Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brightpointe At Lytle Lake during CMS and state inspections, most recent first.
Dishwasher Water Temperature Below Required Sanitizing Level: The facility failed to ensure the low-temperature dishwasher reached the required 120-degree wash temperature. During kitchen observation, the machine was running at 100 degrees on one thermometer and 90 degrees on another, and staff reported the temperature had been below 120 degrees since the new hot water heater was installed. The dishwasher log showed repeated substandard readings, and the Dietary Manager and Maintenance Director both stated the issue had not been reported to them.
Incomplete care plans for wound care, discharge planning, and PICC maintenance: The facility failed to include a resident’s neck wound care in the care plan, failed to include a discharge plan for another resident whose goal was to remain in the facility, and failed to care plan a third resident’s double lumen PICC line maintenance and dressing changes. Records showed the residents had relevant diagnoses and orders for wound treatment and IV antibiotic therapy, while staff interviews confirmed missing PICC maintenance orders and that the care plan only addressed IV antibiotic use.
A resident room on the secured unit had an AC unit cover off and sitting on the floor, exposing the inside of the machine to the resident. An LVN said the cover likely was not put back on correctly after spring cleaning, and the Maintenance Director confirmed the facility had washed the AC units during a facility-wide cleaning. The DON and Administrator were unaware the cover was off.
A resident with a PICC line for IV antibiotics had no physician orders for PICC maintenance, saline flushes, or dressing changes, and the care plan did not include goals or interventions for PICC use and maintenance. Staff stated they were flushing the line and changing the dressing, but these tasks were not ordered on the MAR or TAR, and the DON acknowledged the PICC care had not been care planned.
A resident with hypertension and mobility issues, who was cognitively intact, reported that a CNA entered the room after a call light was activated, yelled at the resident to stop using the call light, and said nurses did not like helping due to frequent use. The resident stated she reported this to the social worker but never received follow-up, while the CNA continued working on her hall. The grievance tracking log reflected the concern, but the grievance binder lacked the corresponding documentation. The Administrator and DON reported they had not received any grievance about the CNA or this incident, whereas the social worker stated she had completed a grievance form and routed it to nursing but did not know its whereabouts. Required steps such as IDT review, development of a resolution plan, notification of the complainant, and full documentation of actions taken were not completed or recorded.
A resident with severe cognitive impairment and on anticoagulant therapy suffered an unwitnessed fall resulting in a head injury. Staff failed to communicate the injury to nursing, did not initiate required neuro checks, and did not document or report changes in the resident's condition. The resident's condition worsened over several days, leading to hospitalization for a subdural hematoma and subsequent death. Facility policies for post-fall assessment and monitoring were not followed.
A resident did not receive treatment and care in accordance with physician orders and their own preferences and goals, as observed by surveyors.
The facility failed to adhere to professional standards for food service safety, with several food items found unsealed and open to air in the kitchen's refrigerator and freezers. The DM acknowledged the issue, and the ADMN admitted to being unaware of the exposed food, recognizing the shared responsibility to ensure food safety. The facility's policies and FDA guidelines emphasize the importance of proper food storage and handling to prevent contamination.
The facility failed to inform residents of smoking policies, affecting their self-determination and choice. A resident with moderate cognitive impairment had her cigarettes confiscated and smoking times restricted without prior notice. Another resident, with no cognitive impairment, was not informed of the smoking policy and smoked freely. A third resident was not allowed to sit on the patio due to others not following the smoking policy, and she was unaware of her rights or the grievance process.
The facility failed to ensure that three residents reviewed and signed their admission paperwork, leading to a deficiency in implementing an admission policy. The Admissions/Marketer did not ensure the paperwork was signed, and the Administrator acknowledged this as a system failure. The lack of a formal admissions policy contributed to the issue.
The facility failed to enforce its smoking policy and provide adequate supervision for three residents, leading to unsupervised smoking and potential hazards. A resident with moderate cognitive impairment was found smoking unsupervised with her own cigarettes and lighter, while another resident with no cognitive impairment smoked outside designated times without a smoking assessment or agreement. A third resident with severe cognitive impairment smoked unsupervised, using discarded cigarette butts, despite requiring supervision. Staff interviews revealed inconsistencies in policy enforcement.
