Below average — CMS composite of the measures below.
The next survey window likely opens around February 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 Three during CMS and state inspections, most recent first.
Resident Council Meeting Not Kept Private: A resident council meeting was held in the dining room, but dietary, nursing, and activity staff repeatedly entered and crossed through the area, handled meal carts, and made noise while residents were meeting. Residents said the interruptions were common and the meeting was not very private, and facility leadership acknowledged staff should only be present when invited by the Resident Council President.
Improper Food Storage and Cross-Contamination in Kitchen: Surveyors found food items in the stand-by freezer and refrigerator that were not properly labeled, dated, or sealed, including a covered package of soup and opened cheese and eggs. In a separate kitchen observation, a cook used the same gloves to handle bread, cheese, and cooked chicken patties while making sandwiches, and the Corporate RD stopped the food from being served due to cross contamination. The facility policy required proper glove use and clear labeling and dating of food items.
A CNA entered 4 of 10 rooms on hall 300 without knocking or introducing herself before entering during rounds prior to shift change. Staff interviews confirmed that CNAs were expected to knock, wait for a response, announce themselves, and explain why they were entering because the room was the resident’s home and privacy had to be respected. Two residents said it bothered them when staff entered without knocking, and the facility’s Privacy and Dignity policy stated that resident care should promote privacy, dignity, and respect.
A resident’s pharmacy receipt containing name, DOB, and morphine information was found on top of an unattended treatment cart in a hallway, leaving confidential PHI visible in an open area. An LVN, the treatment nurse, and the DON all acknowledged that resident information should be kept private and secured, and the DON stated she did not know how the receipt was left there.
A resident with impaired mobility and a fall risk was observed alone in a staff conference room using a microwave to warm coffee while sitting on his walker. He then left with steaming coffee in one hand and his walker in the other. Staff later stated residents were not allowed to use the microwave because of burn and accident risk, and the resident's care plan included 1-person staff assistance.
Unsecured Wound Cleanser on Shared Treatment Cart: A treatment cart in hall 100 was observed locked, but a half-empty bottle of wound cleanser was exposed on the side of the cart while residents were present. LVN A said the cart was shared among nurses and the treatment nurse said biologicals should be stored in locked compartments. The DON stated carts should stay locked and no drugs or biologicals should be out in the open; the facility policy also required carts to remain locked and secured.
A resident with a history of stroke, psychiatric illness, dementia, and documented exit‑seeking behavior repeatedly attempted and actually left the facility without proper authorization, including one episode where he climbed through a fence, walked several blocks away, called 911, and was transported to a hospital without staff knowing when he had left. Elopement risk assessments were inconsistently and incompletely documented, with earlier assessments identifying moderate risk and later ones marked as no risk despite triggered questions not being completed and clear evidence of wandering and elopement. The care plan did not incorporate multiple prior elopement events, and the dementia diagnosis was discontinued based primarily on a high BIMS score, while the MD was not informed of the resident’s exit‑seeking behaviors or elopements. Staff interviews showed inconsistent awareness and recall of the resident’s elopements and exit‑seeking, and family reported multiple prior episodes of the resident leaving through the fence or gate and contacting them or being found by police or hospitals before the facility, leading surveyors to cite a failure to provide adequate supervision and prevent elopement.
A resident with a history of cerebral infarction, psychiatric illness, cognitive impairment, and documented elopement risk repeatedly attempted to leave the facility, including episodes involving security, police, and transfer to a psychiatric hospital. Care plans and progress notes identified elopement risk, impaired cognition, and use of Donepezil, while family reported a prior dementia diagnosis and described the resident leaving facilities independently and contacting them after leaving. However, elopement risk assessments were inconsistently completed and at times classified the resident as no risk, and documentation characterized him as able to make his own decisions. The RNC removed the dementia diagnosis after noting a high BIMS score and reported that the MD approved discontinuation, but the MD later stated he had not been informed of the resident’s exit-seeking or elopement behaviors and saw no such documentation in his or the NP’s notes. Facility policies required prompt physician notification of changes in condition and elopement events, yet the physician was not notified of these behaviors when the dementia diagnosis was discontinued, resulting in the cited deficiency.
A resident with cerebral infarction, psychiatric diagnoses, and documented cognitive impairment was identified in the care plan and elopement evaluations as at risk for elopement, with multiple documented episodes of exit-seeking and actual elopements that involved police and hospital admissions. Despite progress notes describing two elopements on one date and another incident where the resident independently checked into a local hospital after leaving the facility, these events were not incorporated into the updated care plan, and elopement risk assessments were inconsistently and incompletely documented. Staff interviews confirmed that elopements were considered reportable and that the ADM was responsible for notifying the State, but the ADM disputed that elopements occurred or that the resident was an elopement risk and did not report these incidents within the 24-hour timeframe required by the facility’s abuse/neglect reporting policy and regulatory standards.
