Carrollton Regional Medical Center
An acute care hospital in Carrollton, Texas 75010
4343 North Josey Lane, Carrollton, Texas 75010. (972) 394-2255.
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The short answer
Record last released by CMS on Oct 20, 2026.
- 2of 5 CMS’s overall rating
- 2of 5 patient survey rating
- 1 deficiency cited in the last three years
- 216 beds
Each figure’s source sits beside it, in its section below.
What these words mean3
- Star ratings
- CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System.
- Inspection (survey)
- A visit by state inspectors, often unannounced, who check a place against the rules it must meet. For nursing homes and other places Medicare pays, CMS calls these visits surveys: a standard survey of a nursing home comes at least every 15 months, and a complaint survey whenever a complaint calls for one. Source: CMS; 42 CFR 488.308.
- Deficiency, citation, violation
- What inspectors write up when a place didn’t meet a rule: the rule, what they saw, and when. CMS calls it a deficiency; states may say citation or violation. It is the inspectors’ finding, not a court’s, and the place is usually asked for a plan to correct it. Source: CMS, statement of deficiencies (Form CMS-2567); each state’s licensing agency.
What did inspectors find?
The last inspection on record was on Jul 23, 2026: a complaint inspection.
1 deficiency cited in the last three years.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
When those deficiencies happened
1 deficiency in 1 month of the last 36. Last cited Jul 2026. Most serious: Standard-level. The last 3 years, to Nov 5, 2026.
| Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| 2023 | Dec | |||||||||||
| 2024 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2025 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov | Dec |
| 2026 | Jan | Feb | Mar | Apr | May | Jun | Jul | Aug | Sep | Oct | Nov |
Hover or focus a month to read it.
Hearth Record drew this from the dates and levels in the source’s own records.
Each deficiency, as cited
Rule titles as CMS’s inspectors cite them, set in sentence case.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Jul 23, 2026: complaint inspection1 deficiency
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Administration Of Drugs
The inspectors’ words, 859 words
“ADMINISTRATION OF DRUGS CFR(s): 482.23(c)(1), (c)(1)(i) & (c)(2) (1) Drugs and biologicals must be prepared and administered in accordance with Federal and State laws, the orders of the practitioner or practitioners responsible for the patient’s care as specified under §482.12(c), and accepted standards of practice. (i) Drugs and biologicals may be prepared and administered on the orders of other practitioners not specified under §482.12(c) only if such practitioners are acting in accordance with State law, including scope of practice laws, hospital policies, and medical staff bylaws, rules, and regulations. (2) All drugs and biologicals must be administered by, or under supervision of, nursing or other personnel in accordance with Federal and State laws and regulations, including applicable licensing requirements, and in accordance with the approved medical staff policies and procedures. This Standard is not met as evidenced by: 28637 BASED ON record reviews and interviews, the facility failed to ensure drugs are administered according to hospital policy for 2 of 10 patients (Patient #3 and 5). 1. Patient #3 informed her triage nurse she had a known allergy to NSAIDS [nonsteroidal anti-inflammatory drugs]. Despite this, she was administered ketorolac [an NSAID] and developed an allergic reaction requiring additional aggressive antihistamine and steroid medication treatment and inpatient admission for management of allergic reaction 2. Patient #5, a patient admitted for peridiverticular abscess (serious abdominal infection) missed a scheduled dose of her antibiotic Vancomycin on 07/13/2026. The patient’s therapeutic antibiotic level was noted to be low on 07/14/2026. Findings included: 1) Patient #3 was a 39-year-old with a history of left hip replacement and failed 360 spinal fusion who presented to the ED [emergency department] with worsening right hip pain. Patient #3’s ED Triage Notes dated 06/16/2026 at 7:16 PM reflected the patient’s statement of right hip pain, nausea that got increasingly worse over the last day and was not relieved with the patients’ home medication, Percocet. The patient stated being allergic to nonsteroidal anti-inflammatory drugs (NSAIDS) and informed staff she reacted with hives. An allergy notification