The facility failed to implement comprehensive care plans for several residents, leading to deficiencies in fall prevention and care. A resident with Alzheimer's disease experienced falls without updated interventions, while another with severe cognitive impairment had a care plan lacking specific fall prevention measures. A third resident's care plan was not updated after a fall due to dizziness, and a fourth resident's care plan did not document necessary interventions after multiple falls. These failures placed residents at risk of inadequate care.
A resident's legal representative was not provided with medical records within the required timeframe. Despite requesting the records, the facility delayed the release due to a process involving corporate approval, contrary to their policy of providing records within two working days. The representative was initially misinformed about the need for paperwork and was later told it could take weeks to receive the records.
A resident with severe cognitive impairment and multiple health issues did not receive necessary podiatry services despite having thickened and long toenails. The facility failed to document any podiatry visits or recommendations in the resident's EHR, and staff were unable to provide foot care due to the resident's resistance. This lack of care could have placed the resident at risk of pain and injury.
The facility failed to ensure that a resident or their representative was fully informed and provided consents for antianxiety and antipsychotic medications. The resident, with severe cognitive impairments and multiple diagnoses, did not have signed consents for several medications. Staff interviews confirmed that consents were not properly obtained or documented, and alternative methods to obtain consents were not utilized.
The facility failed to implement policies and procedures to prevent abuse, neglect, and exploitation of residents by not conducting required criminal history and EMR/NAR checks for employees. This deficiency was identified for one employee, placing residents at risk.
A facility failed to report a resident's positive cannabis drug screen to the State Survey Agency in a timely manner. The resident had severe cognitive impairments and multiple diagnoses. The administrator and DON delayed reporting, awaiting further information and guidance from the corporate office, despite state regulations requiring immediate reporting of such incidents.
The facility failed to investigate allegations of abuse and neglect for a resident who tested positive for cannabinoids. Despite being notified of the positive drug screen, the administration did not initiate an investigation, citing a lack of evidence and waiting for additional information. Interviews revealed that the administration and DON were aware of the positive drug screen but did not take immediate action, contrary to the facility's policies.
Dishwasher Water Temperature Below Required Sanitizing Level
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety because the low-temperature dishwasher did not reach the required hot water minimum temperature of 120 degrees. During an initial kitchen observation, the dishwasher was in use and the hot water temperature was observed at 100 degrees on the bottom thermometer and 90 degrees on the top thermometer. The dietary staff member using the machine stated the hot water only reached 100 degrees since the new hot water heater was installed and that she recorded the temperature using only the bottom thermometer. A review of the dishwasher testing log showed repeated temperatures below 120 degrees throughout April 2026, including readings of 90, 95, 98, 100, 105, 110, and 110 degrees across morning, noon, and night checks. The Dietary Manager stated the hot water temperature had been below 120 degrees since the new hot water heater was installed and that she had not told anyone about it. The Maintenance Director stated no one had reported the dishwasher water temperature issue to him and that the new hot water heater had been set to 130 degrees. Later observation showed the dish machine testing at 140 degrees, and the Administrator stated it was now testing at 140 degrees. The facility policy on sanitization stated that low-temperature dishwasher wash temperature should be 120 degrees.
Incomplete care plans for wound care, discharge planning, and PICC maintenance
Penalty
Summary
The facility failed to ensure that the comprehensive care plan addressed Resident #1’s wound on the right side of the neck. Resident #1 was an [AGE]-year-old male admitted with diagnoses including other fracture of the upper and lower end of the right fibula, shortness of breath, morbid obesity, and hypertension. His quarterly MDS dated 01/28/2026 showed a BIMS score of 15, indicating he was cognitively intact. The care plan dated 01/28/2026 contained no evidence of wound care for the neck wound, even though physician orders dated 04/08/2026 directed daily wound care to the right side of the neck with cleansing, xeroform gauze, self-adhesive dressing, and lidocaine gel for daily dressing changes. During observation on 04/07/2026, the resident was in bed with a dressing to the right side of the neck dated 04/07/2026. The facility also failed to include a discharge plan in Resident #58’s care plan. Resident #58 was an [AGE]-year-old female admitted with diagnoses of Type 2 diabetes mellitus, bipolar disorder, hypertension, and chronic pain. Her admission MDS dated 03/13/2026 showed a BIMS score of 12 and indicated participation in assessment and goal setting, with the resident’s overall goal to remain in the facility. The care plan dated 03/24/2026 had no evidence of a discharge plan. Physician orders dated 04/01/2026 included a regular diet, mechanical soft texture, regular consistency, quetiapine, trazadone, duloxetine, antiplatelet monitoring, and full code status. The facility further failed to care plan Resident #97’s double lumen PICC line maintenance and dressing changes. Resident #97 was an [AGE]-year-old male admitted with infection and inflammatory reaction due to an unspecified internal joint prosthesis, anxiety, atrial fibrillation, and dementia. His admission MDS dated 03/17/2026 showed a BIMS score of 3, with IV medications and IV access indicated. The care plan dated 03/17/2026 had no goals or interventions for PICC line use, maintenance, or dressing changes. Physician orders dated 04/01/2026 included IV Tyzavan every 18 hours for MRSA, but there were no orders for PICC maintenance or dressing changes. On observation, the resident had IV antibiotic infusing through a double lumen PICC in the right upper arm, with the dressing clean, dry, and intact. Staff interviews confirmed there was no physician order for PICC flushes or dressing changes, that the resident’s PICC dressing was changed every 7 days, and that the care plan addressed only the PICC line being used for antibiotic therapy.
