Dallas, TX

Brentwood Place Three

3-star overall rating with 4-star inspections with $12,740 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle

3505 S Buckner Blvd Bldg 4, Dallas, TX

(214) 381-1815

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

4 / 5

Survey and complaint cycles

Staffing

1 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Opco Skilled Management

Operator or chain grouping

Approved since

1994-06-09

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

52 facilities

Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.35

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.63

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

1.66

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

2.64

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

0.98

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

2.31

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.37

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.01

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.31

CMS adjusted RN staffing hours

Adjusted total hours

2.37

CMS adjusted total nurse staffing hours

Case-mix index

1.52

Higher values indicate more complex resident acuity

RN turnover

50%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

41%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

8,333

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

27.09

Composite VBP score used to determine payment impact.

Payment multiplier

0.9844

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Healthcare-associated infections

Not reported

This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.

Total nurse turnover

5.42

Baseline 51.52% · Performance 41.54% · Measure score 5.42 · Achievement 5.42 · Improvement 3.24

Adjusted total nurse staffing

Baseline 2.97 hours · Performance 2.60 hours · Measure score 0 · Achievement 0 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	Not Available	10.72%	Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Discharge to community	Not Available	50.57%	Not Available · Eligible stays 20 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Medicare spending per beneficiary	1.4	1.02 0.4 pts worse
Drug regimen review with follow-up	88.89%	95.27% 6.4 pts worse	Numerator 24 · Denominator 27
Falls with major injury	0%	0.77% 0.8 pts better	Numerator 0 · Denominator 27
Discharge self-care score	Not Available	53.69%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Discharge mobility score	Not Available	50.94%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 27 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	Not Available	7.12%	Not Available · Eligible stays 19 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly.
Staff COVID-19 vaccination coverage	0%	8.2% 8.2 pts worse	Numerator 0 · Denominator 111
Staff flu vaccination coverage	Not Available	42%	Numerator Not Available · Denominator Not Available · No data were submitted for this measure.
Discharge function score	Not Available	56.45%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 5 · Too few residents or stays to report publicly.
Transfer of health information to patient	Not Available	96.28%	Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly.
Resident COVID-19 vaccinations up to date	Not Available	25.2%	Numerator Not Available · Denominator 6 · Too few residents or stays to report publicly.

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	98.9%	97.1% 1.8 pts better	93.4% 5.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.9% · Q2 100.0% · Q3 100.0% · Q4 96.7% · 4Q avg 98.9%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	99.0%	97.9% 1.1 pts better	95.5% 3.5 pts better	Long Stay · 2024Q3-2025Q2 · 4Q avg 99.0%
Percentage of long-stay residents experiencing one or more falls with major injury	0.8%	3.3% 2.5 pts better	3.3% 2.5 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.1% · Q3 1.0% · Q4 1.1% · 4Q avg 0.8% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	0.3%	2.7% 2.4 pts better	11.4% 11.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.3% · 4Q avg 0.3%
Percentage of long-stay residents who lose too much weight	9.8%	3.3% 6.5 pts worse	5.4% 4.4 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 11.9% · Q2 15.7% · Q3 10.1% · Q4 1.2% · 4Q avg 9.8%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	11.8%	18.9% 7.1 pts better	19.6% 7.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 10.7% · Q2 14.4% · Q3 7.8% · Q4 14.3% · 4Q avg 11.8%
Percentage of long-stay residents who received an antipsychotic medication	10.7%	10.8% 0.1 pts better	16.7% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 9.8% · Q3 10.0% · Q4 16.0% · 4Q avg 10.7% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	14.6%	15.4% 0.8 pts better	16.3% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 15.8% · Q2 18.0% · Q3 10.3% · Q4 14.6% · 4Q avg 14.6% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	13.1%	16.1% 3 pts better	14.9% 1.8 pts better	Long Stay · 2024Q4-2025Q3 · Q1 8.3% · Q2 24.4% · Q3 12.2% · Q4 6.4% · 4Q avg 13.1% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.3%	0.8% 0.5 pts better	1.7% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.1% · 4Q avg 0.3% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	19.4%	15.0% 4.4 pts worse	19.8% 0.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 26.8% · Q2 18.6% · Q3 17.9% · Q4 14.6% · 4Q avg 19.4%
Percentage of long-stay residents with pressure ulcers	3.5%	4.2% 0.7 pts better	5.1% 1.6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.4% · Q3 3.1% · Q4 3.5% · 4Q avg 3.5% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	97.5%	89.7% 7.8 pts better	81.7% 15.8 pts better	Short Stay · 2024Q4-2025Q3 · Q1 98.5% · Q2 98.3% · Q3 98.4% · Q4 94.3% · 4Q avg 97.5%
Percentage of short-stay residents who had an outpatient emergency department visit	30.7%	12.0% 18.7 pts worse	12.0% 18.7 pts worse	Short Stay · 20240701-20250630 · Adjusted 30.7% · Observed 38.1% · Expected 13.9% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	0.0%	1.5% 1.5 pts better	1.6% 1.6 pts better	Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	96.9%	88.0% 8.9 pts better	79.7% 17.2 pts better	Short Stay · 2024Q3-2025Q2 · 4Q avg 96.9%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	20.3%	25.9% 5.6 pts better	23.9% 3.6 pts better	Short Stay · 20240701-20250630 · Adjusted 20.3% · Observed 23.8% · Expected 27.9% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-08 · Fire 2025-01-08