A resident with a history of cerebral infarction, psychiatric conditions, and documented dementia was care planned for impaired cognition, dementia medication (Donepezil), and elopement risk, but the facility failed to keep the care plan and elopement risk assessments accurate and up to date after multiple exit-seeking and elopement events. The RNC removed dementia as a primary diagnosis from the record based on a high BIMS score without documenting justification, while the MD, unaware of the resident’s elopement behaviors, approved discontinuation of the diagnosis even though the resident remained on dementia medication. Subsequent care plan revisions emphasized the resident’s autonomy and decision-making ability and described him as a potential safety risk when leaving, but did not incorporate his prior elopement attempts and actual elopements, and elopement risk evaluations were incompletely and inconsistently documented, preventing proper risk classification.
A resident with a history of stroke, psychiatric illness, and documented dementia had conflicting information in the medical record, including a physician‑signed dementia attestation, care plans and MAR entries showing ongoing Donepezil use for dementia, and psychiatric notes describing cognitive impairment, while the RNC later struck out the dementia diagnosis from the diagnoses list based on a high BIMS score without documenting the MD conversation or rationale. At the same time, progress notes and staff interviews described repeated exit‑seeking and elopement episodes requiring 1:1 monitoring and police involvement, but elopement risk evaluations were incompletely filled out and locked as "No Risk," and the care plan revision did not capture multiple elopement events. These inconsistencies violated the facility’s own medical record policy requiring accurate, complete documentation that supports diagnoses, justifies treatment, and reflects assessments and physician notifications.
A resident with a terminal illness was found to have a nasal spray medication unsecured on their bedside table, with no physician order or assessment for self-administration. Facility staff confirmed that medications should not be stored in resident rooms without proper authorization, and the medication was not detected during routine rounds, contrary to facility policy.
A resident who required assistance with personal hygiene was found with long, chipped, discolored fingernails containing residue, despite facility protocols assigning nail care responsibilities to CNAs and nurses. Staff interviews confirmed the need for nail care and the expectation for regular observation and maintenance, but the resident's nails were not properly cleaned or trimmed.
A CNA in an LTC facility failed to perform hand hygiene between serving meals to residents, despite having received training and being provided with hand sanitizer. This oversight involved interactions with multiple residents, some with cognitive impairments and various medical conditions, increasing the risk of cross-contamination and infection. The CNA acknowledged the lapse, citing time constraints as a reason for not following the established hand hygiene protocols.
A resident with a history of mental health issues was verbally abused by a staff member, who called him 'trash' and used profanity. The incident was confirmed by witness statements and the staff member admitted to the behavior, citing provocation. The facility's policy prohibits such mistreatment, but the incident occurred, indicating a failure to adhere to standards for resident treatment.
The facility failed to ensure accurate MDS assessments for two residents, leading to omissions in critical sections such as BIMS, Mood, Behaviors, and Pain. One resident's assessments did not reflect his medical orders for pain management, while another's assessments omitted her medical diagnoses and treatments, including a Central PICC line catheter and oxygen therapy. Interviews with staff revealed a lack of accountability in ensuring assessment accuracy, which could impact resident care.
Resident Council Meeting Not Kept Private
Penalty
Summary
The facility failed to provide the Resident Council group a private space for its monthly meeting and failed to keep staff out of the meeting area while the resident council meeting was in progress. The meeting was held in the dining room on 03/17/26 from 2:00 PM to 3:05 PM, with eighteen residents gathered initially and fourteen active participants remaining later in the meeting. Although signs were posted on the outside of the double doors instructing staff to stay out because a resident meeting was being held, the dining room remained an open space with kitchen entrances and a glass door to an outdoor patio area along the back wall. During the meeting, staff repeatedly entered the dining room and moved through the area where residents were meeting. Dietary staff exited the kitchen to handle meal carts and trays, a staff member or vendor entered through the double doors and exited through the glass door, and a meal cart was pushed into the room making a loud rumbling sound before residents told the staff member to turn around and leave. Additional interruptions included a dietary staff member walking through the room and exiting, another dietary staff member crossing between the tables where residents were seated, the Activity Director entering and walking past the participants, and a nursing staff member entering with a pitcher and noisily banging ice in the ice machine while talking and laughing with dietary staff. Residents attending the meeting stated that interruptions were common and that the meeting was not very private. One resident reported staff looked through the small windows in the double doors and that, when the surveyor was not present, staff entered whenever they pleased. Residents also stated that staff had private morning meetings and residents should receive the same courtesy. Interviews with the Activity Director, Administrator, DON, and Dietary Manager confirmed they were aware of the issue, understood resident council meetings were supposed to be private, and acknowledged staff should only be in the meeting when invited by the Resident Council President. The facility policies reviewed stated that the facility must provide a resident council with a private space to meet and that residents have a right to privacy and to participate in resident and family group meetings without interference.