Exposed Air Conditioning Unit Cover in Resident Room
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards when the cover of an air conditioning unit in a resident room on the secured unit was found off the unit and sitting on the floor, exposing the inside of the machine to the resident occupying the room. The observation was made during a room check, and the exposed unit was documented as being in 1 of 14 resident rooms reviewed for accident hazards. During interview, an LVN stated the facility had spring cleaning a few weeks earlier and the cover must not have been put back on correctly after the air conditioning units were washed. The Maintenance Director said the facility had a spring cleaning on 3/18/26 that included washing the air conditioning units and that the cover must not have been put back on correctly. The DON and Administrator were both unaware that any air conditioner covers were off at the time of the observation.
Missing Orders and Care Plan for PICC Line Maintenance
Penalty
Summary
The facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive care plan, and the resident’s goals and preferences for one resident with a PICC line. The resident was admitted with diagnoses including infection and inflammatory reaction due to an unspecified internal joint prosthesis, anxiety, atrial fibrillation, and dementia, and the admission MDS indicated severely impaired cognition, IV medications, and IV access. The care plan contained no goals or interventions for use and maintenance of the PICC line or for PICC dressing changes, and the physician orders included IV Tyzavan for MRSA but did not include orders for PICC line maintenance, flushes, or dressing changes. During observation, the resident was receiving IV antibiotic therapy through a double lumen PICC line in the right upper arm, and the dressing was clean, dry, and intact. Staff interviews confirmed that IV medications were being given through the PICC line and that the line was being flushed before and after use and the dressing changed every 7 days, but there were no physician orders for these maintenance tasks and they were not on the TAR or MAR. The DON stated there should be physician orders for PICC maintenance, saline flushes, and dressing changes, and acknowledged that the resident’s PICC care had not been care planned.
Failure to Investigate and Document Resident Grievance About CNA Conduct
Penalty
Summary
The deficiency involves the facility’s failure to follow its grievance policy and fully investigate a resident’s complaint about staff behavior. A cognitively intact resident with hypertension, reduced mobility, and lack of coordination reported that on one occasion, after using the call light for assistance, a CNA entered the room, yelled at her to stop using the call light, and stated that nurses did not like helping her because she used it too much. The resident stated she reported this incident and her concerns to the social worker and never heard anything further, noting that the CNA continued to work on her hall. Review of the facility’s grievance tracking log showed an entry dated for the resident’s concern involving the CNA, but the grievance binder contained no corresponding grievance documentation for this incident. During interviews, the Administrator stated that no resident or employee had brought concerns about this CNA to him and that he had not received any grievance from this resident. The DON similarly reported that no grievance regarding this CNA or an incident involving this resident had come to her and that she had never received anything about the incident. In contrast, the social worker stated she did complete a grievance form for the resident regarding the CNA yelling at the resident and discouraging call light use, and that, because it was a nursing concern, it should have gone to the DON. She acknowledged she did not know where the grievance document was, and that while the tracking log reflected the incident, the actual grievance form was missing from the binder. The facility’s policy stated that staff are encouraged to guide residents on where and how to file a grievance when they believe their rights have been violated, but the documented process steps described by leadership—review in morning meeting with the IDT, assignment to the appropriate department head, coordination of a resolution plan, and written documentation of actions and disposition—were not carried out or documented for this resident’s grievance.
