Heritage Gardens Rehabilitation and Healthcare: Data Analysis and Ratings
CMS Five Star Rating(3 out of 5):
2135 N DENTON DR CARROLLTON, TX 75006
972-242-0666
Data date: April 01, 2023
The Most Important Data about Heritage Gardens Rehabilitation and Healthcare
We've looked at a lot of nursing homes, this is what we think you need to see first and if you don't want to spend a lot of time. (It's the tl;dr section.)
There is no indication of abuse occuring at Heritage Gardens Rehabilitation and Healthcare. (CMS flags facilities where abuse has either happened or is very likely.)
CMS 5-Star Overall Rating:
(3 out of 5):
(The national average overall star rating is 3 stars.)
Current Trend: Improving
Total Nursing Hours Spent Per Resident Per Day: 2.77
(The national average is 3.74 )
According to our analysis, Heritage Gardens Rehabilitation and Healthcare is ranked #39 out of 160 skilled nursing homes within a 25 mile radius. See detailed information from recent inspection reports, nursing hours analysis, surverys, and information on owners and operators. Click here to view the ranked list of nursing homes near Heritage Gardens Rehabilitation and Healthcare.
What is this page all about?
Below is everything shred of information that we can find about Heritage Gardens Rehabilitation and Healthcare, along with our best effort to make sense of the data. Our purpose here is to help you to make good decisions when picking a nursing home and to keep you informed once you have chosen a home. We know from personal experience that choosing a nursing home is not something you do once and then you forget about it. In fact, it gets worse. Once you select a nursing home and get through the initial steps of figuring out how to pay for it, then the real worries start. Are they taking good care of me or my loved one? This is the question that will keep you up at night: Can I really trust these people? We wish we could answer this question, we can't. What he can do is churn through the tons of data and try and help you to make sense of it. We hope it helps.
General Data Card
These are the basic data points for the facility.
Data date: April 01, 2023
Address: 2135 N DENTON DR
CARROLLTON, TX 75006
Phone: 972-242-0666
Ranking: Heritage Gardens Rehabilitation and Healthcare is ranked #12 out of 39 facilities within a 10 mile radius and #39 out of 160 facilities within a 25 mile radius.
Medicare Provider Number: 675111
Participating in Medicare Since: February 11, 1993
No. of Certified Beds: 150
No. of Residents: 70
Occupancy: 46.67 % (as of 05/21/2023 )
Amount fined in recent period: $6,500.00
Complaints filed: 2
Ratings History for Heritage Gardens Rehabilitation and Healthcare
Review of Heritage Gardens Rehabilitation and Healthcare Ratings and Inspection Scores
CMS regularly inspects every skilled nursing facility. (The timing is supposed to be annually, but since the beginning of the Covid pandemic, these inspections have not occured as frequently.) The results of the multi-day inspection is reduced to a series of scores which are then translated into the star ratings. The health inspection scores are an absolute value, so you can compare one facility's score directly to another. The Overall Star rating is based on the facility's performance as compared to other facilities in the same state, so you cannot easily compare one facility's Overall star rating to a facility in another state.
Ratings
| Overall Rating | 3: |
| Health Inspection Rating | 4: |
| Quality Rating | 4: |
| Staffing Rating | 1: |
Inspection Scores
| Cycle 1 Score (as of August 17, 2022) | 20 |
| Cycle 2 Score (as of June 23, 2021) | 20 |
| Cycle 3 Score (as of March 12, 2020) | 44 |
| Weighted All Cycles Score | 24 |
It has been 7 months since the most recent inspection.
What Goes Into the Nursing Home's 5-Star Rating
CMS has put a lot of effort into creating its very elaborate 5-Star Quality Rating System specifically to provide a quick way for residents and family members to easily understand how well a nursing home is performing and to make comparing nursing homes easier. The rating system allows people to easily compare facilities across numerous dimensions with the express purpose of identifying the best and best performing nursing homes. The rating system was initially developed in 2008 and the methodologies are regularly reviewed and updated.
The rating system has five separate ratings including:
- Overall rating
- Health Inspection rating
- Staff rating
- RN Staffing rating
- Quality Measures rating
Nursing homes are rated from 1-star to 5-stars with 1-star being the best rating and 5-star being the best rating. For the Health Inspection Rating the nursing homes in each state are ranked based on their weighted three year inspection score. The top 10 percent of nursing homes (those with the lowest scores) are awarded a 5-star rating; the bottom 20 percent (those with the highest scores) are awarded a 1-star rating. In between 1-star and 5-star, the remaining homes are divided equally into three tranches which correspond with the stars 2 to 4. The staff ratings and quality measure ratings follow a similar process but the divisions are based on a national ranking. The division between star ratings is called the “cut-rate”. Cut-rates are redefined periodically and are published by CMS. See the latest cut rates on this table.
