Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 One during CMS and state inspections, most recent first.
Failure to Apply Ordered Splints and AFOs: A resident with CVA, hemiplegia, and limited ROM had physician-ordered hand splints and bilateral AFOs, but observations showed the devices were often not in use and were left in the room or wheelchair. Staff reported confusion after the restorative aide left, and interviews showed CNAs and nursing staff were not consistently applying the splints or documenting when they were placed, removed, or refused.
A medication cart on the Hall 400/500 unit contained an OTC Aspirin CR 81 mg bottle with a faded, nonvisible expiration date. An MA used that same bottle to give the morning dose to residents on the unit, including 10 residents receiving daily aspirin. The DON stated charge nurses/MAs were responsible for checking carts for expired meds, and the facility policy required unlabeled or expired medications to be immediately removed.
A resident with ESRD, dialysis dependence, and severe cognitive impairment had a permanent central venous dialysis catheter, but the care plan and physician orders did not reflect EBP. During observation, an MA entered the room without gown use or EBP signage in place, checked BP, and examined the resident’s upper extremities and chest catheter site. Staff interviews confirmed the resident was supposed to be on EBP and that the change in dialysis access had not been updated in the record.
A resident with severe cognitive impairment and total dependence on staff for ADLs was found with a call light cord entangled and the call button on the floor, out of reach. Staff and policy confirmed the call light should always be accessible, but this was not ensured, resulting in a deficiency in accommodating the resident's needs.
Two residents with severe cognitive impairment and dependence on staff for ADLs were found with long, dirty, and untrimmed fingernails, despite facility policies and staff awareness that nail care should be provided regularly. Staff interviews confirmed that both CNAs and nurses were responsible for nail care, but the necessary grooming was not performed as required.
The facility failed to maintain comfortable room temperatures for residents, with several rooms recorded below the threshold of 71 degrees. A resident with moderate cognitive impairment and others with various health conditions were found in cold rooms, despite complaints. The rehab/therapy room was also cold during a group interview. The Maintenance Director noted that window units were on backorder, delaying resolution.
A resident with an indwelling catheter was not provided appropriate care during transfers, as staff failed to maintain the catheter drainage bag below the bladder. This occurred on two occasions, where the bag was placed on the resident's chest, lap, or bed, contrary to the care plan and facility policy. Staff interviews revealed a lack of training on handling the catheter bag during mechanical lift transfers.
The facility failed to ensure proper medication management and insulin administration. A controlled medication was found with a broken blister seal, posing a risk of drug diversion. Additionally, an LVN administered insulin without priming the pen, contrary to manufacturer guidelines, risking inaccurate dosing for a resident with diabetes. These deficiencies highlight lapses in adherence to pharmaceutical service protocols.
The facility failed to provide food that conserved nutritive value for residents on pureed diets. Cook A did not follow the standardized recipe for pureed spaghetti, using water instead of broth or milk to adjust consistency. This deviation was observed during a lunch service, and both the Dietary Manager and Dietitian emphasized the importance of following recipes to maintain food quality. The facility's policy highlighted the need for specified ingredients to ensure nutritional content.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper glove use during incontinence care, personal items in the clean linen closet, and failure to clean a soiled mattress before placing new linens. These actions increased the risk of cross-contamination and infection spread.
The facility failed to maintain proper nail hygiene for two residents, one with severe cognitive impairment and another with a colostomy, both requiring assistance with personal hygiene. Observations revealed dirty and untrimmed nails, posing infection risks. Staff interviews confirmed responsibility for nail care, yet the facility's policy was not followed.
The facility failed to maintain a comfortable environment on the 100-hall due to a malfunctioning heating unit, resulting in temperatures below the required range. A resident reported feeling cold, and the Maintenance Supervisor was unaware of the minimum temperature requirement. An attempt to increase the temperature activated the air conditioner, further lowering the temperature due to a faulty pressure switch.
The facility failed to ensure food safety by not checking breakfast food temperatures before serving. The cook, in a rush, forgot to verify temperatures, posing a risk of food-borne illness. The Dietary Manager and Dietitian/Administrator confirmed the importance of this procedure, as outlined in the facility's policy.
