Average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brentwood Place Four during CMS and state inspections, most recent first.
A resident with stroke, HF, HTN, hyperglycemia, respiratory failure, and COPD was observed receiving oxygen via NC at 4.5 L/min, but there was no physician order for the oxygen in the chart or system. An LVN confirmed the resident was on oxygen and stated she had not checked for an order, while the DON stated nursing staff should verify oxygen therapy against the physician order and document the resident’s need for oxygen.
Four residents with significant cognitive and physical impairments did not receive necessary assistance with nail care, resulting in long, dirty, and untrimmed fingernails. Staff interviews and observations confirmed that nail care was not consistently provided as required by care plans and facility policy, despite residents' dependence on staff for personal hygiene.
LVNs assigned to a medication cart did not consistently sign the narcotic count sheets at shift changes, despite performing the counts, due to interruptions and workload. This resulted in missing documentation for several shifts, with the DON confirming that signatures are required to verify counts were completed.
Surveyors observed improper food storage, including unlabeled and undated items in the refrigerator and a scoop left in a bulk oatmeal bin, as well as inadequate hand hygiene by a staff member during meal preparation. Staff handled food and kitchen equipment without washing hands between tasks and used a dirty cloth to clean surfaces, contrary to facility policy and professional standards.
A resident who was totally dependent for eating and cognitively intact was assisted with her meal by a CNA who stood while feeding her, contrary to facility policy and training that require staff to be seated to maintain resident dignity. The DON confirmed that all staff are responsible for ensuring dignity during care, and the CNA acknowledged she should have been seated.
A discharge MDS assessment for a resident was not completed or transmitted to CMS within the required 14-day timeframe after discharge. The MDS Nurse, responsible for these assessments, acknowledged the delay, and both the DON and Administrator confirmed the expectation for timely completion and transmission. The facility lacked a specific policy on MDS assessments, relying instead on the CMS RAI manual.
A resident with right-sided hemiplegia and hand contractures did not receive daily application of a prescribed resting hand splint as outlined in their care plan. Multiple observations showed the splint was not in use, and there was no documentation of refusal. Staff interviews revealed confusion about responsibility for the intervention, and the care plan was not updated to reflect the resident's current needs, contrary to facility policy.
Two residents did not receive proper incontinence and catheter care: one resident's Foley catheter was not secured during transfer, resulting in pain, and another resident did not receive appropriate perineal cleaning after a bowel movement, as the CNA failed to separate the labia and used the brief instead of wipes. These lapses were observed by surveyors and confirmed by staff interviews and record review.
A resident with a tracheostomy and respiratory failure did not receive sterile tracheostomy care as required. An LVN failed to maintain sterile technique, did not perform hand hygiene at key steps, and did not change gloves between dirty and clean tasks during the procedure, contrary to professional standards and facility policy. Both the LVN and DON confirmed that the correct sterile procedures were not followed.
A medication aide failed to administer a chewable aspirin and a sublingual buprenorphine as ordered to a resident with multiple chronic conditions and moderate cognitive impairment, resulting in a medication error rate of 8%, which exceeds the acceptable threshold. The aide acknowledged misreading the administration instructions, and the DON confirmed expectations for following medication administration protocols.
Surveyors found that a nurse failed to properly check and label medications on a medication cart, including leaving a controlled medication in a broken blister pack and using an insulin pen for a resident without documenting the open date. The DON confirmed that staff are required to check for broken seals and date insulin pens, but these steps were not followed, in violation of facility policy.
A resident with mild cognitive impairment but intact cognition reported a missing debit card after using it at the front desk. The card was later used for unauthorized purchases by a CNA, as confirmed by surveillance footage and the facility administrator. The incident was reported to the administrator and police, but the facility did not meet required reporting timelines. Staff interviews confirmed awareness of misappropriation policies and recent training.
A resident with mild cognitive impairment reported a missing debit card, which was later found to have been used by a facility employee for unauthorized purchases. Although staff recognized the need to report misappropriation, the administrator did not notify the state agency within the required 24-hour period or submit the investigation report within five days, violating facility policy.
A resident with mild cognitive impairment reported a missing debit card, which was later found to have been used by a facility employee for unauthorized purchases. The facility did not complete and submit the investigation results to the state within the required 5-day period, and the administrator delayed reporting the incident as misappropriation, resulting in noncompliance with facility policy and regulatory requirements.
The facility failed to notify the physician and responsible party of significant weight loss for two residents. One resident's weight dropped from 226.9 lbs to 178 lbs, and another's from 204 lbs to 164.4 lbs, without timely notification. This failure to follow policy could delay treatment and diagnosis.
