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Last checked October 25, 2026 · 2,492 nursing homes and 2,174 assisted living licenses in 4 states · CMS data processed September 1, 2026

Home › Texas › Denton County › Brookhaven Nursing and Rehabilitation Center

Brookhaven Nursing and Rehabilitation Center

1855 Cheyenne Dr., Carrollton, TX 75010 · CMS Certification Number (CCN) 455412

CMS abuse icon

CMS shows the abuse icon when a nursing home was cited for abuse or neglect at the harm level or above (scope/severity G or higher) on its most recent inspection cycle, or at the potential-harm level (D or higher) on both of its two most recent cycles. CMS data dictionary

At a glance

CMS overall rating
★☆☆☆☆ 1 of 5
Health inspection citations
47 in the last 3 inspection cycles (3 immediate jeopardy, 1 actual harm, 31 from complaints)
Fire safety citations
30
Fines (last 3 years)
3 fines, total $24,739
Payment denials
0
Most recent standard inspection
July 23, 2025
Official record
Medicare Care Compare page for this facility

Source: CMS Nursing Home Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026

CMS star ratings

CMS rates every Medicare- and Medicaid-certified nursing home from 1 to 5 stars. Health inspection stars are relative to other homes in the same state: the top 10% get 5 stars and the bottom 20% get 1 star. CMS says to use the ratings together with other information, including a visit. Technical Users’ Guide

RatingThis facilityTexas averageU.S. average
Overall★☆☆☆☆ 1 of 52.73
Health inspections★☆☆☆☆ 1 of 52.82.8
Staffing★☆☆☆☆ 1 of 5
The accuracy of the staffing data for this measure could not be validated by CMS.
1.92.9
Quality measures★★☆☆☆ 2 of 53.73.6
Long-stay quality★★★★☆ 4 of 5Not publishedNot published
Short-stay quality★☆☆☆☆ 1 of 5Not publishedNot published

Averages: CMS State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026

Health inspections

Inspection cycleStandard survey dateHealth citationsFrom standard surveyFrom complaints
Cycle 1 (most recent)July 23, 20251065
Cycle 2June 6, 202427926

CMS weighted health inspection score: 175.75 (lower is better; it counts citation severity, complaints and repeat revisits). Citations from infection control inspections: 1. How to read these citations

47 health citations across 14 inspection dates, newest first. The letter is CMS’s scope/severity code: A–C means potential for minimal harm, D–F potential for more than minimal harm, G–I actual harm, and J–L immediate jeopardy.

