For profit - Corporation · 180 certified beds · CMS number 455412
Brookhaven Nursing and Rehabilitation Center, Carrollton, TX
CMS records 47 health deficiencies at Brookhaven Nursing and Rehabilitation Center in Carrollton, Texas in its last 3 inspection cycles; the Texas median is 25. Its most recent standard inspection was on Jul 23, 2025. The highest severity cited is K (immediate jeopardy to resident health or safety). 3 citations were at the immediate jeopardy level, 2 of them recorded as past non-compliance (fixed before the inspection). CMS lists 3 fines totaling $24,739 in the last three years.
- 47deficiencies, 3 cycles (TX median 25)
- 10in the latest cycle (TX median 8)
- Khighest severity · Immediate jeopardy
- $24,739fines, last 3 years
- 1CMS overall rating (of 5)
Inspections and deficiencies
CMS findings for Brookhaven Nursing and Rehabilitation Center as of Sep 1, 2026, grouped by inspection cycle (3 cycles); each is a requirement inspectors found not met, and Brookhaven Nursing and Rehabilitation Center may since have corrected or disputed it. Severity letters · Inspection cycles · Care Compare
Most recent cycle (10 deficiencies)
Standard inspection Jul 23, 2025. CMS counts 10 health deficiencies and 9 fire safety deficiencies in this cycle.
May 27, 2026 · Complaint inspection
1 deficiency, highest D
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 3, 2026
Dec 3, 2025 · Complaint inspection
1 deficiency, highest D
F644 · Coordinating with PASARR screening
Requirement cited (CMS): Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 16, 2026
Nov 4, 2025 · Complaint inspection
1 deficiency, highest D
F628 · Discharge paperwork, notices, and bed-hold information
Requirement cited (CMS): Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Nov 17, 2025
Oct 3, 2025 · Complaint inspection
1 deficiency, highest K
F600 · Freedom from abuse and neglect
Requirement cited (CMS): Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Severity
- K Immediate jeopardy to resident health or safety, pattern
- Status
- Correction date Oct 6, 2025
Jul 23, 2025 · Standard + complaint inspection
6 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 30, 2025
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Aug 30, 2025
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Aug 23, 2025
F655 · Baseline care plan within 48 hours
Requirement cited (CMS): Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 23, 2025
F638 · Quarterly assessment reviews
Requirement cited (CMS): Assure that each resident’s assessment is updated at least once every 3 months.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Aug 30, 2025
F636 · Full assessment at admission and yearly
Requirement cited (CMS): Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Aug 30, 2025
Previous cycle: 13 deficiencies (standard inspection Jun 6, 2024)
Standard inspection Jun 6, 2024. CMS counts 13 health deficiencies and 17 fire safety deficiencies in this cycle.
Aug 27, 2025 · Complaint inspection
1 deficiency, highest G
F600 · Freedom from abuse and neglect
Requirement cited (CMS): Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
- Severity
- G Actual harm (not immediate jeopardy), isolated
- Status
- Past non-compliance (fixed before the inspection)
Mar 4, 2025 · Complaint inspection
1 deficiency, highest D
F551 · Role of the resident's representative
Requirement cited (CMS): Give the resident's representative the ability to exercise the resident's rights.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 27, 2025
Feb 12, 2025 · Complaint inspection
1 deficiency, highest D
F726 · Competent nurses and nurse aides
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 12, 2025
Dec 18, 2024 · Complaint inspection
1 deficiency, highest J
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), Nov 13, 2024
Jun 6, 2024 · Standard + complaint inspection
9 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 19, 2024
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 19, 2024
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 19, 2024
F693 · Feeding tube use and care
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 19, 2024
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jul 19, 2024
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 19, 2024
F684 · Quality of care
Requirement cited (CMS): Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 19, 2024
F677 · Help with daily care
Requirement cited (CMS): Provide care and assistance to perform activities of daily living for any resident who is unable.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 19, 2024
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jul 19, 2024
Earlier cycle: 24 deficiencies (standard inspection Apr 25, 2023)
Standard inspection Apr 25, 2023. CMS counts 24 health deficiencies and 4 fire safety deficiencies in this cycle.
Aug 30, 2024 · Complaint inspection
9 deficiencies, highest E
F791 · Dental services in Medicaid nursing facilities
Requirement cited (CMS): Provide or obtain dental services for each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 5, 2024
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 5, 2024
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Sep 5, 2024
F687 · Foot care
Requirement cited (CMS): Provide appropriate foot care.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 5, 2024
F656 · Comprehensive person-centered care plan
Requirement cited (CMS): Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 5, 2024
F645 · Pre-admission screening for mental disorder or intellectual disability
Requirement cited (CMS): PASARR screening for Mental disorders or Intellectual Disabilities
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 5, 2024
F641 · Accurate resident assessments
Requirement cited (CMS): Ensure each resident receives an accurate assessment.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 5, 2024
F585 · Grievances and how they are handled
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 5, 2024
F558 · Accommodating individual needs and preferences
Requirement cited (CMS): Reasonably accommodate the needs and preferences of each resident.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Sep 5, 2024
Jan 30, 2024 · Complaint inspection
3 deficiencies, highest E
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Mar 1, 2024
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 1, 2024
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Mar 1, 2024
Dec 29, 2023 · Complaint inspection
2 deficiencies, highest J
F919 · Working call system
Requirement cited (CMS): Make sure that a working call system is available in each resident's bathroom and bathing area.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jan 26, 2024
- Found in
- infection control inspection
F689 · Accident prevention and supervision
Requirement cited (CMS): Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- Severity
- J Immediate jeopardy to resident health or safety, isolated
- Status
- Past non-compliance (fixed before the inspection), Nov 30, 2023
Apr 25, 2023 · Standard inspection
10 deficiencies, highest E
F880 · Infection prevention and control program
Requirement cited (CMS): Provide and implement an infection prevention and control program.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date Jun 2, 2023
F812 · Food safety and sanitation
Requirement cited (CMS): Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date Jun 2, 2023
F761 · Drug labeling and secure storage
Requirement cited (CMS): 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.
