Deficiencies (last 4 years)
Deficiencies (over 4 years)
9.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
166% worse than Texas average
Texas average: 3.5 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Enforcement
Deficiencies: 2
Aug 29, 2025
Visit Reason
The inspection was conducted due to an Immediate Jeopardy (IJ) situation identified related to neglect and failure to provide appropriate treatment and care for Resident #1 following an unwitnessed fall resulting in a fatal subdural hematoma.
Findings
The facility failed to ensure residents were free from neglect and failed to provide appropriate neurological monitoring and care for Resident #1 after a fall with a head injury. Staff did not report injuries or changes in condition timely, and neuro checks were not initiated as required. Resident #1 suffered a fatal brain bleed. The facility implemented corrective actions including staff suspensions, in-services, and monitoring to address these failures.
Complaint Details
The visit was complaint-related due to allegations of neglect and failure to provide appropriate care. The Immediate Jeopardy was identified on 2025-08-28 and removed on 2025-08-29, but the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm.
Severity Breakdown
Level of Harm - Immediate jeopardy to resident health or safety: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to protect Resident #1 from neglect after an unwitnessed fall resulting in a fatal brain bleed. | Level of Harm - Immediate jeopardy to resident health or safety |
| Failure to provide appropriate treatment and care including neurological assessments and monitoring for Resident #1 after head injury. | Level of Harm - Immediate jeopardy to resident health or safety |
Report Facts
Residents reviewed for neglect: 7
BIMS score: 5
BIMS score: 15
Neuro checks duration: 72
Thickness of subdural hematoma: 15
Midline shift: 7
Number of residents reviewed for anticoagulant use: 14
Number of residents surveyed for safety: 51
Number of in-services conducted: 4
Number of staff randomly questioned daily: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Suspended and terminated pending investigation for failure to report fall and initiate neuro checks for Resident #1. |
| CNA A | Certified Nursing Assistant | Failed to report scratch/cut on Resident #1's head and lethargy; received 1:1 in-service and counseling. |
| CNA C | Certified Nursing Assistant | Witnessed Resident #1 fall but did not report injury or changes in condition. |
| DON | Director of Nursing | Led staff in-services on abuse, neglect, neuro checks, and falls; responsible for monitoring corrective actions. |
| Physician A | Hospital ER MD | Provided expert opinion on Resident #1's brain bleed and need for neurological monitoring. |
| Physician B | Facility Physician | Participated in QAPI meeting and approved corrective actions. |
Inspection Report
Routine
Deficiencies: 4
Feb 5, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights, admission policies, smoking policies, accident hazards, and food safety standards at the nursing facility.
Findings
The facility failed to promote and facilitate resident self-determination regarding smoking policies, failed to ensure residents reviewed and signed admission paperwork, failed to provide adequate supervision to prevent accidents related to smoking, and failed to properly store and label food in the kitchen, potentially placing residents at risk of harm.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to promote and facilitate resident self-determination through support of resident choice regarding smoking policies for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure residents reviewed and signed admission paperwork per facility policy for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure adequate supervision to prevent accidents related to smoking for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store, seal, and label food in the kitchen refrigerators and freezers, risking contamination and foodborne illness. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 3
Residents affected: 3
Residents affected: 1
Smoking times: 5
BIMS scores: 10
BIMS scores: 15
BIMS scores: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrator | Stated smoking policy was addressed in admission packet but was not aware it was missing; acknowledged system failure. | |
| Admission/Marketer | Stated responsibility to inform residents of smoking policy but unaware why paperwork was not signed. | |
| LVN B | Expressed concern about smoking policy noncompliance and unsupervised smoking. | |
| CNA A | Observed passing out cigarettes before scheduled smoke break and lighting cigarettes for residents. | |
| Dietary Manager (DM) | Acknowledged food storage deficiencies and need for proper sealing and covering of food. | |
| Assistant Director of Nursing (ADMN) | Acknowledged responsibility for food safety and stated kitchen staff should follow policies. |
Inspection Report
Routine
Deficiencies: 4
Feb 5, 2025
Visit Reason
The inspection was conducted to assess compliance with resident rights, admission policies, smoking policies, accident hazards, and food safety standards at the facility.