Calculating the Overall Star Rating is done differently. According to CMS, the reason for adopting a different system is to give the Health Inspection Rating higher weight in the Overall Rating. So, since there are FIVE ratings and FIVE stars for each rating, there must also be a FIVE step process to calculate the Overall Rating (so symetrical!) :
- Begin with the Health Inspection Rating
- Add one star to the Health Inspection Rating if the Staffing Rating is at least four-stars and is higher than the Health Inspection Rating. (We will call this the "Adjusted Rating".)
- Subtract one star from the Health Inspection Rating if the Staffing Rating is one-star.
- Add a star to the Adjusted Rating if the Quality Measure Rating is 5-stars.
- Subtract one star from the Adjusted Rating if the Quality Measure Rating is 1-star.
Throughout the calculation of the Overall Rating, the rating cannot exceed 5-stars. The Overall Rating is capped at 2-stars if the Health Inspection rating is 1-star. No Overall Rating is awarded if the nursing home does not have a Health Inspection Rating (This effectively means that a nursing home is not rated until the home has been operating for more than two years.)
Changes in a nursing homes star rating can be due to the results of a new health inspection report, the processing of new complaints, the aging of older complaints, a new inspection control survey, a revisit, or the resolution of disputes that change the scope and or severity of deficiencies.
Most Recent Nursing Home Inspections
CMS is required to inspect each senior nursing facility at least annually. These inspections take several days. Additional follow-up inspections as conducted as needed or for certain purposes. Inspections stopped for more than seven months in 2020 due to the Covid pandemic. That stoppage has caused all inspections to be delayed as the inspectors continue to deal with a backlog. The table below shows the latest inspections for Heritage Gardens Rehabilitation and Healthcare including health, fire, and inspection control inspections:
| Inspection Type | Inspection Date |
|---|---|
| Fire Safety Standard | August 16, 2022 |
| Fire Safety Standard | June 24, 2021 |
| Fire Safety Standard | March 11, 2020 |
| Health Complaint | October 20, 2022 |
| Health Complaint | June 23, 2021 |
| Health Complaint | December 03, 2020 |
| Health Standard | August 17, 2022 |
| Health Standard | June 23, 2021 |
| Health Standard | March 12, 2020 |
| Infection Control | February 28, 2023 |
| Infection Control | January 03, 2023 |
| Infection Control | December 16, 2022 |
| Infection Control | October 20, 2022 |
| Infection Control | March 02, 2022 |
| Infection Control | January 05, 2022 |
| Infection Control | October 29, 2021 |
| Infection Control | August 10, 2021 |
| Infection Control | June 28, 2021 |
| Infection Control | December 27, 2020 |
| Infection Control | December 03, 2020 |
| Infection Control | October 30, 2020 |
| Infection Control | August 26, 2020 |
| Infection Control | July 18, 2020 |
| Infection Control | June 03, 2020 |
| Infection Control | April 07, 2020 |
Owner and Operator Information for Heritage Gardens Rehabilitation and Healthcare
Our database of owners and operators shows all direct owners of the nursing nurse, any managers and directors, and the most adjacent indirect owners of the facility (that is, if the direct owner is company, then the owners of that company.) Lists of nursing home owners are available and you can search for nursing home owners and operators on our site.
Business Entity Name:
EASTLAND MEMORIAL HOSPITAL DISTRICT
Owners:
- EASTLAND MEMORIAL HOSPITAL DISTRICT (DIRECT- 100%)
Managers and Directors:
- SOON BURNAM (OPERATIONAL/MANAGERIAL CONTROL)
- SOON BURNAM (OFFICER)
- SAVOY HEALTHCARE INC. (OPERATIONAL/MANAGERIAL CONTROL)
- LABAN WRIGHT (OPERATIONAL/MANAGERIAL CONTROL)
- LABAN WRIGHT (OFFICER)
Analysis of Nursing Hours Spent Per Patient
CMS provides detailed information about how long nursing staff spends with residents. This data includes nursing subcategories of Registered Nurse, Licensed Practical Nurse, and non-nursing Certified Nursing Assistants. More hours spend per patient should can indicate a better facility or it could indicate more complicated situations.
