Brookhaven Nursing and Rehabilitation Center
CCN: 455412 · Carrollton, TX 75010 · Denton County
Overview
- Address
- 1855 Cheyenne, Carrollton, TX 75010
- Phone
- 9723947141
- Certified beds
- 180
- Avg daily residents
- 99 (55% of beds filled)
- Ownership
- For-profit corporation
- Provider type
- Medicare and Medicaid
- Medicare/Medicaid since
- 1973-07-01
- Setting
- Urban
CMS 5-Star Ratings
CMS rates every Medicare/Medicaid-certified nursing home on four domains. The Overall rating is driven primarily by Health Inspection results, then adjusted up or down by Staffing and Quality Measures.
Staffing & Workforce
Direct-care staffing is the strongest operational driver of quality in nursing homes. Values are hours per resident per day, derived from payroll-based journal (PBJ) submissions. "Case-mix" adjusts for resident acuity; "Adjusted" is the CMS rating-input value.
| Role | Reported | Case-mix expected | Adjusted | Federal floor | |
|---|---|---|---|---|---|
| Total nurse All nursing staff combined: RN + LPN + Aide | 3.28 | 3.56 | 3.56 | ≥ 3.48 | Below floor |
| Registered Nurse (RN) Licensed RN hours. Strongest driver of clinical outcomes. | 0.74 | 0.62 | 0.80 | ≥ 0.55 | |
| Licensed Practical Nurse (LPN) LPN/LVN hours. Often handles medication administration. | 0.70 | 0.79 | 0.76 | — | |
| Nurse aide CNA hours. Bulk of direct resident care — bathing, feeding, mobility. | 1.85 | 2.15 | 2.00 | — | |
| Licensed (RN + LPN) Combined licensed nurse coverage. | 1.44 | — | — | — | |
| Physical therapist Rehabilitation therapist hours — important for post-acute / rehab admissions. | 0.02 | — | — | — |
Federal minimums (phasing in under the CMS 2024 minimum staffing rule) shown for reference. RN: 0.55 hrs/resident/day. Total nurse: 3.48 hrs/resident/day.
Weekend staffing
Weekend under-staffing is a common quality-of-care concern — adverse events are more frequent when licensed coverage drops.
Staff turnover
Resident acuity
Health Inspections
CMS weights three inspection cycles to compute the Health Inspection rating: the most recent (50%), the second most recent (33%), and the oldest (17%). Each standard-survey deficiency is assigned a score based on scope and severity; complaint-survey findings and revisit scores are added to produce the cycle total.
| Cycle | Date | Total defs. | Standard | Complaint | Deficiency score | Revisits | Total score |
|---|---|---|---|---|---|---|---|
| Cycle 1 (most recent) | 2025-07-23 | 10 | 6 | 5 | 189 | 0 | 189 |
| Cycle 2/3 (prior) | 2024-06-06 | 27 | 9 | 26 | 168 | 1 | 168 |
Deficiencies (47)
Individual survey findings. Scope/severity uses the CMS A–L matrix: letters further down the alphabet indicate greater harm and wider scope, up through J–L (immediate jeopardy).
| Tag | Description | Scope/Severity | Survey date | Corrected |
|---|---|---|---|---|
| 0644 | Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | D | 2025-12-03 | 2026-01-16 |
| 0628 | Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. | D | 2025-11-04 | 2025-11-17 |
| 0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | K | 2025-10-03 | 2025-10-06 |
| 0600 | Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | G | 2025-08-27 | — |
| 0638 | Assure that each resident’s assessment is updated at least once every 3 months. | E | 2025-07-23 | 2025-08-30 |
| 0655 | Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | D | 2025-07-23 | 2025-08-23 |
| 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | E | 2025-07-23 | 2025-08-23 |
| 0761 | 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 | 2025-07-23 | 2025-08-30 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2025-07-23 | 2025-08-30 |
| 0636 | Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | D | 2025-07-23 | 2025-08-30 |
| 0726 | 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. | D | 2025-02-12 | 2025-03-12 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | 2024-12-18 | 2024-11-13 |
| 0558 | Reasonably accommodate the needs and preferences of each resident. | D | 2024-08-30 | 2024-09-05 |
| 0585 | 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 | 2024-08-30 | 2024-09-05 |
| 0641 | Ensure each resident receives an accurate assessment. | D | 2024-08-30 | 2024-09-05 |
| 0645 | PASARR screening for Mental disorders or Intellectual Disabilities | D | 2024-08-30 | 2024-09-05 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2024-08-30 | 2024-09-05 |
| 0687 | Provide appropriate foot care. | D | 2024-08-30 | 2024-09-05 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | 2024-08-30 | 2024-09-05 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2024-08-30 | 2024-09-05 |
| 0791 | Provide or obtain dental services for each resident. | D | 2024-08-30 | 2024-09-05 |
| 0677 | Provide care and assistance to perform activities of daily living for any resident who is unable. | D | 2024-06-06 | 2024-07-19 |
| 0558 | Reasonably accommodate the needs and preferences of each resident. | D | 2024-06-06 | 2024-07-19 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2024-06-06 | 2024-07-19 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | D | 2024-06-06 | 2024-07-19 |
| 0690 | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | E | 2024-06-06 | 2024-07-19 |
| 0693 | 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 | 2024-06-06 | 2024-07-19 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | 2024-06-06 | 2024-07-19 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | 2024-06-06 | 2024-07-19 |
| 0880 | Provide and implement an infection prevention and control program. | E | 2024-06-06 | 2024-07-19 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | E | 2024-01-30 | 2024-03-01 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | E | 2024-01-30 | 2024-03-01 |
| 0761 | 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 | 2024-01-30 | 2024-03-01 |
| 0689 | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | J | 2023-12-29 | 2023-11-30 |
| 0919 | Make sure that a working call system is available in each resident's bathroom and bathing area. | D | 2023-12-29 | 2024-01-26 |
| 0656 | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | D | 2023-08-17 | 2023-08-28 |
| 0684 | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | D | 2023-05-09 | 2023-05-18 |
| 0584 | 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. | D | 2023-04-25 | 2023-05-06 |
| 0687 | Provide appropriate foot care. | D | 2023-04-25 | 2023-05-06 |
| 0690 | 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 | 2023-04-25 | 2023-05-06 |
| 0693 | 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 | 2023-04-25 | 2023-05-06 |
| 0695 | Provide safe and appropriate respiratory care for a resident when needed. | D | 2023-04-25 | 2023-05-06 |
| 0732 | Post nurse staffing information every day. | C | 2023-04-25 | 2023-05-06 |
| 0755 | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | D | 2023-04-25 | 2023-05-06 |
| 0761 | 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 | 2023-04-25 | 2023-05-06 |
| 0812 | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | E | 2023-04-25 | 2023-06-02 |
| 0880 | Provide and implement an infection prevention and control program. | D | 2023-04-25 | 2023-06-02 |
Penalties (3)
| Date | Type | Fine amount |
|---|---|---|
| 2023-12-29 | Fine | $7,446 |
| 2024-12-18 | Fine | $8,021 |
| 2025-08-27 | Fine | $9,110 |
Source: CMS Nursing Home Penalties.
Financial Health (FY 2023)
Payer mix (share of resident days)
Operating performance
Revenue & costs
Balance sheet
Source: CMS SNF Cost Report (FY 2023). Cost report data lags by ~2 years.
Ownership & Corporate Structure
Chain: DYNASTY HEALTHCARE GROUP
- Chain ID
649- Facilities in chain
- 5
- Legal business name
- OLNEY-HAMILTON HOSPITAL DISTRICT
Owner / manager organizations (2)
| Organization | Role | Association |
|---|---|---|
| OLNEY-HAMILTON HOSPITAL DISTRICT | 5% OR GREATER DIRECT OWNERSHIP INTEREST | since 04/01/2021 |
| DHC OPCO-CARROLLTON, LLC | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
Owner / manager individuals (3)
| Name | Role | Association |
|---|---|---|
| COHEN, BRADFORD | OPERATIONAL/MANAGERIAL CONTROL | since 04/01/2021 |
| HUFF, MICHAEL | CORPORATE DIRECTOR | since 04/01/2021 |
| IKONNE, ESTHER | W-2 MANAGING EMPLOYEE | since 04/01/2021 |
Source: CMS Nursing Home Ownership. Percent ownership is rarely disclosed — CMS only requires it for specific roles.
Facility Features
- CCRC
- No
- Hospital-based
- No
- Resident / family council
- Resident
- Sprinkler systems
- Yes
- Abuse citation flag
- Yes — last 2 cycles
- Nursing Home Provider Info (
nh-provider-info), vintage 2026, downloaded 2026-04-14 , 14,703 rows. - Nursing Home Penalties (
nh-penalties), vintage 2026, downloaded 2026-04-14 , 16,915 rows. - Nursing Home Health Deficiencies (
nh-deficiencies), vintage 2026, downloaded 2026-04-14 , 418,972 rows. - Nursing Home Ownership (
nh-ownership), vintage 2026, downloaded 2026-04-14 , 160,393 rows. - Skilled Nursing Facility Cost Report (
snf-cost-report), vintage 2023, downloaded 2026-04-14 , 14,120 rows.
All Data
Every labeled field shipped for this facility by CMS. No national median or percentile context is available for SNFs in the current release.
Show 113 rows
| Source | Metric | Value | Raw key |
|---|---|---|---|
| Cost Report | Cost per Resident Day ($) | $40 | metrics.cost_per_resident_day |
| Cost Report | Current Ratio | 5.63 | metrics.current_ratio |
| Cost Report | fiscal_year | 2,023 | fiscal_year |
| Cost Report | Medicaid Day Share (%) | 63.9% | metrics.medicaid_day_share |
| Cost Report | Medicare Day Share (%) | 4.9% | metrics.medicare_day_share |
| Cost Report | Net Income ($) | $-447,704 | metrics.net_income |
| Cost Report | Net Patient Revenue ($) | $7,193,739 | metrics.net_patient_revenue |
| Cost Report | Occupancy Rate (%) | 46.6% | metrics.occupancy_rate |
| Cost Report | Operating Margin (%) | -14.0% | metrics.operating_margin |
| Cost Report | Total Assets ($) | $6,182,133 | metrics.total_assets |
| Cost Report | Total Costs ($) | $1,210,944 | metrics.total_costs |
| Cost Report | Total Fund Balances ($) | $5,648,937 | metrics.fund_balance |
| Cost Report | Total Liabilities ($) | $533,196 | metrics.total_liabilities |
| Cost Report | Total Margin (%) | -5.8% | metrics.total_margin |
| Provider Information | Abuse Icon | Y | Abuse Icon |
| Provider Information | Adjusted LPN Staffing Hours per Resident per Day | 0.75675 | Adjusted LPN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Nurse Aide Staffing Hours per Resident per Day | 2.00139 | Adjusted Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Adjusted RN Staffing Hours per Resident per Day | 0.80036 | Adjusted RN Staffing Hours per Resident per Day |
| Provider Information | Adjusted Total Nurse Staffing Hours per Resident per Day | 3.55850 | Adjusted Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day | 3.11982 | Adjusted Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Administrator turnover footnote | — | Administrator turnover footnote |
| Provider Information | Automatic Sprinkler Systems in All Required Areas | Yes | Automatic Sprinkler Systems in All Required Areas |
| Provider Information | Average Number of Residents per Day | 99.0 | Average Number of Residents per Day |
| Provider Information | Average Number of Residents per Day Footnote | — | Average Number of Residents per Day Footnote |
| Provider Information | Case-Mix LPN Staffing Hours per Resident per Day | 0.79022 | Case-Mix LPN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Nurse Aide Staffing Hours per Resident per Day | 2.14765 | Case-Mix Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Case-Mix RN Staffing Hours per Resident per Day | 0.62287 | Case-Mix RN Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Total Nurse Staffing Hours per Resident per Day | 3.56073 | Case-Mix Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day | 3.13841 | Case-Mix Weekend Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Chain Average Health Inspection Rating | 2.2 | Chain Average Health Inspection Rating |
| Provider Information | Chain Average Overall 5-star Rating | 2.4 | Chain Average Overall 5-star Rating |
| Provider Information | Chain Average QM Rating | 3.4 | Chain Average QM Rating |
| Provider Information | Chain Average Staffing Rating | 3.4 | Chain Average Staffing Rating |
| Provider Information | Chain ID | 649 | Chain ID |
| Provider Information | Chain Name | DYNASTY HEALTHCARE GROUP | Chain Name |
| Provider Information | City/Town | Carrollton | City/Town |
| Provider Information | CMS Certification Number (CCN) | 455412 | CMS Certification Number (CCN) |
| Provider Information | Continuing Care Retirement Community | N | Continuing Care Retirement Community |
| Provider Information | County/Parish | Denton | County/Parish |
| Provider Information | Date First Approved to Provide Medicare and Medicaid Services | 1973-07-01 | Date First Approved to Provide Medicare and Medicaid Services |
| Provider Information | Geocoding Footnote | — | Geocoding Footnote |
| Provider Information | Health Inspection Rating | 1 | Health Inspection Rating |
| Provider Information | Health Inspection Rating Footnote | — | Health Inspection Rating Footnote |
| Provider Information | Latitude | 33.0296 | Latitude |
| Provider Information | Legal Business Name | OLNEY-HAMILTON HOSPITAL DISTRICT | Legal Business Name |
| Provider Information | Location | 1855 Cheyenne,Carrollton,TX,75010 | Location |
| Provider Information | Long-Stay QM Rating | 4 | Long-Stay QM Rating |
| Provider Information | Long-Stay QM Rating Footnote | — | Long-Stay QM Rating Footnote |
| Provider Information | Longitude | -96.886 | Longitude |
| Provider Information | Most Recent Health Inspection More Than 2 Years Ago | N | Most Recent Health Inspection More Than 2 Years Ago |
| Provider Information | Number of administrators who have left the nursing home | 0 | Number of administrators who have left the nursing home |
| Provider Information | Number of Certified Beds | 180 | Number of Certified Beds |
| Provider Information | Number of Citations from Infection Control Inspections | 1 | Number of Citations from Infection Control Inspections |
| Provider Information | Number of Facilities in Chain | 5 | Number of Facilities in Chain |
| Provider Information | Number of Fines | 3 | Number of Fines |
| Provider Information | Number of Payment Denials | 0 | Number of Payment Denials |
| Provider Information | Nursing Case-Mix Index | 1.26141 | Nursing Case-Mix Index |
| Provider Information | Nursing Case-Mix Index Ratio | 0.91562 | Nursing Case-Mix Index Ratio |
| Provider Information | Overall Rating | 1 | Overall Rating |
| Provider Information | Overall Rating Footnote | — | Overall Rating Footnote |
| Provider Information | Ownership Type | For profit - Corporation | Ownership Type |
| Provider Information | Physical Therapist Staffing Footnote | — | Physical Therapist Staffing Footnote |
| Provider Information | Processing Date | 2026-03-01 | Processing Date |
| Provider Information | Provider Address | 1855 Cheyenne | Provider Address |
| Provider Information | Provider Changed Ownership in Last 12 Months | N | Provider Changed Ownership in Last 12 Months |
| Provider Information | Provider Name | Brookhaven Nursing and Rehabilitation Center | Provider Name |
| Provider Information | Provider Resides in Hospital | N | Provider Resides in Hospital |
| Provider Information | Provider SSA County Code | 410 | Provider SSA County Code |
| Provider Information | Provider Type | Medicare and Medicaid | Provider Type |
| Provider Information | QM Rating | 2 | QM Rating |
| Provider Information | QM Rating Footnote | — | QM Rating Footnote |
| Provider Information | Rating Cycle 1 Health Deficiency Score | 189 | Rating Cycle 1 Health Deficiency Score |
| Provider Information | Rating Cycle 1 Health Revisit Score | 0 | Rating Cycle 1 Health Revisit Score |
| Provider Information | Rating Cycle 1 Number of Complaint Health Deficiencies | 5 | Rating Cycle 1 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 1 Number of Health Revisits | 0 | Rating Cycle 1 Number of Health Revisits |
| Provider Information | Rating Cycle 1 Number of Standard Health Deficiencies | 6 | Rating Cycle 1 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 1 Standard Survey Health Date | 2025-07-23 | Rating Cycle 1 Standard Survey Health Date |
