Your report for Brookhaven Nursing and Rehabilitation Center
Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- TexasLowest tier among peers1,167 rated homes · average 2.8★
- Denton CountyLowest tier among peers18 rated homes · average 2.4★
- United StatesLowest tier among peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs TX avg
- StaffingCan add or remove a star3★+0.9 vs TX avg
- Quality measuresCan add or remove a star2★−1.8 vs TX avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
- Abuse citation flagCMS shows an abuse icon: inspectors cited the facility for abuse that led to harm within the past year, or for abuse that could have led to harm in each of the last two years.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersTX avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above 69% of peersTX avg2.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments2★Above only 4% of peersTX avg3.8★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.28hrsAbove 50% of peersTX avg3.40Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.74hrsTop 7%TX avg0.44Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better62%Above only 21% of peersTX avg51%RN turnover47%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$24,577Above only 45% of peersTX avg$55,368Fines · denials3 · 0
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthApr 2023 – Dec 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Dec 3, 2025Cycle 1worst D · no actual harm
- F644Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.Resident Assessment and Care PlanningD · isolatedCorrected Jan 16, 2026
Nov 4, 2025Cycle 1worst D · no actual harm
- F628Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.Resident RightsD · isolatedCorrected Nov 17, 2025
Oct 3, 2025Cycle 1worst K · immediate jeopardy
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationK · patternCorrected Oct 6, 2025
Aug 27, 2025Cycle 1worst G · actual harm$9,110
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationG · isolatedCorrection pending
Jul 23, 2025Cycle 1worst E · no actual harm
- F761Ensure 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 ServiceE · patternCorrected Aug 30, 2025
- Assure that each residentâs assessment is updated at least once every 3 months.Resident Assessment and Care PlanningE · patternCorrected Aug 30, 2025
- F636Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.Resident Assessment and Care PlanningD · isolatedCorrected Aug 30, 2025
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareE · patternCorrected Aug 23, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Aug 30, 2025
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningD · isolatedCorrected Aug 23, 2025
Feb 12, 2025Cycle 1worst D · no actual harm
- F726Ensure 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 ServicesD · isolatedCorrected Mar 12, 2025
Dec 18, 2024Cycle 2worst J · immediate jeopardy$8,021
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Nov 13, 2024
Aug 30, 2024Cycle 2worst E · no actual harm
- F645PASARR screening for Mental disorders or Intellectual DisabilitiesResident Assessment and Care PlanningD · isolatedCorrected Sep 5, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Sep 5, 2024
- F585Honor 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 RightsD · isolatedCorrected Sep 5, 2024
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected Sep 5, 2024
- F656Develop 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 PlanningD · isolatedCorrected Sep 5, 2024
- F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected Sep 5, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Sep 5, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected Sep 5, 2024
- F791Provide or obtain dental services for each resident.Quality of Life and CareD · isolatedCorrected Sep 5, 2024
Jun 6, 2024Cycle 2worst E · no actual harm
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jul 19, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareD · isolatedCorrected Jul 19, 2024
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsD · isolatedCorrected Jul 19, 2024
- F690Provide 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 CareE · patternCorrected Jul 19, 2024
- F693Ensure 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 CareD · isolatedCorrected Jul 19, 2024
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Jul 19, 2024
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected Jul 19, 2024
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jul 19, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jul 19, 2024
Jan 30, 2024Cycle 3worst E · no actual harm
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceE · patternCorrected Mar 1, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareE · patternCorrected Mar 1, 2024
- F761Ensure 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 ServiceD · isolatedCorrected Mar 1, 2024
Dec 29, 2023Cycle 3worst J · immediate jeopardy$7,446
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalD · isolatedCorrected Jan 26, 2024
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareJ · isolatedCorrected Nov 30, 2023
Aug 17, 2023Cycle 3worst D · no actual harm
- F656Develop 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 PlanningD · isolatedCorrected Aug 28, 2023
May 9, 2023Cycle 3worst D · no actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareD · isolatedCorrected May 18, 2023
Apr 25, 2023Cycle 3worst E · no actual harm
- F755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.Pharmacy ServiceD · isolatedCorrected May 6, 2023
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Jun 2, 2023
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected Jun 2, 2023
- F584Honor 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 RightsD · isolatedCorrected May 6, 2023
- F687Provide appropriate foot care.Quality of Life and CareD · isolatedCorrected May 6, 2023
- F690Provide 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 CareD · isolatedCorrected May 6, 2023
- F693Ensure 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 CareD · isolatedCorrected May 6, 2023
- F695Provide safe and appropriate respiratory care for a resident when needed.Quality of Life and CareD · isolatedCorrected May 6, 2023
- F732Post nurse staffing information every day.Nursing and Physician ServicesC · widespreadCorrected May 6, 2023
- F761Ensure 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 ServiceE · patternCorrected May 6, 2023
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.28hrs
- Registered nursesRN hours only0.74hrs
- Licensed practical nursesLPN hours0.70hrs
- Nurse aidesCNA hours1.85hrs
- Weekend nursingAll staff on Saturdays and Sundays2.88hrs
- Texas average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better62%Above only 21% of peersTX avg 51%
- RN turnoverRegistered nurses only47%Not ranked by CMS
- Administrators who leftIn the past year0Stable leadership
- Occupancy180 certified beds · ~99 residents a day55%Above only 25% of peersTX avg 67%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $24,577In fines
- 3Fines
- 0Payment denials
- $55,368TX avg in fines
Actions on record
- Aug 27, 2025Civil money penalty$9,110
- Dec 18, 2024Civil money penalty$8,021
- Dec 29, 2023Civil money penalty$7,446
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Corporation
- Chain
- Dynasty Healthcare Group5 facilities in the chain2.4★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Olney-Hamilton Hospital District
- Dhc Opco-Carrollton, LLC
- Bradford Cohen
- Michael Huff
- Esther Ikonne
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 455412 · 1855 Cheyenne, Carrollton, TX, 75010.
- Percentiles compare this facility with every rated nursing home in Texas and Denton County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









