Brookhaven Nursing and Rehabilitation Center
1855 Cheyenne Dr., Carrollton, TX 75010 · Denton County · 180 certified beds · avg 115 residents/day · certified since Jul 1, 1973
Abuse citation flag (CMS)
The abuse flag means inspectors cited this facility for abuse that caused harm to a resident within the past year, or potential for harm in each of the last two years. Source: CMS.
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Immediate jeopardy, repeated · Oct 3, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Oct 6, 2025 (Deficient, Provider has date of correction)
▲ Immediate jeopardy, one-off · Dec 18, 2024 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 13, 2024 (Past Non-Compliance)
▲ Immediate jeopardy, one-off · Dec 29, 2023 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Nov 30, 2023 (Past Non-Compliance)
▲ Actual harm, one-off · Aug 27, 2025 · F-0600 · triggered by a complaint
The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Why it matters: Abuse and neglect cause direct physical and emotional harm and are among the most serious failures a nursing home can have.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
All citations in the current public record (48)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| May 27, 2026 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Dec 3, 2025 | D · Potential for harm, one-off | The facility did not coordinate resident assessments with the state's pre-admission screening program for mental illness and intellectual disabilities, or failed to refer residents for the special services they need. · from a complaint |
| Nov 4, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). · from a complaint |
| Oct 3, 2025 | ▲ K · Immediate jeopardy, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Aug 27, 2025 | ▲ G · Actual harm, one-off | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint |
| Jul 23, 2025 | E · Potential for harm, repeated | The facility did not update each resident's care assessment at least once every 3 months. These regular check-ins keep the resident's care plan matched to their current condition. |
| Jul 23, 2025 | E · Potential for harm, repeated | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jul 23, 2025 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not fully assess residents on time — a complete assessment of health, abilities, and needs is required when a resident is first admitted and at least once every 12 months after that. · from a complaint |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jul 23, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Mar 4, 2025 | D · Potential for harm, one-off | The facility did not allow a resident's chosen representative — often a family member or someone with power of attorney — to exercise the resident's rights on their behalf. When a resident can't speak for themselves, their representative steps into that role. · from a complaint |
| Feb 12, 2025 | D · Potential for harm, one-off | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint |
| Dec 18, 2024 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 30, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not honor residents' right to voice complaints without discrimination or retaliation, or did not have a working complaint process that resolves issues promptly. · from a complaint |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not properly complete the required screening (called PASARR) that identifies whether a person entering a nursing home has a mental illness or intellectual disability and needs specialized services. · from a complaint |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. · from a complaint |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Aug 30, 2024 | D · Potential for harm, one-off | The facility did not provide or arrange dental services for its residents. Nursing homes are responsible for making sure residents can get dental care. · from a complaint |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. · from a complaint |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. · from a complaint |
| Jun 6, 2024 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own. |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 6, 2024 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. · from a complaint |
| Jan 30, 2024 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jan 30, 2024 | E · Potential for harm, repeated | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. · from a complaint |
| Jan 30, 2024 | D · Potential for harm, one-off | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. · from a complaint |
| Dec 29, 2023 | ▲ J · Immediate jeopardy, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Dec 29, 2023 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. · from a complaint |
| Aug 17, 2023 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint |
| Apr 25, 2023 | E · Potential for harm, repeated | The facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock. |
| Apr 25, 2023 | E · Potential for harm, repeated | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Apr 25, 2023 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 25, 2023 | D · Potential for harm, one-off | The facility did not provide proper foot care for residents. Foot care includes routine care like nail trimming and attention to foot problems, which matter greatly for older adults. |
| Apr 25, 2023 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Apr 25, 2023 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Apr 25, 2023 | D · Potential for harm, one-off | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| Apr 25, 2023 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Apr 25, 2023 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Apr 25, 2023 | C · Minimal risk, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (9 → 6).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 13 | 1 | J ▲ |
| 2024 | 22 | 1 | J ▲ |
| 2025 | 12 | 2 | K ▲ |
| 2026 | 1 | 0 | D |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
3 fines totaling $24,739.