The facility failed to provide timely incontinence care and personal hygiene for three residents. One resident did not receive incontinence care for over eight hours, another had not had her hair washed in over a month, and a third had long, dirty fingernails. These deficiencies were due to communication lapses and staffing issues.
The facility failed to address significant weight loss in two residents, leading to a lack of timely notification to the physician and Dietitian, and inadequate monitoring of enteral feeding. This resulted in substantial weight loss for both residents, with one losing 44.8 pounds (20%) in less than a month and the other losing 34.1 pounds (17%) in a month.
The facility failed to follow enteral feeding physician orders for two residents, leading to significant nutritional deficits. Both residents experienced substantial weight loss, and the facility did not notify the Consultant Dietitian. The enteral feeding pumps were not reprogrammed every 24 hours, resulting in residents not receiving the prescribed nutrition.
The facility failed to provide proper respiratory care for two residents, as the RT and an LVN did not maintain sterile technique or perform hand hygiene during tracheostomy care, potentially risking respiratory infections.
The facility failed to ensure that a dietary aide wore effective hair restraints while cleaning dishes and using the dish machine. Additionally, one of the facility's freezers had an ice accumulation issue due to a slipped hose, which was not addressed promptly due to the lack of a specific freezer maintenance policy.
The facility failed to maintain an Infection Prevention and Control Program, leading to multiple instances of improper hand hygiene and cross-contamination during incontinence care for three residents. CNAs did not perform hand hygiene after changing gloves and placed contaminated items on beds, risking cross-contamination and infection.
The facility failed to maintain a safe and sanitary environment in the laundry room, with significant lint accumulation in dryers and inadequate handwashing facilities. Observations revealed non-compliance with cleaning protocols and improper soap dispensers, posing sanitary and fire hazards.
The facility failed to ensure a resident's call light was within reach, despite the resident's risk of falls and care plan instructions. The resident and their family member, who only spoke Spanish, confirmed the call light was always on the floor, requiring the family member to pick it up. Staff interviews and observations revealed that the call light was not consistently placed within reach, violating facility policies and endangering the resident's safety.
The facility failed to ensure that a resident with a traumatic brain injury wore a helmet as ordered by the physician to prevent possible injury when ambulating. The resident was observed multiple times without the helmet, and staff interviews revealed a lack of awareness and enforcement of the helmet requirement. The resident's call light was also found out of reach, further compromising safety.
A facility failed to provide proper catheter and perineal care for a severely cognitively impaired male resident with multiple medical conditions. The CNA did not follow proper hand hygiene or cleaning procedures, increasing the risk of infection and skin breakdown.
Missing Physician Order for Oxygen Therapy
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had a written physician order for oxygen administration. The resident was a male with diagnoses including stroke, heart failure, high blood pressure, high blood sugar, respiratory failure, and COPD. His quarterly MDS dated 04/02/26 indicated a BIMS score of 11/15 and that he did require oxygen while residing at the facility. However, review of the resident’s care plan dated 05/05/26 showed no indication of oxygen therapy, and review of physician orders on 05/27/26 showed no order for oxygen therapy. On 05/27/26 at 09:13 AM, the resident was observed lying in bed using oxygen at 4.5 liters per minute via nasal cannula, with oxygen tubing dated 05/25/26 and an Oxygen in Use sign on the room door frame. During interview and record review at 11:32 AM, LVN A confirmed there was no oxygen order in the system and physically verified the resident was on oxygen at 4.5 liters per minute. She stated she was familiar with the resident, that he was on oxygen all the time, and that she had not checked to ensure there was an order for the oxygen therapy. The DON stated the nursing staff should confirm oxygen therapy with the physician order and document the resident’s need for oxygen therapy, and that the resident was on oxygen.
Failure to Provide Adequate Nail Care and Personal Hygiene Assistance
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically grooming and personal hygiene, for four residents who were dependent on staff for these tasks. Observations and interviews revealed that these residents had long, dirty, and untrimmed fingernails, with some nails being thickened, jagged, or discolored. In several cases, residents expressed a desire to have their nails trimmed and cleaned, and staff acknowledged that nail care had not been performed as needed. Resident records indicated that all four residents had significant cognitive and/or physical impairments, such as hemiplegia, contractures, diabetes, and severe cognitive deficits, requiring substantial or total assistance with personal hygiene. Care plans for these residents specified the need for staff assistance with nail care, yet observations showed that this care was not consistently provided. Staff interviews confirmed that nail care was a shared responsibility between CNAs and nurses, with some staff noting that nail care should be offered during routine hygiene or as needed, and that certain residents had a history of refusals, though this was not always documented or addressed. The facility's own policy required regular cleaning and trimming of fingernails, but this was not followed for the residents in question. Staff interviews further revealed a lack of consistent monitoring and follow-through, with some CNAs stating they had not noticed the condition of the residents' nails during their rounds. The DON and ADON acknowledged that nail care should be performed regularly and that lapses could pose infection control issues, but the deficiency persisted as observed during the survey.