May 27, 2026: 1 citation (Complaint)
SeverityTagWhat was citedTypeStatus
D F-0880 Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 06/03/2026
December 3, 2025: 1 citation (Complaint)
SeverityTagWhat was citedTypeStatus
D F-0644 Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Resident Assessment and Care Planning Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 01/16/2026
November 4, 2025: 1 citation (Complaint)
SeverityTagWhat was citedTypeStatus
D F-0628 Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Resident Rights Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 11/17/2025
October 3, 2025: 1 citation (Complaint)
SeverityTagWhat was citedTypeStatus
K F-0600 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
Complaint Deficient, Provider has date of correction
Corrected 10/06/2025
August 27, 2025: 1 citation (Complaint)
SeverityTagWhat was citedTypeStatus
G F-0600 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
Complaint Past Non-Compliance
July 23, 2025: 6 citations (Standard + Complaint)
SeverityTagWhat was citedTypeStatus
D F-0880 Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Standard Deficient, Provider has date of correction
Corrected 08/30/2025
E F-0761 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
Standard Deficient, Provider has date of correction
Corrected 08/30/2025
E F-0677 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Standard Deficient, Provider has date of correction
Corrected 08/23/2025
D F-0655 Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Resident Assessment and Care Planning Deficiencies
Standard Deficient, Provider has date of correction
Corrected 08/23/2025
E F-0638 Assure that each resident’s assessment is updated at least once every 3 months.
Resident Assessment and Care Planning Deficiencies
Standard Deficient, Provider has date of correction
Corrected 08/30/2025
D F-0636 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
Standard + Complaint Deficient, Provider has date of correction
Corrected 08/30/2025
March 4, 2025: 1 citation (Complaint)
SeverityTagWhat was citedTypeStatus
D F-0551 Give the resident's representative the ability to exercise the resident's rights.
Resident Rights Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 03/27/2025
February 12, 2025: 1 citation (Complaint)
SeverityTagWhat was citedTypeStatus
D F-0726 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
Complaint Deficient, Provider has date of correction
Corrected 03/12/2025
December 18, 2024: 1 citation (Complaint)
SeverityTagWhat was citedTypeStatus
J F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Complaint Past Non-Compliance
Corrected 11/13/2024
August 30, 2024: 9 citations (Complaint)
SeverityTagWhat was citedTypeStatus
D F-0791 Provide or obtain dental services for each resident.
Quality of Life and Care Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 09/05/2024
D F-0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 09/05/2024
E F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 09/05/2024
D F-0687 Provide appropriate foot care.
Quality of Life and Care Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 09/05/2024
D F-0656 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
Complaint Deficient, Provider has date of correction
Corrected 09/05/2024
D F-0645 PASARR screening for Mental disorders or Intellectual Disabilities
Resident Assessment and Care Planning Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 09/05/2024
D F-0641 Ensure each resident receives an accurate assessment.
Resident Assessment and Care Planning Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 09/05/2024
D F-0585 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
Complaint Deficient, Provider has date of correction
Corrected 09/05/2024
D F-0558 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 09/05/2024
June 6, 2024: 9 citations (Standard + Complaint)
SeverityTagWhat was citedTypeStatus
E F-0880 Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Standard + Complaint Deficient, Provider has date of correction
Corrected 07/19/2024
E F-0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Standard + Complaint Deficient, Provider has date of correction
Corrected 07/19/2024
E F-0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Standard + Complaint Deficient, Provider has date of correction
Corrected 07/19/2024
D F-0693 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
Standard + Complaint Deficient, Provider has date of correction
Corrected 07/19/2024
E F-0690 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
Standard + Complaint Deficient, Provider has date of correction
Corrected 07/19/2024
D F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Standard + Complaint Deficient, Provider has date of correction
Corrected 07/19/2024
D F-0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Quality of Life and Care Deficiencies
Standard + Complaint Deficient, Provider has date of correction
Corrected 07/19/2024
D F-0677 Provide care and assistance to perform activities of daily living for any resident who is unable.
Quality of Life and Care Deficiencies
Standard Deficient, Provider has date of correction
Corrected 07/19/2024
D F-0558 Reasonably accommodate the needs and preferences of each resident.
Resident Rights Deficiencies
Standard + Complaint Deficient, Provider has date of correction
Corrected 07/19/2024
January 30, 2024: 3 citations (Complaint)
SeverityTagWhat was citedTypeStatus
D F-0761 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
Complaint Deficient, Provider has date of correction
Corrected 03/01/2024
E F-0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 03/01/2024
E F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Complaint Deficient, Provider has date of correction
Corrected 03/01/2024
December 29, 2023: 2 citations (Complaint + Infection control)
SeverityTagWhat was citedTypeStatus
D F-0919 Make sure that a working call system is available in each resident's bathroom and bathing area.
Environmental Deficiencies
Complaint + Infection control Deficient, Provider has date of correction
Corrected 01/26/2024
J F-0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Quality of Life and Care Deficiencies
Complaint Past Non-Compliance
Corrected 11/30/2023
April 25, 2023: 10 citations (Standard)
SeverityTagWhat was citedTypeStatus
D F-0880 Provide and implement an infection prevention and control program.
Infection Control Deficiencies
Standard Deficient, Provider has date of correction
Corrected 06/02/2023
E F-0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Nutrition and Dietary Deficiencies
Standard Deficient, Provider has date of correction
Corrected 06/02/2023
E F-0761 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
Standard Deficient, Provider has date of correction
Corrected 05/06/2023
D F-0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Pharmacy Service Deficiencies
Standard Deficient, Provider has date of correction
Corrected 05/06/2023
C F-0732 Post nurse staffing information every day.
Nursing and Physician Services Deficiencies
Standard Deficient, Provider has date of correction
Corrected 05/06/2023
D F-0695 Provide safe and appropriate respiratory care for a resident when needed.
Quality of Life and Care Deficiencies
Standard Deficient, Provider has date of correction
Corrected 05/06/2023
D F-0693 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
Standard Deficient, Provider has date of correction
Corrected 05/06/2023
D F-0690 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
Standard Deficient, Provider has date of correction
Corrected 05/06/2023
D F-0687 Provide appropriate foot care.
Quality of Life and Care Deficiencies
Standard Deficient, Provider has date of correction
Corrected 05/06/2023
D F-0584 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.
Resident Rights Deficiencies
Standard Deficient, Provider has date of correction
Corrected 05/06/2023

