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 Two during CMS and state inspections, most recent first.
A facility failed to maintain a safe, clean, and homelike environment when three resident restrooms had no hot water, one restroom had a plumbing leak, and a resident’s pillow lacked a clean pillowcase. Surveyors observed restroom water temperatures below the facility’s expected range, and the Maintenance Director confirmed one sink leak and explained that the shared water heater could leave some restrooms without hot water. A cognitively intact resident with multiple diagnoses reported being without a pillowcase for about a month, and staff confirmed CNAs were responsible for clean linens and bed making.
A facility failed to ensure residents received drinks with meals and water throughout the day. One resident with severe cognitive impairment was served lunch without a drink, another resident was observed twice at lunch without a drink, and a third resident reported not receiving water and was seen with an empty pitcher. Staff, including the Activity Director, CNA, LVN, dietary staff, DON, and Administrator, acknowledged that residents should have been offered drinks at every meal and water and ice during the day.
Improper Holding and Serving Temperature of Pureed Potato Salad: A pureed potato salad intended for lunch was observed at 90 degrees F, then portioned into small cups and placed in the freezer to cool. When lunch service began, individual cups were still 86 degrees F and 84 degrees F and were being prepared for service before surveyor intervention. The Dietary Mgr, Dietitian, and cook all stated cold foods such as pureed potato salad must be held and served at 41 degrees F or below.
Failure to provide timely toenail care and podiatry referral for a resident with intact cognition, chronic pain, and unsteadiness on feet. The resident's toenails were observed to be long, jagged, and yellow-discolored, and he stated they hurt and that he had repeatedly asked nurses for podiatry. Records showed podiatry visits where he was not seen, while staff were unsure why he was missed and could not provide documentation of toenail care or refusal.
Improper G-tube Medication Administration: An LVN administered crushed Tylenol and water flushes through a resident’s G-tube by pushing them with a syringe plunger instead of allowing them to flow by gravity, despite the resident’s care plan and MD orders for gravity administration. The resident was severely cognitively impaired, had TBI and dysphagia, and received most calories through tube feeding. The DON stated the facility protocol required gravity administration and that pushing medications could cause discomfort.
A resident with respiratory failure, pneumonia, dementia, and dysphagia was ordered oxygen at 2 L/min via NC every shift, but observations showed the concentrator set at 3.5 L/min on multiple occasions while staff documentation still reflected 2 L/min. An LPN later confirmed the order was for 2 L/min, stated he did not know why the concentrator was set higher, and had not assessed the resident’s respiratory status that day; the DON stated oxygen levels were to be checked each shift and as needed.
An LVN left crushed Tylenol prepared for a resident on top of a med cart while entering the resident’s room to assess and position the resident for G-tube medication administration. The medication was out of the LVN’s clear sight, with two residents nearby in the hallway. The LVN stated she thought it was acceptable if the medication was within sight, while the DON stated staff were trained to keep med carts locked and never leave meds unsecured.
Incorrect Therapeutic Diet Texture Served: A resident with stroke, malnutrition, dysphagia, and severe cognitive impairment had a physician-ordered regular diet with MM5 texture and thin liquids, but was served a lunch tray that did not match the ordered texture. The ADON identified the mismatch during the meal, the Dietary Manager confirmed the tray was incorrect, and staff interviews showed nursing was responsible for checking tray accuracy before service.
A resident with severe cognitive impairment and physical limitations did not receive consistent assistance with bathing and personal hygiene as required by his care plan. Despite being scheduled for regular showers, documentation showed missed showers and lack of proper hygiene, with staff unable to provide evidence that care was delivered as scheduled.
A resident with severe cognitive impairment and frequent incontinence was not assisted with incontinence care or toileting in a timely manner, resulting in prolonged exposure to a soiled brief and skin redness. Staff interviews confirmed that required two-hour checks and changes were not performed, and facility policy mandates prompt toileting assistance to maintain dignity and prevent complications.
A resident requiring extensive assistance with personal hygiene received incontinence care during which a CNA and an LVN failed to follow proper hand hygiene and glove-changing protocols. Both staff handled clean gloves and supplies with potentially contaminated hands and did not consistently change gloves or perform hand hygiene between dirty and clean tasks, contrary to facility policy. These lapses were observed and acknowledged by the staff involved.
The facility failed to ensure call lights were within reach for four residents, including those with cognitive impairments and fall risks. Observations revealed call lights were inaccessible, posing a risk to residents' safety and ability to communicate needs. Facility policy required call lights to be within reach, but this was not consistently followed.