The nursing staff of Heritage Gardens Rehabilitation and Healthcare spends LESS time on average with its residents than the state average and LESS time than the national average for total nursing homes spent per resident.
| Type | Facility | State / National Avg |
|---|---|---|
| Registered Nurse (RN) | ||
| Hours | 0.48 | 0.36 / 0.65 |
| Case Mix | 0.55 | 0.42 / 0.39 |
| Adjusted | 0.34 | NA / NA |
| Licensed Practical Nurse (LPN) | ||
| Hours | 0.74 | 1.02 / 0.88 |
| Case Mix | 0.93 | NA / NA |
| Adjusted | 0.59 | NA / NA |
| Certified Nursing Assistants (CNA) | ||
| Hours | 1.55 | 1.93 / 2.21 |
| Case Mix | 2.21 | NA / NA |
| Adjusted | 1.43 | NA / NA |
| Total Licensed Staff | ||
| Hours | 1.22 | 1.38 / 1.53 |
| Physical Therapist (PT) | ||
| Hours | 0.13 | 0.06 / 0.07 |
| Total Nursing Homes Spent per Resident on Average | ||
| Hours | 2.77 | 3.30 / 3.74 |
| Case Mix | 3.69 | 3.22 / 3.16 |
| Adjusted | 2.37 | NA / NA |
Quality Measures
Quality measures are based both on patient survey information and on the results of actual claims that are filed with CMS. It is not clear what period is covered in the measures.
| Desc. | Perc. | State Avg. / Comparison |
|---|---|---|
| Percentage of short-stay residents who were rehospitalized after a nursing home admission (qm521) | 21.9% |
24.5% Better |
| Percentage of short-stay residents who had an outpatient emergency department visit (qm522) | 6.5% |
12.2% Better |
| Number of hospitalizations per 1000 long-stay resident days (qm551) | 2.5% |
1.9% Worse |
| Number of outpatient emergency department visits per 1000 long-stay resident days (qm552) | 0.4% |
1.2% Better |
| Percentage of long-stay residents whose need for help with daily activities has increased (qm401) | 21.4% |
17.2% Worse |
| Percentage of long-stay residents who lose too much weight (qm404) | 2.7% |
4.9% Better |
| Percentage of low risk long-stay residents who lose control of their bowels or bladder (qm405) | 89.5% |
52.3% Worse |
| Percentage of long-stay residents with a catheter inserted and left in their bladder (qm406) | 0.0% |
1.5% Better |
| Percentage of long-stay residents with a urinary tract infection (qm407) | 0.0% |
1.4% Better |
| Percentage of long-stay residents who have depressive symptoms (qm408) | 2.2% |
5.3% Better |
| Percentage of long-stay residents who were physically restrained (qm409) | 0.0% |
0.0% Better |
| Percentage of long-stay residents experiencing one or more falls with major injury (qm410) | 1.0% |
3.4% Better |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine (qm415) | 100.0% |
95.6% Better |
| Percentage of long-stay residents who received an antipsychotic medication (qm419) | 0.0% |
10.1% Better |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine (qm430) | 87.7% |
83.9% Better |
| Percentage of short-stay residents who newly received an antipsychotic medication (qm434) | 3.2% |
1.8% Worse |
| Percentage of long-stay residents whose ability to move independently worsened (qm451) | 5.3% |
13.4% Better |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication (qm452) | 19.6% |
22.1% Better |
| Percentage of high risk long-stay residents with pressure ulcers (qm453) | 6.8% |
7.3% Better |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine (qm454) | 100.0% |
96.1% Better |
| Percentage of short-stay residents who made improvements in function (qm471) | 71.2% |
66.6% Better |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine (qm472) | 73.5% |
77.8% Worse |
Heritage Gardens Rehabilitation and Healthcare Violations, Complaints and Fines
These are complaints and fines that are reported by CMS. Some of the data is not very recent, but we have decided to include it here so that you have as much information as possible.
