Brookhaven Nursing and Rehabilitation Center
Nursing Home · Carrollton, TX
CMS certification number455412
This facility was cited for abuse, neglect or exploitation in a recent inspection (CMS abuse icon).
Contact & location
1855 Cheyenne Dr.Carrollton, TX 75010
Denton County
- Phone
- (972) 394-7141
- ZIP code
- 75010 – all care providers
Facility details
- Certified beds
- 180
- Residents per day
- 114.9 (64% occupied)
- Ownership
- For profit - Corporation
- Legal name
- Olney-Hamilton Hospital District
- Medicare certified since
- July 1, 1973
- Participates in
- Medicare and Medicaid
- Council
- Resident council
CMS star ratings
Staffing
Hours of nursing care per resident per day, from payroll data. More hours generally mean more time for each resident.
- Total nurse staffing
- —
- Registered nurses (RN)
- —
- Licensed practical nurses
- —
- Nurse aides
- —
- Weekend total
- —
- Nursing staff turnover
- 75.3 (state 55.3 · U.S. 45.8)%
- RN turnover
- 72.2 (state 54.6 · U.S. 42.9)%
- Administrators who left
- 1 in the last year
Inspections
- Last standard inspection
- July 23, 2025
- Health deficiencies (last cycle)
- 11.0 (state 9.3 · U.S. 9.3)
- From complaints
- 6
- Infection control citations
- 1
- Citations on record (3 years)
- 48 health · 30 fire safety · includes immediate jeopardy
| Date | Citation | Severity | Status |
|---|---|---|---|
| 2026-05-27 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-06-03 |
| 2025-12-03 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. F0644 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2026-01-16 |
| 2025-11-04 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. F0628 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-11-17 |
| 2025-10-03 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
K Immediate jeopardy to resident health or safety |
Corrected 2025-10-06 |
| 2025-08-27 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. F0600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies · complaint inspection |
G Actual harm |
Past Non-Compliance |
| 2025-07-23 | Assure that each resident’s assessment is updated at least once every 3 months. F0638 · Resident Assessment and Care Planning Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-08-30 |
| 2025-07-23 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-08-23 |
| 2025-07-23 | 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. F0761 · Pharmacy Service Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2025-08-30 |
| 2025-07-23 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. F0636 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-08-30 |
| 2025-07-23 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted F0655 · Resident Assessment and Care Planning Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-08-23 |
| 2025-07-23 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2025-08-30 |
| 2025-03-04 | Give the resident's representative the ability to exercise the resident's rights. F0551 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-27 |
| 2025-02-12 | 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. F0726 · Nursing and Physician Services Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2025-03-12 |
| 2024-12-18 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
J Immediate jeopardy to resident health or safety |
Corrected 2024-11-13 |
| 2024-08-30 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-09-05 |
| 2024-08-30 | Reasonably accommodate the needs and preferences of each resident. F0558 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-09-05 |
| 2024-08-30 | 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. F0585 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-09-05 |
| 2024-08-30 | Ensure each resident receives an accurate assessment. F0641 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-09-05 |
| 2024-08-30 | PASARR screening for Mental disorders or Intellectual Disabilities F0645 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-09-05 |
| 2024-08-30 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-09-05 |
| 2024-08-30 | Provide appropriate foot care. F0687 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-09-05 |
| 2024-08-30 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-09-05 |
| 2024-08-30 | Provide or obtain dental services for each resident. F0791 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-09-05 |
| 2024-06-06 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-06 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-06 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-06 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-06 | Reasonably accommodate the needs and preferences of each resident. F0558 · Resident Rights Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-06 | Provide care and assistance to perform activities of daily living for any resident who is unable. F0677 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-06 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. F0684 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-06 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-06-06 | 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. F0693 · Quality of Life and Care Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-07-19 |
| 2024-01-30 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-03-01 |
| 2024-01-30 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies · complaint inspection |