Improper Food Storage and Cross-Contamination in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in its only kitchen reviewed for food safety. During an observation of the stand-by freezer, surveyors found a package of food with the name covered and dated 4/11/26; the Dietary Manager later identified the item as minestrone soup and stated the date was supposed to read 03/11/26. In the stand-by refrigerator, surveyors observed a used bag of shredded cheese with no label or date and a used bag of hard-boiled eggs dated 03/16/26 with no use-by date. The Dietary Manager stated staff were expected to date food items when they came off the delivery truck and to add opened-on and use-by dates after opening. During a later kitchen observation, [NAME] E was seen using the same pair of gloves to handle slices of bread, slices of cheese, and cooked chicken patties while making three sandwiches, and then proceeded to serve food on the steam tray table using serving utensils. The Corporate RD intervened and stopped the sandwiches from being served, stating the issue was cross contamination. The Corporate RD also stated the cook was touching everything with the same gloves and that this could be a risk to residents with allergies. The facility policy required proper glove usage during meal preparation and serving and required food items to be clearly labeled and dated upon delivery, when opened, and with an expiration or discard date.
Failure to Knock and Announce Before Entering Resident Rooms
Penalty
Summary
The facility failed to respect and value residents’ dignified existence on hall 300 when a CNA entered resident rooms without knocking or introducing herself before entering. During an observation on 03/18/2026 at 5:41 a.m., CNA C and CNA D were doing rounds prior to shift change, and CNA C was seen walking into 4 of 10 resident rooms on hall 300 without knocking or introducing herself. During an interview shortly afterward, CNA C stated she was supposed to knock, say her name, and explain why she was entering before going into residents’ rooms, and said she had been providing ice and doing one more round before leaving. Additional interviews confirmed that staff were expected to knock, wait for a response, announce themselves, and explain why they were at the room before entering. CNA D stated this was important because the room was the resident’s home and privacy had to be respected. LVN B and CNA F also stated staff were to knock and introduce themselves before entering. Resident #3 said CNAs sometimes did not knock before entering and that it bothered her, and Resident #4 said it bothered her when staff walked in without knocking and that she wanted a little respect. The facility’s Privacy and Dignity policy stated that resident care and services should promote privacy, dignity, and respect and that the facility respects the resident’s private space and property.
Resident Record Left Exposed on Unattended Treatment Cart
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident’s personal and medical records when Resident #1’s pharmacy receipt was left on top of an unattended treatment cart in hall 100. The receipt was observed in an open area and included the resident’s name, date of birth, medication name (morphine), and dosage information. Resident #1 had been discharged the day before the observation. During interviews, an LVN stated there should not be resident information in open areas because it would be a HIPAA violation and that residents had the right to have their information kept confidential. The treatment nurse stated resident information should not be placed on top of the cart where it was visible to everyone and said she did not know who placed the receipt there. The DON stated she was not sure how the resident’s information was left in the open area and said her expectation was that all resident information be kept private and secured. The facility’s in-service record showed a HIPAA in-service was provided, including that resident information should be kept in a secured location and discharged resident medication should be removed from the cart.
Resident Allowed to Use Microwave Without Supervision
Penalty
Summary
The facility failed to ensure adequate supervision for Resident #2 when he was observed alone in the staff conference room using the microwave to warm his coffee. During the observation, he was sitting on his walker while heating the coffee, stated that staff had previously offered to warm it for him but had not done so that morning, and said he did not want to bother them. After heating the coffee, he left the room carrying steaming coffee in one hand while pushing his walker with the other. Resident #2's record showed he was admitted with an infection following a surgical procedure, had a BIMS score of 15, and was care planned for fall risk related to gait and balance problems and ADL self-care deficits related to post right knee arthroplasty, with interventions including PT, OT, and 1-person staff assistance. The facility's hot liquid safety evaluation noted impaired functional mobility. Staff interviews confirmed residents were not allowed to use the microwave because of the risk of burns and accidents, and the ADON stated Resident #2 could have spilled the coffee or fallen while using the walker. The facility's hot beverage protocol also stated residents with identified risk factors on the Hot Liquids Assessment should be supervised when consuming hot beverages.
Unsecured Wound Cleanser on Shared Treatment Cart
Penalty
Summary
The facility failed to store drugs and biologicals in a locked compartment for 1 of 4 carts reviewed for medication and biological storage. During an observation on 3/17/2026 at 8:45 a.m., an unoccupied treatment cart in hall 100 was locked, but a bottle of wound cleanser was exposed on the side of the cart. The bottle was half empty, and residents were present in hall 100 at the time of the observation. During interviews, LVN A stated he was not sure who was using the treatment cart because it was shared among the nurses, and he stated drugs and biologicals should be stored inside a locked cart to prevent injuries or adverse reactions if residents got ahold of them. The treatment nurse stated the cart was an extra treatment cart shared among nurses for wound care when she was not available, and she stated all biologicals should be stored in locked compartments. The DON stated all carts should stay locked and there should be no drugs or biologicals out in the open. Record review showed the facility's Medication storage policy, dated 1/2026, stated carts must remain locked and always secured, and access is restricted to authorized, licensed staff.