Failure to Document Narcotic Counts at Shift Change
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one of three nurse medication carts reviewed. Specifically, LVNs responsible for the 100/200 hall nurse cart did not consistently count and sign for controlled drugs at every shift change, as required. Record review and observation revealed missing signatures for both off-duty and on-duty nurses on the narcotic count sheet for three consecutive shifts. Interviews with the involved LVNs confirmed that although they performed the narcotic counts, they did not sign the count sheets immediately after, citing interruptions and being busy with resident care or new admissions. The DON confirmed that the expectation is for nurses to sign the narcotic count sheet at the beginning and end of each shift after completing the count with the incoming and outgoing nurse. The DON also stated that without these signatures, there is no proof that the counts were performed. Review of the facility's policy on receiving controlled substances did not address the specific concerns identified in this incident.
Deficient Food Storage and Hand Hygiene Practices in Kitchen
Penalty
Summary
Surveyors identified deficiencies in the facility's food storage, preparation, and hand hygiene practices during observations and interviews. On one occasion, a scoop was found stored inside a bulk oatmeal bin in the dry storage area, and a zip top bag containing cut strawberries, a lemon, and grapes was found in the refrigerator without a date or label. These practices were not in accordance with the facility's policy, which requires all food items to be labeled, dated, and stored properly to prevent contamination. During meal preparation, a staff member was observed making pureed food without wearing gloves, handling a cell phone near the prep area, and moving between the prep and dishwashing areas without performing hand hygiene. The staff member also used a dirty dish cloth to wipe the counter and donned gloves without washing hands beforehand. After removing the gloves, the staff member did not wash hands before handling clean and sanitized plate covers. These actions were inconsistent with the facility's hand hygiene policy, which mandates handwashing with soap and water before and after food preparation and when moving between kitchen tasks. Interviews with dietary staff and the regional dietitian confirmed that all kitchen staff are responsible for proper food storage and hand hygiene. Staff acknowledged awareness of the policies and the importance of these practices, but admitted to lapses during the observed incidents. The facility's policies and the FDA Food Code were reviewed, both of which emphasize the necessity of proper labeling, dating, storage, and hand hygiene to prevent food contamination and ensure food safety.
Failure to Maintain Dignity During Meal Assistance
Penalty
Summary
A deficiency was identified when a certified nursing assistant (CNA) failed to assist a resident with eating in a dignified manner. The resident, a cognitively intact female with a history of acute and chronic respiratory failure, artificial larynx, and hypertension, was assessed as being totally dependent on staff for eating. During an observation, the CNA was seen standing while feeding the resident, rather than sitting beside her as required by facility policy and the resident's care plan. The CNA acknowledged during an interview that she should have been seated while assisting the resident, as standing could make the resident uncomfortable. The facility's policy on resident rights, as well as statements from the Director of Nursing (DON), confirmed that all staff are responsible for maintaining resident dignity and are trained to do so. The DON specifically stated that staff should be seated when assisting residents with meals to prevent discomfort. The failure to follow these protocols resulted in the resident not being assisted with eating in a manner that promoted her dignity and quality of life.
Failure to Complete and Transmit Discharge MDS Assessment Timely
Penalty
Summary
The facility failed to ensure that a discharge Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS system within 14 days after completion for one resident who was reviewed for discharge assessments. Specifically, a female resident who was admitted in September 2024 and discharged in January 2025 did not have a discharge MDS assessment completed or transmitted as required. Review of the resident's MDS assessments revealed that the discharge MDS was more than 120 days overdue at the time of the survey. Interviews with the MDS Nurse, DON, and Administrator confirmed that the MDS Nurse was responsible for completing and transmitting all MDS assessments, including discharge assessments, within the required timeframe. The MDS Nurse acknowledged starting but not completing or transmitting the assessment, and both the DON and Administrator stated their expectation that all MDS assessments be completed and transmitted on time. The facility did not have a specific policy on MDS assessments and referred to the CMS RAI manual for guidance.
