01 / INSPECTION LEDGER
Survey cycles in this release
| Cycle | Health date | Health deficiencies | Fire date | Fire deficiencies |
|---|---|---|---|---|
| Cycle 1 | 2025-07-23 | 11 | 2025-07-23 | 9 |
| Cycle 2 | 2024-06-06 | 21 | 2024-06-06 | 17 |
| Cycle 3 | 2023-04-25 | 16 | 2023-04-25 | 4 |
CMS CCN 4554122026-08-01 PROCESSING DATE
NURSING HOME PUBLIC RECORD
Brookhaven Nursing And Rehabilitation Center
1855 Cheyenne Dr. · Carrollton, TX 75010 · Denton County
Certified beds180CMS provider file
Recent citation rows78current CMS citation release
Penalty rows3current CMS penalties file
Read this record carefully.
The citation files cover the three most recent standard inspections plus qualifying complaint and infection-control inspections in the prior three years. A correction date is a CMS field; this site does not independently verify conditions. Absence from a file is not proof that no issue exists.
02 / CITATION DETAIL
78 rows in the current release
4 rows carry G–L scope/severity codes; 3 carry J–L. 19 tag codes appear on more than one survey date. These counts describe citation rows, not residents or incidents.
2026-05-27 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2026-06-03 · complaint2025-12-03 · HEALTHF0644Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Correction field: Deficient, Provider has date of correction · 2026-01-16 · complaint2025-11-04 · HEALTHF0628Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
Correction field: Deficient, Provider has date of correction · 2025-11-17 · complaint2025-10-03 · HEALTHF0600Severity K · pattern of immediate jeopardy
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Deficient, Provider has date of correction · 2025-10-06 · complaint2025-08-27 · HEALTHF0600Severity G · isolated actual harm
Freedom from Abuse, Neglect, and Exploitation Deficiencies
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Correction field: Past Non-Compliance · complaint2025-07-23 · HEALTHF0636Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Correction field: Deficient, Provider has date of correction · 2025-08-30 · complaint2025-07-23 · HEALTHF0638Severity E · pattern; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Assure that each resident’s assessment is updated at least once every 3 months.
Correction field: Deficient, Provider has date of correction · 2025-08-302025-07-23 · HEALTHF0655Severity D · isolated; potential for more than minimal harm
Resident Assessment and Care Planning Deficiencies
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Correction field: Deficient, Provider has date of correction · 2025-08-232025-07-23 · HEALTHF0677Severity E · pattern; potential for more than minimal harm
Quality of Life and Care Deficiencies
Provide care and assistance to perform activities of daily living for any resident who is unable.
Correction field: Deficient, Provider has date of correction · 2025-08-232025-07-23 · HEALTHF0761Severity E · pattern; potential for more than minimal harm
Pharmacy Service Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-08-302025-07-23 · HEALTHF0880Severity D · isolated; potential for more than minimal harm
Infection Control Deficiencies
Provide and implement an infection prevention and control program.
Correction field: Deficient, Provider has date of correction · 2025-08-302025-07-23 · FIREK0222Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Add 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.
Correction field: Deficient, Provider has date of correction · 2025-08-162025-07-23 · FIREK0271Severity E · pattern; potential for more than minimal harm
Egress Deficiencies
Have exits that are accessible at all times.
Correction field: Deficient, Provider has date of correction · 2025-08-162025-07-23 · FIREK0321Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Correction field: Deficient, Provider has date of correction · 2025-08-162025-07-23 · FIREK0324Severity D · isolated; potential for more than minimal harm
Smoke Deficiencies
Provide properly protected cooking facilities.
Correction field: Deficient, Provider has date of correction · 2025-08-162025-07-23 · FIREK0341Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Install a fire alarm system that can be heard throughout the facility.