The facility failed to maintain a safe and clean environment in two halls, with issues such as loose sinks, grimy toilets, and chipped toilet seats observed. Staff interviews revealed ineffective reporting of maintenance issues, and residents expressed dissatisfaction with the state of their rooms. The facility's policy to provide a homelike environment was not upheld due to these deficiencies.
The facility failed to maintain safe assistive devices for six residents, with observations revealing cracked wheelchair armrests and an overbed table with exposed wood. Staff interviews indicated a lack of awareness and reporting of repair needs, despite the facility's policy requiring equipment maintenance. This oversight could potentially place residents at risk of injury.
A long-term care facility failed to maintain an effective infection control program, as staff members did not adhere to hand hygiene and equipment sanitization protocols. An MA did not sanitize a blood pressure cuff, and an RN failed to disinfect treatment scissors. Several CNAs did not perform hand hygiene between serving meal trays, despite being trained. The DON acknowledged the training but expressed frustration over staff non-compliance.
A resident with multiple medical conditions, including hypertension, did not receive proper care due to a medication aide's failure to report and document elevated blood pressure readings. Despite in-service training, the aide did not inform the charge nurse of the abnormal readings, preventing necessary follow-up assessments. The resident's condition remained stable, but the lack of communication and documentation posed a risk to their health.
A resident receiving antibiotic therapy for bone infection and urosepsis did not have timely laboratory tests conducted as ordered by the physician. The facility missed the scheduled tests on a specific date, which was discovered through a review of the resident's laboratory results. Interviews with staff revealed that the oversight was due to the tests not being documented in the laboratory book, despite daily monitoring by the ADON and DON. The physician noted the importance of these tests for monitoring potential adverse reactions.
The facility did not follow professional standards for food safety by failing to store dented cans separately in the kitchen. Observations revealed dented cans of tomato juice, tuna, and diced tomatoes were not isolated, contrary to the facility's policy and FDA guidelines. Staff interviews confirmed the risk of food-borne illnesses due to this oversight.
A resident with multiple health conditions was administered Losartan Potassium and Hydralazine HCl despite physician orders to hold the medications if certain vital sign parameters were not met. Several nurses failed to adhere to these orders, administering the medications when the resident's diastolic blood pressure and/or pulse were below the specified limits. Interviews revealed a lack of recall by the staff, and the DON acknowledged the oversight in medication administration record reconciliation.
A resident with multiple diagnoses, including schizophrenia and diabetes, was not adequately monitored for lithium levels, leading to acute toxic encephalopathy and hospitalization. Despite receiving lithium carbonate 55 times in June, no routine monitoring was conducted until a critical level was detected.
A resident with a history of mental health disorders and diabetes was prescribed lithium without routine monitoring, leading to severe lithium toxicity and hospitalization. Despite receiving lithium 55 times in a month, no orders for routine lithium level checks were documented, resulting in critical lithium levels and acute toxic encephalopathy.
The facility failed to provide palatable and nutritive food for three residents. Complaints included inedible oatmeal, room temperature food, and overcooked broccoli. The Dietary Manager acknowledged the issues, and observations confirmed the deficiencies.
A facility failed to report an allegation of neglect involving a resident with a critical lithium level to the appropriate State Agency in a timely manner. The resident, who had a history of schizoaffective disorder and diabetes, was found to have a critical lithium level and was sent to the hospital for treatment. Interviews revealed a lack of communication and understanding of reporting requirements among staff.
Hot Water, Plumbing Leak, and Missing Pillowcase
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment when three resident restrooms did not have hot water and one restroom had a plumbing leak. Record review showed prior work orders related to the hot water heater in September 2025. On 3/3/26, surveyors observed that the hot water in three resident restrooms was not hot after running the faucets for 7 minutes. In one restroom, two residents stated they had no hot water and noted the plumbing under the faucet was leaking. In another restroom, a resident stated he had lukewarm water but never hot water. In a third restroom, the resident was not present during the observation, but the water was still not hot after 7 minutes of running. During a later interview and observation, the Maintenance Director measured restroom water temperatures and found one restroom at 78 degrees with leaking plumbing under the sink, another at 75 degrees, and another at 91 degrees. He stated restroom hot water should be between 98 and 110 degrees and explained that two halls used the same water heater, which could cause restrooms to run out of hot water if too many showers were used. He was unaware of the leak in one restroom and stated it would be fixed immediately because it could be an accident hazard. The Administrator stated the facility had a new water heater in 2025 but could not explain why some restrooms had hot water and others did not. The facility also failed to ensure Resident #58 had clean bed linens. Resident #58’s quarterly MDS reflected diagnoses including hypertension, traumatic brain injury, malnutrition, and asthma, and a BIMS score of 15 indicating cognitive intactness. On 3/3/26, surveyors observed that his pillow had no pillowcase and was stained with multiple brown spots. Resident #58 stated he had been without a pillowcase for about a month and had told a staff member, though he did not recall who. The next day, the pillow still had no pillowcase. A Staffing Coordinator, filling in as a CNA, confirmed the pillow had no pillowcase and stated CNAs were usually responsible for making beds and placing clean sheets and pillowcases on residents’ beds. CNA A later provided a clean pillowcase. The DON stated CNAs were responsible for clean linens and that charge nurses were expected to oversee them to maintain a home-like environment.