Failure to Implement and Update Comprehensive Care Plan for Resident with Contractures
Penalty
Summary
A deficiency was identified when the facility failed to develop and implement a comprehensive care plan with measurable objectives and timeframes for a resident with hemiplegia affecting the right dominant side and right hand contractures. The resident's care plan included an intervention to assist with applying a right resting hand splint daily to prevent complications such as contracture formation, embolism, and immobility. However, observations on multiple occasions revealed that the resident was not wearing the splint, and there was no documentation of the resident refusing the application of the splint. Interviews with staff indicated confusion regarding responsibility for the application of the splint, with the CNA stating that therapy staff were responsible, and the Physical Therapy Manager referencing restorative care and resident refusal, though no such refusal was documented in the care plan. The MDS Coordinator and DON acknowledged that care plan updates were necessary to ensure residents received appropriate care and that failure to update or implement the care plan could negatively impact the resident's condition. The facility's policy required care plans to include measurable objectives, timeframes, and ongoing updates, which was not followed in this case.
Deficient Incontinence and Catheter Care Practices
Penalty
Summary
Two residents were found to have not received appropriate care related to incontinence and catheter management. One male resident with severe cognitive impairment, neuromuscular dysfunction, and an indwelling Foley catheter was observed sitting on the toilet without his catheter tubing secured to his leg. During the process of cleaning and transferring the resident from the toilet to his wheelchair and then to his bed, the catheter remained unsecured. The resident complained of pain in the penile area during this process. Staff interviews confirmed that the catheter should have been secured to prevent pulling and potential injury, and that this step was missed during the observed care. Another female resident with moderate cognitive impairment, a history of septicemia, and requiring substantial assistance for toileting was observed receiving incontinence care. During the cleaning process, the CNA failed to separate the resident's labia and did not clean the area using wipes as required, instead using the brief to wipe. The resident had a bowel movement that had spread between her legs, but the cleaning did not include proper perineal care to ensure all feces was removed from the vaginal area. The CNA acknowledged the correct procedure was not followed and recognized the risk of infection if feces remained. Facility policy required that catheters be anchored with a leg strap to prevent tension and possible injury, and that proper perineal care be performed to reduce infection risk. Both deficiencies were observed directly by surveyors and confirmed through staff interviews and record review.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
A deficiency occurred when a licensed vocational nurse (LVN) failed to provide sterile tracheostomy care to a resident requiring respiratory support. During an observed tracheostomy care procedure, the LVN did not maintain sterile technique, did not perform hand hygiene at appropriate steps, and failed to change gloves between dirty and clean tasks. Specifically, after removing gloves and opening a sterile glove package, the LVN did not sanitize her hands before donning new sterile gloves, handled supplies with sterile gloves, and did not change gloves or perform hand hygiene after removing the old dressing and before applying a clean one. These actions were inconsistent with both professional standards of practice and the facility's own tracheostomy care policy, which requires hand hygiene and the use of clean supplies at each step. The resident involved was a cognitively intact female with acute and chronic respiratory failure, an artificial larynx, and a care plan requiring tracheostomy care and oxygen therapy. The resident's physician orders and care plan specified regular tracheostomy care, including changing and dating trach ties and dressings. The LVN and the Director of Nursing both acknowledged during interviews that the procedure should have been performed using sterile technique to reduce infection risk, and that the correct steps were not followed during the observed care.
Medication Error Rate Exceeds Acceptable Threshold Due to Improper Administration
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 8% based on 2 errors out of 25 opportunities. During a medication pass observation, a medication aide (MA) administered medications to a female resident with chronic embolism, chronic kidney disease, and muscle weakness, who had moderately impaired cognition. The MA did not instruct the resident to chew the prescribed chewable aspirin and failed to ensure the buprenorphine was administered sublingually as ordered. These actions were confirmed through observation, interview, and record review. The MA acknowledged misreading the administration instructions for both the chewable aspirin and the sublingual buprenorphine, stating that medications must be given as ordered by the physician. The Director of Nursing (DON) confirmed that staff are expected to follow the five rights of medication administration and consult with nursing leadership or the physician if there are any questions about medication orders. Facility policy also requires staff to perform three checks comparing the physician's order, pharmacy label, and medication administration record.
Improper Medication Labeling and Storage on Medication Cart
Penalty
Summary
Surveyors observed that drugs and biologicals on one of the medication carts were not labeled and stored according to professional standards. Specifically, a blister pack containing tramadol for a resident had a broken seal with the pill still inside, and an insulin pen for another resident was in use without an open date indicated. The nurse responsible for the cart did not check blister packs during the narcotic count at shift change and was unaware of when or how the blister pack seal was broken. The nurse also administered insulin without verifying or documenting the open date on the pen, which is necessary to ensure the medication's effectiveness within its shelf life. Interviews with the nurse and the DON confirmed that staff are expected to check for broken seals and to date insulin pens when opened, but these procedures were not followed. The facility's policy requires immediate removal and disposal of medications in compromised containers and mandates dating of certain medications upon opening. The DON acknowledged that keeping a pill in a broken blister pack is not acceptable and that insulin pens must be dated to track expiration. The pharmacy consultant and ADONs are supposed to perform regular checks, but these lapses were still found during the survey.