| Date | Type | Amount / length |
|---|---|---|
| Aug 27, 2025 | Fine | $9,272 |
| Dec 18, 2024 | Fine | $8,021 |
| Dec 29, 2023 | Fine | $7,446 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Texas avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 0.00 | 3.46 | 3.95 | — |
| Registered Nurse hours | 0.00 | 0.44 | 0.69 | — |
| Weekend total nurse staffing | 0.00 | 3.04 | 3.50 | — |
| Weekend RN hours (not acuity-adjusted) | 0.00 | 0.34 | 0.48 | — |
| Total nursing staff turnover (%) | 75.3 | 55.3 | 45.8 | bottom 15% in Texas; bottom 3% in the U.S. |
| RN turnover (%) | 72.2 | 54.6 | 42.9 | bottom 26% in Texas; bottom 10% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 0.00, RN 0.00, weekend 0.00. Staffing rating: 1/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 2/5 · long-stay residents: 4/5 · short-stay residents: 1/5
Who owns this facility
For profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Olney-Hamilton Hospital District | Organization | 5% or Greater Direct Ownership Interest | 100% | 04/01/2021 |
| Bauder, Kelly | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/25/2026 |
| Bauder, Madison | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/25/2026 |
| Bauder, Parker | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/25/2026 |
| Bauder, William | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| Boulware, Steven | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/25/2026 |
| Boulware, Thomas | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/25/2026 |
| Coil, Ryan | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| Coil, Ryan | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2025 |
| Dvorak, Kenneth | Individual | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| Dvorak, Kenneth | Individual | ADP of the SNF | NOT APPLICABLE | 11/01/2025 |
| Huff, Michael | Individual | Corporate Director | NOT APPLICABLE | 04/01/2021 |
| PMG Opco - Carrollton, LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 11/01/2025 |
| PMG Opco - Carrollton, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 03/25/2026 |
| Priority Management Group, LLC | Organization | ADP of the SNF | NOT APPLICABLE | 11/01/2025 |
| Walker, Katie | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 03/25/2026 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you identify and arrange specialized services for residents with mental health conditions or disabilities?"
- "What written notices do we get before any transfer or discharge, and what is your bed-hold policy?"
- "How do you track that every resident's quarterly assessment happens on time?"
- "How many aides are on each shift, and how do you make sure every resident gets timely help with bathing, dressing, and meals?"
- "Can you show me how medications are stored and secured on the units, including controlled drugs?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Mustang Park Therapy and Living Center | 1.3 mi | Carrollton, TX | ★☆☆☆☆ | 2/5 | |
| Prestonwood Rehabilitation & Nursing Center | 2.0 mi | Plano, TX | ★★★★☆ | 2/5 | abuse |
| Accel at Willow Bend | 3.1 mi | Plano, TX | ★☆☆☆☆ | 2/5 | |
| Heritage Gardens Rehabilitation and Healthcare | 4.0 mi | Carrollton, TX | ★☆☆☆☆ | 2/5 | abuse |
| The Madison on Marsh | 4.4 mi | Carrollton, TX | ★★★★☆ | 3/5 | |
| Vista Ridge Nursing & Rehabilitation Center | 5.1 mi | Lewisville, TX | ★★★★☆ | 3/5 | |
| Carrollton Health and Rehabilitation Center | 5.7 mi | Carrollton, TX | ★★☆☆☆ | 2/5 | |
| The Legacy at Willow Bend | 5.8 mi | Plano, TX | ★★★★★ | 4/5 | |
| Sandy Lake Rehabilitation and Care Center | 5.8 mi | Coppell, TX | ★★☆☆☆ | 2/5 | |
| Carrara | 6.1 mi | Plano, TX | ★★★★☆ | 4/5 | |
| The Hillcrest of North Dallas | 6.2 mi | Dallas, TX | ★☆☆☆☆ | 1/5 | |
| Landmark of Plano Rehabilitation and Nursing Cente | 6.9 mi | Plano, TX | ★★☆☆☆ | 2/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 455412.