- Severity
- E No actual harm, potential for more than minimal harm, pattern
- Status
- Correction date May 6, 2023
F755 · Pharmacy services and a consultant pharmacist
Requirement cited (CMS): Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 6, 2023
F732 · Daily posting of nurse staffing
Requirement cited (CMS): Post nurse staffing information every day.
- Severity
- C No actual harm, potential for minimal harm, widespread
- Status
- Correction date May 6, 2023
F695 · Respiratory and oxygen care
Requirement cited (CMS): Provide safe and appropriate respiratory care for a resident when needed.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 6, 2023
F693 · Feeding tube use and care
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 6, 2023
F690 · Bladder, bowel, and catheter care
Requirement cited (CMS): Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 6, 2023
F687 · Foot care
Requirement cited (CMS): Provide appropriate foot care.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 6, 2023
F584 · Safe, clean, homelike surroundings
Requirement cited (CMS): 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.
- Severity
- D No actual harm, potential for more than minimal harm, isolated
- Status
- Correction date May 6, 2023
Tags cited in more than one inspection
11 tags cited on more than one inspection date at Brookhaven Nursing and Rehabilitation Center; each date counts once and does not mean the same incident. PNC = past non-compliance.
| Tag | Inspections | Dates |
|---|---|---|
| F689 Accident prevention and supervision | 5 | Dec 18, 2024 (PNC); Aug 30, 2024; Jun 6, 2024; Jan 30, 2024; Dec 29, 2023 (PNC) |
| F755 Pharmacy services and a consultant pharmacist | 4 | Aug 30, 2024; Jun 6, 2024; Jan 30, 2024; Apr 25, 2023 |
| F880 Infection prevention and control program | 4 | May 27, 2026; Jul 23, 2025; Jun 6, 2024; Apr 25, 2023 |
| F761 Drug labeling and secure storage | 3 | Jul 23, 2025; Jan 30, 2024; Apr 25, 2023 |
| F558 Accommodating individual needs and preferences | 2 | Aug 30, 2024; Jun 6, 2024 |
| F600 Freedom from abuse and neglect | 2 | Oct 3, 2025; Aug 27, 2025 (PNC) |
| F677 Help with daily care | 2 | Jul 23, 2025; Jun 6, 2024 |
| F687 Foot care | 2 | Aug 30, 2024; Apr 25, 2023 |
| F690 Bladder, bowel, and catheter care | 2 | Jun 6, 2024; Apr 25, 2023 |
| F693 Feeding tube use and care | 2 | Jun 6, 2024; Apr 25, 2023 |
| F812 Food safety and sanitation | 2 | Jun 6, 2024; Apr 25, 2023 |
Fines and payment denials
| Date | Type | Amount / length |
|---|---|---|
| Aug 27, 2025 | Fine | $9,272 |
| Dec 18, 2024 | Fine | $8,021 |
| Dec 29, 2023 | Fine | $7,446 |
Staffing and CMS ratings
- Total nurse staff hours per resident per day
- not reported
- RN hours per resident per day
- not reported
- Weekend nurse staff hours per resident per day
- not reported
- Nursing staff turnover
- 75.3% (Texas median 52.1%)
- Administrators who left
- 1
- CMS overall rating
- 1 of 5
- Health inspection rating
- 1 of 5
- Staffing rating
- 1 of 5
- Quality measure rating
- 2 of 5
CMS figures for Brookhaven Nursing and Rehabilitation Center, copied as published; Texas medians are ours.
Facility details
- Address
- 1855 Cheyenne Dr., Carrollton, TX 75010
- Phone
- (972) 394-7141
- County
- Denton
- Accepts
- Medicare and Medicaid
- Ownership
- For profit - Corporation
- Chain (CMS)
- Not part of a chain in CMS data
- Certified beds
- 180
- Average residents per day
- 114.9
- In Medicare/Medicaid since
- Jul 1, 1973
- Inside a hospital
- No
- Continuing care retirement community
- No
- Resident and family council
- Resident
- Sprinklers in all required areas
- Yes
Questions to ask on a visit
Based on the tags cited most often here.
- How does the home assess each resident's fall risk and plan to prevent falls? (F689, cited 5 times)
- How are new medication orders filled, and how quickly can urgent medications arrive? (F755, cited 4 times)
- How do staff track and report infections among residents? (F880, cited 4 times)
- How are medications stored and secured on each unit? (F761, cited 3 times)
Other nursing homes in Carrollton
- Mustang Park Therapy and Living Center
Carrollton · 51 deficiencies - Carrollton Health and Rehabilitation Center
Carrollton · 39 deficiencies - Heritage Gardens Rehabilitation and Healthcare
Carrollton · 25 deficiencies - The Madison on Marsh
Carrollton · 24 deficiencies
Source
CMS Provider Data Catalog: Provider Information, Health Deficiencies, Penalties, Survey Summary. Processed by CMS Sep 1, 2026; next update Oct 28, 2026.