Failure to Provide Drinks During Meals and Throughout the Day
Penalty
Summary
The facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain hydration for 3 of 6 residents reviewed. During lunch service, one resident with severe cognitive impairment and diagnoses including thiamine deficiency, hypo-osmolality and hyponatremia, and esophagitis was served food on 3/3/26 without a drink. He remained without a drink after finishing his meal, and staff observed during the meal that the Activity Director was passing out drinks to other residents but did not approach him. A second resident with diagnoses including Type 2 diabetes, lymphedema, acute kidney failure, and an open wound to the right foot was observed during lunch service on 3/4/26 without a drink. On two separate observations that day, the resident was served a meal tray without a drink, staff were seen serving drinks to others, and the resident finished the meal without ever being offered a drink. The resident’s MDS indicated severe cognitive impairment and the need for supervision or touch assistance with eating and partial assistance with transfers. A third resident, who had diagnoses including necrotizing fasciitis and Type 2 diabetes, reported on 3/3/26 that she had not received drinking water that day and that staff had not provided water and ice on a regular basis. An empty water pitcher was observed on her table, and later that day the pitcher was still empty. The resident stated that at times she drank water from her bathroom sink faucet. CNA J acknowledged that he had not yet provided drinking water and ice to this resident that day and stated that not having enough water to drink could lead to dehydration among residents. Interviews with nursing, dietary, activity, DON, and administration confirmed that residents should have received drinks at every meal and water and ice throughout the day, but the observations showed that these residents did not receive them as expected.
Improper Holding and Serving Temperature of Pureed Potato Salad
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen reviewed. During lunch service on 3/4/2026, pureed potato salad was observed at 90 degrees F. The Dietary Manager then scooped the pureed potato salad into about 12 to 16 small cups, covered them, and placed them in the freezer to cool further. The Dietary Manager stated the pureed potato salad should be at 41 degrees F and needed to cool down further before serving. At 12:07 p.m. the same day, lunch service had started and the Dietary Manager removed the individual portions of pureed potato salad to serve to residents. The temperature of one cup was 86 degrees F and another was 84 degrees F. The Dietary Manager handed the cup to the staff member serving lunch until the surveyor intervened regarding the incorrect holding and serving temperature of the cold food. The Dietitian and Dietary Manager both stated cold foods such as pureed potato salad should be held and served at 41 degrees F or below, and the cook stated the item had not cooled to the correct temperature for service.
Failure to Provide Timely Toenail Care and Podiatry Referral
Penalty
Summary
The facility failed to ensure proper foot care for Resident #66, a [AGE]-year-old male with diagnoses including need for assistance with personal care, chronic pain, unsteadiness on feet, mood disorder, Generalized Anxiety Disorder, and Major Depressive Disorder. His MDS reflected intact cognition with a BIMS score of 15 and that he needed partial assistance with putting footwear on and taking it off. The record also showed an active order dated 3/4/26 for a resident-requested podiatry consult for toenails, and prior podiatry visit summaries dated 12/5/25 and 2/12/26 both reflected that he was not seen. During observation on 03/03/2026, Resident #66's toenails were long, thin, jagged, and yellow-discolored, and he stated they hurt and that the podiatrist needed to cut them. He said he had told nurses several times that he needed to see the podiatrist and that the last time his toenails were cut was at another facility. Staff interviews reflected uncertainty about whether he had received toenail care or been seen by podiatry, with the LVN stating she had cut his fingernails but not his toenails and was unsure when his toenails were last cut, the Social Worker stating he had been on the podiatry list since July 2025 but was not sure why he was not seen, and the DON stating there was no documentation that he received toenail care or declined it. The facility policy stated the Director of Social Services coordinates referrals for services including podiatry.
