Carrollton Health And Rehabilitation Center

Penalties

• Jan 14, 2025 — Fine ($10,358)
• Mar 20, 2024 — Fine ($8,827)

Inspection findings

1. Jun 25, 2026 Health · 17 findings
   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     CMS health inspection

   • Not serious Scope/severity E

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     CMS health inspection

   • Not serious Scope/severity E

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     CMS health inspection

   • Not serious Scope/severity D

     F0690 Quality of Life and Care Deficiencies

     Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

     CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     CMS health inspection

   • Not serious Scope/severity E

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     CMS health inspection

   • Not serious Scope/severity F

     F0851 Administration Deficiencies

     Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

     CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     CMS health inspection

   • Not serious Scope/severity D

     F0925 Environmental Deficiencies

     Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

     CMS health inspection

   • Not serious Scope/severity F

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Jun 25, 2026 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     CMS fire safety

2. Mar 26, 2026 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Apr 5, 2026 · CMS health inspection

3. Mar 5, 2026 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Mar 8, 2026 · CMS health inspection

4. Jan 30, 2026 Health · 3 findings
   • Not serious Scope/severity E Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 19, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Feb 19, 2026 · CMS health inspection

   • Not serious Scope/severity E Complaint

     F0919 Environmental Deficiencies

     Make sure that a working call system is available in each resident's bathroom and bathing area.

     Corrected Feb 19, 2026 · CMS health inspection

5. Dec 1, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Dec 2, 2025 · CMS health inspection

6. Nov 20, 2025 Health · 4 findings
   • Not serious Scope/severity D Complaint

     F0583 Resident Rights Deficiencies

     Keep residents' personal and medical records private and confidential.

     Corrected Dec 7, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0684 Quality of Life and Care Deficiencies

     Provide appropriate treatment and care according to orders, resident’s preferences and goals.

     Corrected Dec 7, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Dec 7, 2025 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 7, 2025 · CMS health inspection

7. May 6, 2025 Health · 7 findings
   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected May 30, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected May 30, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected May 30, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0776 Administration Deficiencies

     Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

     Corrected May 30, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected May 30, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected May 8, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected May 8, 2025 · CMS fire safety

8. Jan 14, 2025 Health · 1 finding
   • Serious Scope/severity G Complaint

     F0600 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

     Corrected May 20, 2024 · CMS health inspection

9. Apr 11, 2024 Health · 10 findings
   • Not serious Scope/severity D

     F0558 Resident Rights Deficiencies

     Reasonably accommodate the needs and preferences of each resident.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity E

     F0694 Quality of Life and Care Deficiencies

     Provide for the safe, appropriate administration of IV fluids for a resident when needed.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0756 Pharmacy Service Deficiencies

     Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0760 Pharmacy Service Deficiencies

     Ensure that residents are free from significant medication errors.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected May 3, 2024 · CMS health inspection

   • Not serious Scope/severity E

     K0211 Egress Deficiencies

     Keep aisles, corridors, and exits free of obstruction in case of emergency.

     Corrected May 3, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected May 3, 2024 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected May 3, 2024 · CMS fire safety

10. Mar 20, 2024 Health · 1 finding
    • Serious Scope/severity J Complaint

      F0689 Quality of Life and Care Deficiencies

      Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

      Corrected Jan 5, 2024 · CMS health inspection

Owners and managers (as published by CMS)

• BURNAM, SOON — corporate officer, NOT APPLICABLE, since 04/01/2017
• COIL, RYAN — adp of the snf, NOT APPLICABLE, since 08/01/2025
• COIL, RYAN — operational/managerial control, NOT APPLICABLE, since 08/01/2025
• COIL, RYAN — managing control - governing body, NOT APPLICABLE, since 08/01/2025
• KEETCH, CHAD — corporate officer, NOT APPLICABLE, since 03/01/2011
• TAYLOR, STEPHEN — corporate officer, NOT APPLICABLE, since 07/01/2025
• WARD, CHARLES — operational/managerial control, NOT APPLICABLE, since 12/01/2023
• WARD, CHARLES — managing control - governing body, NOT APPLICABLE, since 12/01/2023
• WARD, CHARLES — adp of the snf, NOT APPLICABLE, since 12/01/2023
• CARETRUST GP LLC — adp of the snf, NOT APPLICABLE, since 12/01/2006
• CARETRUST REIT INC — adp of the snf, NOT APPLICABLE, since 12/01/2006
• CARROLLTON HEIGHTS HEALTHCARE, INC. — adp of the snf, NOT APPLICABLE, since 08/11/2025
• CARROLLTON HEIGHTS HEALTHCARE, INC. — operational/managerial control, NOT APPLICABLE, since 04/01/2017
• CTR PARTNERSHIP LP — adp of the snf, NOT APPLICABLE, since 12/01/2006
• EASTLAND MEMORIAL HOSPITAL DISTRICT — 5% or greater direct ownership interest, 100%, since 04/01/2017
• ENSIGN SERVICES INC — adp of the snf, NOT APPLICABLE, since 03/20/2006
• TRINITY MILL HOLDINGS LLC — adp of the snf, NOT APPLICABLE, since 12/01/2006