Federal nursing home survey record · CMS-certified nursing home· Not a state assisted-living licensing record
Heritage Gardens Rehabilitation and Healthcare
Carrollton, TX · 150 certified beds · Last Life Safety survey January 15, 2026
CMS Certification Number 675111 · first certified February 1993
Ownership
Operated by THE ENSIGN GROUP · For profit - Corporation
No change of ownership on CMS record since January 1, 2016, when the records begin.
Position within TX
13 citations — more than 79% of the 1,177 certified nursing homes in TX. Compared within TX rather than nationally because which state a facility is in explains about 30% of the variation in citation counts between facilities, while bed count explains under 1%. State survey agencies differ far more than the buildings do. How this is calculated
The latest survey found 1 citation; the earlier surveys in the window averaged 6. With 3 surveys on file this is a direction of travel, not a conclusion.
When is the next survey likely?
The window opens February 2027 — about 5 months from now. This facility’s last Life Safety survey was January 2026. Facilities in TX are typically surveyed 13–14 months after the last one (median 14), measured over 1,905 consecutive surveys in the last two years of CMS records.
A range the record supports, not a prediction of a date. State agencies vary widely — from about 11 months in Pennsylvania to three years in Maryland. How the window is measured
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2 inspection-and-testing tags have been cited here at more than one survey. Nationally, that pattern is common: about three quarters of cited facilities have at least one repeated tag, and half of the facilities ever cited for sprinkler inspection and testing are cited for it again. A repeat is usually a recordkeeping gap rather than a new hazard.
Physical environment (health survey)
6 physical-environment citations on the health survey. Cited by the health surveyors under Appendix PP, not the Life Safety Code surveyor: equipment in safe operating condition, the call system, bed rails, pest control, hazards, the environment. Counted separately from the 13 Life Safety citations above. The Physical Environment Index
- F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- F-0880 Provide and implement an infection prevention and control program.
- F-0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
- F-0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
How that compares
Compared with the median facility in TX, and nationally. Surveyors differ markedly between states, so the TX figure is the meaningful one.
| Measure | Citations |
|---|---|
| This facility | 13 |
| Median facility in TX | 7 |
| Median facility nationally | 11 |
Survey history
| Survey date | Citations |
|---|---|
| October 5, 2023 | 7 |
| November 6, 2024 | 5 |
| January 15, 2026 | 1 |
Most-cited tags
| Tag | What the surveyor checks | Times cited | Last cited |
|---|---|---|---|
| K-0363 | Install corridor and hallway doors that block smoke. | 2 | 2024-11-06 |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | 2 | 2024-11-06 |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | 2 | 2024-11-06 |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | 1 | 2024-11-06 |
| K-0222 | 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. | 1 | 2023-10-05 |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | 1 | 2023-10-05 |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | 1 | 2023-10-05 |
| K-0351 | Install an approved automatic sprinkler system. | 1 | 2026-01-15 |
What the citations cover
- Smoke Deficiencies 10
- Gas, Vacuum, and Electrical Systems Deficiencies 2
- Egress Deficiencies 1
| Category | Citations |
|---|---|
| Smoke Deficiencies | 10 |
| Gas, Vacuum, and Electrical Systems Deficiencies | 2 |
| Egress Deficiencies | 1 |
Every citation on file
As published by CMS, newest survey first. Descriptions are CMS’s own wording.
January 15, 2026 — 1 citation
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0351 | Install an approved automatic sprinkler system. | Deficient, Provider has date of correction (February 10, 2026) |
November 6, 2024 — 5 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (November 7, 2024) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (November 7, 2024) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (November 8, 2024) |
| K-0374 | Install smoke barrier doors that can resist smoke for at least 20 minutes. | Deficient, Provider has date of correction (November 8, 2024) |
| K-0929 | Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Deficient, Provider has date of correction (November 6, 2024) |
October 5, 2023 — 7 citations
| Tag | What the surveyor checks | Status |
|---|---|---|
| K-0222 | 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. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0321 | Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0342 | Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0353 | Inspect, test, and maintain automatic sprinkler systems. | Deficient, Provider has date of correction (October 20, 2023) |
| K-0363 | Install corridor and hallway doors that block smoke. | Deficient, Provider has date of correction (October 20, 2023) |
| K-0372 | Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Deficient, Provider has date of correction (October 12, 2023) |
| K-0918 | Have generator or other power source capable of supplying service within 10 seconds. | Deficient, Provider has date of correction (October 12, 2023) |
Reflects the CMS posting of August 1, 2026. Surveys conducted in the last few months may not appear yet.