Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lytle Nursing Home during CMS and state inspections, most recent first.
The facility did not have a grievance policy or process in place, failed to maintain a Grievance Log, and did not provide written forms or feedback for grievances. Grievances were handled informally, and concerns raised in Resident Council meetings were not systematically addressed or communicated back to residents.
A resident with a nephrostomy tube experienced multiple hospitalizations due to the facility's failure to ensure timely medical intervention. The resident's surgery to remove a kidney stone was canceled due to an insurance issue that the facility did not properly address. Despite the resident's severe cognitive impairment, the facility did not follow up with the physician or reschedule the surgery, leading to an Immediate Jeopardy situation.
A resident with a nephrostomy tube experienced multiple hospitalizations due to complications, yet the facility failed to notify the physician or medical director. The resident's scheduled surgery to remove a kidney stone was canceled due to an insurance issue, which the facility did not resolve. The Director of Nursing was aware of the issue but did not take action, and the Medical Director was not informed, leading to a deficiency in care.
The facility failed to report alleged abuse and injuries within the required timeframe for three residents. A resident with severe cognitive impairment was found with a dislocated arm, but the necessary investigation report was not completed. Another resident with severe cognitive impairment suffered a fracture from a fall, and the facility's report lacked staff or resident interviews. A third resident with severe intellectual disabilities sustained a hematoma from an unwitnessed fall, which was not reported within the required two-hour window.
The facility did not update the comprehensive care plans for two residents to reflect their current conditions. One resident's care plan lacked documentation of a left hand contracture, while another's did not include Hospice services, oxygen therapy, and wound care. The facility's policy mandates quarterly updates, which were not followed.
The facility failed to ensure physicians reviewed residents' care programs, including medications and treatments, at each visit. Seven residents lacked evidence of MD visits or progress notes, with only NP notes available, which were not co-signed by an MD. This deficiency could risk residents not receiving appropriate care.
A facility failed to maintain accurate medical records for three residents, leading to deficiencies in documentation. One resident's refusal to attend medical appointments was not documented, another's nephrostomy care and medication consent forms were incomplete, and a third resident's fall and hospital transfer were not recorded. The DON acknowledged these documentation failures, which could affect resident care.
A facility failed to maintain proper infection control during nephrostomy care for a resident with a history of brain injury and hydronephrosis. An LVN did not follow sterile technique or hand hygiene protocols, contaminating supplies and equipment. The facility's policies on sterile procedures and standard precautions were not adhered to, increasing the risk of infection.
The facility failed to maintain a clean and sanitary environment in the B Hallway shower room, which had a strong sulfur odor, black spots, a hole in the floor, and a missing trim plate. The DON expressed concern about infection risks for residents using the shower, especially those prone to infection. The Administrator admitted to not having seen the shower room during rounds, despite acknowledging the risk of wound contamination. The facility's policy on daily bathroom cleaning was not followed, potentially placing residents at risk.
A facility failed to complete a timely comprehensive assessment for a newly admitted resident with severe cognitive impairment and intellectual disabilities. The MDS Coordinator did not conduct the assessment within the required 14 days, delaying the development of a comprehensive care plan. Observations noted the resident's unsteady gait and need for staff assistance, highlighting the importance of timely assessments.
A facility failed to accurately document a resident's limited range of motion due to a left hand contracture in their MDS assessments. The resident, who also used a wheelchair for mobility, was not properly coded in assessments for two periods. The MDS Coordinator acknowledged the oversight and the importance of accurate documentation to ensure necessary care and services.
A facility failed to refer a resident for a PASARR evaluation despite the resident having bipolar disorder and anxiety. The initial PASARR Level 1 screening did not reflect these diagnoses, leading to a lack of follow-up. The resident was on medications for these conditions, and the care plan noted risks for anxiety, depression, and psychotic behaviors.