Unauthorized Use of Resident's Debit Card by Staff Member
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) used a resident's debit card for unauthorized transactions. The resident, who had mild cognitive impairment but was assessed as having intact cognition, reported his debit card missing after last using it at the facility front desk. The resident and his family searched for the card but could not locate it. Subsequent review of the resident's bank transactions revealed several unauthorized purchases, including a bus ticket and department store items. Surveillance footage from a local store showed a facility employee making purchases with the card, and the administrator identified the employee as CNA A. The incident was reported to the facility administrator, who confirmed that the resident's debit card had been used without authorization by CNA A. The administrator attempted to contact CNA A, but the CNA did not respond or return to the facility. The administrator also visited the locations where the card was used, but was unable to obtain video evidence without police involvement. The police were notified, and the incident was reported to the state. The administrator acknowledged that the facility's policy required reporting such incidents within 24 hours and submitting an investigation report within 5 days, but these timelines were not met. Interviews with other staff members indicated that they were aware of the facility's policies regarding misappropriation and had received recent in-service training on the topic. Staff consistently stated that they would not accept cash or bank cards from residents and would direct any such requests to the appropriate department. The resident involved confirmed that he had reported the missing card to staff and the police, and that unauthorized transactions had occurred while he was at the facility.
Failure to Timely Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to implement its written policies and procedures regarding the timely reporting of an allegation of misappropriation of property for one resident. The resident, a male with mild cognitive impairment, hypertension, and glaucoma, reported his debit card missing after last using it at the facility front desk. The resident and his family searched for the card but could not locate it. Subsequent investigation revealed that the card had been used for unauthorized purchases, and surveillance footage identified a facility employee making these transactions. The police were notified, and the employee was terminated. Despite the facility's policy requiring that suspicions of misappropriation be reported to the state agency within 24 hours, the incident was not reported within this timeframe. The administrator initially learned of the missing card but delayed reporting to the state, waiting to see if the card would be found. The administrator later acknowledged that the misappropriation should have been reported within 24 hours of the initial suspicion, as per facility policy. Additionally, the required investigation report was not submitted to the state within the mandated five-day period. Interviews with staff confirmed their understanding of misappropriation and the expectation to report such incidents immediately to the administrator. However, the administrator and corporate administrator both confirmed that the reporting timelines outlined in facility policy were not followed in this case. The failure to report the incident promptly and submit the investigation report within the required timeframe constituted a breach of the facility's abuse prevention and reporting policies.
Failure to Timely Investigate and Report Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure that all alleged violations of misappropriation of property were thoroughly investigated and that the results were reported to the administrator and state officials within the required timeframe. Specifically, after a resident reported his debit card missing, the facility did not complete and submit the results of their investigation within 5 days as required by their policy. The initial report of the missing debit card was made to the RN supervisor, who then notified the administrator. The administrator became aware of the missing card and subsequent unauthorized transactions, including purchases and a bus ticket, but did not report the incident to the state within 24 hours or submit the investigation report within 5 days. The resident involved was a male with mild cognitive impairment, primary open angle glaucoma, and hypertension, who required extensive assistance with activities of daily living but had intact cognition according to his BIMS score. The resident reported the missing debit card after last using it at the facility front desk. Unauthorized transactions were discovered, and surveillance footage identified a facility employee making purchases with the card. The police were notified, and the resident's family, physician, and ombudsman were also informed. However, the timeline of reporting and investigation submission did not comply with facility policy or regulatory requirements. Interviews with facility staff, including the administrator, confirmed that the administrator did not consider the incident as misappropriation until after the family had searched for the card, resulting in a delay in reporting. The administrator acknowledged the failure to report the incident to the state within 24 hours and to submit the investigation report within 5 days. The corporate administrator and other staff also confirmed that the required timelines were not met, and the facility's policy on abuse prevention and reporting was not followed in this case.
Failure to Notify Physician and Responsible Party of Significant Weight Loss
Penalty
Summary
The facility failed to immediately consult with the residents' physicians when there was a significant change in their physical status, specifically significant weight loss, for two residents. Resident #17 experienced a significant weight loss from 226.9 lbs in March to 178 lbs in early May, but the physician was not informed until May 6, and the responsible party was not notified until May 7. The responsible party expressed concern about the lack of detailed information and interventions regarding the weight loss. Similarly, Resident #55 experienced a significant weight loss from 204 lbs in December to 164.4 lbs in early May. The physician and responsible party were not notified of this change. Interviews with the ADON and the Regional Nurse Consultant revealed that the ADON was responsible for notifying the physician and responsible party but failed to do so. The facility's policies on weight management and change of condition notification were not followed, as they require timely notification of significant weight changes to the physician and responsible party. The failure to notify could place residents at risk for delayed treatment and diagnosis of new symptoms, potentially leading to serious health consequences.