Failure to Supervise Exit-Seeking Resident Resulting in Unwitnessed Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and prevent elopement for one resident with known exit‑seeking behavior and prior elopement attempts. The resident was an older male with a history of cerebral infarction, osteoarthritis, schizophrenia, depression, anxiety, and documented dementia/non‑Alzheimer’s dementia in various records. His admission MDS showed a BIMS score of 13 with active diagnoses including non‑Alzheimer’s dementia and stroke, and he had been referred to psychiatry/therapy for depression, confusion, elopement, adjustment disorder, and high‑risk behavior. Progress notes and family interviews documented that he frequently talked about leaving, had a history of leaving prior facilities and psychiatric hospitals independently, and had previously left this facility and checked himself into a local hospital. Elopement risk assessments and care planning for this resident were inconsistent and incomplete despite multiple documented episodes of exit‑seeking and actual elopement. An elopement risk evaluation on 10/13 identified him as a moderate risk, cognitively impaired and ambulatory, but later evaluations on 11/02 and 11/27 were documented as “No Risk” and only the “No Risk” sections were completed, even though the system had triggered questions for moderate or imminent risk that were not answered. There were discrepancies in the assessments regarding his ability to make decisions and ambulate. The care plan initially identified him as at risk for elopement and with impaired cognitive function/dementia, and noted psychotropic medication (Donepezil) for dementia, but the revised care plan dated 11/27 did not incorporate his documented elopement attempt and actual elopements on 10/24, 11/02, and 11/27. Progress notes described episodes where he went to the facility gate wanting to go home, required redirection, had two episodes of elopement with aggression and combativeness, and was sent to a psychiatric hospital with police involvement, as well as an episode where he independently checked himself into a local hospital after leaving the facility. Despite this pattern, the facility’s clinical characterization of the resident’s cognition and risk status was altered without clear supporting documentation of a change in condition, and key information was not consistently communicated to the physician. On 11/27, the resident’s dementia diagnosis was struck out by the RNC after she determined he had a high BIMS score and was not exhibiting signs of dementia based on nursing assessments; she reported that the MD approved discontinuation of the dementia diagnosis based on the BIMS score. The MD later stated he was not aware of the resident’s exit‑seeking behaviors or elopements and that there was no documentation of these behaviors in his or the NP’s notes, although he saw that the resident was on dementia medication and did not know if the resident was safe to leave or ambulate independently. Staff interviews showed inconsistent awareness and recall of the resident’s elopements: some staff remembered retrieving him from the security gate, one nurse reported he was “very tricky” and had been on 1:1 observation and was not safe to be out alone, while others minimized or did not recall elopement events. Family members reported that the resident had dementia, wore a medical bracelet listing dementia and stroke, had left the facility multiple times through the fence or gate, sometimes calling them before the facility did, and that by the third time he left it was “scary.” Ultimately, on the cited elopement date, staff did not know what time he left the building; he climbed through the fence, walked several blocks away, contacted 911 himself, and was transported to a nearby hospital, where he was later located by the social worker calling local hospitals. These actions, inactions, and documentation failures led surveyors to identify a deficiency for failure to ensure adequate supervision and prevention of elopement, with Immediate Jeopardy cited on 02/05/2026.
Failure to Notify Physician of Elopement Behaviors Before Discontinuing Dementia Diagnosis
Penalty
Summary
The deficiency involves the facility’s failure to notify the physician of a resident’s significant change in condition related to repeated elopement behaviors when requesting discontinuation of the resident’s dementia diagnosis. The resident was an older male with diagnoses including cerebral infarction and osteoarthritis, and had a documented history of psychiatric conditions such as schizophrenia, depression, anxiety, cognitive impairment, and high-risk behaviors including elopement. His care plan, initiated and revised in October and November, identified him as at risk for elopement, having impaired cognitive function/dementia, and requiring Donepezil for dementia. Despite this, on a late November date, the Resident Nurse Coordinator (RNC) struck out dementia as a primary diagnosis, and it no longer appeared on the face sheet. The RNC later stated she removed the dementia diagnosis because of a high BIMS score and nursing assessments, and reported that the MD said it was acceptable to discontinue the diagnosis. The resident’s record showed multiple episodes of exit-seeking and elopement-like behavior. Progress notes documented that on one October date, security called nursing staff because the resident was at the gate wanting to go home; he was ambulatory with a walker and had to be redirected back into the building, after which he was placed on two-hour monitoring. On an early November date, notes described two episodes of elopement from the facility, aggression and combativeness when he was prevented from leaving, statements that he was being held hostage, inability to articulate a destination, involvement of police to control behavior, and transfer to a psychiatric hospital. Family members reported that the resident had a long-standing pattern of leaving facilities and psychiatric hospitals independently, often checking himself out or attempting to leave, and that this behavior had occurred at multiple prior settings. They also stated he had records of a dementia diagnosis, wore a medical bracelet listing dementia and stroke, and that he sometimes contacted them after leaving before the facility did. Elopement risk evaluations and documentation in the record were inconsistent with the resident’s behaviors and abilities. An October elopement risk evaluation identified him as a moderate risk, cognitively impaired, ambulatory, and potentially going outdoors but not leaving the grounds. Subsequent evaluations in November were locked as “No Risk,” with staff only completing the “No Risk” section and not answering triggered questions for moderate or imminent risk, resulting in the system not classifying him as higher risk. These evaluations also contained discrepancies about his decision-making ability and ambulation status. Psychiatry/therapy notes from November indicated he was referred for depression, confusion, elopement, adjustment