Findings
The facility failed to promote and facilitate resident self-determination regarding smoking policies, failed to ensure admission agreements were signed and reviewed, did not provide adequate supervision to prevent accidents related to smoking, and failed to properly store and label food in the kitchen, potentially placing residents at risk.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to promote and facilitate resident self-determination through support of resident choice regarding smoking policies for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure admission agreements were reviewed and signed for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide adequate supervision to prevent accidents related to smoking for 3 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to properly store, seal, and label food in the kitchen refrigerators and freezers, risking contamination and foodborne illnesses. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for smoking policy: 3
Residents reviewed for admission agreement: 3
Residents reviewed for accident hazards: 3
Smoking times: 5
BIMS scores: 10
BIMS scores: 15
BIMS score: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Expressed concern about smoking policy noncompliance and residents smoking unsupervised. |
| CNA A | Certified Nursing Assistant | Observed passing out cigarettes early and lighting residents' cigarettes before scheduled smoking times. |
| Administrator | Facility Administrator | Acknowledged system failures related to smoking policy education and admission agreement signing. |
| Admission/Marketer | Responsible for admission paperwork and resident rights education; unaware of missing signed documents. | |
| DM | Dietary Manager | Acknowledged food storage violations and the need to keep food covered and sealed. |
| ADMN | Administrator | Acknowledged responsibility for food safety and storage compliance. |
Inspection Report
Routine
Deficiencies: 3
Nov 6, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, care planning, fall prevention, foot care, and medical record access at Brightpointe at Lytle Lake nursing facility.
Findings
The facility failed to provide timely access to medical records for a resident's representative, did not develop or update comprehensive person-centered care plans with measurable interventions for multiple residents, and failed to provide appropriate foot care including podiatry services for a resident with thickened toenails. Fall prevention interventions were inconsistently implemented and documented, and care plans lacked updates reflecting current interventions.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to allow residents or their legal representatives access or purchase copies of all the resident's records within required timeframes. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to develop and implement a comprehensive person-centered care plan with measurable objectives and updated interventions for 4 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to provide appropriate foot care and podiatry services for Resident #4 despite thickened and long toenails and requests from the resident's representative. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for care plan deficiencies: 5
Residents affected by care plan deficiencies: 4
Falls documented for Resident #4: 3
Dates medical records requested: Oct 29, 2024
Dates survey completed: Nov 6, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN A | Provided information on fall incidents and interventions for Residents #1, #2, and #3. | |
| CNA B | Provided observations and interviews regarding fall prevention and resident behaviors for Residents #1, #2, #3, and #4. | |
| CNA C | Provided observations and interviews regarding fall prevention and resident behaviors for Residents #1 and #4. | |
| Resident #4's RP | Reported issues with medical record access and concerns about foot care and podiatry services. | |
| DON | Director of Nursing | Discussed care plan deficiencies, fall prevention interventions, and podiatry services. |
| ADMN | Administrator | Provided information on medical record release procedures and care plan updates. |
| SW | Social Worker | Responsible for coordinating podiatry visits and documenting refusals. |
| LVN F | Discussed attempts to provide foot care to Resident #4 and podiatry visit frequency. | |
| LVN G | Witnessed attempts to provide foot care to Resident #4. | |
| MR | Responsible for uploading documents into the EHR system. | |
| MD | Physician | Notified of resident falls and provided medical opinions on fall causes and interventions. |
| Physician D | Provided information on Resident #2's falls and care plan meetings. |
Inspection Report
Complaint Investigation
Deficiencies: 4
Apr 9, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to obtain proper consents for antipsychotic and antianxiety medications, failure to conduct criminal background checks for employees, failure to timely report suspected abuse and neglect, and failure to thoroughly investigate allegations of abuse and neglect.
