Nursing home in Carrollton, Texas
Brookhaven Nursing and Rehabilitation Center
Medicare and Medicaid
1855 Cheyenne Dr., Carrollton, TX 75010
(972) 394-7141
- CMS shows its abuse icon for this nursing home: it was cited for abuse or neglect at the harm level or above on the most recent inspection cycle, or at the potential-harm level on both of the last two cycles.
CMS star ratings
CMS gives this nursing home an overall star rating of 1 out of 5. Each rating is compared with the mean of rated nursing homes in Texas (1,165 for the overall rating) and in the U.S. (14,565). How to read an inspection report.
Overall rating
- This nursing home1
- Texas average2.7 (1,165 rated)
- U.S. average3.0 (14,565 rated)
Health inspections
- This nursing home1
- Texas average2.8 (1,165 rated)
- U.S. average2.8 (14,565 rated)
Staffing
[25]
- This nursing home1
- Texas average1.9 (1,163 rated)
- U.S. average2.9 (14,494 rated)
Quality measures
- This nursing home2
- Texas average3.7 (1,162 rated)
- U.S. average3.6 (14,495 rated)
Health inspections
Most recent standard health inspection (rating cycle 1): Jul 23, 2025. CMS counts 10 health deficiencies in rating cycle 1.
- This nursing home10
- Texas average9.4 (1,171 with data)
- U.S. average9.2 (14,652 with data)
Rating cycle 1 health deficiencies. Averages include every nursing home with a count in the CMS file; fewer is better.
Deficiencies since Sep 30, 2023
Inspectors cited 37 health deficiencies on 13 inspection dates since Sep 30, 2023. By level of harm: 3 immediate jeopardy, 1 actual harm, 33 potential for harm.
- 3 Immediate jeopardy to resident health or safety
- 1 Actual harm
- 33 No actual harm, potential for more than minimal harm
- 0 No actual harm, potential for minimal harm
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| May 27, 2026 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jun 3, 2026 |
| Dec 3, 2025 | F0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Jan 16, 2026 |
| Nov 4, 2025 | F0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Nov 17, 2025 |
| Oct 3, 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and Exploitation Deficiencies | K Immediate jeopardy, pattern | Complaint | Deficient, Provider has date of correction Oct 6, 2025 |
| Aug 27, 2025 | F0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and Exploitation Deficiencies | G Actual harm, isolated | Complaint | Past Non-Compliance |
| Jul 23, 2025 | F0638 | Assure that each resident’s assessment is updated at least once every 3 months.Resident Assessment and Care Planning Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Aug 30, 2025 |
| Jul 23, 2025 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Aug 23, 2025 |
| Jul 23, 2025 | F0761 | 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.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard | Deficient, Provider has date of correction Aug 30, 2025 |
| Jul 23, 2025 | F0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Aug 30, 2025 |
| Jul 23, 2025 | F0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Aug 23, 2025 |
Show the other 27 deficiencies
| Date | Tag | Deficiency | Scope and severity | Inspection type | Status |
|---|---|---|---|---|---|
| Jul 23, 2025 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Aug 30, 2025 |
| Mar 4, 2025 | F0551 | Give the resident's representative the ability to exercise the resident's rights.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Mar 27, 2025 |
| Feb 12, 2025 | F0726 | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician Services Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Mar 12, 2025 |
| Dec 18, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Past Non-Compliance Nov 13, 2024 |
| Aug 30, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Aug 30, 2024 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Aug 30, 2024 | F0585 | Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.Resident Rights Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Aug 30, 2024 | F0641 | Ensure each resident receives an accurate assessment.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Aug 30, 2024 | F0645 | PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Aug 30, 2024 | F0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care Planning Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Aug 30, 2024 | F0687 | Provide appropriate foot care.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Aug 30, 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Aug 30, 2024 | F0791 | Provide or obtain dental services for each resident.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Sep 5, 2024 |