Improper G-tube Medication Administration
Penalty
Summary
The facility failed to provide treatment and services to prevent complications of enteral feeding for one of two residents reviewed for feeding tubes. Resident #92 was a severely cognitively impaired female admitted to the facility with diagnoses including traumatic brain injury and dysphagia, and her MDS reflected that she received 51% or more of her total calories through tube feeding. Her care plan and physician orders directed that her G-tube be flushed with 30 mL of water before and after medication administration and 5 to 10 mL of water between each medication. During an observation, LVN G prepared crushed Tylenol for administration through the resident’s G-tube. She placed the resident’s G-tube pump on hold, assessed lung and bowel sounds, and elevated the head of bed. She then attached a Luer lock syringe to the G-tube, checked for residual, and used the syringe plunger to push 30 cc of water into the tube, then pushed the dissolved medication through the tube with the plunger, and again pushed 30 cc of water through the tube with the plunger instead of allowing the medication and flushes to flow by gravity. In interview, LVN G stated she had not tried to give the medication by gravity and was not sure of the risk of pushing medications versus giving them by gravity. The DON stated the facility protocol was to flush G-tubes with 30 cc of water before and after medications and to give medications by gravity, and that pushing medications could cause discomfort to the resident.
Oxygen Flow Rate Not Kept at Ordered Setting
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not ensured for a resident with respiratory failure, pneumonia, dementia, and dysphagia who was severely cognitively impaired and dependent for ADLs. The resident’s care plan directed staff to administer oxygen as prescribed or per standing order, and the physician order specified oxygen at 2 liters per minute via nasal cannula every shift. The MAR reflected that staff signed off oxygen administration at 2 liters per minute on day, evening, and night shifts from 03/01/26 through the day shift on 03/04/26. During observation on 03/03/26 and again on 03/04/26, the resident had a nasal cannula in place, but the oxygen concentrator was set to deliver 3.5 liters per minute. The charge nurse observed the setting, checked the order, confirmed it was for 2 liters per minute, and stated he was not sure why the concentrator was set at 3.5 liters per minute or who changed it. He also stated he had not assessed the resident’s respiratory status that day and turned the concentrator to 2 liters per minute. The DON stated residents on oxygen were supposed to have their oxygen levels checked each shift and as needed, and the facility policy required a physician order specifying the oxygen flow rate.
Unsecured Medication Left on Cart During Administration
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were secured and stored in accordance with accepted professional principles for 1 of 3 medication carts observed, the Nurse cart for Hall 200. During an observation on 03/03/26 at 11:09 a.m., LVN G was preparing medications for Resident #92 at the medication cart in front of the resident’s room. LVN G poured two Tylenol 325 mg tablets, crushed them, placed the crushed medication into a plastic cup with 10 cc of water, and then put on gloves and a gown before entering Resident #92’s room, leaving the medication on top of the medication cart out of her sight. Two residents were observed in close proximity to the cart in the hallway while the medication remained unattended. LVN G then assessed Resident #92’s lung and bowel sounds and elevated the head of the bed to approximately 80 degrees, with her back to the medication cart and out of clear sight of the medication. After completing the assessment, she returned to the cart, retrieved the medication and water, and re-entered the room to administer the medication. During interview, LVN G stated she thought it was okay to leave the medication on top of the cart as long as it was within her sight, but acknowledged her back was to the cart while she was assessing and positioning the resident. The DON stated staff were trained to keep medication carts locked and secured and were never to leave medication on top of the cart unsecured, and the facility policy required medications to be stored so they were not accessible to unauthorized persons.
Incorrect Therapeutic Diet Texture Served
Penalty
Summary
The facility failed to provide the therapeutic diet ordered for a resident with stroke, hypertension, malnutrition, dysphagia, and severe cognitive impairment. The resident’s physician order specified a regular diet with minced and moist (MM5) texture and thin consistency, and the care plan reflected the same diet order and need for proper nutrition. The resident’s lunch meal ticket also listed a regular diet with MM5 texture and included minced or pureed food items. During lunch observation, the resident was served food that did not match the ordered texture. The resident received whole baked beans, two half slices of bread, one piece of chicken breast covered with gravy, pureed potato salad, and a frozen nutrition treat. The resident pulled the chicken apart with a fork and used his left hand to place a small piece in his mouth. The ADON observed that the meal did not match the meal ticket and stated it was the wrong texture, then contacted the Dietary Manager. The Dietary Manager stated the resident should have been served pureed beans, pureed breads, and minced chicken. She removed the meal and provided a corrected lunch tray with minced chicken, pureed beans, pureed bread, and pureed potato salad. Interviews with the ADON, LVN, Speech Therapist, DON, and Dietary Manager confirmed that staff were responsible for checking tray accuracy and that the resident’s ordered minced and moist texture was not provided as prescribed.