Failure to Monitor and Communicate After Resident Fall with Head Injury
Penalty
Summary
Facility staff failed to protect a resident from neglect following an unwitnessed fall that resulted in a head injury. The resident, who had severe cognitive impairment and was on the anticoagulant Eliquis, was identified as having a cut on the right side of his head after the fall. Despite the presence of a head injury and the resident's high risk for bleeding due to anticoagulant therapy, staff did not communicate the injury to the nurse in a timely manner, nor did they initiate neurological assessments as required by facility policy. Multiple staff members observed the injury and noted changes in the resident's behavior, such as increased lethargy, but did not report these findings or escalate care appropriately. The nurse who eventually assessed the resident performed only a single neurological check and, despite being aware of the resident's anticoagulant use, did not initiate ongoing neuro checks or communicate the incident to other staff or the physician as required. The incident report was completed as a late entry, and there was no documentation of physician notification or of the resident's change in condition. Facility policies required neuro checks for 72 hours after any unwitnessed fall or head injury, especially for residents on anticoagulants, but these protocols were not followed. The resident's condition deteriorated over the following days, with staff and family members observing increased lethargy and a lack of normal behavior. The resident was eventually found unresponsive with blood around the mouth and was sent to the hospital, where a large subdural hematoma was diagnosed. The resident subsequently passed away due to a nonsurvivable head bleed. Interviews with staff and review of records confirmed that required assessments, monitoring, and communication were not performed according to policy, resulting in neglect.
Removal Plan
- The facility RN B was suspended immediately pending investigation by the administrator.
- All current staff were in-serviced on abuse and neglect and reporting abuse or neglect policy and procedures by the Director of Nursing. For those who cannot be reached by phone will not return to work without receiving this in-service. Staff will be questioned, 3 random staff members, three times a week for 4 weeks to ensure comprehension.
- The director of nursing was educated on the neurological policy by the VP of Clinical Services. The Director of Nurses was educated by the VP of Clinical Operations, related to the policy stating that neuro checks will be initiated upon any unwitnessed fall or fall with head injury, to continue unless otherwise indicated.
- All current nursing staff were in-serviced on documentation of Unwitnessed falls and Neuro Check Policy by the Director of Nursing. For those who cannot be reached by phone, will not return to work without receiving this in-service. Staff will be questioned, 3 random staff members, three times a week for 4 weeks to ensure comprehension.
- RN B will complete all in-services 1:1 with the DON if allowed to return work with residents.
- The Administrator/Designee is responsible for ensuring that all assigned in-service for abuse and neglect is completed by all staff members. Completion will be reviewed at monthly QAPI meetings.
- DON is responsible for ensuring that all assigned nursing in-service are completed. For those who cannot be reached by phone, will not return to work without receiving this in-service prior to anyone working. The administrator will review any new staff to ensure in-services are completed, prior to their first shift on the floor.
- DON reviewed all other residents on anticoagulants for falls and neuro check documentation. No further injuries were noted on any residents.
- Social worker completed Safe Surveys on the other interviewable residents to ensure they feel safe and free from abuse and neglect. No residents reported signs of Abuse or Neglect.
- Any staff member suspected of committing abuse/neglect will be suspended immediately and/or terminated depending on the outcome of the investigation.
- Staff who fail to report suspected abuse and change in condition will be educated on the significance of reporting time and disciplined accordingly.
- DON/Designee will conduct random questioning on 3 staff members daily for 4 weeks for staff to ensure they are understanding and retaining the education on abuse and neglect and reporting procedures.
- Results from random staff questioning will be reviewed during the monthly QAPI meetings with DON, Administrator, and Medical Director. Any incorrect answers will be corrected immediately. Progress will also be monitored during weekly Committee Meetings and Medical Director will be notified of all progress.
Failure to Follow Treatment Orders and Resident Preferences
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders, as well as the resident's preferences and goals. This deficiency was identified through surveyor observation and review of care practices, which revealed that care provided did not align with the established orders or the expressed wishes and objectives of the resident. Specific details regarding the resident's medical history or condition at the time of the deficiency are not provided in the report.