| Jun 6, 2024 | F0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Jul 19, 2024 |
| Jun 6, 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Jul 19, 2024 |
| Jun 6, 2024 | F0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and Dietary Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Jul 19, 2024 |
| Jun 6, 2024 | F0880 | Provide and implement an infection prevention and control program.Infection Control Deficiencies | E Potential for harm, pattern | Standard, Complaint | Deficient, Provider has date of correction Jul 19, 2024 |
| Jun 6, 2024 | F0558 | Reasonably accommodate the needs and preferences of each resident.Resident Rights Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jul 19, 2024 |
| Jun 6, 2024 | F0677 | Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard | Deficient, Provider has date of correction Jul 19, 2024 |
| Jun 6, 2024 | F0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jul 19, 2024 |
| Jun 6, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jul 19, 2024 |
| Jun 6, 2024 | F0693 | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.Quality of Life and Care Deficiencies | D Potential for harm, isolated | Standard, Complaint | Deficient, Provider has date of correction Jul 19, 2024 |
| Jan 30, 2024 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Mar 1, 2024 |
| Jan 30, 2024 | F0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy Service Deficiencies | E Potential for harm, pattern | Complaint | Deficient, Provider has date of correction Mar 1, 2024 |
| Jan 30, 2024 | F0761 | 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.Pharmacy Service Deficiencies | D Potential for harm, isolated | Complaint | Deficient, Provider has date of correction Mar 1, 2024 |
| Dec 29, 2023 | F0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and Care Deficiencies | J Immediate jeopardy, isolated | Complaint | Past Non-Compliance Nov 30, 2023 |
| Dec 29, 2023 | F0919 | Make sure that a working call system is available in each resident's bathroom and bathing area.Environmental Deficiencies | D Potential for harm, isolated | Complaint, Infection control | Deficient, Provider has date of correction Jan 26, 2024 |
Staffing
Total nurse staffing
Reported hours per resident per day.[25]
- This nursing homeNot available
- Texas average3.39 hours (1,148 with data)
- U.S. average3.86 hours (14,351 with data)
Registered nurse staffing
Reported hours per resident per day.[25]
- This nursing homeNot available
- Texas average0.43 hours (1,148 with data)
- U.S. average0.69 hours (14,351 with data)
Nursing staff turnover
Share of nursing staff who left during the year, as reported to CMS.
- This nursing home75.3%
- Texas average55.3% (1,051 with data)
- U.S. average45.8% (13,538 with data)
Penalties
CMS lists 3 penalties for this nursing home: 3 fines totaling $24,739, and 0 payment denials. CMS counts penalties from the last 3 years.
Facility details
| Certified beds | 180 |
|---|---|
| Average residents per day | 114.9 |
| Ownership | For profit - Corporation |
| Provider type | Medicare and Medicaid |
| Inside a hospital | No |
| Continuing care retirement community | No |
| Resident and family council | Resident |
| Automatic sprinklers in all required areas | Yes |
| Chain | Not part of a chain in the CMS file |
| Legal business name | OLNEY-HAMILTON HOSPITAL DISTRICT |
| First approved for Medicare and Medicaid | Jul 1, 1973 |
| County | Denton |
| CMS certification number | 455412 |
Also in Carrollton
| Nursing home | CMS overall rating | Health inspection rating | Certified beds | Ownership |
|---|---|---|---|---|
| The Madison on Marsh | 125 | For profit - Corporation | ||
| Carrollton Health and Rehabilitation Center | 120 | Government - Hospital district | ||
| Heritage Gardens Rehabilitation and Healthcare | 150 | For profit - Corporation | ||
| Mustang Park Therapy and Living Center | 120 | For profit - Corporation |
| Hospital | CMS overall rating | Type | Emergency services |
|---|---|---|---|
| Carrollton Regional Medical Center | Acute Care Hospitals | Yes | |
| Carrollton Springs | Not available | Psychiatric | No |
CMS footnotes on this page
- [25]
- The accuracy of the staffing data for this measure could not be validated by CMS.