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Complaint Investigation

Brentwood Place Three

Inspection Date: September 11, 2025
Total Violations 1
Facility ID 675352
Location DALLAS, TX
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Inspection Findings

F-Tag F0677

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0677

Provide care and assistance to perform activities of daily living for any resident who is unable.

Level of Harm - Minimal harm or potential for actual harm

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review, the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 1 (Resident #1) of 6 residents reviewed for ADL's. The facility failed to ensure Resident #1 had his fingernails trimmed and cleaned.These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life. Record review of Resident #1's annual MDS assessment dated [DATE REDACTED] reflected Resident #1 was a [AGE] year-old male admitted to the facility on [DATE REDACTED] with diagnoses of lack of coordination, unsteadiness on feet, muscle weakness, and hypertension (elevated blood pressure). He had a BIMS of 10 indicating his cognition was moderately impaired. He required partial/moderate assistance with personal hygiene. Record review of Resident #1's Comprehensive Care Plan last revised 08/31/25 reflected the following. Focus: [Resident#1] has an ADL Self Care Performance Deficit related to Activity Intolerance. Goal: [Resident#1] will improve current level of function in. and Personal Hygiene, ADL Score through the review date. Interventions/Tasks: Personal hygiene: self-performance Extensive assistance. Personal hygiene: support provided One-person physical assist. An observation on 9/11/25 at 10:40 AM revealed Resident #1 was lying in bed. The nails on both his hands were approximately 0.5cm in length, extending from the tip of his finger, and the fifth fingernails on both hands were chipped. The nails were discolored tan, and the underside had dark brown colored residue. Resident #1 stated he wanted his fingernails trimmed and cleaned. In an interview on 09/11/25 at 10:45 AM, LVN A looked at Resident#1 fingernails and stated they needed to be cleaned and trimmed. LVN

A said CNAs and charge nurses were responsible for residents' fingernail care. She stated CNAs were allowed to cut the residents' nails if they were not diabetic. She said she would trim and clean Resident #1's nails right now. LVN A stated the risk to residents was skin break down if they scratched themselves, and infection. In an interview on 09/11/25 at 3:29 PM the DON said all the staff were responsible for making sure residents' fingernails were cleaned and trimmed. The DON further stated nail care should be done as needed and every time aides washed the residents' hands. The DON said nails should be observed daily.

The DON said nurses were responsible for trimming the nails of residents who were diabetic, and CNAs could trim other residents' nails. The DON said she expected CNAs to offer to cut and clean nails if they were long and dirty. The DON said if the resident refused, she expected the CNAs to notify the nurse and family. The DON stated the risk to residents they could scratch themselves, and development of infection.

Record review of the facility's policy titled, Grooming Care of the Fingernails and Toenails undated, reflected, Purpose: Nail care is given to clean and keep the nails trimmed .

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

📋 Inspection Summary

BRENTWOOD PLACE THREE in DALLAS, TX inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DALLAS, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BRENTWOOD PLACE THREE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.
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