Improper Food Storage and Handling in Facility Kitchen
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation of the facility's kitchen, it was noted that several food items in Refrigerator #1 and Freezers #1, #2, and #4 were unsealed and open to air. Specifically, a bag of shredded cheese, a box of hamburger patties, a box of egg omelets, a box of mixed vegetables, and a sheet tray of red velvet chocolate chip cookies were found unsealed. Additionally, an opened box of egg rolls and uncovered trays of rolls were observed in Freezer #4. The Dietary Manager (DM) acknowledged that these items were not properly sealed and understood the importance of covering and sealing food to prevent contamination. The Administrator (ADMN) admitted to being unaware of the exposed food in the kitchen and acknowledged the shared responsibility with the DM to ensure food safety. The ADMN stated that the kitchen staff should have adhered to the facility's food storage policies to prevent residents from consuming contaminated food, which could lead to illness. The facility's Food Safety and Sanitation Plan emphasized the need for food to be stored off the floor and covered, and the FDA Food Code 2022 highlighted the importance of proper date marking and disposition of food items.
Failure to Inform Residents of Smoking Policies
Penalty
Summary
The facility failed to promote and facilitate resident self-determination through support of resident choice, specifically regarding the right to make choices about smoking. Three residents were affected by this deficiency. Resident #97, a female with moderate cognitive impairment, was not informed of the smoking policies, resulting in her cigarettes being confiscated and restrictions placed on her smoking times. Despite having a care plan that acknowledged her nicotine addiction and the need for supervised smoking, there was no evidence that staff discussed the smoking policy with her upon admission or during her stay. Resident #78, a male with no cognitive impairment, also was not informed of the smoking policies upon admission. His comprehensive care plan did not address smoking or resident rights, and there was no evidence of a smoking assessment in his records. He was allowed to smoke whenever he wanted, as staff provided him with cigarettes upon request, indicating a lack of adherence to the facility's smoking schedule. Resident #304, a female with no cognitive impairment, was not allowed to sit on the patio due to other residents not following the smoking policy, despite it not being a designated smoking time. She was not informed of her rights or the grievance process, which made her feel that her rights were not important. The facility's policy required that all residents and family members be notified of the smoking policy during the admission process, but this was not done, leading to confusion and non-compliance with the smoking policy among residents.
Failure to Implement Admission Policy and Secure Signed Agreements
Penalty
Summary
The facility failed to implement an admission policy for three residents, resulting in the absence of signed admission agreements. Resident #97, a female with moderate cognitive impairment, was admitted without reviewing or signing her admission paperwork. Similarly, Resident #78, a male with no cognitive impairment, and Resident #304, a female also with no cognitive impairment, were admitted without signing their admission agreements. Interviews with these residents confirmed that they did not go over or sign any admission paperwork, and Resident #304 was not informed about resident rights or grievance procedures. The Admissions/Marketer admitted to not ensuring the admission paperwork was signed, citing a lack of awareness of the policy and not perceiving any negative outcomes from this oversight. The Administrator acknowledged the issue as a system failure, noting that the lack of a signed admission agreement could lead to residents being unaware of their rights and the facility's expectations. The facility did not have a formal admissions policy in place, and the document titled 'Admission Agreement' was not dated, further contributing to the deficiency.
Failure to Enforce Smoking Policy and Supervision
Penalty
Summary
The facility failed to ensure adequate supervision and adherence to the smoking policy for three residents, leading to potential accident hazards. Resident #97, a female with moderate cognitive impairment, was observed smoking unsupervised with her own cigarettes and lighter, contrary to her care plan which required supervision and storage of smoking materials by staff. There was no evidence of a signed smoking agreement or documentation that staff had discussed the smoking policy with her. Resident #78, a male with no cognitive impairment, also smoked unsupervised and outside designated times. His care plan did not address smoking, and there was no smoking assessment or signed agreement in his records. He reported that staff provided him with cigarettes outside of scheduled smoking times, indicating a lack of adherence to the facility's smoking policy. Resident #74, a male with severe cognitive impairment, was observed smoking unsupervised and using discarded cigarette butts. Despite his care plan indicating he could smoke independently, his smoking assessment required supervision. There was no signed smoking agreement, and staff interviews revealed inconsistencies in enforcing the smoking policy, with residents having access to cigarettes and lighters against facility rules.