Amount fined in recent period: $6,500.00, Complaints filed: 2
| Deficiency | Deficiency Date / Date Corrected |
|---|---|
| Conduct risk assessment and an All-Hazards approach. (Fire Safety) | 03-11-2020 / 04-04-2020 |
| Establish policies and procedures for medical documentation. (Fire Safety) | 03-11-2020 / 04-04-2020 |
| Establish roles under a Waiver declared by secretary. (Fire Safety) | 03-11-2020 / 04-04-2020 |
| Establish emergency prep training and testing. (Fire Safety) | 03-11-2020 / 04-04-2020 |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. (Fire Safety) | 03-11-2020 / 04-10-2020 |
| 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. (Fire Safety) | 03-11-2020 / 04-04-2020 |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. (Fire Safety) | 03-11-2020 / 04-10-2020 |
| Install corridor and hallway doors that block smoke. (Fire Safety) | 03-11-2020 / 04-10-2020 |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. (Fire Safety) | 03-11-2020 / 04-04-2020 |
| Have properly installed electrical wiring and gas equipment. (Fire Safety) | 03-11-2020 / 04-10-2020 |
| Ensure electrical receptacles or cover plates have distinctive color or marking. (Fire Safety) | 03-11-2020 / 04-04-2020 |
| Have generator or other power source capable of supplying service within 10 seconds. (Fire Safety) | 03-11-2020 / 04-04-2020 |
| Ensure precautions for handling oxygen cylinders and equipment are correctly followed. (Fire Safety) | 03-11-2020 / 04-04-2020 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Health) | 03-12-2020 / 03-13-2020 |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. (Health) | 03-12-2020 / 04-17-2020 |
| Provide safe and appropriate respiratory care for a resident when needed. (Health) | 03-12-2020 / 04-17-2020 |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. (Health) | 03-12-2020 / 04-17-2020 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Health) | 03-12-2020 / 04-12-2020 |
| Provide and implement an infection prevention and control program. (Health) | 03-12-2020 / 04-17-2020 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (Health) | 12-03-2020 / 12-26-2020 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Health) | 12-03-2020 / 12-26-2020 |
| Assure that each resident?s assessment is updated at least once every 3 months. (Health) | 06-23-2021 / 06-25-2021 |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. (Health) | 06-23-2021 / 06-25-2021 |
| Ensure medication error rates are not 5 percent or greater. (Health) | 06-23-2021 / 07-25-2021 |
| Provide and implement an infection prevention and control program. (Health) | 06-23-2021 / 07-22-2021 |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. (Fire Safety) | 06-24-2021 / 06-25-2021 |
| Have properly located and lighted "Exit" signs. (Fire Safety) | 08-16-2022 / 08-18-2022 |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. (Fire Safety) | 08-16-2022 / 09-09-2022 |
| Have an alternate power supply for its alarm system. (Fire Safety) | 08-16-2022 / 09-07-2022 |
| Install corridor and hallway doors that block smoke. (Fire Safety) | 08-16-2022 / 09-07-2022 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Health) | 08-17-2022 / 09-01-2022 |
| Provide and implement an infection prevention and control program. (Health) | 10-20-2022 / 11-15-2022 |
Hospitals Near Heritage Gardens Rehabilitation and Healthcare
Quite often skilled nursing facilities and hospitals work closely together to help patients recover or manage a terminal illness. Hospitals deals with acute care while nursing homes treat patients for a longer period of time. New residents at skilled nursing homes typically come from a hospital and nursing home residents may be readmitted to a hospital if their recovery does not proceed well. (Hospital readmission rates are closely monitored by CMS.) Consequently it is important that you consider which hospitals are near a nursing home which choosing one. Below is a list of hospitals near Heritage Gardens Rehabilitation and Healthcare.
This information is based on the most recent Hospital data. Historical data is not available.