Failure to Provide Timely Personal Hygiene Care
Penalty
Summary
The facility failed to provide necessary services to maintain good personal hygiene for three residents who were unable to carry out activities of daily living. Resident #536, who required extensive assistance, did not receive timely incontinence care from 6:00 a.m. to 2:20 p.m. on 05/07/24. Despite requesting to be changed at 1:15 p.m., no staff attended to him until 2:20 p.m., leading to concerns about his catheter and a bowel movement that had not been addressed. The delay was attributed to a lack of communication among staff members, as the CNA assigned to him was not informed of his needs until much later in the shift. Resident #4, who also required extensive assistance, did not receive timely incontinence care from 6:00 a.m. to 2:50 p.m. on 05/07/24. Additionally, her hair had not been washed in over a month, which she expressed a desire to have done. The CNA assigned to her confirmed that the resident's hair had not been washed due to the shower bed being too short and the resident's preference for bed baths. The CNA also mentioned being behind schedule due to working the hall alone and dealing with residents with behaviors, which contributed to the delay in providing care. Resident #32, who required maximal assistance with personal hygiene, was observed with long, discolored fingernails that had dark brown residue underneath. The CNA responsible for his care admitted not noticing the condition of his nails that morning and stated she would address it immediately. The ADON confirmed that nail care should be completed as needed and observed daily, emphasizing that long and dirty nails could pose an infection control issue. The facility's policy mandates that residents receive necessary care and services to maintain their highest practicable physical, mental, and social well-being, which was not adhered to in these cases.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure that residents maintained acceptable parameters of nutritional status, leading to significant weight loss for two residents. Resident #17 experienced a weight loss of 44.8 pounds (20%) from 04/05/24 to 04/28/24, and 46 pounds (21%) from 04/05/24 to 05/03/24. The facility did not notify the physician until 05/06/24 and failed to follow the physician's guidance to notify the Dietitian. The Dietitian was only notified after surveyor intervention on 05/07/24. Additionally, the Dietitian did not observe Resident #17 or follow up to ensure the resident was receiving enteral feeding as ordered by the physician. The facility also failed to monitor Resident #17 after a feeding change, resulting in further weight loss. The facility also failed to notify the physician, Dietitian, and responsible party regarding Resident #55's significant weight loss of 34.1 pounds (17%) from 04/05/24 to 05/04/24. Resident #55 was not weighed weekly as per policy for residents dependent on enteral feeding. The facility did not document any nutrition assessment or progress notes for Resident #55 from 04/01/24 to 05/07/24, nor did they notify the physician or responsible party about the significant weight loss. Interviews with staff revealed a lack of awareness and communication regarding the significant weight loss of both residents. The Restorative Aide, who was responsible for weighing residents, was not aware of the weight loss and did not have access to input weights into the electronic record. The ADON, who took over weight management responsibilities, did not notify the Dietitian or physician about the significant weight loss in a timely manner. The newly hired Consultant Dietitian was not informed about the significant weight loss until surveyor intervention and did not observe the residents or verify their enteral feeding. The facility's policy on weight management was not followed, leading to a failure in addressing the residents' nutritional needs.
Failure to Follow Enteral Feeding Orders
Penalty
Summary
The facility failed to ensure enteral feeding physician orders were followed for two residents, leading to significant deficiencies in their nutritional care. For Resident #17, the facility did not verify that adequate nutrition was provided via enteral tube feeding. The resident's enteral feeding pump history revealed a deficit of 600 ml of formula over a 71-hour period, resulting in a significant shortfall in calories and protein. Additionally, the facility did not notify the Consultant Dietitian of Resident #17's significant weight loss, which was observed to be 49.4 lbs over a short period. The charge nurse was unaware of the need to reprogram the tube feeding pump every 24 hours, contributing to the resident not receiving the prescribed nutrition. For Resident #55, the facility also failed to administer enteral feedings as ordered by the physician. The enteral feeding pump history showed a deficit of 570 ml of formula over a 72-hour period, leading to a shortfall in calories and protein. Similar to Resident #17, the facility did not notify the Consultant Dietitian of Resident #55's significant weight loss. The charge nurse acknowledged the importance of clearing the pump every 24 hours but did not ensure this was done, resulting in the resident not receiving the prescribed nutrition. Interviews with staff, including the Consultant Dietitian and Regional Nurse Consultant, revealed a lack of adherence to protocols for monitoring and administering enteral feedings. The facility's policy on tube feeding was not followed, leading to residents not receiving the necessary nutrition as per physician orders. This failure placed residents at risk for nutritional deficits, weight loss, and overall decline in quality of care.