disorder, and high-risk behavior, described him as an unreliable historian who did not remember attempting to elope, disoriented to situation, endorsing decreased concentration, forgetfulness, and ADL difficulties, and receiving Donepezil for cognitive symptoms. During interview, the MD confirmed he approved discontinuation of the dementia diagnosis based solely on the reported BIMS score, stated he was not aware of the resident’s exit-seeking or elopement behaviors, and noted there was no documentation of such behaviors in his or the NP’s notes. Facility policies required physician notification for changes in condition and for elopement events, but the MD’s lack of awareness of the resident’s elopement behaviors at the time the dementia diagnosis was discontinued demonstrated that the facility failed to ensure the physician was properly informed of these significant changes. Additional documentation and interviews further highlighted the disconnect between the resident’s documented behaviors and the information provided to the physician. A late November progress note described the resident as aware of his needs, able to make decisions regarding his care and safety, and independently checking himself into a local hospital, characterizing this as consistent with his baseline pattern and as evidence of preserved decision-making capacity. This narrative contrasted with psychiatric documentation of cognitive impairment and with family statements that he could not make decisions for himself and had dementia. The Administrator later stated that he did not consider the resident’s departures to be elopements because of the high BIMS score and belief that the resident could make his own decisions, and he did not report the events as elopements. The DON and other staff reported that they had been in-serviced on elopement, exit-seeking behaviors, and the need to notify the physician, and facility policies on wandering and elopement required physician notification when a resident was missing and upon return after leaving without proper procedures. Despite these policies and the documented episodes of exit-seeking and elopement-like behavior, the MD was not informed of these behaviors when the dementia diagnosis was discontinued, resulting in the identified deficiency. The facility’s Medical Record Content policy required accurate, timely documentation and prompt physician notification of changes in condition and unusual occurrences involving the resident, including documentation of attempts to notify the physician. The wandering and elopement policy required assessment of elopement risk upon admission, quarterly, and with changes in condition, and mandated physician notification when a resident could not be located and upon return after leaving without following proper procedures. In this case, the resident’s repeated attempts to leave, documented episodes involving security and police, transfer to a psychiatric hospital, and independent check-in to a local hospital were not fully or consistently reflected in the elopement risk evaluations or in communications to the physician. The MD’s statement that he was unaware of the resident’s exit-seeking and elopement behaviors at the time he agreed to discontinue the dementia diagnosis, combined with the facility’s own policies requiring such notification, formed the basis of the deficiency for failure to ensure the physician was notified of significant changes in the resident’s condition related to elopement behaviors.
Failure to Timely Report Elopement-Related Neglect to State Agency
Penalty
Summary
The deficiency involves the facility’s failure to timely report alleged neglect related to elopement to the State Agency within 24 hours, and failure to report subsequent actual elopements. A male resident with diagnoses including cerebral infarction, osteoarthritis, and a documented dementia diagnosis in the care plan was admitted in October 2025 and discharged in December 2025. His care plan, initiated and revised in October and November 2025, identified him as at risk for elopement based on an Elopement Evaluation risk score, with impaired cognitive function/dementia, use of Donepezil for dementia, and psychiatric diagnoses including schizophrenia, depression, and anxiety. The care plan also documented that he was a potential safety risk when leaving the facility, with a history of leaving facilities independently and self-admitting to hospitals. However, the care plan revised on 11/27/2025 did not reflect his elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/26/2025. Elopement risk evaluations showed inconsistencies and incomplete assessments. On 10/13/2025, the resident was assessed as a moderate elopement risk, cognitively impaired, and able to ambulate or propel himself. On 11/02/2025 and 11/27/2025, the evaluations were locked as completed but only the “No Risk” section was filled out, and questions that would have evaluated him as moderate or imminent risk were not completed, despite additional information stating he was at risk for elopement. These later evaluations also contained discrepancies regarding his ability to make decisions and ambulate. Progress notes documented that on 10/24/2025 security called nursing staff because the resident was at the gate wanting to go home; he was redirected back into the building and placed on two-hour monitoring. On 11/02/2025, notes described two episodes of elopement from the facility, aggressive and combative behavior when he insisted on leaving, inability to articulate a destination, involvement of police, and transfer to a psychiatric hospital, with notifications made to the physician, administrator, DON, and family. Further documentation showed that on 11/26/2025 the resident again left the facility and independently checked himself into a local hospital, with no injuries reported. A subsequent progress note characterized this as consistent with his baseline pattern of independently leaving prior facilities and seeking his own care, and stated he was aware of his needs and able to make decisions regarding his care and safety. Psychiatry/therapy notes from November 2025 indicated he was referred for depression, confusion, elopement, adjustment disorder, and high-risk behavior, and described him as an unreliable historian who did not remember attempting to elope, disoriented to situation, and endorsing cognitive impairment symptoms such as decreased concentration and forgetfulness. Interviews with staff and family revealed that the resident had a history of dementia, wore a medical bracelet listing dementia and stroke, had previously left the facility through the gate or fence, and that family sometimes learned of his departures from him or from hospitals or police. The RNC reported striking out the dementia diagnosis on 11/27/2025 after a high BIMS score and discussion with the MD, who confirmed he discontinued the dementia diagnosis based on the BIMS score and was not aware of the resident’s exit-seeking or elopement behaviors. Interviews with nursing staff, the DON, social