Brookhaven Nursing And Rehabilitation Center
Brookhaven Nursing and Rehabilitation Center in Carrollton, TX — inspection on October 3, 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
jeopardy to resident health or safety
Administrator and DON.
Monitoring the facility's Plan of Removal included the following:
Record review of Resident #1's clinical records revealed the resident was assessed by the facility on 10/02/25. No injuries were noted.
The Family Nurse Practitioner was notified.
Record review of Resident #2's clinical records revealed the resident was sent to the hospital on [DATE] but returned to the facility the same night.
The resident was placed on 1:1 monitoring. An observation on 10/03/25 at 12:20 PM revealed Resident #2 was sitting in his wheelchair in the hallway with the Administrator and transport drivers with a stretcher in the hall talking to the resident. On 10/03/25 at 12:35 PM Resident #2 got onto the stretcher and left the facility with the transport drivers.
Interviews were conducted on 10/03/25 from 1:15 PM to 4:30 PM with staff from various shifts.
The staff included LVN D, LVN E, CNA F, LVN G, CNA H, CNA I, CNA J, CNA K, CNA L, and the SW.All staff were able to identify:What abuse was and the different types of abuse.
The staff understood abuse had to immediately be reported to the Administrator. An interview on 10/03/25 at 3:00 PM with the DON revealed his roles in the facility plan of removal included: Resident #2 was in a psychiatric hospital and when he returned, he would be placed on 1:1 monitoring.
The DON said he spoke to Resident #1 and she was doing well. He said he completed a trauma and emotional assessment, and she was not fearful.
The DON said he would ensure all assessments were completed and he would monitor residents for any signs and symptoms of distress, anxiety, or disturbance and ensure residents did not make threats to other residents. An interview on 10/03/25 at 3:20 PM with Resident #1 revealed she was upset.
She said she was terrified about Resident #1 returning to the facility.
She said the DON spoke to her and she told him she was still afraid of Resident #2. An interview on 10/03/25 at 3:55 PM with Resident #1 and the Corporate Nurse revealed prior to the conversation, Resident #1 did not feel safe.
She was afraid Resident #1 would return to the facility, and she would be threatened by him or even discharged .
The Corporate Nurse reassured the resident and told her Resident #1 would not be returning to the facility and she was not going to be kicked out. Resident #1 told the State Surveyor that after speaking with the Corporate Nurse she felt safe. An interview on 10/03/25 at 4:22 PM with the Administrator revealed he wanted to find Resident #2 a new placement. He said if the resident came back, he would be placed on 1:1 monitoring. He said Resident #2 was not appropriate to stay at the facility. He said he spoke to Resident #1 on 10/02/25 and she was fine. He said he had told the nurses to check with her every 1-2 hours and if anything was concerning at all to give him a call. He said his role in the Plan of Removal would be monitoring to ensure resident safe surveys and/or head-to-toe assessments would be conducted weekly x 4 weeks on all patients, then monthly x 3 months.
Employees would also complete abuse questionnaires/and in-servicing weekly x 4 weeks then monthly x 3 months. An IJ was identified on 10/02/25.
The IJ template was provided to the facility on [DATE] at 4:50 PM.
While the IJ was removed on 10/03/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on the Plan of Removal.
Facility ID: