Inspection·February 12, 2025

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. Based on interviews and record review, the facility failed to ensure sufficient nursing staff with appropriate competencies and skills set to provide nursing and related services for one (Hospitality Aide A) of three employees reviewed for staff qualifications. 1. The facility failed to ensure Hospitality Aide A had a current nurse aide certification while employed at the facility while actively providing care for residents on 02/12/25: 6:00 AM - 2:00 PM shift, 02/10/25: 6:00 AM 2:00 PM shift, 02/08/25: 6:00 AM - 2:00 PM shift, 02/07/25: 6:00 AM - 2:00 PM shift. This failure could result in residents being provided care by staff who do not have the training and competency needed for providing care. Findings include: Record review of Hospitality Aide A's personnel file revealed her date of hire was not listed. She did not have a CNA license. Record review of the facility's schedule revealed Hospitality Aide A was listed as a CNA and counted as a CNA in the numbers for the schedule on dates: 02/12/25: 6:00 AM - 2:00 PM shift 02/10/25: 6:00 AM - 2:00 PM shift 02/08/25: 6:00 AM - 2:00 PM shift 02/07/25: 6:00 AM - 2:00 PM shift An interview on 02/12/25 at 2:00 PM with Hospitality Aide A revealed she was working on Hall 300. She said her job duties included making beds and taking out the trash. She said she helped CNAs provide care to residents. She also said that when the facility was short of staff, she would feed residents, perform incontinence care, and work as the second staff for two person transfers. Hospitality Aide A said she had finished school to be a CNA but had not taken her CNA test. An interview on 02/12/25 at 2:35 PM with ADON revealed she assisted with staffing. She said Hospitality Aide A did not have a CNA license. The ADON said Hospitality Aide A was not supposed to work by herself. The ADON said Hospitality Aide A was not supposed to be counted in the schedule numbers (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455412 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455412 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/12/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brookhaven Nursing and Rehabilitation Center 1855 Cheyenne Carrollton, TX 75010 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)