Health inspection·February 5, 2025

F 0561 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident 97's progress notes from 01/10/25 to 02/05/25 revealed no evidence that staff had met with Resident #97 to discuss the smoking policy. Review of Resident #97's smoking assessment, dated 01/19/25, revealed in part, that Resident was capable of understanding Facility Smoking Policy, Resident verbalized understanding of the Facilities Smoking Policy, Resident needed facility to store lighter and cigarettes, and Resident had no limitations to prevent her from smoking without assistance or supervision. Resident #78 Review of Resident #78's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: blood infection, heart valve replacement, and lung disease. Review of Resident #78's MDS assessment, dated 02/02/25, revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. Review of Resident #78's Comprehensive Care Plan, revised 02/03/25, revealed no evidence related to smoking or resident rights. Review of Resident #78's electronic chart revealed no evidence of a acknowledgement of smoking policy. Review of Resident #78's progress notes from 01/30/25 to 02/05/25 revealed no evidence that staff had met with Resident #78 to discuss the smoking policy. Review of Resident #78's electronic chart revealed no evidence of a smoking assessment. Resident #304 Review of Resident #304's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: heart failure and lung disease. Review of Resident #304's MDS assessment, dated 01/25/25, revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. Further review of MDS indicated resident is not on oxygen therapy. Review of Resident #304's Comprehensive Care Plan, revised 1/23/25, revealed: Focus: I have altered respiratory status/difficulty breathing .Goal: I will maintain normal breathing pattern .Interventions: .Oxygen settings 3 liters via nasal cannula. Review of document posted at the nurses' station revealed Smoking Times: 10:30 AM, 1:30 PM, 3:30 PM, 7:30 PM, and 9:00 PM. Review of facility document titled, admission Agreement, had no evidence of anything regarding smoking or smoking policy for the facility. During observation and interviews on 02/03/25 at 11:17 AM, Resident #78 and Resident #97 wasere outside smoking with no supervision. Resident #78 stated the staff had his cigarettes and they gave him one and let him smoke because he missed smoke break. Resident #97 stated she kept her own (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676416 If continuation sheet Page 2 of 12 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 676416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brightpointe at Lytle Lake 1201 Clarks Dr Abilene, TX 79602 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 0561 cigarettes and lighter with her and she smoked whenever she wanted to. Level of Harm - Minimal harm or potential for actual harm During observation and interview on 02/03/25 at 03:12 PM, Resident #304 was outside on the patio relaxing in her wheelchair. Resident was wearing oxygen via nasal cannula with portable oxygen tank on wheelchair. Staff came outside and told her she had to go inside because residents were about to smoke, and she had on oxygen. Resident #304 stated she did not go over or sign any admission paperwork. She stated no one had discussed resident rights or grievances with her. She stated she did not think it was fair for her to not be able to sit on the patio especially when it was not even a designated smoking time. She stated it made her feel as if her rights and wants to sit outside were not important. She stated she did not know who to speak to about her concerns nor how to file a grievance. Residents Affected - Some During observation on 02/03/25 at 03:16 PM, multiple residents were on the smoking patio with cigarettes but no lighter to light them. CNA A stated smoke break did not start until 3:30 but she had already passed out cigarettes. She stated all cigarettes and lighters were kept by staff and that no resident should have their own on them. CNA A then lit the residents' cigarettes and started the smoke break early. During observation on 02/04/25 at 09:00 AM, Resident #97 was outside smoking and had her own pack of cigarettes with her. No staff supervision was present. During observation on 02/04/25 at 09:10 AM, Resident #78 stated the facility had his cigarettes but gave them to him whenever he asked for them. He stated he was allowed to smoke whenever he wanted to. Resident #78 stated he did not go over or sign any paperwork when he was admitted regarding the smoking policy. During an interview on 02/04/25 at 09:15 AM, Resident #97 stated she did not sign or go over any admission paperwork regarding the smoking policy. She stated she was not aware of any smoking policy and that she had her cigarettes and lighter and smoked whenever she wanted to. During an interview on 02/04/25 at 11:47 AM, LVN B stated her only concern with the facility was the smoking. She stated there were multiple residents that had cigarettes, lighters and vapes on them. She stated the residents were not supposed to go outside and smoke unless a CNA or nurse was present. LVN B stated there were multiple residents that went outside and smoked on their own. She stated there was a smoking schedule, but it was not followed. During observation on 02/04/25 at 03:00 PM, Resident #97 was outside in the smoking area with her own cigarettes and lighter with her. During an interview on 02/05/25 at 10:06 