A resident with severe cognitive impairment and a stage 2 pressure ulcer on her left great toe did not receive proper wound care due to inadequate hand hygiene and failure to cleanse the wound before applying skin prep. The LVN did not change gloves or sanitize hands between treating different wound sites, and inconsistencies in wound care orders were noted. The facility's policy lacked specific wound care procedures, contributing to the deficiency.
A resident with severe cognitive impairment and multiple health conditions did not receive proper respiratory care due to the facility's failure to maintain the oxygen concentrator. The resident's care plan lacked interventions for oxygen therapy, and the filter on the concentrator was found covered with lint. Nursing staff were unaware of how to clean the filter, and the DON admitted there were no specific orders for its maintenance.
The facility failed to ensure physician-signed admission orders for two residents, relying instead on orders signed by a Nurse Practitioner. One resident, with severe asthma and Alzheimer's, was readmitted under hospice care and later expired. Another resident, with severe cognitive impairment, required full assistance with daily activities. Interviews revealed the physician had not signed any orders, contrary to facility policy requiring physician supervision and order signing.
Two LVNs at the facility demonstrated deficiencies in nursing competency and equipment handling. LVN A failed to follow sterile procedures during nephrostomy care, using contaminated equipment and not wearing sterile gloves, which risked infection for a resident with a nephrostomy tube. LVN H lacked knowledge on calibrating glucometers, leading to potential inaccuracies in blood glucose readings and insulin administration. The DON acknowledged these deficiencies, highlighting a failure to adhere to facility policies.
A resident with moderate cognitive impairment was administered Depakote for mood disorder without obtaining consent from their family representative. The consent form lacked the medication classification, and the resident, unable to make informed decisions, signed it themselves. The DON acknowledged the oversight, and the family representative was unaware of the medication's administration.
The facility failed to ensure proper storage and labeling of drugs and biologicals, with issues found in the nurse supply room's refrigerator and the C hall medication cart. The refrigerator contained staff food and expired items, while the medication cart had loose pills and expired medications. The crash cart also contained expired items. These deficiencies were due to non-compliance with facility policies on food storage and medication labeling.
A resident with a history of cerebrovascular issues and missing teeth was not provided a mechanical soft diet as prescribed, leading to potential risks of aspiration or choking. Observations showed the resident eating regular textured food, contrary to physician orders. Staff interviews revealed communication lapses and improper meal ticket checks, contributing to the dietary error.
The facility lacked a Quality Assurance and Performance Improvement (QAPI) plan, policies, and procedures, affecting the quality of care for all residents. The DON confirmed the absence of a QAPI Program and Performance Improvement Projects (PIPs), with no written plan or procedures. Monthly meetings with department heads and the MD occurred, but direct care staff were not involved, and no root cause analyses were conducted.
The facility did not ensure the survey results binder was accessible to residents and families for four out of seven survey days. Residents were unaware of its location, and the ADM could not find it in the lobby. The ADON later provided the binder, which was on her desk, containing outdated results from 2022. Facility policy requires the binder to be in a common area.
The facility failed to conduct and document a comprehensive facility-wide assessment for the past three years, with the last assessment completed in 2021. The Administrator acknowledged that no assessment had been conducted since his arrival in September 2023. A notebook in the Administrator's office contained outdated assessments from 2019, 2020, and 2021, but no updates had been made since then, potentially placing residents at risk.
The facility failed to provide the required minimum of 80 square feet per resident in four double occupancy rooms, with space per resident ranging from 70.97 to 79.62 square feet. The Administrator acknowledged the deficiency and sought a room size waiver, but one bed needed to be de-licensed as it did not meet waiver requirements.
Failure to Establish and Implement Grievance Policy and Process
Penalty
Summary
The facility failed to establish and implement a grievance process to ensure the prompt resolution of all grievances related to residents' rights. Record review revealed the absence of a Grievance Log, and interviews confirmed that grievances were handled informally as they arose, without documentation or a formal tracking system. The DON stated that there was no written form available for residents or families to submit concerns or grievances, nor was there a process to provide written feedback regarding the resolution of such grievances. Additionally, concerns voiced during Resident Council meetings were relayed to administration by the Activity Director through written notes, but there was no established process for communicating responses or resolutions back to the residents. When asked, the DON confirmed that the facility did not have a written grievance policy in place. These failures affected all residents, as there was no formal mechanism to ensure their grievances were addressed and resolved in a timely manner.
