Brookhaven Nursing And Rehabilitation Center
Brookhaven Nursing and Rehabilitation Center in Carrollton, TX — inspection on May 27, 2026.
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
prevention and control program designed to provide a safe, sanitary, and comfortable environment and
(Resident #10) of 6 residents, reviewed for infection control. 1. LVN A failed to don PPE prior to performing the high contact resident care activity on a resident who was on enhanced barrier precaution.
This failure placed residents at risk for healthcare associated cross contamination and infections.
Findings included:
Record review of Resident #10's Comprehensive MDS Assessment, dated 04/23/26, reflected the resident was a [AGE] year-old female, had a BIMS score of 15 indicating her cognition was considered intact and functioning normally.
The resident had diagnoses which included pressure ulcer of left buttock, malnutrition (refers to deficiencies, excesses, or imbalances in a person's intake of energy and/or nutrients), multiple sclerosis (a chronic autoimmune disease of the central nervous system (brain, spinal cord, and optic nerves) and hypertension (condition where the force of blood pushing against your artery walls is consistently too high).
Record review of Resident #10's Comprehensive Care Plan, initiated 04/28/26, reflected (Residents name) had stage 4 pressure ulcer of left buttock.
Physician order dated 04/15/2026 had nursing intervention: implement and maintain enhanced barrier precautions when performing high contact care activities, related to wound care every shift. An observation on 05/27/2026 at 10:46 AM revealed Resident #10's room had an Enhanced Barrier Precaution sign outside of her room, and the cart set up with PPE. LVN A prepared Resident #10's wound care and incontinent care items. LVN A performed hand hygiene with sanitizer and entered the resident's room. He did wound care and incontinent care without PPE (gown).An interview on 05/27/26 at 11:00 AM revealed LVN A knew that Resident #10 was on enhanced barrier precaution, and he should have donned PPE before accessing Resident 10's wound.
He stated that he forgot to wear the gown, and failure to use PPE could put the resident at risk for infection. He stated that he had been in-serviced on enhanced barrier precautions. An interview on 05/27/2026 at 1:41 PM with the DON revealed that her expectation was that the staff should use appropriate PPE while providing care to residents on enhanced barrier precautions.
She stated a risk to the patient was infection.
She stated that the staff had been in-serviced on infection control and enhance barrier precautions.
Record review of the facility's policy titled Implementation of Standard and Transmission-Based Precautions dated March 2024, reflected: Enhanced Barrier Precautions (EBPs) - Expand the use of PPE and refer to the use of gown and gloves during high-contact resident care activities that provide opportunities for transfer of MDRO to staff hands and clothing. MDROs may be indirectly transferred from resident-to-resident during these high-contact care activitiesExamples of Enhanced-Based Precaution residents:ˆ Wounds - Includes chronic wounds, but are not limited to pressure ulcers, diabetic ulcers, unhealed surgical wounds and venous statis ulcers.ˆ Indwelling medical devices - Include central lines, urinary catheters, feeding tubes, and tracheostomies/vents.Enhanced-Based Precautions are indicated during:ˆ Dressingˆ Bathing/showering in a shared/common shower roomˆ Transferringˆ Providing hygieneˆ Changing linens Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
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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.