worker, and the administrator clarified the facility’s internal reporting practices and the failure to report these elopements to the State. RN E stated that elopements were reportable to the State, that nurses did not report directly, and that the administrator was responsible for reporting. The previous social worker recalled the 11/26/2025 elopement, stating that facility staff notified the administrator that the resident was not in the facility, and she then located him at a local hospital and contacted the family. The DON stated that staff reported incidents to her and the administrator, and that the administrator was responsible for deciding if an incident was reportable to the State, emphasizing that reporting was important for regulatory compliance and resident safety. The administrator stated that he was responsible for reporting incidents, that elopements without injury were to be reported within 24 hours, and that staff were to report to him immediately so he could investigate. He also asserted that the 11/02/2025 notes were not accurate, that there were no elopements, and that the resident was not an elopement risk because of a high BIMS score and lack of dementia. The facility’s Abuse Prevention and Prohibition Program policy required reporting allegations of abuse, neglect, exploitation, and other qualifying incidents, including neglect, to the state survey agency and other authorities within 2 hours if involving abuse or serious bodily injury, and within 24 hours if not, and specified that failure to file reports within required time frames could result in disciplinary action. Despite these policies and the documented elopement-related events, the facility did not immediately report the alleged neglect and actual elopements to the State Agency within the required 24-hour timeframe. The facility’s written policy designated the administrator as responsible for coordinating and implementing the abuse prevention program, including investigation and reporting of abuse, neglect, and related incidents. It specified that all mandated reporters must report reasonable suspicion of neglect and that the administrator would submit initial and follow-up written reports of investigations to appropriate agencies. Interviews with staff confirmed that they relied on the administrator to determine reportability and submit reports. However, in this case, the administrator did not report the resident’s elopement attempt and actual elopements as required, and instead disputed that elopements had occurred or that the resident was an elopement risk, despite documentation in progress notes, care plans, and interviews describing exit-seeking behavior, elopement episodes, and involvement of police and hospitals. This failure to follow the facility’s own abuse/neglect reporting policy and federal/state reporting requirements constituted the cited deficiency.
Failure to Maintain Comprehensive Care Plan for Dementia and Elopement Risk
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a comprehensive, person-centered care plan with measurable objectives and timetables to address a resident’s medical, nursing, mental, and psychosocial needs, specifically related to dementia and elopement risk. The resident was an older male with diagnoses including cerebral infarction and osteoarthritis, and his admission MDS documented non-Alzheimer’s dementia and a BIMS score indicating intact cognition at that time. Despite this, on a later date the Resident Assessment Coordinator (RNC) struck out dementia as a primary diagnosis from the medical record and it no longer appeared on the face sheet, based on the resident’s high BIMS score and nursing assessments, without documenting the rationale or the conversation with the MD. The MD confirmed he discontinued the dementia diagnosis after being informed of the BIMS score, and he was not aware of the resident’s exit-seeking or elopement behaviors. The resident’s care plan initially included problems for impaired cognitive function/dementia, use of psychotropic medication (Donepezil) for dementia, and risk for elopement related to an elopement evaluation risk score. However, the most recent care plan revision did not include the resident’s elopement attempt and actual elopements that occurred on multiple dates. Instead, the revised care plan described the resident as a potential safety risk when leaving the facility, referenced his history of leaving facilities independently, and emphasized his autonomy and independent decision-making, citing a BIMS score of 13 and his pattern of self-checking into hospitals. The care plan continued to list impaired cognitive function/dementia and dementia medication, even though the dementia diagnosis had been removed from the medical record, and it did not incorporate the documented episodes of exit-seeking, aggression, and involvement of police. Elopement risk evaluations for the resident were inconsistently completed and contained discrepancies. An evaluation on one date identified the resident as a moderate elopement risk, cognitively impaired and able to ambulate or propel himself, while later evaluations marked him as no risk and either unable or able to make decisions and ambulate, with only the “No Risk” section completed. Questions that would have evaluated him as moderate or imminent risk were triggered but left incomplete, preventing the electronic system from classifying him appropriately. Progress notes documented that security called nursing when the resident attempted to leave through the gate, that he had two episodes of elopement with aggressive behavior and statements about wanting to leave, and that he later left the facility and independently checked into a local hospital. Staff interviews confirmed awareness of his unsafe status to be out alone and acknowledged that care plans are the guide for care and must be updated with changes in condition, yet the resident’s care plan was not revised to reflect his dementia diagnosis status, his ongoing dementia medication, or his repeated elopement attempts and actual elopements. Facility policy required the IDT to develop a culturally competent, trauma-informed, comprehensive person-centered care plan with measurable objectives and timetables, to be completed and periodically reviewed and revised with each assessment and with changes in condition, behavior, or care. The policy also specified that the care plan must describe services to meet the resident’s highest practicable well-being and be revised for changes in behavior and care. Interviews with the DON and Administrator confirmed that admitting nurses initiate care plans, the MDS nurse and nursing leadership are responsible for updates, and that failure to keep care plans current poses a risk because staff may miss needed care. Despite these requirements and acknowledgments, the resident’s care plan and elopement risk tools were not accurately or fully updated to reflect his dementia-related diagnosis history, his use of dementia medication, and his documented exit-seeking and elopement events.