Failure to Ensure Timely Medical Intervention for Resident with Nephrostomy Tube
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, specifically regarding the removal of a nephrostomy tube. The resident, who had a history of kidney stones and a nephrostomy tube, was scheduled for surgery to remove a kidney stone. However, the surgery was canceled due to an insurance issue that the facility did not properly follow up on. The facility did not reschedule the surgery or follow up with the resident's physician, resulting in the resident experiencing multiple hospitalizations due to complications from the nephrostomy tube. The resident, who had a history of traumatic brain injury, cerebral infarction, and other medical conditions, was documented to have severe cognitive impairment and was unable to make decisions. Despite this, the facility did not take appropriate steps to ensure the resident's medical needs were met. The resident's nephrostomy tube required frequent replacement, and hospital records indicated that long-term percutaneous drainage was not feasible. The facility's failure to address the insurance issue and reschedule the surgery led to the identification of an Immediate Jeopardy situation. Interviews with facility staff revealed a lack of communication and follow-up regarding the resident's medical care. The Director of Nursing (DON) admitted to being aware of the insurance issue but did not take action to resolve it, citing being busy with other tasks. The Medical Director was not informed of the issues with the referral process and stated that he could have facilitated the necessary arrangements if he had been aware. The facility's deficient practices placed the resident at risk of delayed medical intervention, pain, and a decline in health.
Failure to Notify Physician of Resident's Significant Change in Condition
Penalty
Summary
The facility failed to immediately consult with the resident's physician when there was a significant change in the resident's status, specifically for a resident with a nephrostomy tube due to kidney stones. The resident was sent to the hospital emergency room on at least 15 occasions for complications related to the nephrostomy tube, yet the facility did not notify the physician or medical director. This lack of communication denied the physician the opportunity to intervene and potentially prevent further complications. The resident, who had a history of hypertension secondary to renal disorders and hydronephrosis with ureteropelvic junction obstruction, was scheduled for surgery to remove a kidney stone. However, the surgery was canceled due to an insurance issue, as the facility did not follow up on the insurance requirements. The facility also failed to reschedule the surgery or follow up with the resident's physician, leaving the resident at risk for continued complications from the nephrostomy tube. Interviews with staff revealed that the Director of Nursing (DON) was aware of the insurance issue but had not taken action to resolve it, citing being busy with other tasks. The Medical Director was not informed of the issues with the insurance referral and stated he could have intervened if he had been notified. The facility's policies required physician notification for changes in the resident's condition, but these were not followed, contributing to the deficiency.
Failure to Timely Report Alleged Abuse and Injuries
Penalty
Summary
The facility failed to report alleged violations involving abuse, including injuries of unknown source, within the required timeframe for three residents. Resident #7, who had severe cognitive impairment and was receiving hospice services, was found with a dislocated arm. The facility did not complete the necessary Provider Investigation Report (PIR) within five days, and the Administrator (ADM) was unfamiliar with the required form. Despite conducting interviews and an in-service on abuse and neglect, the ADM could not locate the investigation file. Resident #48, with severe cognitive impairment and a history of falls, suffered a fracture after pulling on a tablecloth and falling. The facility's internal report included a description of the incident and a TULIP report, but lacked documented staff or resident interviews. The ADM was unaware of the requirement to submit the Provider Investigation Report Form 3613 A within five days of the incident. Resident #200, who had severe intellectual disabilities and was at high risk for falls, sustained a hematoma from an unwitnessed fall. The DON questioned the reportability of the incident, and the ADM acknowledged the failure to report it within the required two-hour window. The facility's abuse policy mandates reporting the results of all investigations to the State Survey Agency within five working days, which was not adhered to in these cases.