Failure to Maintain Sterile Technique During Tracheostomy Care
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care consistent with professional standards of practice. For Resident #20, the Respiratory Therapist (RT) did not perform hand hygiene during tracheostomy care and failed to maintain sterile technique during the suctioning process. The RT repeatedly changed gloves without performing hand hygiene and used non-sterile techniques, which could introduce infection into the resident's lungs. The RT acknowledged the mistakes and attributed them to nervousness and a misunderstanding of the tracheal suctioning kit contents. For Resident #76, the Licensed Vocational Nurse (LVN) also failed to perform hand hygiene during tracheostomy care and did not change gloves before handling a clean trach drainage sponge. The LVN admitted that trach care was supposed to be a sterile procedure to reduce the risk of infection and pneumonia but did not follow the proper protocol due to nervousness. Both the RT and LVN had been previously validated as competent in tracheostomy care but did not adhere to the facility's policy and procedures during the observed care. The facility's policy on tracheostomy care and the competency validation checklist clearly outlined the steps for maintaining sterility and performing hand hygiene between glove changes. However, these protocols were not followed during the care of Residents #20 and #76, leading to potential risks for respiratory infections. The Regional Director of Respiratory Therapy confirmed the importance of sterile procedures and hand hygiene to prevent lung infections and stated that retraining would be conducted immediately.
Failure to Adhere to Hair Restraint Policy and Freezer Maintenance
Penalty
Summary
The facility failed to ensure that Dietary Aide ZB wore effective hair restraints while cleaning dishes and using the dish machine. Observations revealed that ZB did not cover the back of his hair and facial hair adequately. Despite being aware of the requirement, ZB did not comply with the hair restraint policy. The facility's dietary staff in-service records indicated that ZB had been previously trained on the importance of wearing hair nets and beard guards, but this training was not adhered to during the observed incident. Additionally, the facility failed to maintain one of its three freezers, which had an ice accumulation of about one inch at the bottom. The Dietary Supervisor acknowledged the issue and explained that a hose had slipped off, causing water to drip and freeze at the bottom of the freezer. The Maintenance Supervisor confirmed that ice accumulation had occurred before and required periodic cleaning. The facility did not have a specific policy regarding freezer maintenance, which contributed to the oversight.
Infection Control Failures During Incontinence Care
Penalty
Summary
The facility failed to maintain an Infection Prevention and Control Program, leading to multiple instances of improper hand hygiene and cross-contamination during incontinence care for three residents. For Resident #536, CNAs K and G did not perform hand hygiene after changing gloves and placed a contaminated catheter bag on the bed, risking cross-contamination. The resident had a history of drainage from his catheter and a wound on his bottom, which was not properly addressed during care. Additionally, the resident reported not being changed for an extended period, further increasing the risk of infection. For Resident #38, CNA H did not perform hand hygiene after removing gloves and before re-gloving, and failed to provide proper catheter care during incontinence care. The resident, who was severely cognitively impaired and had multiple medical conditions including a stage 4 pressure ulcer and a foley catheter, was at increased risk of infection due to the improper care. CNA H acknowledged the failure to perform necessary hygiene steps and catheter care, which could lead to urinary tract infections and further skin breakdown. For Resident #32, CNA U did not change gloves or perform hand hygiene between cleaning soiled areas and handling clean items during incontinence care. The resident, who was severely cognitively impaired and always incontinent of bowel and bladder, was exposed to potential infections due to the improper care. Both CNAs involved in the care of Resident #32 failed to follow proper hand hygiene protocols, increasing the risk of cross-contamination and infection for the resident.
