Brookhaven Nursing And Rehabilitation Center
Brookhaven Nursing and Rehabilitation Center in Carrollton, TX — inspection on August 27, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Provide staff with opportunities to express challenges related to their job and work environment.6.
Identify and assess all possible incidents of abuse;7.
Investigate and report any allegations of abuse within timeframes as required by federal requirements;8.
Protect residents during abuse investigations;9.
Establish and implement a QAPI [VT15] review and analysis of abuse incidents; and implement changes to prevent future occurrences of abuse; and10.
Involve the resident council in monitoring and evaluating the facility's abuse prevention program.
Record review of facility's policy for Routine Resident Checks, dated 2001, revised July 2013, reflected, Policy StatementStaff shall make routine resident checks to help maintain resident safety and well-being.Policy Interpretation and Implementation1.To ensure the safety and well-being of our residents, nursing staff shall make a routine check on each unit at least once every 2 hours and as needed.2.Routine resident checks involve entering the resident's room and/or identifying the resident elsewhere on the unit to determine if the resident's needs are being met, identify and change in the resident's condition, identify if the resident has any concerns, and if the resident is sleeping, needs toileting assistance, etc.3.The person conducting the routine check shall report promptly to the Nurse Supervisor/Charge Nurse any changes in the resident's condition and medical needs.4.The Nursing Supervisor/Charge Nurse shall keep documentation related to these routine checks, including the time, identify of the person making checks, and any outcomes of each check. (Note: CNA's may also record this information and provide it to the Nurse Supervisor/Charge Nurse).
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.