| Provider Information | Rating Cycle 1 Total Health Score | 189 | Rating Cycle 1 Total Health Score |
| Provider Information | Rating Cycle 1 Total Number of Health Deficiencies | 10 | Rating Cycle 1 Total Number of Health Deficiencies |
| Provider Information | Rating Cycle 2 Number of Standard Health Deficiencies | 9 | Rating Cycle 2 Number of Standard Health Deficiencies |
| Provider Information | Rating Cycle 2 Standard Health Survey Date | 2024-06-06 | Rating Cycle 2 Standard Health Survey Date |
| Provider Information | Rating Cycle 2/3 Health Deficiency Score | 168 | Rating Cycle 2/3 Health Deficiency Score |
| Provider Information | Rating Cycle 2/3 Health Revisit Score | 0 | Rating Cycle 2/3 Health Revisit Score |
| Provider Information | Rating Cycle 2/3 Number of Complaint Health Deficiencies | 26 | Rating Cycle 2/3 Number of Complaint Health Deficiencies |
| Provider Information | Rating Cycle 2/3 Number of Health Revisits | 1 | Rating Cycle 2/3 Number of Health Revisits |
| Provider Information | Rating Cycle 2/3 Total Health Score | 168 | Rating Cycle 2/3 Total Health Score |
| Provider Information | Rating Cycle 2/3 Total Number of Health Deficiencies | 27 | Rating Cycle 2/3 Total Number of Health Deficiencies |
| Provider Information | Registered Nurse hours per resident per day on the weekend | 0.55969 | Registered Nurse hours per resident per day on the weekend |
| Provider Information | Registered Nurse turnover | 46.7 | Registered Nurse turnover |
| Provider Information | Registered Nurse turnover footnote | — | Registered Nurse turnover footnote |
| Provider Information | Reported Licensed Staffing Hours per Resident per Day | 1.43604 | Reported Licensed Staffing Hours per Resident per Day |
| Provider Information | Reported LPN Staffing Hours per Resident per Day | 0.69791 | Reported LPN Staffing Hours per Resident per Day |
| Provider Information | Reported Nurse Aide Staffing Hours per Resident per Day | 1.84578 | Reported Nurse Aide Staffing Hours per Resident per Day |
| Provider Information | Reported Physical Therapist Staffing Hours per Resident Per Day | 0.01846 | Reported Physical Therapist Staffing Hours per Resident Per Day |
| Provider Information | Reported RN Staffing Hours per Resident per Day | 0.73814 | Reported RN Staffing Hours per Resident per Day |
| Provider Information | Reported Staffing Footnote | — | Reported Staffing Footnote |
| Provider Information | Reported Total Nurse Staffing Hours per Resident per Day | 3.28183 | Reported Total Nurse Staffing Hours per Resident per Day |
| Provider Information | Short-Stay QM Rating | 1 | Short-Stay QM Rating |
| Provider Information | Short-Stay QM Rating Footnote | — | Short-Stay QM Rating Footnote |
| Provider Information | Special Focus Status | — | Special Focus Status |
| Provider Information | Staffing Rating | 3 | Staffing Rating |
| Provider Information | Staffing Rating Footnote | — | Staffing Rating Footnote |
| Provider Information | State | TX | State |
| Provider Information | Telephone Number | 9723947141 | Telephone Number |
| Provider Information | Total Amount of Fines in Dollars | 24577.00 | Total Amount of Fines in Dollars |
| Provider Information | Total number of nurse staff hours per resident per day on the weekend | 2.87725 | Total number of nurse staff hours per resident per day on the weekend |
| Provider Information | Total Number of Penalties | 3 | Total Number of Penalties |
| Provider Information | Total nursing staff turnover | 62.2 | Total nursing staff turnover |
| Provider Information | Total nursing staff turnover footnote | — | Total nursing staff turnover footnote |
| Provider Information | Total Weighted Health Survey Score | 183.750 | Total Weighted Health Survey Score |
| Provider Information | Urban | Y | Urban |
| Provider Information | With a Resident and Family Council | Resident | With a Resident and Family Council |
| Provider Information | ZIP Code | 75010 | ZIP Code |