Source: CMS Health Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026

Fire safety inspections

30 fire safety citations across 3 inspection dates
DateSeverityTagWhat was citedStatus
07/23/2025FK-0918Have generator or other power source capable of supplying service within 10 seconds.
Gas, Vacuum, and Electrical Systems Deficiencies
Deficient, Provider has date of correction
Corrected 07/31/2025
07/23/2025FK-0916Have a battery powered remote alarm panel in a location accessible by operating personnel.
Gas, Vacuum, and Electrical Systems Deficiencies
Deficient, Provider has date of correction
Corrected 09/08/2025
07/23/2025EK-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 07/28/2025
07/23/2025FK-0353Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 07/28/2025
07/23/2025FK-0341Install a fire alarm system that can be heard throughout the facility.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 07/25/2025
07/23/2025DK-0324Provide properly protected cooking facilities.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 08/16/2025
07/23/2025EK-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 08/16/2025
07/23/2025EK-0271Have exits that are accessible at all times.
Egress Deficiencies
Deficient, Provider has date of correction
Corrected 08/16/2025
07/23/2025EK-0222Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Egress Deficiencies
Deficient, Provider has date of correction
Corrected 08/16/2025
06/06/2024FK-0918Have generator or other power source capable of supplying service within 10 seconds.
Gas, Vacuum, and Electrical Systems Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024FK-0916Have a battery powered remote alarm panel in a location accessible by operating personnel.
Gas, Vacuum, and Electrical Systems Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024EK-0912Have power receptacles that are properly grounded.
Gas, Vacuum, and Electrical Systems Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024FK-0511Have properly installed electrical wiring and gas equipment.
Services Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024EK-0372Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024EK-0363Install corridor and hallway doors that block smoke.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024FK-0355Properly select, install, inspect, or maintain portable fire extinguishes.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024FK-0353Inspect, test, and maintain automatic sprinkler systems.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024FK-0345Have approved installation, maintenance and testing program for fire alarm systems.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024FK-0324Provide properly protected cooking facilities.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024EK-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024EK-0293Have properly located and lighted "Exit" signs.
Egress Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024EK-0222Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Egress Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024FE-0031Provide emergency officials' contact information.
Emergency Preparedness Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024FE-0018Establish procedures for tracking staff and patients during an emergency.
Emergency Preparedness Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024FE-0007Address patient/client population and determine types of services needed.
Emergency Preparedness Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
06/06/2024FE-0006Conduct risk assessment and an All-Hazards approach.
Emergency Preparedness Deficiencies
Deficient, Provider has date of correction
Corrected 07/19/2024
04/25/2023FK-0900Meet Health Care Facilities Code mechanical requirements.
Miscellaneous Deficiencies
Deficient, Provider has date of correction
Corrected 05/16/2023
04/25/2023EK-0374Install smoke barrier doors that can resist smoke for at least 20 minutes.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 05/16/2023
04/25/2023EK-0347Properly provide smoke detection systems in areas open to corridors.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 05/16/2023
04/25/2023DK-0321Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Smoke Deficiencies
Deficient, Provider has date of correction
Corrected 05/16/2023

Automatic sprinklers in all required areas: Yes. CMS does not count fire safety citations in the health inspection star rating.