Deficiencies in Care Plan Implementation and Fall Prevention
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for four residents, which resulted in deficiencies in addressing their individual needs and fall prevention. Resident #1, an elderly female with Alzheimer's disease and a history of falls, had care plan interventions that were not updated since October 2023, despite recent falls. Observations revealed that staff were not present in the hallway when Resident #1 fell, and interviews indicated that staff were unaware of recent falls, highlighting a lack of communication and implementation of care plan interventions. Resident #2, who has severe cognitive impairment and a history of falls, had a care plan that did not include specific interventions to prevent falls, such as stopping staff from guiding her with touch, which was identified as a trigger for her anxiety and falls. Despite having fallen and sustained injuries, the care plan was not updated to reflect necessary interventions, and the resident's representative was not informed of care plan meetings or fall prevention strategies. Resident #3, with Alzheimer's disease and a history of falls, had a care plan that lacked updates and specific interventions for fall prevention, such as frequent toileting and physical guidance. The resident fell due to dizziness, and the care plan did not reflect changes in interventions post-fall. Similarly, Resident #4, with dementia and a history of falls, had a care plan that was not updated after multiple falls, and interventions such as placing a mattress on the floor were not documented. The facility's failure to update and implement care plans placed residents at risk of not receiving adequate care to meet their needs.
Failure to Provide Timely Access to Medical Records
Penalty
Summary
The facility failed to provide a resident's legal representative with access to medical records within the required timeframe. The representative of a resident, who had severe cognitive impairment and was diagnosed with dementia, requested the resident's medical records on 10/29/2024. Despite the facility's admission agreement stating that records should be provided within two working days, the records were not released in this timeframe. Interviews revealed that the facility's process for releasing medical records involved sending requests to a corporate office, which delayed the release. The Administrator and Medical Records staff were under the impression that they had up to 14 or 15 days to release the records, contrary to the facility's policy. The representative was initially told no paperwork was needed, but later had to fill out a form, and was informed it could take 2-3 weeks to receive the records. The facility's policy required corporate approval before releasing records, which contributed to the delay. The representative did not receive any communication about payment or denial of the request, and the facility did not provide the records within the stipulated two working days. This failure to comply with the policy could potentially place residents and their representatives at risk by not having timely access to important health information.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to ensure that a resident received proper foot care and treatment in accordance with professional standards of practice. Resident #4, who had severe cognitive impairment and multiple health issues including dementia, muscle weakness, and a history of falls, did not receive podiatry services despite having thickened and long toenails. The resident's responsible party (RP) had requested podiatry services, but there was no documentation of any appointments or recommendations for podiatry care in the resident's electronic health record (EHR). The facility's records showed that Resident #4's toenails were documented as long on multiple occasions, yet no action was taken to address this issue. Nursing assistants (NAs) noted that the resident's toenails were complicated, and they were not able to perform foot care. The social worker (SW) was responsible for coordinating podiatry visits but failed to document any visits or refusals in the EHR. Interviews with staff revealed that attempts to provide foot care were met with resistance from the resident, who would pull away and become agitated. Despite the facility's policy requiring referrals to a podiatrist for residents with complicating disease processes, there was no evidence that Resident #4 was seen by a podiatrist. The Director of Nursing (DON) and other staff members were unable to provide any documentation of podiatry visits or notes for Resident #4. This lack of proper foot care could have placed the resident at risk of pain, injury, and decreased quality of life.
Failure to Obtain Medication Consents
Penalty
Summary
The facility failed to ensure that residents or their representatives were fully informed and provided consents for the administration of certain medications. Specifically, Resident #1 did not have signed consents for antianxiety and antipsychotic medications, including Clonazepam, Ativan, Divalproex, Temazepam, Risperidone, Aripiprazole, and Haloperidol. This failure was identified through record reviews and interviews with staff and the resident's representative, revealing that the necessary consents were either missing or incomplete. Resident #1, a [AGE] year-old female with diagnoses including Cerebral Palsy, Bipolar disorder with psychotic features, Depression, Anxiety, and Autistic Disorder, had severe cognitive impairments and required substantial assistance with daily activities. Despite these conditions, there was no evidence of signed consents for the medications prescribed to her. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), Medical Records (MR) staff, and the Medical Director (MD) confirmed that the consents were not properly obtained or documented. The DON admitted that the facility did not use alternative methods to obtain the necessary consents, such as email or phone communication, and relied on in-person visits from the resident's representative, who lived in a different town. The ADON acknowledged being behind on consents due to illness, and the MD stated that consents were not signed because the resident was hospitalized. The resident's representative confirmed that she had not been contacted for consents beyond the initial admission paperwork. This lack of proper consent documentation could lead to the resident's representative being unaware of the medications and their potential side effects, as well as the associated risks and benefits.
