Health inspection·March 12, 2024

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some after every use with a sanitizers that killed all organisms. The HSKS stated she would in-service her staff on cleaning and when to report conditions to herself and the maintenance director. In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the expectation for the facility be clean and sanitary at all times, which was a responsibility of all facility staff. The ADMIN stated if facility staff noticed a needed repair, it was expected of them to report the issue, so it could be repaired. The ADMIN stated the residents were not affected by the black substances in the shower because the showers were cleaned daily and after each use with a sanitizer solution. The ADMIN stated the facility in-service facility staff on facility cleanliness, and maintenance request submission. The ADMIN stated he would monitor the condition of the shower rooms in the future to ensure the shower rooms were clean and in sanitary condition. Record review of the facility's policy entitled Resident Room and Environment, revised in August of 2020, read in part: Purpose: To provide resident with a safe, clean, comfortable and homelike environment. Policy: The facility provides residents with a safe, clean, comfortable and homelike environment . Procedure: I. Facility staff aim to create a personalized, homelike atmosphere, paying close attention to the following: A. Cleanliness and order; . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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 ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain nutrition, grooming and personal and oral hygiene for one (Resident #1) of six residents reviewed for ADLs. Residents Affected - Few The facility failed to ensure Resident #1 was provided incontinent care in a timely manner, resulting in the resident smearing fecal matter on his mattress, bed linens, window ledge and throwing the fecal matter on the floor of his bedroom. This failure could place residents at risk for discomfort, infection, and dignity issues. The findings included: Record review of Resident #1's face sheet, printed on 03/12/24, reflected Resident #1 admitted to the facility on [DATE]. Resident #1 had diagnoses of dementia (the loss of cognitive functioning), lack of coordination, apraxia following cerebral infarction (cognitive disorder that can occur after stroke), lack of coordination, obesity, hyperlipidemia (in excess of lipids or fats in your blood), essential (primary) hypertension (high blood pressure), heart failure, aphasia following cerebral infarction (a disorder that affects how you communicate), hemiplegia and hemiparesis following cerebral infarction affecting right dominant side (paralysis of partial or total body function on one side of the body), muscle weakness, dysphagia - oropharyngeal phase (swallowing problems occurring in the mouth and/or the throat). Record review of Resident #1's quarterly MDS assessment, dated 02/25/24, reflected Resident #1 was not recommended for the brief interview for mental status. Section C - Cognitive Patterns, revealed Resident #1 had short-term and long-term memory problems and had severely impaired cognitive skills for decision making. Section GG - Functional Abilities and Goals, Question GG0130. Self-Care indicated Resident #1 required substantial physical assistance in ADLs of oral hygiene, toileting, dressing and personal hygiene and was completely dependent on facility staff in ADLs of bathing. Record review of Resident #1's care plan, last reviewed on 12/12/23, revealed the following: [Resident #1] has bowel and bladder incontinence r/t Right sided paresis secondary to Multiple CVA . Interventions - INCONTINENT: Check [Resident #1] frequently and as required for incontinence. Wash, rinse and dry perineum. Change clothing PRN after incontinence episodes [Resident #1 has an ADL Self Care Performance Deficit r/t Hemiplegia, Impaired balance . Interventions . Toilet use: self-performance Extensive assistance. Toilet use: support provided One-person physical assist. Personal hygiene: self-performance Extensive assistance. Personal hygiene: support provided One-person physical assist. In an observation and interview on 03/12/24 at 2:32 p.m., Resident #1 was observed lying in his bed. Resident #1 stated he was well. Resident #1's room had a pungent smell of urine and stool. Fecal matter was observed on Resident #1's hands, on the floor, near the foot of his bed, on his bed linens and on the window seal near his bed. Resident #1 stated he did not know how long he had been left soiled. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675352 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place Three 3505 S Buckner Blvd Bldg 4 Dallas, TX 75227 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few On 03/12/24 at 2:36 p.m., the surveyor notified RN A, which was the nurse assigned to Resident #1, of Resident #1's condition. RN A accompanied the surveyor to Resident #1's room and stated, he was not like this. RN A stated she was not sure where Resident #1's aide was, but she would ensure the resident was cleaned. On 03/12/24 at approximately 2:45 p.m., the ADMIN, DON, RD, and RN A, were observed to enter Resident #1's room. Shortly after their entrance, the ADMIN and RD exited, and Resident #1 could be heard yelling no. On 03/12/24 at 3:08 p.m., the RD stated to the surveyor, Resident #1 began to display a behavior of throwing his fecal matter around his room and refused to be changed. The RD stated Resident #1 would be referred for psychiatric services for the newly onset behavior. In an interview on 03/12/24 at 4:21 p.m., RN A stated it was the facility's expectation for residents to be dry at all times. RN A stated aides were to ensure residents were checked every 2 hours and incontinent care be provided, as needed. RN A stated she conducted rounds at roughly 2:15 p.m. and did not recall a stool smell in Resident #1's room. RN A stated residents would experience skin breakdown, if they were left soiled for too long. RN A stated she would conduct rounds on residents more often, to ensure incontinent care was provided at all times. In an interview on 03/12/24 at 5:53 p.m., the DON stated it was the facility's expectation that facility aides and nurses checked on resident every 2 hours and provided incontinent care when needed. The DON stated failing to provide incontinent care promptly could increase residents' chances of skin breakdown. The DON stated Resident #1's recently increased his refusals of care and this incident was his first time throwing his fecal matter. The DON stated she would begin to Inservice nursing staff on incontinent care and refusals. In an interview on 03/12/24 at 6:08 p.m., the ADMIN stated it was the facility's expectation for nursing staff to round every 2 hours, answer call lights as they are pressed and provide incontinent care when a resident was wet. The ADMIN stated not providing incontinent care when needed could cause a resident to have skin breakdown. The ADMIN stated if a resident was observed to be soiled, they were to be changed immediately. The ADMIN stated it was the responsibility of facility aides to provide incontinent care but, the nurse was also responsible for ensuring care was provided to residents as needed. The ADMIN stated the facility would begin to Inservice nursing staff on ADL care and incontinent care. Record review of the facility's policy entitle Perineal Care, revised in June 2020, read in part: Purpose: To maintain cleanliness of the genital area, to reduce odor, and to prevent infection or skin breakdown. Policy: Perineal care is provided as part of a resident's hygienic program, a minimum of once daily and per resident need. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675352 If continuation sheet Page 4 of 4