Health inspection·November 7, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen in that: The facility failed to ensure the morning cook checked the temperatures of the breakfast food before serving to residents. This failure could place residents who ate the food from the kitchen at risk for food-borne illness Findings included: Observation on 11/07/24 at 7:18 AM revealed [NAME] started to plate hot cereal over the serving line for two residents before checking temperatures of the food on the line. The Dietary Manager asked the cook if she had checked temperatures and she stated, no that she had forgot. The cook disposed of her gloves and went and grabbed the thermometers. The cook washed her hands and put her gloves back on. The cook placed the thermometers in water and started to check the food. The cook checked the temperatures for the scrambled eggs and cheese and the hot cereal. The cook then started back putting the food on the plate to serve to the residents. The food on the line that did not have the temperatures checked included: White Gravy Biscuits sausage patty bacon mechanical/pureed sausage Pureed eggs 2 boiled eggs 2 Fried eggs Interview on 11/07/24 at 8:30AM the [NAME] stated she was rushing because they ran behind this (continued on next page) 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 Page 1 of 2 Event ID: 675680 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 675680 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/07/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brentwood Place One 3505 S Buckner Blvd Bldg 2 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)