Failure to Provide Consistent ADL Assistance and Personal Hygiene
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically bathing and personal hygiene, for a resident with severe cognitive impairment and physical limitations. The resident, a male with dementia, muscle weakness, and an amputation, required substantial to maximum assistance with bathing as documented in his care plan. Despite being scheduled for showers three times a week, records showed that he received only two showers and one bed bath over a two-week period in April, and only one shower and one refusal in May, with another refusal in June. There was no documentation to confirm that showers were consistently provided according to the schedule. During an observation, the resident was found in bed with an odor and unshaved facial hair, stating he had not received a shower in a week and expressing a desire to be showered. Interviews with staff, including the DON and an LVN, confirmed that showers were to be provided on scheduled days and refusals documented, but the facility was unable to provide documentation verifying that the resident received showers as required. The facility's policy emphasized the importance of maintaining residents' dignity and quality of life through proper personal care, which was not upheld in this instance.
Failure to Provide Timely Incontinence Care and Toileting Assistance
Penalty
Summary
A resident with dementia, muscle weakness, and a history of frequent bowel and bladder incontinence was not provided timely incontinence care and toileting assistance as required by his care plan. On the morning of the survey, the resident was observed lying in bed in a heavily soiled and swollen incontinent brief, emitting a strong odor of urine. The resident was unable to respond to questions due to severe cognitive impairment. Certified nursing assistant (CNA) staff confirmed that the resident had not been changed since the start of the shift, which began at 6:00 AM, and could not provide an explanation for the delay. During the provision of care, redness was observed on the resident's scrotum, and the charge nurse was notified to address the skin issue. Interviews with the charge nurse and the director of nursing (DON) confirmed that facility protocol requires staff to check and change residents at least every two hours. Both acknowledged that failure to provide timely incontinence care could result in skin breakdown and infection. Review of facility policy emphasized the importance of prompt toileting assistance to maintain resident dignity and quality of life. The deficiency was identified through observation, interview, and record review, which demonstrated that the resident did not receive care and services to meet toileting needs in accordance with the comprehensive assessment and care plan.
Failure to Follow Hand Hygiene and Glove Protocols During Incontinence Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene and glove use during incontinence care for one resident. The resident, an elderly male with dementia, muscle weakness, and severe cognitive impairment, required extensive assistance with personal hygiene and was frequently incontinent. During observed care, a CNA entered the resident's room, donned gloves, and performed incontinence care without changing gloves or performing hand hygiene between dirty and clean tasks. The CNA handled clean briefs and gloves with potentially contaminated hands and did not change gloves or wash hands before moving from soiled to clean procedures. Additionally, the CNA carried gloves into the room before performing hand hygiene, contrary to facility policy. An LVN was also observed entering the room holding gloves in her hands, washing hands, and then donning the gloves, but she had previously handled the gloves before hand hygiene. Both the CNA and LVN acknowledged during interviews that they did not follow proper hand hygiene and glove protocols, and the DON confirmed that staff are required to perform hand hygiene before and after care, and to change gloves between dirty and clean tasks. Facility policy states that hand hygiene is the primary means to prevent infection and must be performed after removing PPE and before donning clean gloves. These lapses in infection control practices were directly observed and confirmed through staff interviews and record review.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to accommodate the needs and preferences of four residents by not ensuring their call lights were within reach. This deficiency was observed for Residents #3, #20, #96, and #19, who were unable to access their call lights on specific dates. The lack of access to call lights could prevent residents from obtaining assistance for activities of daily living or in emergencies. Resident #3, a female with a history of stroke and moderate cognitive impairment, was found unable to reach her call light, which was clipped on the opposite side of her bed. Resident #20, a male with severe cognitive impairment and a history of stroke, was also unable to reach his call light, which was placed at the head of his bed while he was seated in a wheelchair at the foot. Both residents had care plans that included ensuring their call lights were within reach due to their risk of falls. Resident #96, a male with no cognitive impairment, had his call light under the bed, making it inaccessible. He expressed that he would have to leave his room to seek help. Resident #19, a female with severe cognitive impairment, had her call light on the floor, out of reach. The facility's policy required call lights to be within residents' reach, but observations and interviews revealed this was not consistently followed, posing a risk to residents' safety and ability to communicate their needs.