Failure to Implement Policies to Prevent Abuse and Neglect
Penalty
Summary
The facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. Specifically, the facility did not conduct criminal history checks and/or EMR/NAR checks prior to offering employment and annually for employees. This deficiency was identified for one of eight employees reviewed for employability, placing residents at risk of receiving care from someone who might be unemployable. The personnel file of CNA-A, who was hired on 08/02/2022, lacked documented evidence of a criminal history check and initial or annual EMR/NAR checks. Interviews with facility staff revealed inconsistencies and lapses in the hiring process. The current HR, hired in 02/2024, acknowledged the absence of necessary documents in CNA-A's file. The previous HR, who served until 02/2024, admitted that criminal history and EMR/NAR verifications were not consistently conducted. The Administrator and DON also confirmed the lack of a process to ensure these checks were completed, attributing the responsibility to HR. The failure to conduct proper background checks potentially exposed residents to staff with abusive or neglectful backgrounds.
Failure to Report Positive Drug Screen
Penalty
Summary
The facility failed to report allegations of abuse and neglect involving a resident who tested positive for cannabis in a timely manner. The resident, a female with severe cognitive impairments and multiple diagnoses including Cerebral Palsy, Bipolar disorder, Depression, Anxiety, and Autistic Disorder, had a positive hospital lab result for cannabis. The facility's administrator, who was also the abuse coordinator, was informed of the positive drug screen but did not report it to the State Survey Agency as required by regulations. Instead, the administrator waited for further information and confirmation from the corporate office and hospital records before deciding whether to report the incident. During interviews, the administrator and the Director of Nursing (DON) both indicated that they were uncertain about the necessity of reporting the positive drug screen. They relied on guidance from the corporate office and the presence of a surveyor in the facility to delay the reporting process. The DON acknowledged that if the lab result was accurate, other residents could have been at risk, but she did not believe there was a failure in not reporting the incident to the Health and Human Services Commission (HHSC). The facility's policy and state regulations require immediate reporting of any suspected abuse, neglect, or exploitation, including incidents resulting in serious accidental injury or hospitalization. Despite this, the facility did not report the positive drug screen to the appropriate authorities within the required timeframe. This failure to report could potentially place residents at risk by delaying the investigation and intervention by the facility and state agencies.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse and neglect for a resident who tested positive for cannabinoids (marijuana). The resident, a female with severe cognitive impairments and multiple diagnoses including Cerebral Palsy, Bipolar disorder with psychotic features, Depression, Anxiety, and Autistic Disorder, had a positive urine drug screen result from the hospital. Despite being notified of the positive drug screen, the facility's administration did not initiate an investigation, citing a lack of evidence and waiting for additional information from the hospital. The facility's incident report files showed no evidence of an investigation into the allegations of abuse or neglect for this resident. Interviews with the facility's administration and Director of Nursing (DON) revealed that they were aware of the positive drug screen but did not take immediate action to investigate. The Administrator stated that he did not feel there was a failure in not investigating and was waiting for all the evidence before proceeding. The DON confirmed that they were waiting for the resident's hospital records and acknowledged that failing to begin an investigation could place other residents at risk. The facility's policies on resident abuse/neglect reporting and conducting internal investigations were not followed, as they require immediate investigation upon receiving an allegation of abuse or neglect.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 129 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Abilene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Oaks At Radford Hills Healthcare Center | 0.9 mi | ★★★★★ | 12 | 0 |
| Hendrick Skilled Nursing Facility | 2.6 mi | ★★★★★ | 1 | 0 |
| Silver Spring | 2.7 mi | ★★★★★ | 2 | 0 |
| Avir At Coronado | 2.8 mi | ★★★★★ | 28 | 0 |
| Northern Oaks Living & Rehabilitation Center | 3.8 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Brightpointe At Lytle Lake.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.