Findings
The facility failed to ensure that residents or their representatives were fully informed and had signed consents for psychotropic medications. The facility also failed to conduct criminal history and registry checks for an employee prior to hire and annually. Additionally, the facility failed to timely report a positive drug screen for cannabinoids for a resident and did not thoroughly investigate the allegation of abuse and neglect related to that positive drug screen.
Complaint Details
The complaint investigation focused on Resident #1 who had no signed consents for multiple psychotropic medications. The facility also failed to report a positive hospital drug screen for cannabinoids and did not investigate the allegation of abuse and neglect related to this finding. The investigation included interviews with the Director of Nursing, Assistant Director of Nursing, Medical Director, Administrator, Human Resources, and Resident Representative. The facility lacked documentation of criminal background checks for an employee. The Administrator and DON acknowledged failures in reporting and investigation processes.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure residents or their representatives had signed consents for antipsychotic and antianxiety medications. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to implement policies and procedures to prevent abuse, neglect, and theft by not conducting criminal history and registry checks for an employee. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to timely report suspected abuse and neglect to the appropriate authorities. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to thoroughly investigate allegations of abuse and neglect for a resident with a positive drug screen for cannabinoids. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Number of residents reviewed for consent issues: 1
Number of employees reviewed for employability: 8
Number of residents affected by abuse reporting failure: 1
Number of residents affected by investigation failure: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Interviewed regarding medication consents, reporting, and investigation failures |
| ADON | Assistant Director of Nursing | Interviewed regarding medication consents and consent form delays |
| MD | Medical Director | Interviewed regarding signing medication consents |
| MR | Interviewed regarding consent form filing and uploading | |
| HR | Human Resources | Interviewed regarding missing criminal background and registry checks for employee |
| MA | Former Human Resources | Interviewed regarding missing criminal background and registry checks for employee |
| ADMN | Administrator | Interviewed regarding abuse reporting and investigation failures |
| Resident Representative | Interviewed regarding lack of signed medication consents |
Inspection Report
Annual Inspection
Deficiencies: 6
Jan 18, 2024
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements related to resident care, medication administration, food service, and safety systems.
Findings
The facility was found deficient in multiple areas including failure to ensure comprehensive care plans were prepared by the interdisciplinary team, inadequate respiratory care including lack of physician orders and oxygen tubing replacement, improper medication storage and labeling, failure to follow recipes for pureed food, improper food storage and labeling, and non-functional resident call light systems.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure comprehensive care plans were prepared by a team including attending physician, nurse, and nurse aide for 6 of 6 residents reviewed. | Level of Harm - Potential for minimal harm |
| Failure to provide safe and appropriate respiratory care including lack of oxygen in use signage, no physician order for oxygen, and failure to change oxygen tubing every 7 days for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store medications in original containers and label them properly; medications were placed in unlabeled cups in medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food was prepared according to recipe for pureed meatloaf, including unauthorized addition of bread altering nutritional value. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure open food items in freezer, refrigerator, and dry storage were dated, labeled, and free from expired foods. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a working call system in residents' bathrooms and bathing areas; call lights were non-functional and residents were given squeaky toys or bells that were often out of reach. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 6
Medication cups observed: 4
Dates on oxygen tubing: 2
Residents reviewed for oxygen administration: 2
Residents reviewed for call system: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in medication storage deficiency and call light system interviews |
| DON | Director of Nursing | Provided statements regarding care plan attendance, oxygen administration, medication preparation, and call light system |
| MDS Coordinator E | MDS Coordinator | Provided information on care plan attendance and signatures |
| DM | Dietary Manager | Interviewed regarding pureed food preparation and food storage policies |
| ADMN | Administrator | Interviewed regarding medication preparation, food storage, and call light system |
| CNA C | Certified Nursing Assistant | Interviewed regarding care plan meetings and call light system |
| LVN D | Licensed Vocational Nurse | Interviewed regarding care plan meetings and call light system |
| TNA G | Nursing Assistant | Interviewed regarding call light system |
| CNA H | Certified Nursing Assistant | Interviewed regarding call light system |
| LVN F | Licensed Vocational Nurse | Interviewed regarding call light system |
Inspection Report
Annual Inspection
Deficiencies: 6
Jan 18, 2024
Visit Reason
The inspection was conducted as a comprehensive annual survey to assess compliance with regulatory requirements related to resident care, medication administration, food service, and safety systems.