bracelet was applied. Patient #3 ED Physician Orders dated 06/26/2026 at 10:02 PM reflected the one-time order of Ketorolac 30 mg/ml (also known as Toradol which is classified as an NSAID) 10 mg IV (intravenous). Patient #3’s ED medication administration record reflected Ketorolac 10 mg was administered IV on 06/26/2026 at 10:38 PM. Patient #3’s ED physician History and Physical, dated 06/26/2026 at 10:00 PM reflected the patient was a 39-year-old with a history of left hip replacement and failed 360 spinal fusion who presented to the ED with worsening right hip pain due to a labral tear on MRI following a motor vehicle accident. The physician noted the patient’s “moderate severity” NSAIDS allergy ... “reaction: hives.” The ED course documentation reflected the Patient #3 arrived with “severe, unmanageable right hip pain .... associated significant nausea.” Emergency interventions included intravenous administration of narcotic pain medication and “Toradol, Zofran, IV fluids, and antiemetics.” The physician noted that “ ...shortly after Toradol administration, patient developed an allergic reaction (lip swelling, throat itching, sensation of lump in throat). - Benadryl administered with partial improvement; additional antihistamines and steroids (Decadron, Pepcid) given ... Hospitalist was consulted and discussed admission options with the patient ... continuous telemetry [heart] monitoring were planned for admission ...” The assessment noted the patient had an “acute allergic reaction to Toradol ...angioedema and risk of airway compromise. Treated with antihistamines, steroids, and close monitoring. Admission for observation and management of allergic reaction ...” During an interview on 07/21/2026 at 9:45 AM, Staff A and Staff C stated they were aware of the incident. 2) Patient #5 was 72-year-old with past medical history that included cardiac and pulmonary (lung) conditions. The patient was emergently treated on 07/06/2026 for acute diverticulitis pain and peridiverticular abscess (pocket of infection in the colon) that worsened after her inpatient hospital admission. The patient sought emergency care on 7/6/2026 with complaints of lower abdominal pain. CT scan done in the emergency room revealed finding of acute diverticulitis with 2.5 x 2.9 cm size peridiverticular abscess. She was admitted for treatment. An Infectious Disease Progress Note dated 07/10/2026 included the plan to add Vancomycin, a strong antibiotic, as the colon abscess had increased in size. Physician orders dated 07/10/2026 reflected Vancomycin 1500mg to be administered every 24 hours. The order was increased two days later, on 07/12/2026 to be administered every 12 hours as morning and evening dose. Patient #5’s Medication Administration Record dated 07/13/2026 reflected the morning dose administration only. There was no additional information about why the 07/13/2026 evening dose had not been administered. During an interview on 07/21/2026 at 10:13 AM, Staff C stated it appeared the patient had missed a dose on 07/13/2026 and her Vancomycin medication blood level (trough level) was low on 07/14/2026. Review of facility’s policy titled “Medication Administration” dated 03/2020 reflected the procedure of safe medication administration that included to verify that no contraindications existed and the patient right to receive the medication at the correct time was preserved. Review of the facility’s policy titled “Timing of Medication Administration” dated 03/2020 reflected missed or late administrations of medications is a drug administration error.”
All 2 inspections in the last three years
| Date | Visit | What the record says |
|---|---|---|
| Jul 23, 2026 | Complaint inspection | 1 deficiency cited |
| Feb 14, 2024 | Complaint inspection | No deficiencies cited |
How do patients fare?
- CMS’s overall CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System. for it is 2 of 5.
- Of the measures behind its CMS rates some kinds of place from 1 to 5 stars, more stars meaning better on CMS’s own measures for that kind: for a nursing home, its health inspections, staffing and quality measures. A rating is CMS’s summary of those measures; it doesn’t promise good care. Source: CMS, Care Compare and the Five-Star Quality Rating System., CMS counts against the national value: mortality, 0 better and 0 worse of 4; safety of care, 0 better and 0 worse of 4; readmission, 1 better and 1 worse of 5.
- Patients rate it 2 of 5 in CMS’s patient survey (249 surveys completed, Oct 1, 2024 to Sep 30, 2025): 61% rated it 9 or 10 out of 10, and 54% would definitely recommend it.
