Federal inspection record · CMS data as of October 1, 2026
Brookhaven Nursing and Rehabilitation Center
1855 Cheyenne Dr., Carrollton, TX · (972) 394-7141
- Cited for abuse (CMS abuse icon)
- Certified beds
- 180
- Residents per day
- 110
- Ownership
- For-Profit
- Chain
- No chain reported
- Medicare / Medicaid
- Medicare + Medicaid
- Certified since
- July 1, 1973
1
How this home got 1 star
The overall rating isn't an average. CMS starts from the inspection rating and nudges it at most two steps. Here is the arithmetic for this home, using CMS's own rules.
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Health inspections
★★★★★starting point
Everything starts from what state inspectors found on site. This is a ranking against other homes in Texas.
-
Staffing
★★★★★no change (already 1)
Only a 5-star staffing rating adds a star, and only a 1-star rating removes one. Ratings of 2 to 4 change nothing.
-
Quality measures
★★★★★no change
Same rule: 5 stars adds one, 1 star takes one away. These measures are mostly reported by the home itself.
-
Overall
★★★★★1 of 5
Matches the rating CMS publishes on Care Compare.
This home carries CMS's abuse icon, which caps its inspection rating at 2 stars and so its overall rating at 4.
2
Where it sits among Texas homes
Brookhaven Nursing and Rehabilitation Center carries 175.75 inspection points. That is fewer than 14% of Texas's 1,166 rated homes.
Inspectors' citations earn points by how serious and how widespread they were (the grid below). CMS then ranks every home in Texas: the 10% with the fewest points get 5 stars, the 20% with the most get 1 star, and the middle 70% split evenly into 2, 3 and 4.
- 5★ 0–26 pts
- 4★ 26–51 pts
- 3★ 51–85 pts
- 2★ 85–145.75 pts
- 1★ over 145.75 pts
Bars show every rated home in Texas by its weighted inspection score. CMS recalibrates the cut points monthly but holds a home's rating until its own score changes, so a home can sit just outside today's band.
3
What inspectors found
47 health citations on record since 2023. Each one gets a letter: the row says how badly residents were affected, the column how many.
Immediate jeopardyResidents at risk of serious injury or death
Actual harmA resident was hurt
Potential for harmNo one was hurt, but could have been
Minimal harmPaperwork-level problems
Read the rows, not the total. Most citations nationwide are a D: one problem, nobody hurt. Rows G–I mean a resident was harmed; J–L mean inspectors found residents in immediate danger of serious injury or death.
Small numbers in each cell are the inspection points CMS assigns per citation. Those points are what the state curve above ranks.
Harm and immediate-jeopardy citations (4)
-
K
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
G
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
-
J
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Everything else, by area of care
Quality of Life and Care14E
- E
Provide care and assistance to perform activities of daily living for any resident who is unable.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate foot care.
- D
Provide or obtain dental services for each resident.
- E
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Provide care and assistance to perform activities of daily living for any resident who is unable.
- D
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
- D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Ensure 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.
- E
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
- D
Provide appropriate foot care.
- D
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
- D
Ensure 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.
- D
Provide safe and appropriate respiratory care for a resident when needed.
Resident Assessment and Care Planning7E
- D
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
- E
Assure that each resident’s assessment is updated at least once every 3 months.
- D
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
- D
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
- D
Ensure each resident receives an accurate assessment.
- D
PASARR screening for Mental disorders or Intellectual Disabilities
- D
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Pharmacy Service7E
- E
Ensure 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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- E
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
- D
Ensure 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.
- E
Ensure 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.
- D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Resident Rights6D
- D
Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies.
- D
Give the resident's representative the ability to exercise the resident's rights.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Honor 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.
- D
Reasonably accommodate the needs and preferences of each resident.
- D
Honor 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.
Infection Control4E
- D
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
- E
Provide and implement an infection prevention and control program.
- D
Provide and implement an infection prevention and control program.
Nursing and Physician Services2D
- D
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
- C
Post nurse staffing information every day.
Nutrition and Dietary2E
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
- E
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Environmental1D
- D
Make sure that a working call system is available in each resident's bathroom and bathing area.
Inspection history
2025-07-23
10 health deficiencies · 9 fire-safety deficiencies
Top issue: Resident Assessment and Care Planning (4 deficiencies)
2024-06-06
13 health deficiencies · 17 fire-safety deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
2023-04-25
24 health deficiencies · 4 fire-safety deficiencies
Top issue: Quality of Life and Care (9 deficiencies)
5
Fines and payment denials
$24,739 in federal fines on record over the past three years.
| Date | Penalty | Amount |
|---|---|---|
| 2025-08-27 | Fine | $9,272 |
| 2024-12-18 | Fine | $8,021 |
| 2023-12-29 | Fine | $7,446 |
6
Resident outcomes
Quality measures compared with state and national averages. Most come from assessments the home itself reports.
