Health inspection·July 17, 2025

F 0553 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete attending a quarterly review meeting. Interview with Resident #'3 sister on 7/16/25 at 1:48 revealed she had not attended a formal care plan review meeting. Interview with Resident #4 on 7/16/25 at 1:15 PM was unsuccessful due to low cognitive functioning skills. Interview with Resident #4's sister on 7/16/25 at 1:20 PM was incomplete due to no response. Interview with Resident #8 on 7/16/25 at 2:00 PM revealed Resident #8 did not recall attending a formal care plan conference but did state that she has talked with the staff individually about her care needs.Interview on 7/16/25 at 2:09 PM with the ADON revealed the facility did not have a record or sign in sheet indicating that resident and/or representative were invited to, informed of, attended and participated in or did not attend and participate in quarterly care plan review interdisciplinary meetings. Interview on 7/16/25 at 3:42 PM with the facility SW revealed the facility did not notify the resident or representatives of scheduled care plan interdisciplinary meetings. The SW stated the ADON, or the DON would call the representative at the time of the care plan meetings. Interview on 7/17/25 at 3:30 PM with the DON revealed that she was not aware the facility did not send or document notification to the resident and/or their representative of scheduled care plan meetings and acknowledged that failure to include the resident and/or their representative in the quarterly review meetings could place the resident at risk for identifying and treating the resident's physical, social and mental needs. Interview on 7/17/25 at 3:30 PM with the ADM revealed that he was not aware the residents and/or their representatives were not being informed of review meeting. Review of facility policy, titled Care Plans, Comprehensive Person-Centered, revised December 2016, read: 1. The inter-disciplinary team (IDT) in conjunction with the resident and his/her family or legal representative, develops and implements a comprehensive, person-center care plan for each resident. 2. The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 14. The Interdisciplinary team must review and update the care plan: d. At least quarterly, in conjunction with the required quarterly MDS assessment. Event ID: Facility ID: 675295 If continuation sheet Page 2 of 11 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 07/17/2025 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 0638 Assure that each resident’s assessment is updated at least once every 3 months. 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 assess each resident for using the quarterly review instrument specified by the State and approved by CMS in a timely manner for 2 of 2 residents reviewed for timely assessments, in that:1. Resident #3's last Quarterly MDS was completed 3/14/25 and the Quarterly MDS dated [DATE] was opened but not completed and transmitted.2. Resident #16's last Quarterly MDS was completed 9/5/24, and no additional MDS had been initiated. This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information. The findings were: Record review of Resident #3's face sheet (undated) revealed a [AGE] year-old female admitted [DATE]. Diagnoses include cerebral atherosclerosis (a condition where the arteries in the brain become thickened and hardened), vascular dementia (brain damage caused by multiple strokes), Diabetes Type II (long term condition in which the body has trouble controlling blood sugar), Hypertension (high blood pressure), psychosis (mental disorder characterized by a disconnection from reality), seizures (uncontrolled jerking caused by abnormal electrical activity in the brain) and Chronic kidney Disease (longstanding disease of the kidneys). Record review of Resident #3's BIMS assessment dated [DATE] revealed a score of 7 indicating severe cognitive impairment. Record review of Resident #3's MDS Assessment list revealed her Quarterly MDS, dated [DATE] had been initiated but was not completed or submitted to CMS. Record review of Resident #16's face sheet (undated) revealed a [AGE] year-old male admitted [DATE]. Diagnoses included Hypertension (high blood pressure), seizure disorder (uncontrolled jerking caused by abnormal electrical activity in the brain), hyperlipidemia (high cholesterol), depression, and insomnia. Record review of Resident #16's BIMS assessment dated [DATE] revealed score of 8 indicating moderate cognitive impairment. Record review of Resident #16's MDS assessment list revealed his Quarterly (comprehensive) assessment was last completed 9/5/24 and no additional quarterly assessment has been initiated. Interview on 7/17/25 with MDS 1 revealed that she was behind on the quarterly assessments and had assessments that were incomplete. Interview on 7/17/25 at 3:30 PM with the DON revealed that she was overall responsible for ensuring MDSs were completed timely and accurately. The DON stated, failure to submit MDSs timely could create inaccurate data for the facility. The MDS Coordinator was asked for a policy on MDS record completion and submission, and the policy was not received prior to survey exit on 7/17/25. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 3 of 11 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 07/17/2025 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 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure that residents were free from any significant medication errors, for 1 of 5 residents (Resident #37) reviewed for significant medication administration errors. LVN A intended to administer Resident #37's Lacosamide, a medication used to control seizures, by crushing the medication contrary to the physician's orders and the pharmacist's recommendations. This failure could place residents at risk for not receiving the intended therapeutic effects of their prescribed medications.The findings included: A record review of Resident #37's Face Sheet dated 1/15/2025 revealed an admission date of 3/17/2023 with diagnoses which included seizures (a sudden burst of electrical activity in the brain. It can cause changes in behavior, movements, feelings and levels of consciousness.) A record review of Resident #37's quarterly MDS assessment dated [DATE] revealed Resident #37 was a [AGE] year-old male admitted for long term care and assessed with a BIMS score of 10 out of a possible 15 which indicated moderate cognitive impairment. A record review of Resident #37's physician's orders revealed on 12/16/2024 the physician prescribed that Resident #37 should receive lacosamide 100mg by mouth twice a day for recurrent seizures. Further review revealed on 3/24/2025 the physician prescribed for Resident #37 to receive crushed medications, crush crushable meds and serve with pudding or jelly every shift. A record review of Resident #37's medication card labeled, (Resident #37) Lacosamide tab 100mg take 1 tablet by mouth twice daily . swallow whole. Do not chew or crush. A record review of Resident #37's care plan dated 3/18/2025 revealed, (Resident #37) is at risk for injuries due to reoccurring and worsening seizure activity . lacosamide . 1. Nurse to administer anticonvulsant medication as ordered. During an observation and interview on 7/17/2025 at 9:47 AM revealed LVN A prepared to administer Resident #37's lacosamide 100mg tablet by crushing the tablet. The State Agency Surveyor intervened and inquired what LVN A's intentions were. LVN A replied, I am crushing his medications which included the lacosamide. The State Agency Surveyor intervened and requested LVN A to re-examine Resident #37's lacosamide medication card, specific to the pharmacy's administration recommendations. LVN A reviewed the lacosamide medication card and stated do not crush . I will not crush it. During an interview on 7/17/2025 at 2:24 PM the Pharmacist stated Resident #37's lacosamide should not be crushed and the risk to Resident #37 could be he would not receive the therapeutic effects of the prescribed medication and may have adverse reactions to include dizziness. During an interview on 7/17/2025 at 11:00 AM the DON stated Resident #37 had physician's orders to receive crushed medication for medications that could be crushed, however lacosamide was a medication identified by the Pharmacist to not be crushed. The DON stated she reported to the physician and received a new order for Resident #37 to receive liquid lacosamide. The DON stated LVN A should have followed the administration instructions labeled on the medication card. During an interview on 7/17/2025 at 4:40 PM the Administrator stated he concurred with the DON and the Pharmacist that LVN A should have not attempted to crush and administer Resident #37's lacosamide and should have read the medication card administration instructions. A record review of the facility's Adverse Consequences and Medication Errors policy dated April 2024, revealed, 1. Residents receiving any medication that has a potential for an adverse consequence will be monitored to ensure that any such consequences are promptly identified and reported.2. An adverse consequence is defined as an unpleasant symptom or event that is due to or associated with a medication, such as an impairment or decline in an individual's mental or physical condition or functional or psychosocial status. An adverse consequence may include:a. Adverse drug/medication reaction;b. Side effect;c. Medication-medication interaction; ord. Medication-food interaction.3. An adverse drug reaction (ADR), a form of adverse consequences, Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 4 of 11 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 07/17/2025 