- Infections, compared by CMS with the national benchmark (Oct 1, 2024 to Sep 30, 2025): catheter urinary tract infections (CAUTI), no different than national benchmark; C. diff infections, better than the national benchmark.
- CMS’s patient safety composite for serious complications, PSI 90, Jul 1, 2022 to Jun 30, 2024: no different than the national value.
- Deaths within 30 days, as CMS gives them (Jul 1, 2022 to Jun 30, 2025): heart attack 11.7%, heart failure 12.1%, pneumonia 12.7%, stroke 10.6%. CMS gives no comparison with the national rate for them in this release.
- Readmissions within 30 days, as CMS gives them (Jul 1, 2023 to Jun 30, 2025): heart attack 15%, heart failure 22.5%, pneumonia 18.6%, COPD 18.7%, hip or knee replacement 6.1%. CMS gives no comparison with the national rate for them in this release.
- After outpatient care, compared by CMS: unplanned hospital visits after outpatient surgery, no different than expected.
- Emergency department patients spent a median of 205 minutes there before leaving (Oct 1, 2024 to Sep 30, 2025), and 4% left before being seen.
- 55% of patients with severe sepsis or septic shock got the care CMS measures, SEP-1 (Oct 1, 2024 to Sep 30, 2025).
- Medicare’s spending per patient here is 1.12 times the national median (Jan 1, 2024 to Dec 31, 2024).
CMS, Hospital General Information, Patient survey (HCAHPS) - Hospital, Healthcare Associated Infections - Hospital, Timely and Effective Care - Hospital and Medicare Spending Per Beneficiary - Hospital. Released Aug 13, 2026. Updated quarterly.
CMS, Complications and Deaths - Hospital and Unplanned Hospital Visits - Hospital. Released Sep 30, 2026. Updated quarterly.
| Measure | Rating |
|---|---|
| Overall ratingCMS’s overall hospital quality star rating, 1 to 5 | 2 of 5 |
| Patient survey ratingCMS star rating from its survey of the hospital’s patients (HCAHPS), 1 to 5 | 2 of 5 |
Is it certified, and in good standing?
- Medicare-certified acute care hospital since Feb 20, 1985.
- Ownership: proprietary.
- It is accredited by The Joint Commission, whose surveys stand in for the state’s routine inspections.
- No For hospices, home health agencies, hospitals and dialysis facilities, CMS writes deficiencies at two levels. Standard is the usual one; condition-level is the more serious, when a problem is serious enough that the provider doesn’t meet a whole condition of taking part in Medicare. Source: CMS, State Operations Manual. deficiency on record in the last three years.
- Proprietary.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
Has it been penalized?
- CMS doesn’t publish fines or other penalties for hospitals.
- Not among the hospitals whose Medicare payments CMS cut under the Hospital-Acquired Condition Reduction Program for fiscal year 2026.
- 1 deficiency cited in the last three years came from an inspection that included a complaint investigation.
CMS, Hospital-Acquired Condition (HAC) Reduction Program. Released Aug 13, 2026. Updated yearly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
CMS, QCOR Hospital 2567 statements of deficiencies. Released Oct 20, 2026. Updated monthly.
What do patients say about their care?
- CMS doesn’t publish staffing levels for hospitals.
- In CMS’s patient survey, patients rate how well its nurses communicated 2 of 5.
- 75% of its health care workers got a flu shot (Oct 1, 2024 to Mar 31, 2025).
CMS, Patient survey (HCAHPS) - Hospital and Timely and Effective Care - Hospital. Released Aug 13, 2026. Updated quarterly.
Who owns it?
- 5 owners or officers are people: Krishna P Surapaneni (owns 5% or more directly, 100%); Krishna P Surapaneni (managing employee (on the payroll), 100%); Krishna P Surapaneni (runs it (operational or managerial control), 100%); John Keefe (runs it (operational or managerial control), 0%); Caleb Orear (managing employee (on the payroll), 0%).
- CMS’s Provider of Services file records 4 changes of ownership, the latest on Mar 1, 2020.
