Inspection·November 4, 2025

F 0628 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide the required documentation or notification related to the resident's needs, appeal rights, or bed-hold policies. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay that included diagnoses, course of treatment, pertinent labs, a final summary of the resident's status and reconciliation of all pre-discharge medications with the resident's post-discharge medications for 1 of 5 residents (Resident #1) reviewed for closed records.The facility failed to ensure Resident #1 was discharged from the facility with a discharge summary that included an accurate and current description of the clinical status of the resident.The facility failed to provide the required notice to the Office of the long-term Care Ombudsman regarding the discharge of Resident#1.This failure could place residents at risk for not receiving appropriate and timely care due to confusion among various facilities, agencies, practitioners, and caregivers involved with the resident's care.Findings Included: Record review of Resident #1's MDS dated [DATE], reflected the [AGE] year-old male resident was admitted to the facility on [DATE]. Diagnoses included: Schizophrenia (a chronic mental health condition characterized by a combination of cognitive symptoms that significantly impair a person's daily functioning), anemia (a condition in which there is an abnormally low number of red blood cells (RBCs) or hemoglobin in the blood), hypertension (a condition in which the force of blood against the artery walls is consistently too high). Further review of the Resident #1's MDS, dated [DATE], revealed there was no documented BIMS score. Resident #1's MDS section E0200. Behavioral Symptom - Presence and Frequency reflected Resident#1 had Physical behavioral symptoms directed toward others (this behavior occurred once), Verbal behavioral symptoms directed toward others (this behavior occurred 4-6 times but less than daily). Record review of Resident #1's DISCHARGE - Recapitulation of Stay reflected one dated 10/02/2025 discharge to [hospital name 2]. There was no documented Discharge - Recapitulation of Stay for 10/03/2025 when Resident one went to the hospital. Record review of Resident #1's Physician orders dated 10/03/2025 revealed the following: Send to hospital for further evaluation and treatment. Interview with Ombudsman on 11/04/2025 at 10:09 AM revealed on 10/3/2025 the facility contacted her to get a list of suitable facilities for Resident#1's alternative placement. She stated SW B told her Resident#1 was going for treatment but did not specify the facility. She stated in immediate discharges the facility must provide clinical discharge summary of the residents to the receiving facility, and the notice of discharge to the Ombudsman manager which was not done. Attempted interview with FM 2 on 11/04/2025 at 1:43 PM was unsuccessful. A voicemail was left with a call back number. Attempted interview with FM1 on 11/04/2025 at 1:45 PM was unsuccessful. The surveyor left a voicemail with a call back number. Interview with LVN A on 11/04/2025 at 4:30PM revealed she was the nurse when Resident#1 was transferred to. She stated that she was not aware if he signed a discharge notice. Interview with SW B on 11/04/2025 at 4.45pm revealed that she did not send clinical documents or complete discharge summary because the former Administrator and the DON oversaw the transfer. Interview with SW C on 11/04/2025 at (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 11/04/2025 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)