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 0760 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete is defined as a secondary and usually undesirable effect of a drug and is different from the therapeutic and helpful effects of the drug. An ADR is any noxious and unintended response to a drug and occurs in doses for prophylaxis, diagnosis or therapy.4. The staff and practitioner shall strive to minimize adverse consequences by:a. Following relevant clinical guidelines and manufacturer's specifications for use, dose, administration, duration, and monitoring of the medication; . A medication error is defined as the preparation or administration of drugs or biological which is not in accordance with physician's orders, manufacturer specifications, or accepted professional standards and principles of the professional(s) providing services.6. Examples of medications errors include:e. Wrong dosage form (e.g., liquid ordered, capsule given); . A record review of the United States of America's National Library of Medicines' website https://medlineplus.gov/druginfo/meds/a609028.htmlTitled, Lacosamide accessed 7/17/2025, revealed, How should this medicine be used?Lacosamide comes as a tablet, a capsule, and as a solution (liquid) to take by mouth. The tablet and oral solution are usually taken twice a day with or without food. The capsule is usually taken once a day with or without food. Take lacosamide at around the same time(s) every day. Follow the directions on your prescription label carefully and ask your doctor or pharmacist to explain any part you do not understand. Take lacosamide exactly as directed. Do not take more or less of it or take it more often than prescribed by your doctor. Swallow the tablets and capsules whole; do not chew, split, open, or crush them. Event ID: Facility ID: 675295 If continuation sheet Page 5 of 11 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 07/17/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure the storage of all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys, for 1 of 43 residents (Resident #10) reviewed for medication storage. The DON failed to secure Resident #10's, 30 pills of trazadone 50mg (a drug used to treat depression), when the pills were left unattended and unsecured on the nurse's station desk for 2 hours. This failure could place residents at risk for not receiving the therapeutic effects of the drugs prescribed.The findings included: A record review of Resident #10's admission record dated 7/17/2025 revealed an admission date of 8/12/2022 with diagnoses which included generalized anxiety disorder and depression. A record review of Resident #10's Quarterly MDS assessment dated [DATE] revealed Resident #10 was a [AGE] year-old male admitted for LTC and assessed with a BIMS Score of 10 which indicated moderate cognitive impairment. Further review revealed the resident had episodes of depression for the 2 weeks reviewed 5/19/2025 through 6/2/2025. A record review of Resident #10's physician's orders dated 7/17/2025 revealed the physician, on 8/28/2023, prescribed for Resident #10 to receive daily trazadone 50 mg 1 tablet by mouth at bedtime for, insomnia due to other mental disorder. A record review of Resident #10's care plan dated 7/17/2025 revealed, (Resident #10) is at risk for depression and is receiving antidepressant medications *TRAZODONE . *Staff to observe (Resident #10) for adverse side effects, document and report to physician. *Nurse to monitor and record (Resident #10's) target behaviors restless, anxiousness, etc. *Pharmacy consultant to review (Resident #10's) medication monthly for increase or decrease of dose. During an observation on 7/13/2025 at 12:11 PM revealed the nurses station desktop had Resident #10's trazadone medication card atop of the desktop. The medication card was dated 7/14/2025 and was labeled with Resident #10's name, the drug name, and the drug strength, (Resident #10), Trazadone 50mg. The card had 30 pills stored in a blister pack. During observations of the nurse station desktop from 12:11 PM to 2:11 PM revealed Resident #10's trazadone medication continued to be unsecured atop of the nurse's station desk. The desk was in a public space and observations of staff, residents, and visitors revealed they had ambulated by the nurse station. During an interview on 7/13/2025 at 2:12 PM the DON stated Resident #10's medication regiment had been reviewed by the Pharmacist mid-June 2025, and the Pharmacist had made recommendations for a GDR (Gradual Dose Reduction) for Resident #10's Trazadone to which the physician agreed and reduced Resident #10's dosage of trazadone from 50mg to 25mg daily. The DON stated she was handed Resident #10's card of 30 pills of 50mg trazadone by a nurse so the DON could return the 50mg pills to the pharmacy. The DON stated she was at the nurse station and placed the medication card atop of the