Facility Fails to Maintain Safe and Clean Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in two of the six halls observed, specifically Hall 100 and Hall 600. Observations revealed multiple issues in resident bathrooms, including sinks hanging loosely on walls, toilets with missing caulking and black grime at their bases, chipped toilet seats exposing veneer, and walls with missing paint and black marks. These deficiencies were noted in several rooms, indicating a widespread issue with the physical environment. Interviews with staff and residents highlighted a lack of effective communication and reporting regarding maintenance issues. The Plant Operations staff acknowledged that repairs were not being reported through the electronic system as intended, and some staff members admitted to not reporting issues they deemed minor. Residents expressed dissatisfaction with the cleanliness and state of repair in their rooms, with one resident noting that the issues had persisted for a long time. The facility's policy aimed to provide a safe and homelike environment, but the observed conditions and lack of proper reporting and maintenance undermined this goal.
Failure to Maintain Safe Assistive Devices
Penalty
Summary
The facility failed to ensure that all assistive devices were maintained and free of hazards for six residents. Observations revealed that several residents were using wheelchairs with cracked armrests and exposed foam, which could potentially cause injury. Specifically, one resident's wheelchair was missing an armrest entirely, while another resident's wheelchair had a cracked back. Additionally, an overbed table used by a resident was missing veneer, exposing rough wood. Interviews with staff, including the Maintenance Assistant (MA), Plant Operations, Director of Nursing (DON), and the Administrator, indicated a lack of awareness regarding the need for repairs. The MA and Plant Operations stated that repairs should be reported through an electronic system, but no such reports were found. The DON and Administrator were also unaware of any repair needs, despite the availability of parts and replacement equipment. The facility's policy on maintenance services, revised in August 2020, requires that all mechanical, electrical, and patient care equipment be maintained in safe operating condition. However, the failure to report and address the necessary repairs for wheelchairs and the overbed table suggests a breakdown in communication and adherence to this policy, potentially placing residents at risk of injury.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple staff members not adhering to proper hand hygiene and equipment sanitization protocols. Specifically, MA K did not sanitize the blood pressure cuff before and after using it on a resident, which could lead to the spread of infections. RN A also failed to disinfect her treatment scissors before using them on a resident's foot, potentially causing cross-contamination. Several CNAs, including CNA G, CNA D, CNA H, CNA J, and CNA I, did not perform hand hygiene between serving meal trays to residents across different halls. These CNAs were observed adjusting bedside tables, assisting residents, and handling utensils without sanitizing their hands between each interaction, increasing the risk of healthcare-associated infections. Despite being trained on hand hygiene, these staff members cited reasons such as being in a hurry or forgetting due to nervousness as reasons for their non-compliance. The Director of Nursing (DON), who also served as the infection control preventionist, acknowledged that all staff had been trained on infection control measures, including hand hygiene and equipment cleaning. However, the DON expressed frustration over the staff's failure to adhere to these protocols, despite the availability of hand hygiene products and sanitation wipes. The report highlights the facility's inability to ensure consistent compliance with infection control practices, which could compromise resident safety.
Failure to Report and Document Elevated Blood Pressure
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, specifically regarding acute charting guidelines and the management of high blood pressure. This deficiency was identified for one resident who was severely cognitively impaired and required extensive assistance for activities of daily living. The resident had multiple medical conditions, including hypertension, kidney failure, and a history of cerebral infarction. Despite these conditions, the facility did not adequately document or communicate changes in the resident's blood pressure, which is critical for managing his health needs. The deficiency was primarily due to the actions of a medication aide (MA K) who failed to follow acute charting guidelines and did not report an elevated blood pressure reading to the charge nurse. The MA took the resident's blood pressure, which was elevated, but chose to wait and recheck it later without documenting the initial reading or informing the charge nurse. This lack of communication and documentation meant that the charge nurse and other healthcare providers were unaware of the resident's condition, preventing necessary follow-up assessments and potential adjustments to the resident's care plan. Interviews with staff, including the charge nurse and the Director of Nursing (DON), revealed that there was an expectation for abnormal blood pressures to be reported immediately. However, despite in-service training on this procedure, the MA did not adhere to the guidelines, resulting in a failure to provide the resident with the necessary nursing assessments and care. The physician was also not informed of the changes, which could have led to a negative outcome for the resident, although in this case, the resident remained stable.
