Health inspection·January 8, 2025

F 0880 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #62's quarterly MDS Assessment, dated 12/11/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #62 had diagnoses which included: Hypertension (increased blood pressure), depressive disorder (mental illness), and muscle wasting (weakness). Resident #62 was moderately cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. Residents Affected - Some Record review of Resident #52's quarterly MDS Assessment, dated 12/05/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #52 had diagnoses which included: Hypertension (increased blood pressure), cerebral vascular disease (stroke), and muscle wasting (weakness). Resident #52 was severely cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #91's quarterly MDS Assessment, dated 12/06/2024, revealed a [AGE] year-old female who admitted to the facility on [DATE]. Resident #91 had diagnoses which included: Diabetes (increased blood sugar), seizures (brain disorder), and psychotic disorder (mental illness). Resident #91 was severely cognitively impaired and unable to make decisions and required assistance of one staff for activities of daily living. Record review of Resident #73's quarterly MDS Assessment, dated 12/16/2024, revealed a [AGE] year-old male who admitted to the facility on [DATE]. Resident #73 had diagnoses which included: Hypertension (increased blood pressure), peripheral vascular disease (poor circulation), and osteomyelitis (infection of the bone). Resident #73 was alert and oriented and able to make decisions and required assistance of one staff for activities of daily living. Observation on 01/07/2025 beginning at 8:00 a.m., revealed CNA A had walked down the hallway, did not use hand sanitizer, and served a breakfast tray to Resident #81, touched, and moved the overbed table in the resident's room, touched the hand and shoulder of Resident #81 assisting him to sit up and prepared the meal tray for the resident to eat his breakfast. CNA A did not have on gloves. CNA A was observed to not wash her hands or use hand sanitizer, available in the hallway and in her pocket, that had been provided to her by another staff member. Observation on 01/07/2025 beginning at 8:05 a.m., CNA A was observed to enter Resident #30's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. CNA A did not have on gloves. She did not complete hand hygiene before going to the next resident. Observation on 01/07/2025 beginning at 8:07 a.m., CNA A was observed to enter Resident #10's room touching the resident on the shoulder and hand, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. CNA A did not have on gloves. She did not complete hand hygiene before going to the next resident. Observation on 01/07/2025 beginning at 8:08 a.m., CNA A was observed to enter Resident #50's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident. Observation on 01/07/2025 beginning at 8:10 a.m., CNA A was observed to enter Resident #62's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next (continued on next page) 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 01/08/2025 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 0880 resident. Level of Harm - Minimal harm or potential for actual harm Observation on 01/07/2025 beginning at 8:11 a.m., CNA A was observed to enter Resident #52's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident. Residents Affected - Some Observation on 01/07/2025 beginning at 8:12 a.m., CNA A was observed to enter Resident #91's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident. Observation on 01/07/2025 beginning at 8:15 a.m., CNA A was observed to enter Resident #73's room, setting up the resident's breakfast tray, adjusted the overbed table, and unwrapped the utensils, removed tops off drinks for the resident. She did not complete hand hygiene before going to the next resident. An interview on 01/07/2025 at 8:25 a.m., CNA A stated she did not complete hand hygiene after having direct contact with residents. CNA A stated she was supposed to use the hand sanitizer in between serving each tray or wash her hands and she had some hand sanitizer in her pocket that had been provided by another staff member earlier. CNA A said she had been educated on completing hand hygiene. CNA A stated she did not sanitize her hands, after the first meal tray that was served because she had been called in to work and she was trying to get the breakfast trays served and she did not want the food to get cold. CNA A stated she knew she could spread germs if she did not clean her hands. An interview with the DON on 01/08/2025 at 11:00 a.m., revealed that all staff must complete hand hygiene after having contact with residents. She stated CNAs were trained to wash their hands with soap and water prior to tray service, then use hand sanitizer between each tray service. The DON stated if the CNAs do not use appropriate hygiene, they can spread germs to the residents and themselves. The DON was the infection control preventionist and she stated they had completed hand washing and hand sanitizing in recent in-services and provided the CNAs with pocket size hand sanitizer. An interview with the Administrator on 01/08/2025 at 11:15 a.m. revealed he could not believe that staff member had not followed their education concerning meal service and hand sanitizer. The Administrator stated he and the DON had both in-serviced and provided personal pocket hand sanitizer to the staff and educating them on the spread of germs, which could happen if they did not practice appropriate hand sanitizing. Record review of an in-service dated November 2024 revealed CNA A received handwashing and hand sanitizing training, to prevent the spread of infection. Further review of in-service logs revealed an in-service conducted in November 2024 reflected: when passing trays in the hallways, sanitize after going in every room. Remember to wash your hands before starting meal service and use hand sanitizer between each tray served. Record Review of an in-service dated December 2024 revealed CNA A received hand washing and hand sanitizing in-service explaining when to wash hands and when to use hand sanitizing and why to wash your hands and use the hand sanitizer. Further review reflected the use of alcohol gel or washing hands between each meal service tray. (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 01/08/2025 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the Facility's Policy titled Hand Hygiene revised June 2020 reflected: To ensure that all individuals use appropriate hand hygiene while at the facility . The facility considers hand hygiene the primary means to prevent the spread of infections . I. Facility staff are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections III. Facility staff follow the hand hygiene procedures to help prevent the spread of infections to other staff, residents, and visitors . IV. Hand hygiene products and supplies (sinks, soap, towels, alcohol-based hands rub, etc.) are readily accessible and convenient for the staff use to encourage compliance with hand hygiene policy. V. Facility Staff and volunteers must perform hand hygiene procedures in the following circumstances including but not limited to . A. Wash hands with soap and water: . vi. Before and after food prep . 8. Alcohol-based hand hygiene products can and should be used to decontaminate hands: i. immediately upon entering a resident occupied area (single or multiple bed room, procedures or treatment room) regardless of glove use; .ii. Immediately upon exiting a resident occupied area 9 e.g., before exiting into a common area such as a corridor) regardless of glove use; . iii. Before moving from one resident to another in a multiple-bed room or procedure area regardless of gloves use Event ID: Facility ID: 675352 If continuation sheet Page 4 of 4