desk around noon and had intended to begin the process to return the medication to the pharmacy when she became distracted and left the medications atop of the desk. The DON stated the policy, and procedure was for all medications to be locked away and not available to anyone other than nurses and herself. The DON stated the potential risk for residents was loss of control of their medications. During an interview on 7/17/2025 at 4:00 PM the Administrator stated the DON had reported she had left Resident #10's medications at the desk at the nurse's station, unattended, and unsecured. The Administrator stated that was not acceptable and stated per the facility's policies and procedures all medications should be secured and not accessible to anyone other than nurses. The Administrator stated the potential risk for residents was loss of control of their medications. A record review of the facility's policy titled, Storage of Medications dated April 2019, revealed, Policy StatementThe (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 6 of 11 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 07/17/2025 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation1. Drugs and biologicals used in the facility are stored in locked compartments under proper temperature, light and humidity controls.2. Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they are received. Only the issuing pharmacy is authorized to transfer medications between containers.3. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed. Event ID: Facility ID: 675295 If continuation sheet Page 7 of 11 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 07/17/2025 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, and or distributed in accordance with professional standards for food service safety, for 1 of 1 facility's reviewed for professional standards for food service safety, in that: 1. The snack cart had expired thickened tea available for serving to residents and sandwiches without labels. 2. One gallon of unidentified juice dated 06/30/2025 was located in walk-in cooler, unknown if that was the open date, prepared date or use by date. 3. Pantry items were improperly stored on the floor without the use of a pallet to include 1 case of canned [NAME] Pasado beans, 1 case of canned pie filling, 1 case of oatmeal cream pies, 1 case of dill pickle relish, 1 case of quaker oats, 1 case of yellow frying corn. This failure could place residents at risk for food borne illness. The findings included: During an observation and interview on 7/15/2025 at 4:30 PM of the facility's pantry room revealed a wheeled snack cart with a bottle of half empty thickened iced tea beverage with a handwritten date of 6/21/2025. Further review of the bottles label revealed, Storage and handling: store in cool, dry, place. Refrigerate unused portion. Discard if not used within 10 days of opening. Further observation revealed the cart had six peanut butter and jelly sandwiches in clear plastic bags. The sandwiches were without labels. LVN B stated the bottle of iced tea, and the sandwiches were available to be served to residents. LVN B stated the bottle of iced tea was dated 6/21/2025 and the manufactures label stated to discard after 10 days of opening the bottle. LVN A stated she did not know if the date on the bottle was when the kitchen received the bottle from the supplier or if the date indicated when the bottle was opened. LVN B stated the six sandwiches had no labels to indicate when the sandwiches were made or when they should be discarded. LVN B stated she did not know if the sandwiches were safe to serve and would report to the FSM. During an observation and interview on 7/15/2025 at 4:40 PM the FSM received a report from LVN B along with the bottle of iced tea from the snack cart. The FSM stated the kitchen made and distributed snacks three times a day to include snacks after breakfast, after lunch and after dinner. The FSM stated the leftover snacks would be discarded when the fresh snacks were delivered. The FSM stated the sandwiches should have a date label to indicate when they were made. If staff identified sandwiches older than 24 hours, the sandwiches would be discarded. The FSM stated the sandwiches that did not have a date should be discarded. The FSM stated the kitchen ordered and received thickened liquids to include iced tea. The FSM stated the bottles were labeled with a handwritten marker with the date they were received from the supplier. The FSM stated the bottle should be dated with the date the bottle was opened as well. The FSM stated the 1/2 full bottle of iced tea with only 1 date, 6/21/2025, should be discarded because the open date was not on the bottle and thus could not be identified if the bottle was more than 10 days after opening. The FSM stated the risk to residents receiving expired foods was food borne illnesses. During