Health inspection·January 9, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few up emails from that far back. The Administrator stated he would have forwarded the email to the MDS nurse who handled PASRR paperwork. The Administrator stated residents were at risk of not getting PASRR services if the paperwork was not properly completed. During an interview on 01/09/2024 at 12:13 p.m. the MDS nurse stated she did receive the email from the Administrator on September 29th, 2023, but did not do anything with it because she thought she had submitted all the necessary paperwork. The MDS nurse stated she was not familiar with the NFSS form and did not think she needed to submit any further paperwork despite the email describing how to submit the form and providing a due date. The MDS nurse stated if PASRR paperwork was not properly completed a resident was at risk of missing out on services. During an interview on 01/09/2024 at 1:24 p.m. the DON stated she had not seen the email requesting the NFSS form be submitted until that moment. The DON stated the MDS nurse should have filled out the form and the Administrator should have followed up on it because it was sent to him with detailed instructions. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, stated policy statement: a comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy interpretation and implementation .8. The comprehensive, person-centered care plan will: .d. Describe any specialized services to be provided as a result PASARR recommendations. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 2 of 6 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 01/09/2024 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 - Few 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 that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for comprehensive care plans in that: Resident #1's comprehensive care plan did not address refusal for select PASRR services. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed and accessible to address their specific needs. The findings included: Record review of Resident #1's admission record, dated 11/06/2023, revealed a [AGE] year-old female who admitted on [DATE] with diagnosis that included dementia, pain, schizophrenia, major depressive disorder, and bradycardia (slow heart rate). Record review of Resident #1's Annual MDS assessment, dated 12/01/2023, reflected a BIMS score of 5, indicating severe cognitive impairment. Record review of Resident #1's care plan, date initiated 08/30/2023, revealed Resident #1's was PASRR positive and was entitled to services recommended by PASRR with approaches including 1. Staff to assist resident #1 caseworker with obtaining any needed information 2. IDT meeting as per state requirements with PASRR guardian, DON, MDS coordinator, LAR and whoever else is appropriate for this meeting. 3. Ensure NFSS forms are provide to TMHP in a timely manner to ensure that services are provided to Resident #1 as recommended by PASRR 4. Receiving PT/ OT/ ST services with habilitative therapy services 5. resident #1 will receive provider coordinator services for monthly outings 5. communicate regularly with representative regarding services: [representative e-mail]. Goal: Resident #1 will receive all services recommended by PASRR over the next 90 days. Resident #1's care plan from 08/30/23 did not document any refusal for services. During an interview on 01/05/2024 at 1:04 p.m. the Rehab Director stated Resident #1 participated in PT and OT services depending on her mood. The Rehab Director stated some days she would refuse PT or OT services. The Rehab Director stated Resident #1 was enrolled in ST services but refused to participate so they discharged her. During an interview on 01/05/2024 at 1:28 p.m. the MDS nurse stated Resident #1 received day habilitation, habilitation coordination, and independent living skills trainings through PASRR services. The MDS nurse stated Resident #1 was going to the school for day habilitation and declined and did not want to go back. During an interview on 01/05/2024 at 3:11 p.m. Resident #1 stated she did not know what PT was but that she did exercise sometime using a bike and did hand exercises. Resident #1 ended the interview and stated she wanted to sleep. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 3 of 6 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 01/09/2024 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 - Few During an interview on 01/05/2024 at 3:25 p.m. the DON stated Resident #1 received services that included therapy, monthly outings, and refused to go to day habilitation because she felt like it was work. The DON was asked if they document refusals anywhere and she stated it might be in documents that have left the facility. No documentation was provided. During an interview on 01/05/2024 at 10:45 p.m. the QIDP PASRR Director [from a non-profit program] stated Resident #1 received life skills training by going on a monthly outing. The QIDP stated the resident had only been on two outings since qualifying for services in May of 2023 because she did not have personal funds needed the other times the life skills training personnel arrived to take her out. The QIDP stated she had a meeting with the facility to remove the day habilitation service because Resident #1 did not want to participate any longer. Record review of the facility's policy titled Comprehensive Assessment and the Care Delivery Process, dated 12/2016, stated Policy statement, comprehensive assessment will be conducted to assist in developing person