Inaccurate Dementia Diagnosis Documentation and Mismanaged Elopement Risk Records
Penalty
Summary
The deficiency involves the facility’s failure to maintain complete, accurate, accessible, and systematically organized medical records for a male resident with a history of cerebral infarction, osteoarthritis, schizophrenia, depression, anxiety, and documented dementia. The resident’s admission MDS showed a BIMS score of 13 (cognitively intact) with an active diagnosis of non‑Alzheimer’s dementia and no wandering behaviors. His clinical history and a Mental Illness/Dementia Resident Review signed by the MD indicated a dementia diagnosis, and the MD attested on 11/11/2025 that the resident had a primary or dementia diagnosis. The care plan initiated in October and revised in late November documented impaired cognitive function/dementia, use of Donepezil for dementia, and psychiatric diagnoses, as well as risk for falls and safety concerns related to leaving the facility without notice. Despite these records, on 11/27/2025 the RNC struck out dementia as a primary diagnosis from the resident’s medical diagnoses, and the diagnosis no longer appeared on the face sheet. The RNC reported she discontinued the dementia diagnosis based on the resident’s high BIMS score and nursing assessments, after a verbal conversation with the MD, but she did not document this conversation or any justification for changing the medical record. The MD confirmed he approved discontinuation of the dementia diagnosis after being informed of the BIMS score, but he was not aware of the resident’s exit‑seeking behaviors or elopements, and there was no documentation of those behaviors in his or his NP’s notes. At the same time, the resident continued to be care planned and medicated for dementia, and psychiatric notes documented cognitive impairment symptoms, including decreased concentration, forgetfulness, difficulties with ADLs, disorientation to situation, and unreliable history. The facility also failed to accurately and consistently complete and document the resident’s elopement risk evaluations. Progress notes described multiple episodes of exit‑seeking and elopement, including the resident going to the facility gate wanting to go home, two elopement episodes leading to transfer to a psychiatric hospital with police involvement, and an incident where he independently left and checked himself into a local hospital. Staff interviews (LVN, RN, previous SW) described the resident as an elopement risk, with behaviors such as exit‑seeking, frequent talk of leaving, digging under the fence, and requiring 1:1 monitoring. However, elopement risk evaluations on 11/02/2025 and 11/27/2025 were locked as “No Risk,” and staff only completed the “No Risk” section despite triggers for moderate or imminent risk. These evaluations contained internal discrepancies regarding the resident’s ability to make decisions and ambulate, and the care plan revised on 11/27/2025 did not reflect the documented elopement attempt and actual elopements on 10/24/2025, 11/02/2025, and 11/27/2025. The DON and ADM acknowledged the importance of accurate records and documentation of physician notifications and elopements, but the facility’s records for this resident remained inconsistent with his diagnoses, behaviors, and treatment. The facility’s own Medical Record Content policy required accurate, timely, and complete records that support diagnoses, justify medical necessity, and facilitate continuity of care, including consistent assessments and progress notes aligned with care plans and documented physician notifications and orders. In this case, there was no documentation of the physician order or rationale to discontinue the dementia diagnosis, no integration of the PASRR/MD‑signed dementia attestation into the record review, and incomplete elopement risk assessments that did not match the resident’s documented behaviors and staff observations. These inconsistencies resulted in a medical record that did not accurately reflect the resident’s active diagnoses, dementia treatment, or elopement risk status as required by facility policy and accepted professional standards. The DON stated that residents with high BIMS scores or who could make decisions were not considered elopement risks, and that if a resident had dementia but could make decisions, they were not an elopement risk. This view contrasted with other staff who identified the resident as an elopement risk regardless of his BIMS score. The administrator also stated that the resident was not an elopement risk because of his high BIMS score and lack of dementia, and he asserted that certain nursing notes about elopement were not accurate. These differing interpretations and the lack of consistent documentation contributed to the inaccurate and incomplete medical record for the resident, including the discrepancy between the discontinued dementia diagnosis and ongoing dementia‑related care and medications, as well as the under‑documented and misclassified elopement risk.
Unsecured Medication Found in Resident Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and accessible only to authorized personnel, as required by state and federal regulations. During an observation, a nasal spray was found on top of a resident's side table in plain view. The resident, who was cognitively intact and had a terminal prognosis related to hepatic malignancy, reported that the nasal spray was obtained during a prior hospital admission and had remained on his side table. Record review confirmed there was no physician order for the nasal spray, no assessment for self-administration, and no documentation indicating the resident was permitted to self-administer medications. Interviews with nursing staff and facility leadership confirmed that medications should not be kept in residents' rooms unless there is a documented assessment and order for self-administration. Staff acknowledged that the presence of the nasal spray in the resident's room was not noticed during routine rounds, and there was no indication that the medication had been brought in by family or authorized for use. The facility's policy requires that medications be stored securely and only accessible to licensed nursing or authorized personnel, which was not followed in this instance.