E No actual harm, potential for more than minimal harm |
Corrected 2024-03-01 |
| 2024-01-30 | 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. F0761 · Pharmacy Service Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-03-01 |
| 2023-12-29 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. F0689 · Quality of Life and Care Deficiencies · complaint inspection |
J Immediate jeopardy to resident health or safety |
Corrected 2023-11-30 |
| 2023-12-29 | Make sure that a working call system is available in each resident's bathroom and bathing area. F0919 · Environmental Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2024-01-26 |
| 2023-08-17 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. F0656 · Resident Assessment and Care Planning Deficiencies · complaint inspection |
D No actual harm, potential for more than minimal harm |
Corrected 2023-08-28 |
| 2023-04-25 | 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. F0761 · Pharmacy Service Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2023-05-06 |
| 2023-04-25 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. F0812 · Nutrition and Dietary Deficiencies |
E No actual harm, potential for more than minimal harm |
Corrected 2023-06-02 |
| 2023-04-25 | 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. F0584 · Resident Rights Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-05-06 |
| 2023-04-25 | Provide appropriate foot care. F0687 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-05-06 |
| 2023-04-25 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. F0690 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-05-06 |
| 2023-04-25 | 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. F0693 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-05-06 |
| 2023-04-25 | Provide safe and appropriate respiratory care for a resident when needed. F0695 · Quality of Life and Care Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-05-06 |
| 2023-04-25 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. F0755 · Pharmacy Service Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-05-06 |
| 2023-04-25 | Provide and implement an infection prevention and control program. F0880 · Infection Control Deficiencies |
D No actual harm, potential for more than minimal harm |
Corrected 2023-06-02 |
| 2023-04-25 | Post nurse staffing information every day. F0732 · Nursing and Physician Services Deficiencies |
C No actual harm, potential for minimal harm |
Corrected 2023-05-06 |
Severity letters A–L combine how widespread a problem was (isolated, pattern, widespread) with how serious (from potential for minimal harm to immediate jeopardy). How to read inspection results
Fines & penalties
3 penalties in the last three years, including $24,739 in fines.
| Date | Type | Amount |
|---|---|---|
| 2025-08-27 | Fine | $9,272 |
| 2024-12-18 | Fine | $8,021 |
| 2023-12-29 | Fine | $7,446 |
Ownership & management
| Name | Role | Since |
|---|---|---|
| Olney-Hamilton Hospital District (organization) | 5%+ Direct Ownership Interest · 100% | |
| Coil, Ryan (individual) | Administrator · NOT APPLICABLE | |
| Dvorak, Kenneth (individual) | Administrator · NOT APPLICABLE | |
| PMG Opco - Carrollton, LLC (organization) | Administrator · NOT APPLICABLE | |
| Priority Management Group, LLC (organization) | Administrator · NOT APPLICABLE | |
| Huff, Michael (individual) | Corporate Director · NOT APPLICABLE | |
| Bauder, Kelly (individual) | Individual Is An Owner, Partner Or Trustee Of Any Administrator · NOT APPLICABLE | |
| Bauder, Madison (individual) | Individual Is An Owner, Partner Or Trustee Of Any Administrator · NOT APPLICABLE | |
| Bauder, Parker (individual) | Individual Is An Owner, Partner Or Trustee Of Any Administrator · NOT APPLICABLE | |
| Boulware, Steven (individual) | Individual Is An Owner, Partner Or Trustee Of Any Administrator · NOT APPLICABLE | |
| Boulware, Thomas (individual) | Individual Is An Owner, Partner Or Trustee Of Any Administrator · NOT APPLICABLE | |
| Walker, Katie (individual) | Individual Is An Owner, Partner Or Trustee Of Any Administrator · NOT APPLICABLE | |
| Bauder, William (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Coil, Ryan (individual) | Operational/managerial Control · NOT APPLICABLE | |
| Dvorak, Kenneth (individual) | Operational/managerial Control · NOT APPLICABLE | |
| PMG Opco - Carrollton, LLC (organization) | Operational/managerial Control · NOT APPLICABLE |
Frequently asked questions
What is the rating of Brookhaven Nursing and Rehabilitation Center?
Brookhaven Nursing and Rehabilitation Center has a 1-star overall rating from the Centers for Medicare & Medicaid Services on a scale of 1 to 5, compared with a 2.6-star average in Texas.
How many beds does Brookhaven Nursing and Rehabilitation Center have?
It has 180 certified beds and cares for about 115 residents per day.
Has Brookhaven Nursing and Rehabilitation Center been fined?
Yes. CMS lists 3 penalties totaling $24,739 in the last three years.
What is the phone number of Brookhaven Nursing and Rehabilitation Center?
(972) 394-7141. The facility is located at 1855 Cheyenne Dr., Carrollton, TX 75010.
Other nursing homes in Carrollton
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Source: CMS Care Compare, August 2026. Information is provided as published by CMS; verify details directly with the facility.