Correction field: Deficient, Provider has date of correction · 2025-07-252025-07-23 · FIREK0353Severity F · widespread; potential for more than minimal harm
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
Correction field: Deficient, Provider has date of correction · 2025-07-282025-07-23 · FIREK0372Severity E · pattern; potential for more than minimal harm
Smoke Deficiencies
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Correction field: Deficient, Provider has date of correction · 2025-07-282025-07-23 · FIREK0916Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Correction field: Deficient, Provider has date of correction · 2025-09-082025-07-23 · FIREK0918Severity F · widespread; potential for more than minimal harm
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Correction field: Deficient, Provider has date of correction · 2025-07-312025-03-04 · HEALTHF0551Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Give the resident's representative the ability to exercise the resident's rights.
Correction field: Deficient, Provider has date of correction · 2025-03-27 · complaint2025-02-12 · HEALTHF0726Severity D · isolated; potential for more than minimal harm
Nursing and Physician Services Deficiencies
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.
Correction field: Deficient, Provider has date of correction · 2025-03-12 · complaint2024-12-18 · HEALTHF0689Severity J · isolated immediate jeopardy
Quality of Life and Care Deficiencies
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Correction field: Past Non-Compliance · 2024-11-13 · complaint2024-08-30 · HEALTHF0558Severity D · isolated; potential for more than minimal harm
Resident Rights Deficiencies
Reasonably accommodate the needs and preferences of each resident.
Correction field: Deficient, Provider has date of correction · 2024-09-05 · complaint03 / ENFORCEMENT FILE
Penalties reported by CMS
Fine amounts and payment-denial days are shown exactly as aggregated from the current penalties file. They do not imply an unpaid balance.
| Date | Type | Fine amount | Payment-denial days |
|---|---|---|---|
| 2025-08-27 | Fine | $9,272 | 0 |
| 2024-12-18 | Fine | $8,021 | 0 |
| 2023-12-29 | Fine | $7,446 | 0 |
04 / OWNERSHIP DISCLOSURES
Who appears in the CMS file
- OLNEY-HAMILTON HOSPITAL DISTRICTOrganization · 5% OR GREATER DIRECT OWNERSHIP INTEREST100% · since 04/01/2021
- HUFF, MICHAELIndividual · CORPORATE DIRECTORNOT APPLICABLE · since 04/01/2021
- PMG OPCO - CARROLLTON, LLCOrganization · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2025
- BAUDER, WILLIAMIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2025
- COIL, RYANIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2025
- DVORAK, KENNETHIndividual · OPERATIONAL/MANAGERIAL CONTROLNOT APPLICABLE · since 11/01/2025
- BAUDER, KELLYIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/25/2026
- BAUDER, MADISONIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/25/2026
- BAUDER, PARKERIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/25/2026
- BOULWARE, STEVENIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/25/2026
- BOULWARE, THOMASIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/25/2026
- WALKER, KATIEIndividual · INDIVIDUAL IS AN OWNER, PARTNER OR TRUSTEE OF ANY ADP OF THE SNFNOT APPLICABLE · since 03/25/2026
- PMG OPCO - CARROLLTON, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 03/25/2026
- PRIORITY MANAGEMENT GROUP, LLCOrganization · ADP OF THE SNFNOT APPLICABLE · since 11/01/2025
- COIL, RYANIndividual · ADP OF THE SNFNOT APPLICABLE · since 11/01/2025
- DVORAK, KENNETHIndividual · ADP OF THE SNFNOT APPLICABLE · since 11/01/2025
Names and roles are self-reported CMS disclosure fields. Exact-name pages do not prove that similarly named people or organizations are the same entity.
05 / CMS STAFFING FIELDS
Reported hours and turnover
Staffing fields are provider-reported and case-mix context matters. CMS applies footnotes and exclusions not reproduced as a new score here.
Total nurse hours—per resident day
RN hours—per resident day
Weekend nurse hours—per resident day
Staff turnover75.3%CMS reported field
06 / LOCAL RECORDS
Open the Carrollton ledger →Other published facilities nearby
Carrollton Health And Rehabilitation Center120 beds · CMS overall 2/546 citation rowsHeritage Gardens Rehabilitation And Healthcare150 beds · CMS overall 1/538 citation rowsMustang Park Therapy And Living Center120 beds · CMS overall 1/561 citation rowsThe Madison On Marsh125 beds · CMS overall 4/535 citation rows