.0 mi	Carrollton, TX	★★★★☆	3/5
Sandy Lake Rehabilitation and Care Center	3.3 mi	Coppell, TX	★★☆☆☆	2/5
Treemont Healthcare and Rehabilitation Center	5.2 mi	Dallas, TX	★★☆☆☆	2/5
Vista Ridge Nursing & Rehabilitation Center	5.3 mi	Lewisville, TX	★★★★☆	3/5
Signature Pointe	5.5 mi	Dallas, TX	★★☆☆☆	2/5
Brookhaven Nursing and Rehabilitation Center	5.7 mi	Carrollton, TX	★☆☆☆☆	1/5	abuse

Compare this facility with the 3 closest →

All facilities in Carrollton →

Facility data as of CMS processing date 2026-08-01. CCN 675972.

The Care File

Visit checklist — Carrollton Health and Rehabilitation Center

1618 Kirby Rd, Carrollton, TX 75006 · 9722451573

Health inspection rating 2/5 · CMS overall 2/5· Fines (3y): $19,185

Most serious findings on record:

▲ Mar 20, 2024 (F-0689, Immediate jeopardy, one-off): The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
▲ Jan 14, 2025 (F-0600, Actual harm, one-off): The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.

Questions for the administrator:

☐ "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
☐ "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
☐ "How do your actual daily staffing levels compare to what's reported on Medicare's Care Compare website?"
☐ "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
☐ "How do you make sure each resident's care follows the doctor's orders, and what changed after this citation?"
☐ "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
☐ "What is your current medication error rate, and what have you changed to bring errors down?"
☐ "Can you show me how medications are stored and secured on the units, including controlled drugs?"
☐ "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
☐ "Can I see the results and plan of correction from your most recent state inspection?"

While you're there, notice:

☐ Smell and cleanliness in hallways, not just the lobby
☐ How staff speak to residents; call lights answered promptly
☐ Residents up, dressed, and engaged (visit mealtimes and a weekend if you can)

Data: CMS Provider Data Catalog, version 2026-08-01 · CCN 675972 · Verify at medicare.gov/care-compare · Printed from The Care File (thecarefile.com)