centered care plans. Policy interpretation and implementation 1. comprehensive assessments, care planning and the care delivery process involved collecting and analyzing information, choosing and initiating interventions, and then monitoring results and adjusting interventions .5. Monitoring results and adjusting interventions includes: a. periodically reviewing progress and adjusting treatments. (1) Continue to define or refine the objectives of specific treatments as well as overall care and services .7. Completed assessment (baseline, comprehensive, MDS, etc.) are maintained in the residents' active record for a minimum of 15 months. These assessments are used to develop, review and revise the resident's comprehensive care plan. Record review of the facility's policy titled Care Plans, Comprehensive Person-Centered, dated 12/2016, stated policy statement: a comprehensive, person centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. The policy interpretation and implementation .8. The Comprehensive, person-centered care plan will .c. Describe services that would otherwise be provided for the above, but are not provided due to the residents exercising his or her rights, including the right to refuse treatment .15. The resident has the right to refuse to participate in the development of his/ her care plan and medical and nursing treatments. Such refusals will be documented in the residence clinical record in accordance with established policies. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 4 of 6 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 01/09/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 4 residents (Resident #1 and #2) reviewed for accuracy of medical records in that: Resident #1 and Resident #2 comprehensive care plan was not accessible to all staff in the medical records system. This deficient practice could affect residents whose records were maintained by the facility and place them at risk for errors in care and treatment. The findings included: 1. Record review of Resident #1's admission record, dated 11/06/2023, revealed a [AGE] year-old female who admitted on [DATE] with diagnosis that included dementia, pain, schizophrenia, major depressive disorder, and bradycardia (slow heart rate). Record review of Resident #1's Annual MDS assessment, dated 12/01/2023, reflected a BIMS score of 5, indicating severe cognitive impairment. Record review of Resident #2's admission record, dated 11/06/2023, revealed a [AGE] year-old female who admitted on [DATE] with diagnosis that included dysphagia, type 2 diabetes, and generalized anxiety disorder. Record review of Resident #2's BIMS assessment, dated 06/02/2023, reflected a BIMS score of 12, indicating moderately impaired cognition. Record review of Resident #1's and Resident #2's paper medical records revealed no baseline or comprehensive care plans. During an interview on 01/09/2024 at 12:44 p.m. the MDS nurse stated all resident records are kept in paper chart at the facility. The MDS nurse stated they do not keep the baseline or comprehensive care plans in the paper record charts. The MDS nurse stated she had the care plans for all residents at the facility on her computer and they could be accessed by her only. The MDS nurse stated the DON was recently shown how to access the care plans because she was out for personal reasons the week before and no one was able to access the care plans. The MDS nurse stated the purpose of the care plans was to show individualized characteristics for each residents' care needs. The MDS nurse stated all staff should have access to the care plans and they planned on printing care plans out for all residents and adding them to the paper charts. The MDS nurse said floor staff that do not have the ability to access the resident's care plan could possibly not be aware of the individual residents' care needs and not provide the proper care. During an interview on 01/09/2024 1:24 p.m. the DON stated the MDS nurse had access to the care plans on her computer where she created them. The DON stated if this surveyor requested a comprehensive care plan, she could request one from the MDS nurse. The DON stated the prior week the MDS nurse was out of the facility and the DON could have asked the MDS nurse for her computer password to access (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 5 of 6 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 01/09/2024 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few resident care plans if needed. The DON stated the facility planned to switch to an electronic medical record system, but all records were on paper at that time. The DON stated the purpose of a care plan was to take care of the resident as an individual because not every resident was the same and they have different needs. The DON stated there was no risk to the resident if all staff did not have access to resident care plans because all of the staff had worked at the facility for a long time and they knew the residents needs well. Record review of the facility's policy titled Comprehensive Assessment and the Care Delivery Process, dated 12/2016, stated Policy statement, comprehensive assessment will be conducted to assist in developing person centered care plans. Policy interpretation and implementation .7. Completed assessment (baseline, comprehensive, MDS, etc.) are maintained in the residents' active record for a minimum of 15 months. These assessments are used to develop, review and revise the resident's comprehensive care plan. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 6 of 6