- No private-equity firm among the owners CMS lists.
- No real-estate investment trust among the owners CMS lists.
CMS, Hospital All Owners and Hospital Enrollments. Released Sep 29, 2026. Updated monthly.
CMS, Provider of Services File - Hospital & Non-Hospital Facilities. Released Oct 14, 2026. Updated quarterly.
How does it compare nearby?
- Of the 17 hospitals CMS lists in Denton County, 8 have an overall star rating from CMS: 3 rated 5 of 5, 2 rated 4 of 5, 2 rated 3 of 5, 1 rated 2 of 5.
- CMS rates this one 2 of 5.
CMS, Hospital General Information. Released Aug 13, 2026. Updated quarterly.
| Place | Overall star rating |
|---|---|
| Carrollton Springs | Not given |
| Medical City Denton | 4 |
| Medical City Lewisville | 3 |
| Texas Health Presbyterian Hospital Denton | 5 |
| Baylor Scott & White Medical Center - Frisco | 3 |
| Baylor Medical Center at Trophy Club | Not given |
| The Heart Hospital Baylor Denton | 5 |
| Baylor Scott White the Heart Hospital Corinth | Not given |
| University Behavioral Health of Denton | Not given |
| Medical City Mental Health and Wellness Center | Not given |
| Mayhill Hospital | Not given |
| Baylor Scott & White Emergency Hospital | Not given |
What the record doesn’t say
- CMS doesn’t publish fines or other penalties for hospitals, so none are shown. The one payment cut CMS publishes for each hospital, under its Hospital-Acquired Condition Reduction Program, is shown where it applies.
- Only complaints that led to a citation appear; complaints that didn’t aren’t published.
- Most hospitals are accredited by a private organisation (The Joint Commission, DNV and others) whose routine inspections stand in for the state’s; those reports aren’t public, and QCOR holds only the state’s surveys: no inspection on record here doesn’t mean none took place.
- QCOR says its hospital inspection data are complete only through September 17, 2026, while it moves to a new system.
- CMS doesn’t publish staffing levels for hospitals.
- In its September 2026 release CMS gives no comparison with the national rate for death and readmission rates, though it gives the rates.
Sources
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Centers for Medicare & Medicaid Services, Hospital General Information (xubh-q36u).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Patient survey (HCAHPS) - Hospital.
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Healthcare Associated Infections - Hospital (77hc-ibv8).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Complications and Deaths - Hospital (ynj2-r877).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Unplanned Hospital Visits - Hospital (632h-zaca).
Released Sep 30, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Timely and Effective Care - Hospital (yv7e-xc69).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Medicare Spending Per Beneficiary - Hospital (rrqw-56er).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital-Acquired Condition (HAC) Reduction Program (yq43-i98g).
Released Aug 13, 2026 and checked Nov 5, 2026. Updated yearly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Provider of Services File - Hospital & Non-Hospital Facilities (Hospital_and_other.DATA.Q3_2026.csv).
Released Oct 14, 2026 and checked Nov 5, 2026. Updated quarterly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, QCOR Hospital 2567 statements of deficiencies (Hospital_2567s_2010_to_2026YTD.xlsx).
Released Oct 20, 2026 and checked Oct 27, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital All Owners (Hospital_All_Owners_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
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Centers for Medicare & Medicaid Services, Hospital Enrollments (Hospital_Enrollments_2026.09.29.csv).
Released Sep 29, 2026 and checked Nov 5, 2026. Updated monthly. Public domain (U.S. Government work).
If you believe something here is wrong, a correction starts with the agency whose record this copies: CMS. CMS’s own record is on Care Compare. If Hearth Record copied something wrongly, it will fix it and log the correction publicly, with its date: how corrections work.
This copy of the record was made on Nov 5, 2026.
From the hospital
The public record above comes first. Anything the hospital adds will appear here, below it, and say who wrote it.
Replies
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Paid listing
None. Paid listings aren’t open yet. When they open, anything paid for will say “Paid by the hospital”, and paying will never change a finding, a rating or the order of results.