Source: CMS Fire Safety Deficiencies: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026

Penalties

DateTypeFine amountPayment denial
August 27, 2025Fine$9,272—
December 18, 2024Fine$8,021—
December 29, 2023Fine$7,446—

Source: CMS Penalties: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026

Staffing

MeasureThis facilityTexas averageU.S. average
Total nurse staff hours per resident per dayThe accuracy of the staffing data for this measure could not be validated by CMS.3.393.86
Registered nurse (RN) hours per resident per dayThe accuracy of the staffing data for this measure could not be validated by CMS.0.430.69
LPN/LVN hours per resident per dayThe accuracy of the staffing data for this measure could not be validated by CMS.Not publishedNot published
Nurse aide hours per resident per dayThe accuracy of the staffing data for this measure could not be validated by CMS.Not publishedNot published
Total nurse staff hours per resident per day, weekendsThe accuracy of the staffing data for this measure could not be validated by CMS.Not publishedNot published
RN hours per resident per day, weekendsThe accuracy of the staffing data for this measure could not be validated by CMS.Not publishedNot published
Total nursing staff turnover (%)75.355.345.8
Registered nurse turnover (%)72.2Not publishedNot published
Administrators who have left1Not publishedNot published

Reported hours come from the Payroll-Based Journal (PBJ) staffing data that facilities submit to CMS each quarter.

Source: CMS Provider Information; State and US Averages: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026

Facility details

Legal business name
Olney-Hamilton Hospital District
Ownership type
For profit - Corporation
Chain
Not published
Ownership changed in last 12 months
No
Certified beds
180
Average residents per day
114.9
Participates in
Medicare and Medicaid
Located inside a hospital
No
Continuing care retirement community
No
Resident and family council
Resident
First approved for Medicare/Medicaid
July 1, 1973
County/parish
Denton

Source: CMS Provider Information: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026

Owners and managers reported to CMS

16 ownership and management records
NameRoleTypeOwnership %Since
OLNEY-HAMILTON HOSPITAL DISTRICT5% OR GREATER DIRECT OWNERSHIP INTERESTOrganization100%undefined undefined, NaN
HUFF, MICHAELCORPORATE DIRECTORIndividualNOT APPLICABLEundefined undefined, NaN
PMG OPCO - CARROLLTON, LLCOPERATIONAL/MANAGERIAL CONTROLOrganizationNOT APPLICABLEundefined undefined, NaN
BAUDER, WILLIAMOPERATIONAL/MANAGERIAL CONTROLIndividualNOT APPLICABLEundefined undefined, NaN
COIL, RYANOPERATIONAL/MANAGERIAL CONTROLIndividualNOT APPLICABLEundefined undefined, NaN
DVORAK, KENNETHOPERATIONAL/MANAGERIAL CONTROLIndividualNOT APPLICABLEundefined undefined, NaN
BAUDER, KELLYINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFIndividualNOT APPLICABLEundefined undefined, NaN
BAUDER, MADISONINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFIndividualNOT APPLICABLEundefined undefined, NaN
BAUDER, PARKERINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFIndividualNOT APPLICABLEundefined undefined, NaN
BOULWARE, STEVENINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFIndividualNOT APPLICABLEundefined undefined, NaN
BOULWARE, THOMASINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFIndividualNOT APPLICABLEundefined undefined, NaN
WALKER, KATIEINDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFIndividualNOT APPLICABLEundefined undefined, NaN
PMG OPCO - CARROLLTON, LLCADP OF THE SNFOrganizationNOT APPLICABLEundefined undefined, NaN
PRIORITY MANAGEMENT GROUP, LLCADP OF THE SNFOrganizationNOT APPLICABLEundefined undefined, NaN
COIL, RYANADP OF THE SNFIndividualNOT APPLICABLEundefined undefined, NaN
DVORAK, KENNETHADP OF THE SNFIndividualNOT APPLICABLEundefined undefined, NaN

Source: CMS Ownership: data.cms.gov · data as of September 1, 2026 · last checked October 25, 2026

Check it yourself

Page built from CMS data files processed September 1, 2026 (CMS refreshes monthly). Last checked October 25, 2026. Not a ranking or endorsement.