Failure to Obtain Timely Laboratory Services for a Resident
Penalty
Summary
The facility failed to obtain timely laboratory services for a resident, identified as Resident #59, who was under antibiotic therapy for bone infection and urosepsis. The physician had ordered weekly laboratory tests to monitor the resident's condition, specifically on Fridays. However, the facility did not collect the required laboratory tests on the specified date, 12/06/2024, as per the physician's order. This oversight was discovered during a review of the resident's laboratory results, which showed tests were conducted on 11/29/2024 and then again on 12/10/2024, missing the scheduled date. Interviews with facility staff, including the Assistant Director of Nursing (ADON) and the Director of Nursing (DON), revealed that the laboratory tests were not documented in the laboratory book for the missed date, leading to the oversight. The ADON and DON were responsible for monitoring laboratory tests daily, but they were unsure how the tests for Resident #59 were missed. The physician confirmed that the tests were crucial for monitoring potential adverse reactions due to the resident's antibiotic treatment, although missing one week of tests was not expected to cause adverse reactions. The facility's policy mandates coordination of laboratory services as ordered by a physician, emphasizing the importance of timely and quality service delivery.
Failure to Properly Store Dented Cans in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety by not storing dented cans in a separate area, as observed in the dry storage area. During an inspection, it was noted that a 46oz can of tomato juice, a 66.5oz can of light chunk tuna, and a 6lbs can of diced tomatoes were dented and not stored separately. The Dietary Manager (DM) acknowledged that dented cans were supposed to be stored in her office and returned to the vendor weekly, but this practice was not followed consistently. Interviews with staff confirmed the risks associated with not storing dented cans separately, which include potential food poisoning and food-borne illnesses. The facility's Food Storage Policy, revised in September 2024, mandates that dented or bulging cans should be placed in a separate area and returned for credit. This policy aligns with the U.S. FDA Food Code 2022, which considers dented cans a potential hazard. The failure to comply with these standards could compromise food safety and resident health.
Failure to Hold Medications Based on Vital Signs
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically for one resident who was reviewed for medication administration. The resident, a male with a history of nontraumatic intracerebral hemorrhage, hyperlipidemia, type 2 diabetes, hypertensive heart disease, chronic kidney disease, and end-stage renal disease, was prescribed Losartan Potassium and Hydralazine HCl to manage hypertension. The physician's orders specified that these medications should be held if the resident's systolic blood pressure was less than 110, diastolic blood pressure was less than 60, or heart rate/pulse was less than 60, and the physician should be notified. Despite these orders, multiple instances were documented where the medications were administered when the resident's diastolic blood pressure and/or pulse were below the specified parameters. On several occasions, different nurses, including LVN A, RN B, LVN C, and RN D, administered the medications without holding them as required by the physician's orders. These actions were recorded in the Medication Administration Record, showing that the medications were given even when the vital signs indicated they should not have been. Interviews with the nursing staff revealed a lack of recall regarding the incorrect administration of the medications. The Director of Nursing (DON) acknowledged that the facility trained nurses to follow physician orders and expressed uncertainty about how the issue was missed during weekly reconciliations of medication administration records. The facility's policy on medication administration emphasized the importance of adhering to the seven rights of medication administration and conducting vital sign checks before administering medications, which were not followed in these instances.
Failure to Monitor Lithium Levels Leads to Toxicity
Penalty
Summary
The facility failed to protect a resident's right to be free from neglect by not conducting adequate therapeutic drug monitoring of a resident's lithium levels. This failure led to the resident being admitted to an acute care hospital with a diagnosis of acute toxic encephalopathy secondary to lithium toxicity. The resident's lithium level was critically high at 5.3 mmol/L upon arrival at the hospital. The resident, a male with diagnoses including anxiety disorder, depression, schizophrenia, elevated blood pressure, and type 2 diabetes mellitus, was receiving lithium carbonate as part of his treatment. Despite the care plan indicating the need to monitor for drug-related complications, there was no order to routinely monitor the resident's lithium levels. The resident received lithium carbonate 55 times in June 2023 without any monitoring of his lithium levels until a critical level was detected on June 30, 2023. Interviews with facility staff, including the Nurse Practitioner, Pharmacy Consultant, Medical Doctor, and Director of Nursing, revealed a lack of clarity and communication regarding the responsibility for ordering and monitoring lithium levels. The failure to monitor the resident's lithium levels was identified as neglect, placing the resident at risk for serious adverse outcomes, including drug toxicity and hospitalization.
