Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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 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.
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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Nursing homes near Dallas
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brentwood Place Three | 0 mi | — | 14 | 1 |
| South Dallas Nursing & Rehabilitation | 0 mi | — | 37 | 0 |
| Brentwood Place One | 0 mi | — | 3 | 0 |
| Brentwood Place Four | 0 mi | — | 0 | 0 |
| Carrollton Health And Rehabilitation Center | 2.9 mi | — | 10 | 0 |
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