Findings
The facility was found deficient in multiple areas including failure to ensure interdisciplinary care plan team attendance, inadequate respiratory care practices, improper medication storage and labeling, failure to follow food preparation recipes, improper food storage and labeling, and non-functional resident call light systems.
Severity Breakdown
Level of Harm - Potential for minimal harm: 1
Level of Harm - Minimal harm or potential for actual harm: 5
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to ensure the comprehensive care plan was prepared by a team including the attending physician, nurse, and nurse aide for 6 of 6 residents reviewed. | Level of Harm - Potential for minimal harm |
| Failure to provide safe and appropriate respiratory care including lack of oxygen in use signage, failure to obtain physician orders prior to oxygen administration, and failure to change oxygen tubing weekly for 2 residents. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to store medications in original containers and label them properly; medications were placed in unlabeled plastic cups in medication cart. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure food was prepared according to recipe for pureed meatloaf, including unauthorized addition of bread altering nutritional value. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to ensure open food items in freezer, refrigerator, and dry storage were dated, labeled, and free from expired foods. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide a working call system in resident bathrooms and bathing areas; call lights were non-functional and residents were given squeaky toys or bells that were often out of reach. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 6
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN B | Registered Nurse | Named in medication storage deficiency and call light system deficiency |
| DON | Director of Nursing | Provided statements regarding care plan attendance, respiratory care, medication storage, and call light system |
| MDS Coordinator E | Provided information on care plan attendance signatures | |
| CNA C | Certified Nursing Assistant | Interviewed regarding attendance at care plan meetings |
| LVN D | Licensed Vocational Nurse | Interviewed regarding attendance at care plan meetings |
| DM | Dietary Manager | Interviewed regarding food preparation and storage deficiencies |
| ADMN | Administrator | Interviewed regarding food preparation, storage, and call light system deficiencies |
| TNA G | Nursing Assistant | Interviewed regarding call light system |
| CNA H | Certified Nursing Assistant | Interviewed regarding call light system |
| LVN F | Licensed Vocational Nurse | Interviewed regarding call light system |
Inspection Report
Annual Inspection
Deficiencies: 3
Oct 23, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with regulatory requirements related to resident care, food safety, and facility environment during the annual survey.
Findings
The facility was found deficient in accommodating a resident's needs due to inaccessible call light, maintaining safe food temperatures, and ensuring a functional phone system. These deficiencies posed risks of harm to residents including inability to obtain assistance, risk of foodborne illness, and communication failures.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 3
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to ensure Resident #5 could make her needs known due to the call light being out of reach and inability to use it without assistance. | Level of Harm - Minimal harm or potential for actual harm |
| Failed to ensure food was at a safe and appetizing temperature; pork riblets held at 115°F instead of required 155°F. | Level of Harm - Minimal harm or potential for actual harm |
| Phone system was down from 10/13/2023 to 10/19/2023, preventing calls or faxes, risking resident safety and communication. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents reviewed for accommodation of needs: 6
Residents affected by call light deficiency: 1
Residents affected by food temperature deficiency: 6
Phone system downtime days: 6
Call light BIMS score: 7
Call light care plan revision date: Aug 11, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | DON | Interviewed regarding Resident #5's condition and call light usage |
| Dietary Manager | Dietary Manager | Interviewed regarding unsafe food holding temperature |
| Administrator | Administrator | Interviewed regarding phone system outage and communication issues |
| Site Coordinator | Site Coordinator | Interviewed regarding failed phone communication from referring physician's office |
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 15, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility Brightpointe at Lytle Lake to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection, indicating the facility met the required standards at the time of the survey.