3 health deficiencies

Top issue: Infection Control (1 deficiency)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 2 Health 2023-11-16 · Fire 2023-11-16

9 health deficiencies

Top issue: Resident Assessment and Care Planning (2 deficiencies)

3 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 3 Health 2022-09-27 · Fire 2022-09-27

13 health deficiencies

Top issue: Quality of Life and Care (3 deficiencies)

1 fire-safety deficiencies

Top issue: Smoke (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-08

K741 · Miscellaneous Deficiencies

Fire Safety

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Corrected 2025-01-14

F · Potential for more than minimal harm 2023-11-16

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2023-11-17

F · Potential for more than minimal harm 2023-11-16

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-11-16

K343 · Smoke Deficiencies

Fire Safety

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Corrected 2023-11-17

E · Potential for more than minimal harm 2022-09-27

K363 · Smoke Deficiencies

Fire Safety

Install corridor and hallway doors that block smoke.

Corrected 2022-09-28

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-12-02

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Not marked corrected

D · Potential for more than minimal harm 2025-09-11

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2025-09-12

E · Potential for more than minimal harm 2025-01-08

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2025-01-09

D · Potential for more than minimal harm 2025-01-08

F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Corrected 2024-03-12

D · Potential for more than minimal harm 2024-11-12

F641 · Resident Assessment and Care Planning Deficiencies

Health

Ensure each resident receives an accurate assessment.

Corrected 2024-11-13

E · Potential for more than minimal harm 2024-03-12

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2024-03-13

D · Potential for more than minimal harm 2024-03-12

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2024-03-13

E · Potential for more than minimal harm 2023-11-16

F584 · Resident Rights Deficiencies

Health

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-11-16

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-11-16

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-11-16

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-11-17

D · Potential for more than minimal harm 2023-11-16

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-11-17

E · Potential for more than minimal harm 2023-06-09

F677 · Quality of Life and Care Deficiencies

Health

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

Corrected 2023-06-12

D · Potential for more than minimal harm 2023-04-26

F656 · Resident Assessment and Care Planning Deficiencies

Health

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Corrected 2023-05-05

D · Potential for more than minimal harm 2023-04-26

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-05-05

D · Potential for more than minimal harm 2023-04-26

F806 · Nutrition and Dietary Deficiencies

Health

Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.

Corrected 2023-05-05

D · Potential for more than minimal harm 2023-04-26

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-05-05

E · Potential for more than minimal harm 2022-09-27

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-09-28