Brookhaven Nursing And Rehabilitation Center
Inspection Findings
F-Tag F0600
F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some
FORM CMS-2567 (02/99) Previous Versions Obsolete
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 REDACTED] 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 REDACTED] 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.
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Brookhaven Nursing and Rehabilitation Center in Carrollton, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Carrollton, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Brookhaven Nursing and Rehabilitation Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.