Heritage Gardens Rehabilitation and Healthcare
2135 N Denton Dr, Carrollton, TX 75006 · Dallas County · 150 certified beds · avg 67 residents/day · certified since Feb 11, 1993
Abuse citation flag (CMS)
Part of chain: THE ENSIGN GROUP (342 facilities, chain avg rating 3.2★)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★☆☆☆2/5 · CMS overall rating: 1/5
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)
▲ Actual harm, one-off · Jul 8, 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: Jun 26, 2025 (Deficient, Provider has date of correction)
All citations in the current public record (25)
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 |
|---|---|---|
| Apr 14, 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 |
| Apr 14, 2026 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. · from a complaint |
| Mar 9, 2026 | D · Potential for 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 |
| Mar 9, 2026 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint |
| Mar 9, 2026 | D · Potential for harm, one-off | The facility did not respond appropriately to alleged violations, such as reports of abuse, neglect, or mistreatment. Facilities must investigate every allegation and protect residents while they do. · from a complaint |
| Jan 15, 2026 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. |
| Jan 15, 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. |
| Jan 15, 2026 | 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. |
| Jan 15, 2026 | 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. |
| Jul 8, 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 9, 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 |
| Mar 13, 2025 | E · Potential for harm, repeated | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Nov 6, 2024 | E · Potential for harm, repeated | The facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights. · from a complaint |
| Nov 6, 2024 | E · Potential for harm, repeated | The facility did not have a registered nurse on duty at least 8 hours a day, or did not have a registered nurse serving full-time as director of nursing. |
| Nov 6, 2024 | E · Potential for harm, repeated | The facility did not provide the social services residents need — such as counseling, help with adjustment, or connecting to outside resources — to achieve the best possible quality of life. |
| Nov 6, 2024 | E · Potential for harm, repeated | The facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems. |
| Nov 6, 2024 | 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. · from a complaint |
| Mar 8, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint |
| Feb 8, 2024 | D · Potential for harm, one-off | The facility did not provide safe, appropriate care for residents who need dialysis — the treatment that filters the blood when kidneys fail. · from a complaint |
| Oct 5, 2023 | F · Potential for harm, facility-wide | 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. |
| Oct 5, 2023 | E · Potential for harm, repeated | The facility did not maintain an effective pest control program to prevent or deal with mice, insects, or other pests. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Oct 5, 2023 | 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. |
| Oct 5, 2023 | D · Potential for harm, one-off | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (5 → 4).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 5 | 0 | F |
| 2024 | 8 | 0 | E |
| 2025 | 3 | 1 | G ▲ |
| 2026 | 9 | 0 | E |
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)
1 fine totaling $38,840.
| Date | Type | Amount / length |
|---|---|---|
| Jul 8, 2025 | Fine | $38,840 |
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) | 2.91 | 3.46 | 3.95 | bottom 18% in Texas; bottom 11% in the U.S. |
| Registered Nurse hours | 0.35 | 0.44 | 0.69 | bottom 41% in Texas; bottom 16% in the U.S. |
| Weekend total nurse staffing | 2.42 | 3.04 | 3.50 | bottom 11% in Texas; bottom 7% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.30 | 0.34 | 0.48 | top 48% in Texas; bottom 32% in the U.S. |
| Total nursing staff turnover (%) | 59.7 | 55.3 | 45.8 | bottom 33% in Texas; bottom 17% in the U.S. |
| 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 3.15, RN 0.38, weekend 2.63. Staffing rating: 1/5.
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: 4/5 · long-stay residents: 5/5 · short-stay residents: 4/5
Who owns this facility
For profit - Corporation
| 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 | 05/01/2010 |
| Caretrust Reit INC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2010 |
| Ctr Partnership LP | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2010 |
| Ensign Services INC | Organization | ADP of the SNF | NOT APPLICABLE | 02/18/2010 |
| Hernandez, Miguel | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/01/2023 |
| Hernandez, Miguel | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/01/2023 |
| Hernandez, Miguel | Individual | ADP of the SNF | NOT APPLICABLE | 07/01/2023 |
| Josey Ranch Healthcare Holdings LLC | Organization | ADP of the SNF | NOT APPLICABLE | 05/01/2010 |
| Keetch, Chad | Individual | Corporate Officer | NOT APPLICABLE | 03/01/2011 |
| Paterson, Morley | Individual | Managing Control - Governing Body | NOT APPLICABLE | 07/21/2025 |
| Paterson, Morley | Individual | Operational/Managerial Control | NOT APPLICABLE | 07/21/2025 |
| Paterson, Morley | Individual | ADP of the SNF | NOT APPLICABLE | 07/21/2025 |
| Savoy Healthcare, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 04/01/2017 |
| Savoy Healthcare, INC. | Organization | ADP of the SNF | NOT APPLICABLE | 08/12/2025 |
| Taylor, Stephen | Individual | Corporate Officer | NOT APPLICABLE | 07/01/2025 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "How do you protect residents' privacy, both in their medical records and in day-to-day care?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "If someone reports suspected abuse or neglect here, what happens in the first 24 hours?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "How does your pharmacist review residents' medications, and how quickly can you fill new or urgent prescriptions?"
- "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 |
|---|---|---|---|---|---|
| Carrollton Health and Rehabilitation Center | 1.9 mi | Carrollton, TX | ★★☆☆☆ | 2/5 | |
| Sandy Lake Rehabilitation and Care Center | 2.6 mi | Coppell, TX | ★★☆☆☆ | 2/5 | |
| The Madison on Marsh | 3.0 mi | Carrollton, TX | ★★★★☆ | 3/5 | |
| Vista Ridge Nursing & Rehabilitation Center | 3.9 mi | Lewisville, TX | ★★★★☆ | 3/5 | |
| Brookhaven Nursing and Rehabilitation Center | 4.0 mi | Carrollton, TX | ★☆☆☆☆ | 1/5 | abuse |
| Brentwood Place Three | 4.7 mi | Dallas, TX | ★☆☆☆☆ | 2/5 | |
| South Dallas Nursing & Rehabilitation | 4.7 mi | Dallas, TX | ★☆☆☆☆ | 1/5 | |
| Brentwood Place One | 4.7 mi | Dallas, TX | ★★★★★ | 5/5 | |
| Brentwood Place Two | 4.7 mi | Dallas, TX | ★★★☆☆ | 3/5 | |
| Brentwood Place Four | 4.7 mi | Dallas, TX | ★★★☆☆ | 3/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 675111.