Failure to Apply Ordered Splints and AFOs
Penalty
Summary
The facility failed to ensure a resident with limited ROM received ordered splints and braces to support ROM and mobility. Resident #4 was admitted with diagnoses including diabetes, CVA, and hemiplegia, and his MDS reflected functional limitation in ROM in both upper extremities. His physician orders included a resting hand splint for the left hand, a C-grip for the right hand, and bilateral AFOs for both feet, with care plan and CNA task list instructions for daily or tolerated use and passive ROM services. During observations on 04/07/2026 and 04/08/2026, the resident was seen in bed without splints in use on his hands or feet. The hand splints were observed sitting on his chest of drawers, and the AFOs were observed sitting on his wheelchair. The resident stated staff did not put the splints on every day and said no one had put them on that morning. On 04/08/2026, CNA B placed the hand splints on both hands after the resident agreed, but did not offer to put on the ankle-foot orthotics. Interviews with the DOR, CNA B, the MDS nurse, LVN A, the COTA, and the DON showed the facility had recently lost its restorative aide and had trained CNAs and nursing staff to handle splint placement. Staff stated the CNAs were responsible for putting on the splints and the nurses were responsible for skin checks after removal. Staff also stated they had not been documenting when splints were placed, removed, or refused, and the DON stated communication about expectations had been poor. The facility policy stated RNA staff may apply splints under nursing supervision and that the RNA responsible for splint application will document and initial each time the splint is applied and removed.
Expired Aspirin Bottle Kept in Medication Cart
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with currently accepted professional principles for 1 of 4 medication carts observed. During observation and interview on 04/07/26 at 10:42 AM, the Hall 400/500 medication cart contained an over-the-counter bottle of Aspirin CR 81 mg oral tablets with a faded and nonvisible expiration date. MA C stated he used that same bottle and administered the morning dose of Aspirin 81 mg CR to residents in Hall 400/500. He also stated it was his responsibility to check the medication cart daily at the start of the shift for expired medications and remove them from resident stock. Record review showed 40 residents on the 400/500 halls, with 10 residents receiving Aspirin 81 mg CR daily in the morning, and all 10 were given their morning dose by MA C on the morning of 04/07/26. During interview on 04/09/26 at 11:50 AM, the DON stated charge nurses and MAs were supposed to check medication carts for expired medications and that pharmacists checked the carts monthly. The DON stated the aspirin bottle with the nonvisible expiration date should have been removed from resident medication stock and replaced with an appropriate one. The facility policy titled Medication Storage in the Facility, revised January 2026, stated that unlabeled, expired, or discontinued medications are to be immediately removed.
Failure to Use EBP for Resident With Dialysis Catheter
Penalty
Summary
The facility failed to maintain an infection prevention and control program for a resident with a permanent dialysis catheter and an undated dressing who was supposed to be on enhanced barrier precautions (EBP). The resident’s quarterly MDS reflected diagnoses including renal failure/ESRD, dependence on dialysis, hypertension, and non-Alzheimer’s dementia, with a BIMS score of 05 indicating severe cognitive impairment. The care plan did not indicate the permanent central venous catheter for dialysis treatment, and the physician orders reviewed did not include an order for EBP or the dialysis catheter. During observation, a staff member entered the resident’s room to check blood pressure without gown use, despite the resident not having any EBP signage or PPE supplies posted in the room. The staff member sanitized hands, put on gloves, checked the blood pressure, pulled up the resident’s sleeves to look for dialysis access in both upper extremities, and unbuttoned the resident’s shirt to look at the permanent catheter in the left upper chest. The staff member then removed gloves, sanitized hands, and left the room. In interview, the staff member stated he did not know the resident was supposed to be on EBP. The ADON stated residents with medical devices were supposed to be on EBP, that the resident should have been on EBP with the permanent central venous catheter, and that the charge nurse was responsible for updating the record after the catheter change. The DON stated the resident should have been in EBP related to the catheter and that the failure to do so was due to the charge nurses forgetting or failing to notice the change from arteriovenous access to a permanent central venous catheter.
Failure to Ensure Accessible Call Light System for Dependent Resident
Penalty
Summary
The facility failed to ensure that a resident with severe cognitive impairment and total dependence on staff for activities of daily living had access to a working communication system. During an observation, the resident's call light cord was found entangled around the head of the bed frame, with the call button on the floor and out of the resident's reach while he was asleep in bed. The resident's care plan specifically required that the call light be within reach and that staff anticipate and meet his needs due to his high risk for falls and inability to communicate effectively. Interviews with facility staff, including a CNA, the DON, and the Administrator, confirmed that the call light should always be within the resident's reach and that it is the responsibility of all staff to ensure this before leaving the room. The facility's policy also required call cords to be placed within reach in resident rooms. The failure to provide a readily accessible call light system for this resident constituted a deficiency in reasonably accommodating the resident's needs and preferences as required.