AM, the Admission/Marketer stated she did not know anything about who informed the residents of the smoking policy. During an interview on 02/05/25 at 02:51 PM, the Administrator stated the smoking policy was addressed and explained to all admits with the admission packet and paperwork. He stated he was not aware that it was not part of the packet. He stated no resident should have cigarettes or lighters on them. He stated he was not aware that any residents had their own or that residents were not aware of the smoking policy. He stated it was the Marketer/Admissions responsibility to ensure that residents were aware of the smoking policy on admission. He stated it was a system failure. He stated not reviewing the smoking policy on admission could lead to residents not knowing their rights and not knowing the expectations of the facility. He stated residents having their own cigarettes and lighters (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676416 If continuation sheet Page 3 of 12 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 676416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brightpointe at Lytle Lake 1201 Clarks Dr Abilene, TX 79602 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 0561 could cause many negative or harmful situations. Level of Harm - Minimal harm or potential for actual harm During observation and interview on 02/05/25 at 03:30 PM, Resident #97 and Resident #78 were sitting on the patio smoking. Resident #97 stated the administrator confiscated her cigarettes and lighter and reviewed the smoking policy and times with her. She stated she felt this should have been discussed on admission and not after she had already been in the facility for a month. Resident #78 stated the smoking policy was reviewed with him also and that he felt it was against his rights to restrict his smoking times since he was not informed of the policy on admission. Residents Affected - Some Review of facility policy titled, Resident Smoking, dated 2024, revealed in part: Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking .Policy Explanation .3.) All residents and family members will be notified of this policy during the admission process, and as needed. 4.) All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. 5.) Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if the resident is safe to smoke at all. 6.) Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking area, at designated times, and in accordance with his/her care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676416 If continuation sheet Page 4 of 12 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 676416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brightpointe at Lytle Lake 1201 Clarks Dr Abilene, TX 79602 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 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure an admission policy was implemented for 3 of 3 residents (Resident #97, Resident #78, and Resident #304), reviewed for admissions. The facility failed to ensure that Resident #97 reviewed and signed her admission paperwork per facility policy. The facility failed to ensure that Resident #78 reviewed and signed her admission paperwork per facility policy. The facility failed to ensure that Resident #304 reviewed and signed her admission paperwork per facility policy. These failures could place residents at risk who are not being informed of the admission requirements, services, and processes. Findings Include: Resident #97 Review of Resident #97's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: artificial hip joint, high cholesterol, and tobacco use. Review of Resident #97's MDS assessment, dated 01/14/25, revealed his BIMS score was 10 of 15 reflective of moderate cognitive impairment. Review of Resident #97's electronic chart revealed no evidence of a signed admission agreement. Review of Resident 97's progress notes from 01/10/25 to 02/05/25 revealed no evidence that staff had met with Resident #97 to discuss the admission agreement. During an interview on 02/04/25 at 09:15 AM, Resident #97 stated she did not sign or go over any admission paperwork. Resident #78 Review of Resident #78's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: blood infection, heart valve replacement, and lung disease. Review of Resident #78's MDS assessment, dated 02/02/25, revealed his BIMS score was 15 of 15 reflective no cognitive impairment. Review of Resident #78's electronic chart revealed no evidence of an admission agreement. Review of Resident #78's progress notes from 01/30/25 to 02/05/25 revealed no evidence that staff had met with Resident #78 to discuss the admission agreement. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676416 If continuation sheet Page 5 of 12 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 676416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brightpointe at Lytle Lake 1201 Clarks Dr Abilene, TX 79602 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 0620 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 02/04/25 at 09:10 AM, Resident #78 stated he did not go over or sign any paperwork when he was admitted . Resident #304 Review of Resident #304's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: heart failure and lung disease. Review of Resident #304's MDS assessment, dated 01/25/25, revealed his BIMS score was 15 of 15 reflective of no cognitive impairment. Review of Resident #304's electronic chart revealed no evidence of an admission agreement. Review of Resident #304's progress notes from 01/20/25 to 02/05/25 revealed no evidence that staff had met with Resident #78 to discuss the admission agreement. During an interview on 02/03/25 at 03:12 PM, Resident #304 stated she did not go over or sign any admission paperwork. She stated no one had discussed resident rights or grievances with her. She stated she did not know who to speak to about her concerns nor how to file a grievance. During an interview on 02/05/25 at 10:06 AM, Admissions/Marketer stated she brought all residents into her office when they were admitted and went through all the admission paperwork and resident rights. She stated she did not know why these were not signed. She stated she must have missed these admissions. She stated she did not know the policy as to when the paperwork needed to be signed and that she did not see any negative outcome to not doing it. During an interview on 02/05/25 at 02:51 PM, the Administrator stated he was not aware that the admission agreement was not being signed and reviewed on admission. He stated it was the Marketer/Admissions responsibility to ensure that this was being done. He stated it was a system failure. He stated not reviewing the admission agreement could lead to residents not knowing their rights and not knowing the expectations of the facility. Administrator stated the faility did not have an admissions policy. Record review of the facility document titled admission Agreement, not dated, stated Preamble: This admission Agreement is a legally binding contract that defines the rights and obligations of each person who signs it .If you are able to do so, you must sign this agreement in order to be admitted to this center. If you are not able to sign this agreement, your legal representative, who has been given authority by you to admit you to the center, must sign it on your behalf . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676416 If continuation sheet Page 6 of 12 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 676416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brightpointe at Lytle Lake 1201 Clarks Dr Abilene, TX 79602 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 3 residents (Resident #97, Resident #78, and Resident #74) reviewed for accident hazards. The facility failed to follow the smoking policy with Resident #97 leaving her unsupervised while smoking, smoking at undesignated smoking times, and allowing her to have her cigarettes and lighter with her. The facility failed to follow the smoking policy with Resident #78 leaving him unsupervised when smoking and smoking at undesignated times. The facility failed to follow the smoking policy with Resident #74 leaving him smoking already smoked cigarettes, smoking unsupervised, and smoking at undesignated times. These failures could place residents at risk for injuries and fire hazards. Findings included: Resident #97 Review of Resident #97's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: artificial hip joint, high cholesterol, and tobacco use. Review of Resident #97's MDS assessment, dated 01/14/25, revealed his BIMS score was 10 of 15 reflective of moderate cognitive impairment. Review of Resident #97's Comprehensive Care Plan, revised 1/16/25, revealed: Focus: Nicotine addiction- I am a smoker. I have been assessed to be a supervised smoker. I smoke traditional cigarettes. Goal: The resident's desire to smoke will be honored daily and will smoke in designated area. Interventions: . Ensure I am aware of smoking times and assist if needed if on supervised smoking schedule. I will be aware and practice safe smoking techniques: A. Designated smoking area, B. safe use of lighter, C. Safely extinguishing cigarettes, D. Cigarettes will be kept locked up with nurses . Review of Resident #97's smoking assessment, dated 01/19/25, revealed in part, that Resident was capable of understanding Facility Smoking Policy, Resident verbalized understanding of the Facilities Smoking Policy, Resident needed facility to store lighter and cigarettes, and Resident had no limitations to prevent her from smoking without assistance or supervision. Review of Resident #97's electronic chart revealed no evidence of a signed smoking agreement. Review of Resident 97's progress notes from 01/10/25 to 02/05/25 revealed no evidence that staff had met with Resident #97 to discuss the smoking policy. During an observation on 02/04/25 at 09:00 AM, Resident #97 was outside smoking and had her own pack of cigarette with her. No staff supervision was present. Resident #74 was wheeling around with a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676416 If continuation sheet Page 7 of 12 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 676416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brightpointe at Lytle Lake 1201 Clarks Dr Abilene, TX 79602 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some lighter asking residents for a cigarette. Resident #97 gave him a cigarette. No staff supervision was present. Resident #74 lite the cigarette and smoked it. Red trash can in smoking area was filled with trash and a lighter. No obvious burns or injuries from smoking noted to Resident # 97 or Resident #74. During interview on 02/04/25 at 09:15 AM, Resident #97 stated she did not sign or go over any admission paperwork regarding the smoking policy. She stated she was not aware of any smoking policy and that she had her cigarettes and lighter and smoked whenever she wanted to. During observation on 02/04/25 at 03:00 PM, Resident #97 was outside in the smoking area with her own cigarettes and lighter with her. Resident #78 Review of Resident #78's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: blood infection, heart valve replacement, and lung disease. Review of Resident #78's MDS assessment, dated 02/02/25, revealed his BIMS score was 15 of 15 reflective no cognitive impairment. Review of Resident #78's Comprehensive Care Plan, revised 02/03/25, revealed nothing related to smoking. Review of Resident #78's electronic chart revealed no evidence of a smoking assessment. Review of Resident #78's electronic chart revealed no evidence of a signed smoking agreement. Review of Resident #78's progress notes from 01/30/25 to 02/05/25 revealed no evidence that staff had met with Resident #78 to discuss the smoking policy. During an observation and interviews on 02/03/25 at 11:17 AM, Resident #78 and Resident #97 were outside smoking with no supervision. No obvious burns or injuries from smoking noted to Resident # 97 or Resident #78. Resident #78 stated the staff had his cigarettes and they gave him one and let him smoke because he missed smoke break. Resident #97 stated she kept her own cigarettes and lighter with her and she smoked whenever she wanted to. During an observation and interview on 02/04/25 at 09:10 AM, Resident #78 stated the facility had his cigarettes but gave them to him whenever he asked for them. He stated he was allowed to smoke whenever he wanted to. Resident #78 stated he did not go over or sign any paperwork when he was admitted regarding the smoking policy. Resident #74 Review of Resident #74's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: lung disease, depression, anxiety, and tobacco use. Review of Resident #74's admission MDS assessment, dated 12/25/24, revealed his BIMS score was 02 of 15 reflective of severe cognitive impairment. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676416 If continuation sheet Page 8 of 12 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 676416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brightpointe at Lytle Lake 1201 Clarks Dr Abilene, TX 79602 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #74's Comprehensive Care Plan, revised 12/30/24, revealed: Focus: I am able to use tobacco products independently without adaptations or supervision. Goal: I will follow the tobacco policy of the community without injuring self or others. Interventions: I can smoke unsupervised. Review of Resident #74 smoking assessment, dated 10/08/24, revealed in part, that Resident was capable of understanding Facility Smoking Policy, Resident verbalized understanding of the Facilities Smoking Policy, Resident needed facility to store lighter and cigarettes, and Resident had no limitations to prevent her from smoking without assistance or supervision. Evaluation: Resident requires supervision while smoking. Comments: Resident understands the policy but is non-compliant with rules. Residents smoking material will be put in a locked area and will be given out during smoke break and has to be a supervised smoker. Review of Resident #74 electronic chart revealed no evidence of a signed smoking agreement. Review of Resident #74's progress notes from 12/25/24 to 02/05/25 revealed no evidence that staff had met with Resident #97 to discuss the smoking policy. During an observation and interview on 02/04/25 at 02:12 PM, Resident #74 stated that he was a smoker. He stated that he went out and smoked any chance he could get. He stated that there have been times where he was outside and smoking by himself. He stated he did not have a lighter, but he got them from another resident because a few of them had lighters. He stated he got cigarettes from other residents or traded for them if he needed to. He stated he smoked cigarettes that were half smoked from other residents that he found. Review of document, not dated, posted at the nurses' station revealed Smoking Times: 10:30 AM, 1:30 PM, 3:30 PM, 7:30 PM, and 9:00 PM. During an observation and interview on 02/03/25 at 03:16 PM, multiple residents were on the smoking patio with cigarettes but no lighter to light them. Resident #74 was wheeling around with an already smoked cigarette butt asking people for a lighter. CNA A stated smoke break did not start until 3:30 but they had already passed out cigarettes. She stated all cigarettes and lighters were kept by staff and that no resident should have their own on them. CNA then lite the residents' cigarettes and started the smoke break early. During an interview on 02/04/25 at 11:47 AM, LVN B stated her only concern with the facility was the smoking. She stated there were multiple residents that had cigarettes, lighters and vapes on them. She stated the residents were not supposed to go outside and smoke unless a CNA or nurse was present. LVN B stated there were multiple residents that went outside and smoked on their own. She stated there was a smoking schedule, but it was not followed. During an interview on 02/05/25 at 10:06 AM, Admission/Marketer stated she did not know anything about who informed the residents of the smoking policy. During an interview on 02/05/25 at 02:51 PM, the Administrator stated the smoking policy was addressed and explained to all admits with the admission packet and paperwork. He stated he was not aware that it was not part of the packet. He stated no resident should have cigarettes or lighters on them. He stated he was not aware that any residents had their own or that residents were not aware of the smoking policy. He stated it was the Marketer/Admissions responsibility to ensure that residents were aware of the smoking policy on admission. He stated it was a system failure. He stated not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676416 If continuation sheet Page 9 of 12 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 676416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brightpointe at Lytle Lake 1201 Clarks Dr Abilene, TX 79602 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete reviewing the smoking policy on admission could lead to residents not knowing their rights and not knowing the expectations of the facility. He stated resident having their own cigarettes and lighters could cause many negative or harmful situations. Review of facility policy titled, Resident Smoking, dated 2024, revealed in part: Policy: It is the policy of this facility to provide a safe and healthy environment for residents, visitors, and employees, including safety as related to smoking .Policy Explanation .3.) All residents and family members will be notified of this policy during the admission process, and as needed. 4.) All residents will be asked about tobacco use during the admission process, and during each quarterly or comprehensive MDS assessment process. 5.) Residents who smoke will be further assessed, using the Resident Safe Smoking Assessment, to determine whether or not supervision is required for smoking, or if the resident is safe to smoke at all. 6.) Any resident who is deemed safe to smoke, with or without supervision, will be allowed to smoke in designated smoking area, at designated times, and in accordance with his/her care plan. Event ID: Facility ID: 676416 If continuation sheet Page 10 of 12 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 676416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brightpointe at Lytle Lake 1201 Clarks Dr Abilene, TX 79602 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure food stored in the kitchen were sealed and/or labeled properly in the facilities refrigerator #1 and freezers (#1, #2, and #4). These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses. Findings included: During an observation on 2/3/25 at 10:05 AM of facility kitchen revealed; Refrigerator #1: 1 bag of shredded cheese was unsealed and open to air. Freezer #1: 1 box of hamburger patties was unsealed and open to air. Freezer #2: 1 box of egg omelets was unsealed and open to air. Freezer #4: 1 box of mixed vegetables was unsealed and open to air. Sheet tray of red velvet chocolate chip cookies was open to the air. During an observation and interview on 2/5/25 at 3:15 PM, freezer #4 had an opened box of egg rolls. The DM stated that she would not consider that box to be sealed and open to the air. There were 3 trays of rolls sitting out, DM stated the rolls should be covered even if they are coming to room temperature. She stated she understood that all foods need to be covered and sealed and that an open box did not count as being covered or sealed. DM stated this should be done so the residents do not get sick from any contaminants that could be getting on the food . During an interview on 01/16/25 at 5:12 PM, the ADMN stated he did not know the food was exposed in the kitchen. He stated it was his responsibility as well as the DM to keep all food covered and safe. He stated the kitchen staff should have followed the facility's policies for food storage. He stated the negative impact on residents was residents could have ate contaminated foods resulting in residents getting sick. He stated that all residents ate from the kitchen. Review of the Food Safety and Sanitation Plan, dated 07/22/2021, revealed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676416 If continuation sheet Page 11 of 12 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 676416 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/05/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Brightpointe at Lytle Lake 1201 Clarks Dr Abilene, TX 79602 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 0812 - Level of Harm - Minimal harm or potential for actual harm Foods are stored off the floor .and covered. - Residents Affected - Many All cooked or prepared foods shall be protected at all times from cross contamination Review of FDA Food Code 2022: Full Document accessed on 01/31/2025 in annex 7 page 37, 38 revealed: Applicable Code Sections: 3-501.16(A)(2) and (B) Time/Temperature Control for Safety Food, Hot and Cold Holding (P) 23. Proper date marking and disposition FDA Food Code 2022 Annex 7: Model Forms, Guides, and Other Aids Annex 7 -38 IN/OUT This item should be marked IN or OUT of compliance. This item would be IN compliance when there is a system in place for date marking all foods that are required to be date marked and is verified through observation. If date marking applies to the establishment, the PIC should be asked to describe the methods used to identify product shelf-life or consume-by dating. The regulatory authority must be aware of food products that are listed as exempt from date marking. For disposition, mark IN when foods are all within date marked time limits or food is observed being discarded within date marked time limits or OUT of compliance, such as when date marked food exceeds the time limit or date-marking is not done. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676416 If continuation sheet Page 12 of 12