Inspection Report
Complaint Investigation
Deficiencies: 1
Jun 30, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to maintain complete and accurate clinical records for Resident #1, specifically the lack of documentation of the circumstances and staff interventions when the resident was found unresponsive and CPR was performed.
Findings
The facility failed to document the change of condition and CPR intervention for Resident #1, who was found unresponsive and later expired. Multiple staff interviews confirmed the event and lack of documentation. Facility policies require timely and accurate documentation of any change in condition, which was not met.
Complaint Details
The complaint investigation found that the facility did not document the change in condition and CPR performed on Resident #1, despite multiple staff witnessing the event. The lack of documentation did not meet facility standards and staff responsible were to be retrained and disciplined.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to document the circumstances of Resident #1's change of condition and staff intervention of CPR during a medical emergency. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Staff tenure: 3
Staff tenure: 1
Staff tenure: 8
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Participated in CPR on Resident #1 and did not document the event |
| LVN A | Licensed Vocational Nurse | Witnessed CPR on Resident #1 and did not document the procedure |
| TNA A | Therapeutic Nursing Assistant | Found Resident #1 unresponsive, initiated CPR, and did not document the event |
| DON | Director of Nursing | Stated the lack of documentation did not meet expectations and staff would be retrained and disciplined |
| Administrator | Facility Administrator | Stated documentation of incidents and CPR was expected and the lack of documentation did not meet facility standards |
| ADON | Assistant Director of Nursing | Present during Resident #1's emergency, assisted with CPR, and did not document the event |
Inspection Report
Annual Inspection
Deficiencies: 4
Nov 29, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including pre-admission screening, pressure ulcer prevention, catheter care, and respiratory care.
Findings
The facility was found deficient in multiple areas including failure to provide accurate PASRR Level 1 assessments, inadequate pressure ulcer prevention and care, failure to provide catheter care as ordered, improper use of personal protective equipment during incontinence care, and improper storage and replacement of respiratory therapy equipment such as nasal cannulas and oxygen tubing.
Severity Breakdown
Level of Harm - Minimal harm or potential for actual harm: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing for 1 of 7 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide appropriate catheter care and prevent urinary tract infections for 2 of 3 residents reviewed for incontinence care. | Level of Harm - Minimal harm or potential for actual harm |
| Failure to provide safe and appropriate respiratory care including proper storage and timely replacement of respiratory therapy equipment for 3 of 6 residents reviewed. | Level of Harm - Minimal harm or potential for actual harm |
Report Facts
Residents affected: 5
Residents affected: 7
Residents affected: 2
Residents affected: 3
Missed catheter care opportunities: 21
BIMS score: 10
BIMS score: 15
BIMS score: 4
BIMS score: 15
BIMS score: 11
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| LVN B | Licensed Vocational Nurse | Reported on wound care and skin assessments for Resident #13 |
| CNA D | Certified Nursing Assistant | Reported family concerns and observations related to Resident #13's heel wound |
| MDS Nurse | Verified PASRR evaluation issues for Resident #58 | |
| DON | Director of Nursing | Provided interviews regarding PASRR screening, pressure ulcer monitoring, catheter care, and respiratory care |
| LVN A | Licensed Vocational Nurse | Interviewed regarding catheter care and oxygen tubing procedures |
| CNA A | Certified Nursing Assistant | Observed providing incontinence care without proper glove changes |
| CNA B | Certified Nursing Assistant | Observed providing incontinence care |
| CNA C | Certified Nursing Assistant | Interviewed regarding catheter care practices and documentation |
| Wound Care Nurse | Provided wound care assessments and interviews related to Resident #13 | |
| Physician | Interviewed regarding wound care orders for Resident #13 |
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