| Measure | This home | State | U.S. |
|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days0.7 pts better | 1.3 | 2.0 | 1.8 |
| Number of outpatient emergency department visits per 1000 long-stay resident days0.6 pts better | 1.4 | 2.0 | 1.7 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine1.2 pts better | 97.6% | 96.4% | 93.7% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine4.3 pts worse | 92.7% | 97.0% | 95.3% |
| Percentage of long-stay residents experiencing one or more falls with major injury2 pts better | 1.2% | 3.2% | 3.2% |
| Percentage of long-stay residents who have depressive symptoms2.7 pts worse | 5.0% | 2.3% | 13.5% |
| Percentage of long-stay residents who lose too much weight0.1 pts worse | 3.0% | 2.9% | 5.1% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication3.9 pts worse | 21.7% | 17.8% | 19.5% |
| Percentage of long-stay residents who received an antipsychotic medication2.3 pts worse | 12.1% | 9.8% | 15.4% |
| Percentage of long-stay residents who were physically restrained0.2 pts worse | 0.2% | 0.0% | 0.1% |
| Percentage of long-stay residents whose ability to walk independently worsened4.8 pts worse | 17.7% | 12.9% | 12.7% |
| Percentage of long-stay residents whose need for help with daily activities has increased3.3 pts worse | 19.1% | 15.8% | 13.5% |
| Percentage of long-stay residents with a catheter inserted and left in their bladder0.1 pts worse | 0.4% | 0.3% | 0.7% |
| Percentage of long-stay residents with a urinary tract infection0.1 pts better | 0.7% | 0.8% | 1.5% |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence0.6 pts worse | 13.1% | 12.5% | 18.3% |
| Percentage of long-stay residents with pressure ulcers0.2 pts worse | 3.9% | 3.7% | 4.5% |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine2.4 pts better | 91.1% | 88.7% | 82.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit1.2 pts worse | 13.4% | 12.2% | 11.8% |
| Percentage of short-stay residents who newly received an antipsychotic medication1.8 pts worse | 3.2% | 1.4% | 1.5% |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine16.8 pts worse | 68.6% | 85.4% | 80.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission9.6 pts worse | 35.1% | 25.5% | 23.4% |
·
Who owns and runs it
16 owners and managers reported to CMS. The last column counts how many nursing homes each one is tied to.
Show ownership list
| Name | Role | Share | Homes |
|---|---|---|---|
| Olney-Hamilton Hospital District | 5% Or Greater Direct Ownership Interest · Organization | 100% | 4 facilities |
| Bauder, Kelly | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 28 facilities |
| Bauder, Madison | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 28 facilities |
| Bauder, Parker | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 28 facilities |
| Bauder, William | Operational/Managerial Control · Individual | 0% | 42 facilities |
| Boulware, Steven | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 48 facilities |
| Boulware, Thomas | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 30 facilities |
| Coil, Ryan | Operational/Managerial Control · Individual | 0% | 4 facilities |
| Coil, Ryan | Adp Of The SNF · Individual | 0% | 4 facilities |
| Dvorak, Kenneth | Operational/Managerial Control · Individual | 0% | 1 facilities |
| Dvorak, Kenneth | Adp Of The SNF · Individual | 0% | 1 facilities |
| Huff, Michael | Corporate Director · Individual | 0% | 4 facilities |
| Pmg Opco - Carrollton, LLC | Operational/Managerial Control · Organization | 0% | 1 facilities |
| Pmg Opco - Carrollton, LLC | Adp Of The SNF · Organization | 0% | 1 facilities |
| Priority Management Group, LLC | Adp Of The SNF · Organization | 0% | 40 facilities |
| Walker, Katie | Individual Is An Owner, Partner Or Trustee Of Any Adp Of The SNF · Individual | 0% | 30 facilities |
·
Fire safety
30 life-safety citations (sprinklers, exits, alarms). These don't count toward the star rating.
Smoke15F
- F
Install a fire alarm system that can be heard throughout the facility.
- F
Inspect, test, and maintain automatic sprinkler systems.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- D
Provide properly protected cooking facilities.
- F
Provide properly protected cooking facilities.
- F
Have approved installation, maintenance and testing program for fire alarm systems.
- F
Inspect, test, and maintain automatic sprinkler systems.
- F
Properly select, install, inspect, or maintain portable fire extinguishes.
- E
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
- E
Install corridor and hallway doors that block smoke.
- E
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
- E
Properly provide smoke detection systems in areas open to corridors.
- E
Install smoke barrier doors that can resist smoke for at least 20 minutes.
- D
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Gas, Vacuum, and Electrical Systems5F
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- F
Have a battery powered remote alarm panel in a location accessible by operating personnel.
- F
Have generator or other power source capable of supplying service within 10 seconds.
- E
Have power receptacles that are properly grounded.
Egress4E
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- E
Have exits that are accessible at all times.
- E
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
- E
Have properly located and lighted "Exit" signs.
Emergency Preparedness4F
- F
Establish procedures for tracking staff and patients during an emergency.
- F
Provide emergency officials' contact information.
- F
Conduct risk assessment and an All-Hazards approach.
- F
Address patient/client population and determine types of services needed.
Services1F
- F
Have properly installed electrical wiring and gas equipment.
Miscellaneous1F
- F
Meet Health Care Facilities Code mechanical requirements.
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