Failure to Update Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to ensure that the comprehensive care plans for two residents were reviewed and revised by the interdisciplinary team to reflect their current conditions. Resident #4's care plan was not updated to include her left hand contracture, despite observations confirming the condition. The MDS Coordinator acknowledged the omission, emphasizing the importance of capturing all health needs in the care plan. Similarly, Resident #7's care plan did not reflect her current status of receiving Hospice services, oxygen therapy, and wound care for a Stage 2 pressure ulcer on her left great toe. The DON confirmed that the care plan was outdated and did not address these critical care areas. The facility's policy requires that care plans be reviewed and updated at least quarterly, in conjunction with the required MDS assessments, but this was not adhered to in these cases.
Lack of Physician Oversight and Documentation in Resident Care
Penalty
Summary
The facility failed to ensure that physicians reviewed the residents' total program of care, including medication and treatments, at each visit. This deficiency was observed in seven residents, where physician visits and progress notes were either missing or not properly documented. The facility relied on nurse practitioners (NPs) to conduct visits and sign orders, but these were not co-signed by a medical doctor (MD), as required. This lack of oversight and documentation could potentially place residents at risk for not receiving appropriate care. For Resident #4, there was no evidence of any visits or physician progress notes from the MD since her admission. The records provided only included notes from the NP, which were not co-signed by the MD. Similarly, Resident #7's records showed no evidence of MD visits or progress notes, with only NP notes available. Resident #15's records also lacked MD signatures on physician orders, and there were no MD progress notes since his admission. Resident #17, Resident #40, Resident #45, and Resident #200 all had similar issues, with no evidence of MD visits or progress notes. The MD admitted to attending monthly meetings at the facility but did not provide documentation of individual resident visits. The facility's policy required the MD to conduct initial visits for new admissions within 30 days and subsequent visits every 30 to 60 days, but this was not adhered to, leading to the deficiency.
Deficiencies in Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for three residents, leading to deficiencies in documentation and communication. For one resident, the facility did not document his refusal to attend medical appointments, despite his cognitive impairment and the need for follow-up care after a throat mass removal. The Director of Nursing (DON) acknowledged that the resident's refusal should have been documented in the nursing notes, but it was not, potentially affecting the resident's care and follow-up treatment. Another resident's medical records were incomplete regarding nephrostomy care and medication consent forms. The resident had a nephrostomy tube due to kidney stone obstruction, and the facility's Treatment Administration Record (TAR) and Medication Administration Record (MAR) were missing documentation for several dates in March and April. The DON admitted that nursing staff were performing the care but not documenting it, despite previous in-service training on the importance of documentation. Additionally, the consent forms for psychoactive medications were incomplete, lacking signatures and dates, which the resident's representative signed without full awareness of the contents. The third resident's records lacked documentation of a fall and subsequent hospital transfer. The resident, who had severe cognitive impairment and was at high risk for falls, was sent to the hospital after a fall, but there were no progress notes or transfer forms completed. The DON confirmed that the nursing staff failed to document the incident, the reason for the transfer, and the hospital to which the resident was sent, contrary to the facility's policy on charting and documentation.
Infection Control Deficiency in Nephrostomy Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper care practices observed during nephrostomy care for Resident #45. The resident, who had a history of diffuse traumatic brain injury, cerebral infarction, and hydronephrosis with ureteropelvic junction obstruction, required careful monitoring and care of a nephrostomy tube. However, during a dressing change, LVN A did not adhere to proper sterile technique and hand hygiene protocols, which are critical to preventing infection. During the procedure, LVN A contaminated the supplies and failed to sanitize the scissors before use. She handled various items with bare hands, touched her scrubs, and reached into her pockets, which compromised the sterility of the equipment. Additionally, LVN A did not wash her hands in the resident's room before starting the wound care and touched the resident's room door with gloved hands, further increasing the risk of cross-contamination. The facility's policy on nephrostomy tube care and standard precautions clearly outlined the need for sterile technique and proper hand hygiene. However, LVN A's actions deviated from these guidelines, as she did not sanitize equipment before use and failed to maintain a sterile field. The Director of Nursing acknowledged these lapses, noting the increased risk of infection due to the direct connection of the nephrostomy tube to the resident's kidney.