Failure to Provide Adequate Nail Care for Dependent Resident
Penalty
Summary
A deficiency was identified when a resident who required partial to moderate assistance with personal hygiene was observed to have fingernails that were approximately 0.5 cm in length, chipped, discolored, and with dark brown residue underneath. The resident expressed a desire to have his fingernails trimmed and cleaned. Record review indicated the resident had a history of lack of coordination, unsteadiness, muscle weakness, and moderately impaired cognition. The care plan specified that the resident needed extensive assistance with personal hygiene, including nail care. Interviews with staff revealed that both CNAs and nurses were responsible for ensuring residents' fingernails were cleaned and trimmed, with CNAs permitted to trim nails for non-diabetic residents. Staff acknowledged that the resident's nails needed attention and confirmed that nail care should be performed as needed and observed daily. Facility policy also required nail care to maintain cleanliness and proper trimming. Despite these protocols, the resident's fingernails were not maintained, resulting in a failure to provide necessary services for activities of daily living.
Inadequate Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by the actions of CNA A, who did not perform hand hygiene after direct contact with residents while serving meals. This deficiency was observed during a survey where CNA A interacted with eight residents, including those with various medical conditions such as schizoaffective disorder, hypertension, Parkinson's disease, and diabetes. Despite having been provided with hand sanitizer and having received training on hand hygiene, CNA A neglected to sanitize her hands between serving meal trays to different residents. During the observations, CNA A was seen entering multiple residents' rooms, setting up breakfast trays, and making physical contact with residents without washing her hands or using hand sanitizer. This occurred repeatedly as she moved from one resident to another, increasing the risk of cross-contamination and infection among the residents. The residents involved had varying levels of cognitive impairment and required assistance with activities of daily living, making them particularly vulnerable to infections. Interviews with CNA A and the Director of Nursing (DON) revealed that CNA A was aware of the hand hygiene protocols but failed to adhere to them due to time constraints and the desire to serve meals promptly. The DON confirmed that staff were trained to use hand sanitizer between each tray service and acknowledged the potential for germ spread if proper hygiene practices were not followed. Despite previous in-service training sessions on hand hygiene, the facility's policy was not effectively implemented by CNA A during the meal service.
Verbal Abuse Incident Involving Resident and Staff Member
Penalty
Summary
The facility failed to ensure the right to be free from abuse for a resident, identified as Resident #36, who was subjected to verbal abuse by a staff member. On March 7, 2024, Hospitality Aide B called Resident #36 'trash' and used profanity during an interaction. This incident was reported by Resident #36, who has a history of anxiety, depression, and schizophrenia, but was assessed with no cognitive impairment as per his BIMS score of 15. The resident expressed that the incident made him mad but did not cause him harm. Hospitality Aide B admitted to calling the resident 'trash' after an altercation where she felt provoked by the resident's comments. Witness statements from two other residents confirmed the aide's use of derogatory language. The aide justified her actions by claiming that the resident was verbally abusive towards her, but acknowledged that her response could be considered abuse. The facility's policy on abuse prevention clearly states that residents have the right to be free from mistreatment, including verbal abuse. Despite this policy, the incident occurred, highlighting a lapse in adherence to the facility's standards for resident treatment. The Director of Nursing (DON) and Administrator (ADM) were involved in addressing the situation, with the DON noting that the aide's actions were dismissed as insignificant due to the resident's cognitive status, which was a misjudgment of the potential impact of verbal abuse.
Inaccurate MDS Assessments for Two Residents
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the residents' status for two residents. Resident #1's discharge and quarterly MDS assessments did not address critical sections such as BIMS, Mood, Behaviors, and Pain, which were necessary to reflect his current medical orders for pain management. Additionally, Resident #1 had a history of schizophrenia and substance abuse, which were not adequately addressed in the assessments. The MDS assessments were completed by the MDSC and approved by the DON, but they failed to capture the resident's cognitive and behavioral status accurately. Resident #3's admission and discharge MDS assessments also contained significant omissions. The assessments did not address her medical diagnoses of anxiety and depression, nor did they reflect her use of a Central PICC line catheter and other treatments such as oxygen therapy and IV medications. Despite having a BIMS score indicating cognitive intactness, the assessments failed to document her active diagnoses and special treatments, which were crucial for her care. The MDS assessments were completed by LVN R, but they did not accurately capture the resident's medical and treatment needs. Interviews with facility staff, including the MDSC, ADON, SW, and DON, revealed a lack of accountability and responsibility in ensuring the accuracy of the MDS assessments. The staff acknowledged that inaccurate assessments could lead to a decline in resident care. The facility's policy on the RAI process emphasized the need for accurate assessments, but the deficiencies in the MDS assessments for Residents #1 and #3 highlighted a failure to adhere to these guidelines.
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 1,335 citations issued within 25 miles in the last 12 months — including the 55 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) |
|---|---|---|---|---|
| South Dallas Nursing & Rehabilitation | 0 mi | ★★★★★ | 38 | 0 |
| Brentwood Place One | 0 mi | ★★★★★ | 3 | 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 Three.
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.