Failure to Provide Adequate Nail Care for Dependent Residents
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining good grooming and personal hygiene for two residents who were dependent on staff for care. Both residents had severe cognitive impairment and required maximum or extensive assistance with personal hygiene, as documented in their care plans and MDS assessments. On the day of observation, both residents were found with fingernails that were long, jagged, discolored, and had visible debris underneath. One resident expressed a desire to have her nails cleaned and trimmed, while the other was unable to participate in an interview but was observed looking at her fingernails. Interviews with staff, including CNAs, an RN, and the DON, confirmed that responsibility for nail care was shared between CNAs and nurses, with nurses specifically responsible for residents with diabetes. Staff acknowledged that nail care should be performed on shower days and as needed, and that dirty, untrimmed nails could pose an infection risk. Facility policy required nail care to be provided to keep nails clean and trimmed, with specific instructions for residents with certain medical conditions. Despite these policies and staff awareness, the necessary nail care was not provided to the two residents on the day of observation.
Facility Fails to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment for its residents, specifically in terms of room temperature. On multiple occasions, residents were found in rooms with temperatures below the comfortable threshold of 71 degrees. Resident #88, a female with moderate cognitive impairment and various health conditions, was observed in a room with temperatures ranging from 67 to 71 degrees. Despite being covered with blankets, she expressed feeling weak and was unable to communicate effectively about her comfort level. Resident #44, a male with no cognitive impairment but with several health conditions, was found in a room with temperatures between 67 and 69.4 degrees. He was covered with multiple blankets and expressed dissatisfaction with the cold temperature, stating that he had complained multiple times without any resolution. Similarly, Resident #92, a male with no cognitive impairment but with mobility issues, reported that his room had been cold since the previous month, and his complaints had not been addressed. Additionally, during a group interview in the rehab/therapy room, residents reported the room being cold, with temperatures recorded at 66.9 and 66.8 degrees. The Maintenance Director acknowledged the temperature issues and mentioned that window units were on backorder, contributing to the delay in resolving the problem. The facility's failure to address these temperature issues promptly and effectively resulted in an uncomfortable and potentially unsafe environment for the residents.
Improper Catheter Care During Resident Transfers
Penalty
Summary
The facility failed to provide appropriate care for a resident with an indwelling catheter, leading to a deficiency in maintaining the catheter drainage bag below the bladder during transfers. On two separate occasions, staff members were observed mishandling the urinary drainage bag while transferring the resident using a mechanical lift. During these transfers, the drainage bag was placed on the resident's chest, lap, or bed, rather than being kept below the bladder level, which is necessary to ensure proper drainage and prevent urine backflow. The resident involved was a male with a neurogenic bladder, diabetes, and heart failure, who required substantial assistance with activities of daily living and was dependent on two-person assistance for transfers. The resident's care plan specifically indicated the need to position the catheter bag below the bladder to prevent urinary tract infections. Despite this, staff members, including a CNA and a Resident Assistant, failed to adhere to this requirement during the observed transfers. Interviews with the staff revealed a lack of training on how to handle the catheter bag during mechanical lift transfers. Although the staff had been taught to keep the catheter bag below the bladder, they were unsure of the correct procedure during transfers, leading to improper handling of the drainage bag. The facility's policy also emphasized the importance of positioning the catheter bag below the bladder, but this was not followed during the incidents observed.
Deficiencies in Medication Management and Insulin Administration
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in deficiencies related to medication management and administration. During an observation of a medication cart, it was found that a controlled medication, hydrocodone acetaminophen, had a broken blister seal with the pill still inside and taped over. The medication aide responsible for the cart was unaware of when the seal was broken and did not check the blister packs during the narcotics count at shift change. This oversight posed a risk of drug diversion and infection control issues, as confirmed by the Director of Nursing (DON), who stated that broken seals should lead to the medication being discarded. Additionally, the facility failed to ensure proper administration of insulin for a resident with Type 2 diabetes. An LVN administered Novolog insulin without priming the pen, contrary to the manufacturer's instructions. The LVN was unaware of the need to prime the pen before each dose, which could result in the resident not receiving the full dosage of insulin. The DON was also initially unaware of the manufacturer's guidelines regarding insulin pen priming, indicating a lack of awareness and training on proper medication administration procedures. The facility's policies on medication storage and insulin pen administration were not adhered to, contributing to these deficiencies. The policy required that medications in compromised containers be immediately removed and disposed of, while the insulin pen administration policy emphasized following manufacturer guidelines to ensure accurate dosing. These lapses in following established protocols and guidelines led to the identified deficiencies in pharmaceutical services.