an interview on 7/17/2025 at 4:30 PM the Administrator concurred with the FSM that the snacks should be dated the day they were made and or received and a date they were opened and a date they should be discarded. A record review of the facility's Food Receiving and Storage policy dated July 2014, revealed, Policy Statement: Foods shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents.14. Food items and snacks kept on the nursing units must be maintained as indicated below:a. All food items to be kept below 41 F must be placed in the refrigerator located at the nurses' station and labeled with a use by date. Event ID: Facility ID: 675295 If continuation sheet Page 8 of 11 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 07/17/2025 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 FORM CMS-2567 (02/99) Previous Versions Obsolete 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 a record of resident's activity assessments for 2 of 2 [Resident #3, Resident #16] residents reviewed for accuracy of records.The facility failed to ensure Resident #3 and Resident #16 had quarterly evaluations and assessments for activities. This failure could place residents at risk for decline in quality of life and poor psychosocial well-being due to not identifying resident's activity preferences and needs. The findings included:Record review of Resident #3's face sheet (undated) revealed a [AGE] year-old female admitted [DATE]. Diagnoses include cerebral atherosclerosis (a condition where the arteries in the brain become thickened and hardened), vascular dementia (brain damage caused by multiple strokes), Diabetes Type II (long term condition in which the body has trouble controlling blood sugar), Hypertension (high blood pressure), psychosis (mental disorder characterized by a disconnection from reality), seizures (uncontrolled jerking caused by abnormal electrical activity in the brain) and Chronic kidney Disease (longstanding disease of the kidneys). Record review of Resident #3's BIMS assessment dated [DATE] revealed score of 7 indicating severe cognitive impairment. Record review of activity data for this resident revealed no completed activity assessments or participation logs according to facility policy.Record review of Resident #16's face sheet (undated) revealed a [AGE] year-old male admitted [DATE]. Diagnoses included Hypertension (high blood pressure), seizure disorder (uncontrolled jerking caused by abnormal electrical activity in the brain), hyperlipidemia (high cholesterol), depression, and insomnia. Record review of Resident #16's BIMS assessment dated [DATE] revealed score of 8 indicating moderate cognitive impairment. During an interview on 7/16/25 at 2:26 PM, the AD 1 revealed that she did not utilize any assessment form or progress note to document admission or quarterly assessments for each resident. AD 1 stated she had received a form but had not really familiarized herself with it yet. AD 1 stated she had many residents who preferred in-room activities, but she did not document their participation in activities on any form. During an interview on 7/17/25 at 3:30 PM, the ADM revealed that he was aware that the Activity Director had been provided an assessment form and he needed to assist her with understanding the purpose of and timely completion of the activity assessments. Review of Activity Evaluation (Revised June 2018) revealed 2. The resident's activity evaluation is conducted by the Activity Department personnel.who evaluates related factors such as functional level, cognition and medical conditions that may affect activities participation., and 9. The completed activity evaluation is part of the resident's medical record and is updated as necessary, but as least quarterly. Event ID: Facility ID: 675295 If continuation sheet Page 9 of 11 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 07/17/2025 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 0851 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interviews and record reviews the facility failed electronically submit to the Centers for Medicare and Medicaid Services (CMS) complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, for 1 of 1 facility's reviewed for Payroll Based Journal (PBJ) reporting to CMS. The facility's Business Office Manager and the Administrator failed to report the January, February, and March 2025 PBJ data to the CMS. This failure could place residents at risk for neglect.The findings included. A record review of the facility's census for the months of January, February, and March 2025 revealed an average census of 40 residents. A record review of the facility's CMS PBJ Staffing Data Report, dated 7/9/2025, revealed, FY Quarter 2 2025 (January 1 - March 31) . This Staffing Data Report identifies areas of concern that will be triggered (e.g., requires follow-up during the survey).Metric