Deficiencies in Laundry Room Maintenance and Sanitation
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in the laundry room. Observations revealed significant lint accumulation in the lint traps and collection areas of the dryers, with layers of lint up to 2 inches thick and clumps on the floor. The Housekeeping Supervisor admitted to not knowing if there was a lint trap cleaning log and acknowledged that the lint traps should be cleaned after each use and at the beginning or end of every shift. Despite posted instructions for cleaning lint traps every 2 hours, the buildup indicated that this was not being followed. The Laundry Supervisor confirmed the unacceptable amount of lint buildup and recognized the sanitary and fire hazards posed by this negligence. An in-service had been started with all laundry staff to address the issue. Additionally, the facility failed to maintain a sanitary handwashing area in the laundry room and the laundry employee restroom. The handwashing sink in the laundry room had a bag of handwashing soap placed next to the faucet handle, which was not compatible with the soap dispenser. The restroom for laundry employees had no soap in the dispenser, which was missing its front panel, and an unlabeled bottle with a pink liquid identified as hand sanitizer. The Housekeeping Supervisor and Maintenance Supervisor both acknowledged the issues and stated that staff had not reported the problems. The facility's policies required daily checks of machines and appliances and proper handwashing before and after laundry tasks, which were not being adhered to.
Failure to Ensure Call Light Accessibility for Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was placed within their reach, which is a violation of resident rights and safety protocols. The resident, who had a history of traumatic brain injury, Methicillin Susceptible Staphylococcus Aureus infection, and anemia, was observed multiple times with the call light coiled on the floor and out of reach. Despite the care plan indicating that the call light should be within reach to prevent falls, staff did not consistently ensure this was the case. The resident and their family member, who only spoke Spanish, confirmed that the call light was always on the floor, and the family member had to pick it up to use it. The resident stated that he would have to bend over or walk to get a nurse, which was risky given his unsteady condition. Staff interviews revealed that the call light should always be within reach, especially for residents at risk of falls. However, observations showed that this protocol was not followed. The facility's policies on call light placement and fall prevention were reviewed, and both emphasized the importance of keeping the call light within reach to prevent falls and ensure resident safety. Despite these policies, the call light was repeatedly found out of reach, posing a risk to the resident's safety and well-being.
Failure to Ensure Resident Wore Helmet as Ordered
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents. Specifically, the facility did not ensure that a resident with a traumatic brain injury wore a helmet as ordered by the physician to prevent possible injury when ambulating. The resident was observed multiple times without the helmet, despite having a care plan and physician orders indicating the necessity of wearing the helmet at all times when out of bed. Interviews with staff revealed a lack of awareness and enforcement of the helmet requirement, with some staff members never having seen the resident wear the helmet and others relying on verbal communication rather than checking the resident's care plan or Kardex for updated information. The resident, who had a history of traumatic brain injury and a craniotomy, was observed walking around the facility without the helmet on several occasions. The resident and a family member, who only spoke Spanish, indicated that the resident did not wear the helmet often and experienced headaches when wearing it for extended periods. Despite the resident's high risk of falls and potential for serious injury, the staff did not consistently ensure the resident wore the helmet as required. The resident's call light was also found coiled on the floor, out of reach, further compromising the resident's safety. Interviews with various staff members, including a Licensed Vocational Nurse (LVN), a Certified Nursing Assistant (CNA), an Occupational Therapist, and the Assistant Director of Nursing (ADON), highlighted a lack of consistent communication and adherence to the resident's care plan. The facility's policies on resident rights and fall prevention were not adequately followed, leading to the deficiency. The Regional Nurse Consultant confirmed that the resident's care plan and physician orders required the helmet to be worn when out of bed, and the failure to comply with these orders could result in serious injury due to the resident's condition.
Failure to Provide Proper Catheter and Perineal Care
Penalty
Summary
The facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Specifically, a CNA did not provide proper catheter and perineal care for a severely cognitively impaired male resident with multiple medical conditions, including a stage 4 pressure ulcer, a foley catheter, and a colostomy. The resident's care plan required foley catheter care every shift and as needed, but this was not adhered to during an observed care session on 05/08/24. During the observation, the CNA did not perform hand hygiene before or after providing care, and failed to clean the resident's penis, scrotum, and buttocks properly. The CNA used the same wipe for different areas and did not follow the correct procedure for catheter care. Additionally, the CNA did not change gloves or perform hand hygiene after handling soiled materials, which could lead to contamination and increased risk of infection. Interviews with the CNA and the Regional Nurse Consultant confirmed that the proper procedures for catheter and perineal care were not followed. The facility's policies on catheter care and perineal care, which include specific steps for cleaning and hand hygiene, were not adhered to. This failure in care could place residents at risk for urinary tract infections, skin breakdown, and overall poor hygiene.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 1,348 citations issued within 25 miles in the last 12 months — including the 56 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Dallas
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brentwood Place Three | 0 mi | ★★★★★ | 14 | 1 |
| South Dallas Nursing & Rehabilitation | 0 mi | ★★★★★ | 38 | 0 |
| Brentwood Place One | 0 mi | ★★★★★ | 3 | 0 |
| Brentwood Place Two | 0 mi | ★★★★★ | 10 | 0 |
| Carrollton Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.