Failure to Follow Standardized Recipe for Pureed Diets
Penalty
Summary
The facility failed to provide food that conserved nutritive value, flavor, and appearance for residents on pureed diets. Specifically, Cook A did not follow the standardized recipe for pureed spaghetti during a lunch service. Instead of using broth or milk as specified in the recipe, Cook A added water to the spaghetti mixture to adjust its consistency. This deviation from the recipe was observed during an interview and observation session, where Cook A admitted to not consulting the standardized recipe binder and acknowledged the risk of decreasing the nutritional content of the meal by not following the recipe. The Dietary Manager and the Dietitian both expressed that their expectation was for all cooks to adhere to standardized recipes to ensure food quality and nutritional content. The Dietary Manager had previously provided in-service training on following recipes, and both she and the Dietitian were responsible for conducting such training. The facility's policy on standardized recipes emphasized the importance of using specified ingredients to maintain the quality of food served. The failure to follow the recipe could potentially place residents at risk of weight loss, altered nutritional status, and diminished quality of life.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during a survey. One incident involved a CNA providing incontinence care to a resident without changing gloves and performing hand hygiene appropriately. The CNA, after removing a soiled brief and cleaning the resident's anal area, used the same soiled gloves to place a clean draw sheet and brief under the resident. This action was contrary to the facility's policy, which requires changing gloves and washing hands when moving from dirty to clean tasks. Another deficiency was observed in the clean linen closet, where a personal handbag was placed above clean linens on a cart. This was against the facility's policy, which mandates that clean linen closets and carts should only contain clean linens to prevent cross-contamination. The presence of personal items in the clean linen area posed a risk of infection control lapses, as acknowledged by the staff involved. Additionally, a resident's mattress was not cleaned after being soiled with bowel movement before a clean fitted sheet was placed on it. The CNA involved failed to disinfect the mattress, which was contaminated from a colostomy bag leak, before putting on new linens. This oversight was recognized by the CNA, who admitted that the failure to clean the mattress increased the risk of contamination and infection spread.
Failure to Maintain Resident Nail Hygiene
Penalty
Summary
The facility failed to provide necessary services for two residents who were unable to carry out activities of daily living, specifically in maintaining good grooming and personal hygiene. Resident #7, a male with severe cognitive impairment and requiring moderate assistance for personal hygiene, was observed with dirty and jagged fingernails on two occasions. Interviews with staff revealed that both nurses and CNAs were responsible for nail care, and it was acknowledged that dirty, jagged nails could lead to infection risks. Despite the resident's compliance with care, the staff did not ensure his nails were cleaned and trimmed as required. Similarly, Resident #82, a female with a BIMS score indicating cognitive intactness and requiring moderate assistance with personal hygiene, was found with long, discolored nails containing residue. The resident attributed the residue to her attempts to secure her colostomy bag. Staff interviews confirmed that both CNAs and nurses were responsible for nail care, and the risk of infection was noted. The facility's policy stated that nail care should be provided to keep nails clean and trimmed, yet this was not adhered to, resulting in the deficiency.
Failure to Maintain Proper Temperature in Facility
Penalty
Summary
The facility failed to maintain a comfortable and homelike environment for residents on the 100-hall, as the heating unit was not producing hot air, resulting in temperatures below the required range of 71 to 81 degrees Fahrenheit. Observations revealed that the thermostat on the 100-hall read 68 degrees Fahrenheit, and a resident reported feeling cold during the nights, despite being offered additional blankets. The Maintenance Supervisor was unaware that the minimum temperature requirement was 71 degrees Fahrenheit and believed that maintaining a temperature of 70 degrees was compliant with regulations. The issue was further compounded when an attempt to increase the temperature resulted in the air conditioner turning on, making the hall colder. This was due to a malfunctioning pressure switch on the roof, which caused the air conditioner to activate when the heat was turned on. The facility's maintenance logs did not document any concerns regarding the heating unit, and no grievances were filed about the temperature. The facility did not have a specific policy related to temperature maintenance, as it followed the Texas Administrative Code directly.
Failure to Check Food Temperatures Before Serving
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not ensuring that the morning cook checked the temperatures of breakfast food before serving it to residents. During an observation, it was noted that the cook began plating hot cereal for two residents without verifying the food temperatures. Upon being reminded by the Dietary Manager, the cook acknowledged forgetting to check the temperatures due to being rushed. The cook then proceeded to check the temperatures of some items, such as scrambled eggs and hot cereal, but did not check others, including white gravy, biscuits, sausage patty, bacon, mechanical/pureed sausage, pureed eggs, and both boiled and fried eggs. Interviews with the cook, Dietary Manager, and Dietitian/Administrator confirmed that the cook was responsible for checking and documenting food temperatures to ensure they were not in the danger zone, which could lead to food-borne illnesses. The facility's policy, revised in December 2020, outlined the procedure for checking food temperatures, including sanitizing the thermometer, inserting it into the center of the product, and recording the reading. However, the cook's failure to follow this procedure on the observed day posed a risk to residents consuming potentially unsafe food.
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 1,346 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 Two | 0 mi | ★★★★★ | 10 | 0 |
| Brentwood Place Four | 0 mi | ★★★★★ | 1 | 0 |
| Carrollton Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 10 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Brentwood Place One.
100% money-back within 48 hours.
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.