Result DefinitionFailed to Submit Data for the Quarter Triggered.Triggered = No Data Submitted for Quarter.One Star Staffing Rating Triggered.Triggered = Star Staffing Rating Equals 1.Excessively Low Weekend Staffing This metric is suppressed for thisfacility and quarter.Triggered = Submitted Weekend Staffing data is excessively low.No RN Hours This metric is suppressed for this facility and quarter.Triggered = Four or More Days Within the Quarter with no RNHours. Failed to have Licensed Nursing Coverage 24 Hours/Day This metric is suppressed for this facility and quarter.Triggered = Four or More Days Within the Quarter with <24Hours/Day Licensed Nursing Coverage. Possible reasons for suppressed metrics:Invalid data. During an interview on 7/17/2025 at 4:55 PM the BOM and the Administrator stated the BOM was responsible for compiling and reporting the payroll-based journal data to CMS quarterly. The BOM stated she had the responsibility to report quarterly to CMS the previous 90 days of PBJ data and had not done so for the quarter January through March 2025. The BOM stated she had no excuse and was currently compiling the data to submit to CMS. The Administrator stated it was his responsibility to ensure oversight with the BOM specifically for accurate and timely reporting to CMS the PBJ at a minimum Quarterly. The Administrator stated he began as the Administrator at the beginning of March 2025 and had not ensured the BOM reported the PBJ to CMS. The Administrator stated the risk to residents was inaccurate PBJ data reported to CMS. The Administrator stated the facility followed State and Federal HHS guidelines for reporting PBJ data. Event ID: Facility ID: 675295 If continuation sheet Page 10 of 11 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 07/17/2025 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 0908 Keep all essential equipment working safely. Level of Harm - Minimal harm or potential for actual harm Based on Observations and interviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, for 1 of 1 laundry facilities reviewed for safe operating clothing washers and dryers. The facility was licensed for 70 residents and had 2 commercial washers for which only 1 was operational and had 2 commercial dryers for which only 1 was operational. These failures could place residents at risk for not having adequate hygiene and laundry services. The findings included: A record review of the facility's license revealed the facility was licensed to care for 70 residents. During an observation and interview on 7/16/2025 at 4:14 PM revealed the facility's laundry department. The Laundry department had 2 commercial washers and 2 commercial dryers. One of the commercial washers was labeled with a paper sign DO NOT USE. One of the commercial dryers was labeled with a paper sign DO NOT USE. The Maintenance Director stated he had been employed as the Maintenance Director for the past year and a half and the washer was broken before he was employed. The Maintenance Director stated the dryer had been broken for about 3 months. The Maintenance Director stated the facility had solicited estimates for repairs and or replacements for the dryer and the washer but had not received any estimates. The Maintenance Director stated the facility currently had around 40 residents and could meet their needs for laundry services but would need another dryer and washer if the facility reached full census. The Maintenance Director stated the administrator was researching the repairs and or replacements. During an interview on 7/17/2025 at 4:30 PM the Administrator stated he was the new administrator for the facility and had been so for the past 3 months. The Administrator stated he received a report from The Maintenance Director that the laundry department needed a washer and a dryer, and he had not received any estimates for repairing and or replacing the equipment and intended to solicit estimates for repairing the equipment. The Administrator stated he concurred with The Maintenance Director that the needs of the residents were currently being met however the administrator stated he intended to have 2 functioning washers and 2 functioning dryers. A record review of the facility's Maintenance Service policy dated December 2009, revealed, Policy Statement: Maintenance service shall be provided to all areas of the building, grounds, and equipment. Policy Interpretation and Implementation: 1. The Maintenance Department is responsible for maintaining the buildings, grounds, and equipment in a safe and operable manner at all times. 3. The Maintenance Director is responsible for developing and maintaining a schedule of maintenance service to assure that the buildings, grounds, and equipment are maintained in a safe and operable manner. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675295 If continuation sheet Page 11 of 11