| Hospital | 5-Star Overall Rating |
|---|---|
|
PARKLAND HEALTH & HOSPITAL SYSTEM 5200 HARRY HINES BLVD DALLAS, TX 75235 |
2 |
|
MEDICAL CITY ARLINGTON 3301 MATLOCK ROAD ARLINGTON, TX 76015 |
2 |
|
METHODIST CHARLTON MEDICAL CENTER 3500 W WHEATLAND ROAD DALLAS, TX 75237 |
2 |
|
TEXAS HEALTH ARLINGTON MEMORIAL HOSPITAL 800 W RANDOL MILL RD ARLINGTON, TX 76012 |
2 |
|
METHODIST RICHARDSON MEDICAL CENTER 2831 E PRESIDENT GEORGE BUSH HIGHWAY RICHARDSON, TX 75082 |
2 |
|
MEDICAL CITY PLANO 3901 W 15TH ST PLANO, TX 75075 |
2 |
|
BAYLOR SCOTT AND WHITE MEDICAL CENTER SUNNYVALE 231 SOUTH COLLINS ROAD SUNNYVALE, TX 75182 |
2 |
|
BAYLOR SCOTT & WHITE MEDICAL CENTER-WHITE ROCK 9440 POPPY DR DALLAS, TX 75218 |
2 |
|
TEXAS HEALTH PRESBYTERIAN HOSPITAL DENTON 3000 N I-35 DENTON, TX 76201 |
3 |
|
MEDICAL CITY NORTH HILLS 4401 BOOTH CALLOWAY ROAD NORTH RICHLAND HILLS, TX 76180 |
3 |
|
MEDICAL CITY LAS COLINAS 6800 N MACARTHUR BLVD IRVING, TX 75039 |
3 |
|
SANA HEALTHCARE CARROLLTON D/B/A CARROLLTON REGIONAL MEDICAL CENTER 4343 NORTH JOSEY LANE CARROLLTON, TX 75010 |
3 |
|
METHODIST DALLAS MEDICAL CENTER 1441 NORTH BECKLEY AVENUE DALLAS, TX 75203 |
3 |
|
BAYLOR SCOTT AND WHITE MEDICAL CENTER LAKE POINTE 6800 SCENIC DR ROWLETT, TX 75088 |
3 |
|
TEXAS HEALTH PRESBYTERIAN HOSPITAL PLANO 6200 W PARKER RD PLANO, TX 75093 |
3 |
|
TEXAS HEALTH PRESBYTERIAN HOSPITAL DALLAS 8200 WALNUT HILL LANE DALLAS, TX 75231 |
3 |
|
U S M D HOSPITAL AT ARLINGTON L P 801 W INTERSTATE 20 ARLINGTON, TX 76017 |
3 |
|
TEXAS HEALTH PRESBYTERIAN HOSPITAL ALLEN 1105 CENTRAL EXPRESSWAY NORTH ALLEN, TX 75013 |
3 |
|
BAYLOR UNIVERSITY MEDICAL CENTER 3500 GASTON AVE DALLAS, TX 75246 |
3 |
|
JPS HEALTH NETWORK 1500 S MAIN ST FORT WORTH, TX 76104 |
3 |
Medical Professionals Associated with Heritage Gardens Rehabilitation and Healthcare
These are the doctors who are affiliated with Heritage Gardens Rehabilitation and Healthcare. The data is from the most recent period. Historical data is not available.
- CHIRAG PATEL ( INTERNAL MEDICINE - PREMIER INTERNISTS OF NORTH TEXAS, PLLC )
Detailed Analysis Pages:
Depending on the nursing home, this page can get really long. So, we have also broken up the data onto separate pages to allow you to find what you want more easily. We will keep adding to these pages as we continue to analyze the nursing home database.
CMS Five Star Ratings and Quality Measures for Heritage Gardens Rehabilitation and Healthcare
Five different rating results plus detailed inspection numbers and quality measures for Heritage Gardens Rehabilitation and Healthcare.
Covid Infections at Heritage Gardens Rehabilitation and Healthcare
This report is updated weekly and shows new and historical infection levels.
Nursing Hours Analysis for Heritage Gardens Rehabilitation and Healthcare
How long a nurse spends with a resident can be an important factor in their recovery. This page shows the average nursing hours spent per resident for RNs, LPNs, CNAs, PTs and all licensed staff.
Ownership Details for Heritage Gardens Rehabilitation and Healthcare
A list of all of the registered owners for Heritage Gardens Rehabilitation and Healthcare. This includes direct and indirect owners and managers.
Noted Deficiencies for Heritage Gardens Rehabilitation and Healthcare
A list of all of the deficiencies for the facility. This includes a description, type of deficiency, incident date and when the facility reports that the incident was corrected.
Comparison Ranking of Nearby Skilled Nursing Facilities
How does Heritage Gardens Rehabilitation and Healthcare compare to other skilled nursing facilities? This list shows the competitive set within a 25 mile radius.
Best Nursing Homes in CARROLLTON, TX
Homes that you should consider. A list ranking the best skilled nursing facilities in CARROLLTON based on their weighted inspection score as of April 01, 2023.
Worst Nursing Homes in CARROLLTON, TX
Homes that you avoid if possible. A list ranking the worst skilled nursing facilities in CARROLLTON based on their weighted inspection score as of April 01, 2023.
Other Data Periods:
Data on Heritage Gardens Rehabilitation and Healthcare is available for the following periods:
