Inspection visit

Health inspectionMarch 22, 2023

LYTLE NURSING HOMECMS #6752958 citations on this visit

8 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 8 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0558 Reasonably accommodate the needs and preferences of each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 of 15 residents reviewed for call light: Residents Affected - Few Resident # 1's call light was not placed within reach of her . This failure could place residents who used call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being. Findings included: Record review of Resident's #1's face sheet, undated, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included: [Schizophrenia] (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).[ rheumatoid arthritis] (is an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation in the affected parts of the body) and [Chronic obstructive pulmonary disease] (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Review of Resident # 1's Quarterly MDS dated [DATE] revealed a BIMS score of 15, suggesting the patient is cognitively intact. Review of Resident #1's Quarterly MDS dated [DATE] revealed that under section G, G0300, option # 2 was selected, stating the patient is unsteady on feet and required assistance X 2. Record review of Resident # 1's care plan dated 10/21/2021 revealed keep call light within reach of resident Observation and interview on 03/19/2023 at 10:51 AM of Resident #1's room revealed that the call light was not visible. Further observation revealed Resident #1's call light was on the floor. Resident #1 stated that she did not have a call light and did not know where her call light was. She added that they (staff or roommate) took the switch. She last saw the call light a while back. Resident #1 further commented, the switch is for when you are sick .today I will YELL if I get sick. During an interview on 03/19/2023 at 10:55 AM with CNA E, she stated that Resident #1's call light was on the floor; she stated it must have fallen to the floor when making this bed this morning. She noted that the lack of accessibility of a call light could negatively affect any resident if they (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 17 Event ID: 675295 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0558 needed assistance. Level of Harm - Minimal harm or potential for actual harm During an interview on 03/19/2023 at 11:05 am with LVN F, she stated that resident #1's call light was out of reach of Resident #1. However, she confirmed that it was not normal nursing practice for one resident to be left without a call light. LVN F remarked that the absence of the call light could constitute potential harm if the resident needed assistance in an emergency. Residents Affected - Few During an interview on 03/19/22 at 11:49 AM with the DON, she stated that the facility had a call light policy and staff has been in-serviced many times to keep call light within residents reach. The DON also confirmed that Resident # 1's care plan addressed the need for a call light within reach. She said she did not know why it was not within Resident # 1's reach but would ensure all staff was in-serviced on this process again. Record review of facility policy. Answering Call Light, dated 2001, revised October 2010, revealed When a resident is in bed or a wheelchair, ensure call light is within easy reach. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 2 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident status for 1 (Resident #56) of 15 residents reviewed for assessments in that: Residents Affected - Few Resident #56's thick nectar liquids were not reflected on the MDS. This failure could affect residents at the facility who had been assessed and could contribute to inadequate care. The findings were: Record review of Resident # 56's face sheet, undated, revealed a [AGE] year-old male admitted on [DATE] with a diagnoses that included [cerebral infarction] (the pathologic process that results in an area tissue in the brain that is disrupted blood supply); [dysphagia] takes more time and effort to move food or liquid from your mouth to your stomach);[ hyperlipidemia] (high cholesterol, means too many lipids in your blood). Record review of Resident # 56's quarterly MDS dated [DATE] revealed a BIMS score of 99, suggesting the resident could not complete the interview. Record review of physicians' orders for Resident # 56, dated March 2023 revealed a physician's order for thick nectar liquids on 10/06/2022. Record review of Resident #56 's updated care plan, undated, did not reveal a care plan to address the resident's physician's order for thick nectar liquids. Record review of Residents's # 56's Quarterly MDS dated [DATE] section K, swallowing /nutritional /status,

K 0100, Z none of the above was marked revealing patient does not have a swallowing condition. Observation on 3/21/23 at 12:45 p.m. during dining observation revealed Resident #56 in a chair and she had a tray and a plate of food with lunch which consisted of hamburger steak, scalloped potatoes, glazed carrots, a dinner roll and thickened tea. Review of Resident #56's meal ticket on his tray revealed Nectar Thick Liquids Interview on 3/21/23 at 1:00 p.m. with the Food Service Manager revealed that Resident #56 was on nectar thick liquids. Interview on 3/22/23 at 10:30 a.m. with the Dietician, she stated that Resident #56 was ordered nectar thick liquids. Interview on 3/22/23 at 4:00 p.m. with the MDS nurse revealed the MDS for Resident #56 needed to reflect he was on nectar thick liquids. She stated she did not know why it was missed. She stated she was responsible for doing the MDS and the DON checked for accuracy. She stated the DON reviewed them before submission. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 3 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Interview on 3/22/23 at 5:30 p.m. with the DON revealed that it was important for the MDS to be coded accurately because it triggered areas for the resident's person-centered care plan and staff needed to know what type of diet texture the resident was on so she wouldn't choke or have difficulty eating. Review of the facility policy and procedure titled Certifying Accuracy of the Resident Assessment, revised November 2019, revealed 3. The information captured on the assessment reflects the status of the resident during the observation (look-back) period for that assessment. Different items on the MDS may have different observation periods. 4. The Resident Assessment Coordinator is responsible for ensuring that an MDS assessment has been completed for each resident. Event ID: Facility ID: 675295 If continuation sheet Page 4 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on in Interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable to avoid duplicate testing and effort for 2 of 15 resident's ( Resident #1 and Resident #10), reviewed for PASARR in that : 1. Resident #1 had a serious mental disorder that was not referred for level II review. 2. Resident #10 had a serious mental disorder and was not referred for level II review. This failure could place residents with serious mental disorders by not receiving support services. The findings were: 1. Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included: [Schizophrenia] (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation).[ rheumatoid arthritis] (is an autoimmune and inflammatory disease, which means that your immune system attacks healthy cells in your body by mistake, causing inflammation in the affected parts of the body and [Chronic obstructive pulmonary disease] (is a chronic inflammatory lung disease that causes obstructed airflow from the lungs). Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 15, suggesting the patient was cognitively intact. Further review revealed in section I, 6000 Schizophrenia entered as a diagnosis. Record review of Resident #1's physician orders dated March 2023 revealed that Resident #1 had been prescribed Rexulti for Schizophrenia on 10/21/2021. Record review of Resident #1's consent for psychiatric medication dated 01/18/2023 revealed it was signed by Resident #1, giving consent to administer medication. Record review of Resident #1's PASARR Level I screening dated 2/25/2022, revealed Is there evidence or an indicator this is an individual that has a Mental Illness? No. 2. Record review of Resident #10's face sheet, undated, revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included: [Schizophrenia] (a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation). [Alcohol Induced Dementia] (damage to their brain, caused by regularly drinking too much alcohol over many years). [Hyperlipidemia] (your blood has too many lipids, such as cholesterol and triglycerides). Record review of Resident #10's Quarterly MDS dated [DATE] revealed a BIMS score of 99, suggesting the patient could not complete the interview. Further review revealed in section I, 6000 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 5 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0644 Schizophrenia entered as a diagnosis. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #10's physician orders dated March 2023 revealed that Resident #10 had been prescribed Quetiapine Sulfate for Schizophrenia on 10/24/2019. Residents Affected - Few Record review of Resident #10's consent for psychiatric medication dated 10/24/2019 revealed it was signed by Resident #10's family, giving consent to administer medication. Record review of Resident #10's PASARR Level I screening dated 2/3/ 2023 revealed, Is there evidence or an indicator this is an individual with a Mental Illness? No. During an interview with the MDS nurse on 03/20/2023 at 10:17 a.m., the MDS nurse stated that Resident #1 and #10's PASARR Level I were correct upon admission. However, she was unaware that when the residents were placed on psychiatric medication, a PASARR II was required triggering the local health authority to come and evaluate residents for services. She said she thought this was only needed for residents with intellectual disabilities, not mental disorders. The MDS nurse further stated that Resident #1 and Resident #10 had not been referred to the local mental health authority for evaluation and should have been. The MDS nurse stated that Resident #1 and Resident #10 may have been eligible to receive specialized support services from the local mental health authority if Resident #1 and Resident #10 had been referred to the authority. The MDS nurse stated she was responsible for ensuring PASARR documentation was complete and correct. During an interview with the DON on 03/21/2023 at 2:17 p.m., the DON stated that the MDS coordinator was responsible for ensuring that PASARR documentation was complete and correct. The DON confirmed that Residents #1 and #10 may have been eligible for specialized support services from the local mental health authority if they had been referred. The DON was unable to provide a policy on PASARR. Record Review of the RAI manual updated revealed, Guidelines for Determining When a Significant Change Should Result in Referral for a Preadmission Screening and Resident Review (PASARR) Level II Evaluation: o If an SCSA occurs for an individual known or suspected to have a mental illness, intellectual disability, or related condition (as defined by 42 CFR 483.102), a referral to the State Mental Health or Intellectual Disability/Developmental Disabilities Administration authority (SMH/ID/DDA) for a possible Level II PASRR evaluation must promptly occur as required by Section 1919(e)(7)(B)(iii) of the Social Security Act.5. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 6 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to develop and implement a baseline care plan which includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 3 of 5 residents (Resident #27, Resident #31, and Resident #52) reviewed for baseline care plans. The facility failed to develop a baseline care plan for Resident #27, Resident #31, and Resident #52. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs are met. The findings included: Record review of Resident #27's face sheet revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of unspecified dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), unspecified severity, low vision (vision loss that cannot be corrected by medical or surgical treatments or conventional eyeglasses) both eyes, hypertension (high blood pressure), hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides), embolism (sudden blocking) and thrombosis (blood clots) of unspecified artery, and inflammatory disease of prostate unspecified. Record review of Resident #27's Quarterly MDS, dated [DATE], revealed Resident #27 BIMS score was 15 indicating intact cognition. Record review of Resident #27's paper chart revealed Resident #27 did not have a baseline care plan. Record review of Resident #31's face sheet revealed Resident #31 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), type 2 diabetes mellitus, schizoaffective disorder, bipolar type (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), generalized anxiety, and hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides). Record review of Resident #31's Quarterly MDS, dated [DATE], revealed Resident #31 BIMS score was 14 indicating intact cognition. Record review of Resident #31's paper chart revealed Resident #31 did not have a baseline care plan. Record review of Resident #52's face sheet revealed Resident #52 was admitted to the facility on [DATE] with diagnoses of unspecified dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), unspecified severity, hypertension (high blood pressure), overactive bladder (frequent and sudden urge to urinate that may be difficult to control), edema, wedge compression fracture of T11-T12 vertebra, and wedge compression fracture of first (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 7 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0655 lumbar vertebra. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #52's Quarterly MDS, dated [DATE], revealed Resident #52 BIMS score was 11 indicating moderate cognitive impairment. Residents Affected - Some Record review of Resident #52's paper chart revealed Resident #52 did not have a baseline care plan. During an interview on 03/22/2023 at 2:35 p.m. the DON stated the baseline care plans were to be done upon admission, however the facility hadn't been having baseline care plans with the residents or responsible party of the residents. The DON further stated the DON was responsible for completing baseline and comprehensive care plans. During an interview on 03/22/2023 at 6:50 p.m. the DON stated she was unable to provide a policy for baseline care plan. The DON further stated the facility didn't have a policy for baseline care plans. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 8 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 7 of 15 residents (Residents #1, #3, #8, #10, #13, #27, #31, and #56) reviewed for care plans in that: 1. Resident #1's diagnosis of schizophrenia was not addressed in the care plan. 2. Resident #3 received pain medications with pain not addressed in the care plan. 3. Resident #8's care plan goals and interventions were contradictory and not individualized. 4. Resident #10's diagnosis for schizophrenia was not addressed in the care plan. 5. Resident #13's care plan did not address the use of bilateral prosthesis. 6. Resident #27's received skeletal muscle relaxant with muscle spasms/pain not addressed in care plan. 7. Resident #31's care plan did not address Resident #31 being a smoker. 8. Resident # 56's care plan did not address the need for nectar thick liquids. This failure could place residents at risk of receiving inadequate goals and interventions not individualized to their care needs. The findings included: 1. Record review of Resident #1's face sheet, undated, revealed a [AGE] year-old female admitted on [DATE] with diagnoses that included: Schizophrenia [a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation]; rheumatoid arthritis [an autoimmune and inflammatory disease, which means that the immune system attacks healthy cells in the body by mistake, causing inflammation (painful swelling) in the affected parts of the body]; and chronic obstructive pulmonary disease [a chronic inflammatory lung disease that causes obstructed airflow from the lungs. Symptoms include breathing difficulty, cough, mucus (sputum) production, and wheezing. It's typically caused by long-term exposure to irritating gases or particulate matter, most often from cigarette smoke.] Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 15, suggesting the patient was cognitively intact. Record review of Resident #1's Quarterly MDS dated [DATE] revealed section I, 6000 Schizophrenia entered as a diagnosis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 9 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0656 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #1's physician orders dated March 2023 revealed that Resident #1 had been prescribed Rexulti for Schizophrenia on 10/21/2021. Record review of the care plan updated for Resident #1 did not reveal a care plan to address diagnosis of schizophrenia. Residents Affected - Some 2. Record review of Resident #3's face sheet revealed Resident #3 was admitted to the facility on [DATE] with diagnoses that included pain unspecified. Record review of Resident #3's physician progress notes with date of service date of 01/13/2023 revealed resident with the follow acute problems: chronic pain syndrome, hip pain, and debility. Record review of Resident #3's Quarterly MDS, dated [DATE], revealed Resident #3 BIMS score was 15 intact cognition and section J-Health Conditions J0100 Pain management at any time in the last 5 days, has the resident (A) been on scheduled pain medication regimen of which answer was coded yes, (B) received PRN pain medications also coded yes. Record review of Resident #3's Physician Orders dated, 03/06/2023, signed by physician read Norco 7.5-325 tablet give one tab PO Q6H PRN (NTE 4/DAY) (do not exceed 3 grams of Tylenol from all sources in 24 hours), Voltaren arthritis pain 1% gel apply 2 grams to R hand (3rd-5th finger) PRN, Voltaren Gel apply to bilateral knees QHS. Record review of Resident #3's March 2023 MAR revealed resident having received Norco 7.5-325 tablet thirty-eight times between 03/01/2023 to 03/22/2023 and Voltaren Gel applied daily to bilateral knees QHS. Record review of Resident #3's care plan printed on 03/19/2023 did not reveal a care plan to address Resident #3's pain. During an interview on 03/22/2023 at 2:59 p.m. the DON stated Resident #3 did not have a care plan for pain. The DON further stated the care plan should have been automatically drafted from the MDS when completed. The DON stated she was responsible at the time for care plans and pain would typically be care planned. The DON further stated Resident #3 did not have a care plan for pain. 3. Record review of Resident #8's Face Sheet dated 06/02/22, revealed an [AGE] year-old female admitted to facility 06/01/22 with diagnoses that included unspecified dementia, generalized anxiety disorder and heart failure. Record review of Resident #8's Quarterly MDS dated [DATE] revealed a BIMS score of 5 indicating she was severely cognitively impaired. Section B of the MDS indicated Resident #8 had minimal difficulty hearing, had unclear speech, was sometimes understood indicating she was limited to making concrete requests and sometimes understands others. Section 0 of the MDS indicated Resident #8 was on hospice care. Record review of Resident #8's undated Care Plan indicated a problem stating [Resident #8] has difficulty making self understood. The approaches for this problem included Make sure [R #8]'s notepad and pen are within reach, [R#8] uses a communication board to show you what is need, Speak to [R #8] on right side. [R #8] has left sided hearing loss, Speak to [R #8] on left side. [R #8] has right sided hearing loss, [R #8] need for you to speak directly in front to increase chance of hearing. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 10 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Resident #8's undated Care Plan indicated a problem stating [R #8] is unable to bathe independently. The goals for this problem included, [R #8] will be able to bathe independently; [R #8] will increase ability to bathe independently; [R #8] will be able to perform own shampoo; and [R #8] will be able to wash face and upper body independently. The approaches for this problem included, [R #8] prefers morning showers, [R #8] prefers evening showers, [R #8] prefers bathing in the tub in the morning, [R #8] prefers bathing in the tub in the evening, [R #8] prefers a bed bath, Occupational Therapist to work with [R #8] on ADS re-training, Physical Therapist to work with [R #8] on transfers and ambulation, One person to assist [R #8] with bathing, and Two person to assist [R #8] with bathing. Record review of Resident #8's March Physician Orders revealed Bathing/shower by Hospice 3 x week. During an interview on 03/19/23 at 12:00 pm, LVN F revealed Resident #8 had recently fractured her hip and was able to express whether or not she was in pain. LVN F also noted that Resident #8 was on hospice services. Observation of Resident #8 on 03/22/23 at 5:30 pm did not reveal a pen or notepad by bed nor a communication board. During an interview on 03/22/23 at 5:30 pm, CNA H verified that Resident #8 does not have a communication board and does not use a pen and notepad to communicate. CNA H stated Resident #8 was able to express basic needs verbally. 4. Record review of Resident #10's face sheet, undated, revealed a [AGE] year-old male admitted on [DATE] with diagnoses that included: Schizophrenia [a serious mental condition of a type involving a breakdown in the relation between thought, emotion, and behavior, leading to faulty perception, inappropriate actions and feelings, withdrawal from reality and personal relationships into fantasy and delusion, and a sense of mental fragmentation; alcohol induced dementia [damage to their brain, caused by regularly drinking too much alcohol over many years]; and hyperlipidemia [ your blood has too many lipids (or fats), such as cholesterol and triglycerides]. Record review of Resident #10's Quarterly MDS dated [DATE] revealed a BIMS score of 99, suggesting the patient could not complete the interview. Further review revealed in section I, 6000 Schizophrenia entered as a diagnosis. Record review of Resident #10's physician orders dated March 2023 revealed that Resident #10 had been prescribed Quetiapine Sulfate for Schizophrenia on 10/24/2019. Record review of the care plan update for Resident #10 did not reveal a care plan to address diagnosis of schizophrenia. 5. Record review of Resident #13's face sheet, undated, revealed a [AGE] year-old male admitted on [DATE] with a diagnosis that included: bilateral amputee [a person who is missing or has had amputated both arms or both legs; heart failure [a condition that develops when your heart doesn't pump enough blood for your body's needs and diabetes [chronic, long-lasting health condition that affects how your body turns food into energy]. Record review of Resident #13's Annual MDS dated [DATE] revealed a BIMS score of 14, suggesting the patient is cognitively intact. Further review revealed in section G 0 600 the use of a prosthesis. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 11 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0656 Level of Harm - Minimal harm or potential for actual harm Record Review of Resident #13's physicians' orders dated March 2023 revealed no orders for applying or removing leg prostheses. Record review of the care plan updated for Resident #13 did not reveal a care plan to address double amputee use of prostheses. Residents Affected - Some 6. Record review of Resident #27's face sheet revealed Resident #27 was admitted to the facility on [DATE] with diagnoses of unspecified dementia (symptoms affecting memory, thinking and social abilities severely enough to interfere with your daily life), unspecified severity, low vision (vision loss that cannot be corrected by medical or surgical treatments or conventional eyeglasses) both eyes, hypertension (high blood pressure), hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides), embolism (sudden blocking) and thrombosis (blood clots) of unspecified artery, and inflammatory disease of prostate unspecified. Record review of Resident #27's Quarterly MDS, dated [DATE], revealed Resident #27 BIMS score was 15 indicating intact cognition. Record review of Resident #27's Nurse's Notes dated 02/28/2023 read Resident c/o muscle spasms to bilateral LE [lower extremities] on over nights dr. notified. Received new order for increase to Baclofen . Record review of Resident #27's Physician Orders Dated 03/06/2023 signed by physician read Baclofen 5mg tab give 1 PO TID for Spasms. Record review of Resident #27's care plan printed on 03/19/2023 did not reveal a care plan to address muscle spasms or pain with Resident #27 having received muscle relaxing medication regularly. During an interview on 03/22/2023 at 2:39 p.m. the DON stated muscle spasms would not be care planned however, the pain caused by them should be care planned. The DON further stated pain was not care planned for Resident #27. 7. Record review of Resident #31's face sheet revealed Resident #31 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), type 2 diabetes mellitus, schizoaffective disorder, bipolar type (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), generalized anxiety, and hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides). Record review of Resident #31's Quarterly MDS, dated [DATE], revealed Resident #31's BIMS score was 14 indicating intact cognition Record review of Resident #31's care plan printed on 03/19/2023 did not reveal a care plan to address Resident #31 was a smoker. During an interview on 03/22/2023 at 10:01 a.m. Resident #31 stated he gets two cigarettes during each smoke break and the breaks were at 9:00 a.m., 1:30 p.m., and 3:00 p.m. He further stated he didn't always go out to smoke every day and had missed some smoke breaks due to the facility taking residents out earlier. Resident #31 stated he was familiar with the facility's smoking policy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 12 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 03/22/2023 at 2:56 p.m. the DON stated Resident #31 was a smoker and he smoked during every smoke break. The DON stated smokers should have care plans regarding smoking so it would make staff aware of whether the resident was a safe smoker, need for smoking apron or the need for supervision. The DON further stated Resident #31 did not have a care plan for smoking. 8. Record review of Resident #56's face sheet, undated, revealed a [AGE] year-old male admitted on [DATE] with a diagnosis that included cerebral infarction [the pathologic process that results in an area tissue in the brain that is disrupted blood supply]; dysphagia [takes more time and effort to move food or liquid from the mouth to the stomach]; hyperlipidemia [high cholesterol, means too many lipids [fats] in the blood]. Record review of Resident's #56 quarterly MDS dated [DATE] revealed a BIMS score of 99, suggesting the resident could not complete the interview. Record review of Resident #56's physicians' orders dated March 2023 revealed a physician's order for nectar thick liquids on 10/06/2022. Record review of the updated care plan for Resident #56 did not reveal a care plan to address the resident's physician's order for nectar thick liquids. During an interview on 03/21/23 at 3:00 p.m., the DON stated she was responsible for care plans and does not know why care plans were not individualized but would ensure that they were moving forward; she would pay close attention to ensure all care plans were patient centered. The DON stated the care plans were auto populated after doing the MDS and they come as a draft. The DON or MDS Coordinator must then take out the goals and interventions that do not apply to the resident. The DON stated this had not been done with the current care plans. The DON stated the care plan should be patient centered and ensure all team members were on the same page at the same time, allowing for positive patient outcomes. The DON stated the residents risked the possibility of not having all team members on the same page regarding patient care. During an interview on 3/22/23 at 1:15 p.m. the Administrator stated that the DON was responsible for developing and revising the care plan as needed. The administrator said, the purpose of the care plan is to have some information available to the staff on how to take care of the resident. The care plan should accurately describe what the resident is like. He said he expected all care plans in his building to be completed and reflect the whole picture. Record review of facility policy Care Plans, Comprehensive Person-Centered, 2001 revised December 2016, revealed Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's condition changes. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 13 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that residents received appropriate treatment and services to prevent urinary tract infections for 1 of 15 residents (Resident #51) who were reviewed for indwelling urinary catheter care, in that: a. Resident #51's indwelling urinary catheter (suprapubic urinary catheter) tubing touched the floor. b. Resident #51's catheter anchor was not placed on the leg These failures could affect residents with indwelling urinary catheters and place them at risk of urinary tract infections. The findings were: Record review of Resident #51's face sheet, undated, revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included: [Benign prostatic hyperplasia] (is also called an enlarged prostate; symptoms include blocking urine flow from the bladder). [Hyperthyroidism] (happens when the thyroid gland makes too much thyroid hormone symptoms include weight loss, hand tremors, and rapid or irregular heartbeat). [Diabetes]( is a chronic health condition that affects how your body turns food into energy). Record review of Resident #51's Quarterly MDS, dated [DATE], revealed the resident had a BIMS of 99, which indicated that Resident #51 could not conduct an interview. Record review of Resident #51's physician order, dated 11/07/2022, revealed the order change catheter with 22 French every month. Record review of Resident #51's care plan undated, revealed a secure catheter to thigh to prevent pulling and keep tubing off the floor. a. Observation on 03/19/2023 at 11:22 AM revealed Resident #51 was in bed sleeping Further observation revealed that Resident # 51's indwelling urinary catheter tubing was touching the floor, and no anchor was in place. During an interview with CNA A on 03/19/2023 at 11:27 AM, CNA A , stated that Resident #51's indwelling urinary catheter tubing was touching the floor, and no anchor was in place to prevent catheter pulling. During an interview with RN D on 3/19/2023 at 1135 am, RN D stated that Resident # 51's catheter tubing was on the floor and Resident # 51's foley catheter was not secured with an anchor. She stated she did not know where to find an anchor and would ensure weekend staff knew that catheter tubing should not be on the floor. This was not good nursing practice and could lead to possible urinary infections and risked the catheter being pulled from the urethra by not being secured. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 14 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview with LVN B on 3/19/2023 at 1130 am, LVN B stated she was the charge nurse for Resident #51. She stated that the foley catheter tubing for Resident #51 was on the floor, and Resident #51's foley catheter was not secured in place. She did not know why the foley catheter was not secured and the catheter tubing was on the floor; she stated that everything was in place when she did rounds at the start of the shift. She noted that the resident risked a possible urinary infection by catheter tubing being on the floor and risked possibly the catheter being pulled from the urethra by it not being secured in place with an anchor. During an interview with the DON on 03/20/2023 at 10:33 AM, the DON stated that Resident #51's indwelling urinary catheter tubing should not have been touching the floor and that Resident # 51's catheter should have been secured with an anchor. She stated that all staff had been in-serviced regarding not allowing catheter tubing to touch the floor to prevent urinary infections, including ensuring all residents wearing a catheter should have them secured with an anchor. The DON stated she did not know this deficient practice occurred but would in-service all staff again. The DON noted the possible risk to the resident by not wearing an anchor could lead to the catheter accidentally being pulled out, causing trauma to the area, and by catheter tubing being on the floor resident risked a possible kidney infection as urine bacteria could travel through the tubing and make their way into the kidneys, causing a urinary infection. Record review of facility policy Catheter Care Urinary, dated 2001, revised September 2014, revealed, Be sure to catheter tubing is kept off the floor, ensure catheter remains secured with a leg strap. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 15 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview, the facility failed to provide 3 of 35 double occupancy resident rooms (rooms [ROOM NUMBER]) with at least 80 square feet per resident in that: Rooms 27, 28 and 34 did not have the required minimum of 80 square feet per resident. This failure could affect residents placed in these multiple occupancy rooms by reducing their living space. The findings included: Observation on 03/21/2023 by life safety code revealed the following measurements of resident room dimensions for the room size waiver: 1. room [ROOM NUMBER] (two-person room) had a total of 157.34 square feet and 78.67 square feet per resident. 2. room [ROOM NUMBER] (two-person room) had a total of 156.79 square feet and 78.40 square feet per resident. 3. room [ROOM NUMBER] (two-person room) had a total of 141.94 square feet and 70.97 square feet per resident. Review of the Bed Classifications form 3740, dated 03/20/2023 revealed each room had two beds. room [ROOM NUMBER]a was occupied, room [ROOM NUMBER]b was occupied, room [ROOM NUMBER]a was occupied, 28b was occupied, room [ROOM NUMBER]a was unoccupied and room [ROOM NUMBER]b was occupied. During an interview with the Administrator on 03/21/2023 at 5:07 p.m., he stated the dimensions for rooms 27, 28 and 34 had less than the 80 square feet per resident in the rooms and stated he would like to continue with the room size waiver for the resident rooms. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 16 of 17 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 675295 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/22/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Lytle Nursing Home 15366 Oak St Lytle, TX 78052 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 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to implement establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, and smoking safety for 1 (Resident's #31) of 6 residents reviewed did not have their smoking assessment. Residents Affected - Few The facility failed to ensure Resident #31 was assessed for safe smoking per the facility policy. This failure could affect smoking residents and could result in harm if policies were not followed. The findings included: Record review of Resident #31's face sheet revealed Resident #31 was admitted to the facility on [DATE] with diagnoses of hypertension (high blood pressure), type 2 diabetes mellitus, schizoaffective disorder, bipolar type (mental health disorder that is marked by a combination of schizophrenia symptoms, such as hallucinations or delusions, and mood disorder symptoms, such as depression or mania), generalized anxiety, and hyperlipidemia (blood has too many lipids (or fats), such as cholesterol and triglycerides). Record review of Resident #31's Quarterly MDS, dated [DATE], revealed Resident #31's BIMS score was 14 indicating intact cognition. Record review of Resident #31's assessments revealed Resident #31 did not have a smoking assessment. Record review of Resident #31's care plan printed on 03/19/2023 did not reveal a care plan to address Resident #31 was a smoker. During an interview on 03/20/2023 at 9:39 a.m. the DON stated a smoking assessment should be completed upon admission and all smokers should have one. The DON further stated the nurse on the hall who admitted the resident should complete the assessment. The DON after having looked through Resident #31's medical chart stated Resident #31 did not have an assessment for smoking. The DON then stated the smoking assessment was used to determine a resident's safety level when smoking and whether a resident needs supervision, or a smoking apron to protect resident. During an interview on 03/22/2023 at 10:01 a.m. Resident #31 stated he gets two cigarettes during each smoke break and the breaks were at 9:00 a.m., 1:30 p.m., and 3:00 p.m. He further stated he didn't always go out to smoke every day and had missed some smoke breaks due to the facility taking residents out earlier. Resident #31 stated he was familiar with the facility smoking policy During an interview on 03/22/2023 at 2:56 p.m. the DON stated Resident #31 was a smoker and he smoked during every smoke break. Record review of the facility's Nursing Home Smoking Policy revealed under Purpose:, To provide safety for all resident and employees. 1) Residents will be assessed upon admission and as needed for smoking safety. 2) If a resident demonstrates the ability to safely smoke during their assessment, resident may smoke in designated area. If a resident cannot demonstrate the ability to safely smoke during their assessment, resident may smoke with supervision. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 17 of 17

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Citations

8 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0655GeneralS&S Epotential for harm
F655 - Comprehensive Person-Centered Care Planning
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
0656GeneralS&S Epotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0912GeneralS&S Dpotential for harm
F912 - Measure at least 80 square feet per resident in multiple resident
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
0926GeneralS&S Dpotential for harm
F926 - Establish policies, in accordance with applicable Federal, State, and
Have policies on smoking.
0558GeneralS&S Dpotential for harm
F558 - The right to reside and receive services in the facility with reasonable
Reasonably accommodate the needs and preferences of each resident.
0641GeneralS&S Dpotential for harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0644GeneralS&S Dpotential for harm
F644 - Coordination
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

FAQ · About this visit

Common questions about this visit

What happened during the March 22, 2023 survey of LYTLE NURSING HOME?

This was a inspection survey of LYTLE NURSING HOME on March 22, 2023. The surveyor cited 8 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at LYTLE NURSING HOME on March 22, 2023?

Yes, 8 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted"

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.

Data from CMS Care Compare public records. Dataset last refreshed June 22, 2026. If you believe any information is inaccurate, report it here.

Health inspection·March 22, 2023