Failure to Monitor Lithium Levels Leads to Toxicity
Penalty
Summary
The facility failed to ensure that Resident #1's drug regimen was free from unnecessary drugs, specifically lithium, which was administered at an excessive dose and for an excessive duration without adequate monitoring. Resident #1, a male with a history of anxiety disorder, depression, schizophrenia, elevated blood pressure, and type 2 diabetes mellitus, was admitted to the facility and prescribed lithium carbonate. Despite the prescription, there was no order to monitor lithium levels routinely, leading to a critical lithium level of 5.3 mmol/L when Resident #1 was admitted to the hospital with acute toxic encephalopathy secondary to lithium toxicity. The facility's records revealed that Resident #1 received lithium carbonate 55 times out of 55 opportunities between the dates of 06/01/23 through 06/30/23. However, there was no documentation of routine lithium level monitoring. On 06/30/23, Resident #1's lithium level was found to be critically high at 4.5 mmol/L, and he was subsequently sent to the hospital where his lithium level was recorded at 5.3 mmol/L. The hospital diagnosed him with acute on chronic kidney disease and acute toxic encephalopathy due to lithium toxicity. Interviews with the facility's staff, including the NP, Pharmacy Consultant, MD, and DON, revealed a lack of clarity and responsibility regarding the monitoring of lithium levels. The NP and Pharmacy Consultant acknowledged the necessity of routine monitoring to prevent toxicity but failed to implement it. The MD and DON also expressed expectations for monitoring but did not ensure it was carried out. This lack of monitoring and communication among the staff led to Resident #1's severe lithium toxicity and subsequent hospitalization.
Failure to Provide Palatable and Nutritive Food
Penalty
Summary
The facility failed to provide food that was palatable and nutritive for three residents. Resident #4, who has been at the facility for 2 1/2 years, described the food quality as horrible and inedible. Resident #5, who was admitted recently, laughed at the quality of the food, calling it a joke. Resident #4 showed a picture of his breakfast, which included oatmeal that was so thick it felt like a brick, making it inedible. Observations of the lunch tray revealed that the food was at room temperature, the broccoli was mushy and overcooked, and a brownie was served instead of the listed cookies. Resident #3 also complained about the broccoli, describing it as funky and likening it to drinking a V8 juice. The Dietary Manager acknowledged that the broccoli should not be overcooked and explained that it is seared before being placed on the steam table, where it continues to cook. The facility's recipe for broccoli and its policy on vegetable cookery both emphasize the importance of not overcooking vegetables and preparing them close to serving time to preserve quality and nutrient retention. Despite these guidelines, the facility failed to adhere to them, resulting in unpalatable and improperly prepared food for the residents.
Failure to Report Alleged Neglect Timely
Penalty
Summary
The facility failed to ensure all alleged violations involving abuse and neglect were reported immediately, as required by regulations. Specifically, the facility did not report an allegation of neglect involving a resident who had a critical lithium level to the appropriate State Agency in a timely manner. The resident, who had a history of schizoaffective disorder, diabetes, and other conditions, was found to have a critical lithium level of 4.5 mmol/l, which was significantly above the reference range. Despite this critical finding, the incident was not reported immediately as required by the facility's policy and state regulations. The resident's medical records indicated that he was on lithium therapy and had received the medication consistently throughout June 2023. However, there was no order to monitor lithium levels routinely until late June when the resident showed signs of drowsiness. A subsequent lab test revealed a critical lithium level, and the resident was sent to the hospital for further evaluation and treatment. The hospital confirmed lithium toxicity and acute kidney issues, necessitating dialysis. Interviews with the Director of Nursing (DON) and the Administrator revealed a lack of communication and understanding of reporting requirements. The DON admitted to not reporting the incident to the Administrator, focusing instead on checking other residents on psychotropic medications. The Administrator was unaware of the incident and acknowledged the importance of timely reporting to prevent further risk to residents. The facility's policy clearly stated the obligation to report known or suspected instances of abuse or neglect immediately, which was not followed in this case.
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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.
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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 Four | 0 mi | ★★★★★ | 1 | 0 |
| Carrollton Health And Rehabilitation Center | 2.9 mi | ★★★★★ | 10 | 0 |
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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.