Unsanitary Conditions in Resident Shower Room
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents in one of the three resident shower rooms observed, specifically the B Hallway shower room. During an observation, the shower room was found to have a strong sulfur odor, black spots on the floor and shower wall, a half-foot hole in the shower floor filled with white cloudy water, and a missing trim plate around the shower faucet. The Director of Nursing (DON) acknowledged the condition of the shower room and expressed concern about the risk of infection for residents using the shower, particularly those prone to infection or with uncovered feet. The facility's policy on bathroom maintenance, which requires daily cleaning and sanitation, was not adhered to, as evidenced by the unsanitary conditions observed in the B Hallway shower room. The Administrator admitted to not having seen the shower room during rounds because it was always in use, despite acknowledging the risk of wound contamination for residents using the shower. The facility's failure to maintain the shower room in a clean and sanitary manner could potentially place residents at risk for an unsafe and unsanitary environment.
Failure to Complete Timely Comprehensive Assessment
Penalty
Summary
The facility failed to conduct an initial comprehensive assessment of a resident's functional capacity, including needs, strengths, goals, life history, and preferences, within the required timeframe. Specifically, the MDS Coordinator did not complete the comprehensive assessment for a resident within 14 days of admission, as required by the facility's policy. This oversight was identified during a review of the resident's records, which showed no indication of the initial MDS being completed from the time of admission until over a month later. The resident in question was admitted with diagnoses including Fragile X Chromosome and severe intellectual disabilities, requiring assistance with all activities of daily living and being at high risk for falls. Observations noted the resident's severe cognitive impairment and unsteady gait, with staff needing to redirect her back to her room. Interviews with the MDS Coordinator and the DON confirmed the lapse in completing the assessment, which was crucial for developing a comprehensive care plan to address the resident's needs.
Inaccurate Resident Assessment Documentation
Penalty
Summary
The facility failed to ensure that the assessments accurately reflected the status of a resident, specifically regarding the resident's limited range of motion due to a left hand contracture. The MDS Coordinator did not code this condition in the resident's assessments for two periods, on 6/2/23 and 2/15/24. This oversight could potentially affect the care and services provided to the resident. The resident, who was admitted with diagnoses including hypertension and Alzheimer's disease, was observed with a left hand contracture and used a wheelchair for mobility, neither of which were accurately documented in the assessments. Interviews with the MDS Coordinator confirmed the omission of the resident's left hand contracture and wheelchair use in the assessments. The coordinator acknowledged the importance of capturing all health needs in the MDS assessments to ensure appropriate care and services are provided. Despite being asked for a policy on the accuracy of MDS assessments, the facility did not provide one by the exit date of the survey.
Failure to Refer Resident for PASARR Evaluation
Penalty
Summary
The facility failed to refer a resident for a PASARR evaluation upon a significant change in status assessment, despite the resident having diagnoses of bipolar disorder and anxiety. The resident's initial PASARR Level 1 screening did not reflect these mental health diagnoses, and as a result, a follow-up evaluation was not initiated. The resident was admitted with multiple diagnoses, including traumatic brain injury, cerebral infarction, and anxiety disorder, but bipolar disorder was not documented on the face sheet. Further review of the resident's medical records revealed that the resident was being treated with medications for anxiety and bipolar disorder, including sertraline, Depakote, and Seroquel. The resident's care plan indicated risks for anxiety, depression, and psychotic behaviors, with corresponding medications prescribed. An interview with the MDS Coordinator confirmed that the initial PASARR evaluation did not indicate a mental illness, and a new PASARR Level 1 was not submitted until the deficiency was identified.
Inadequate Wound Care and Hand Hygiene Practices
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in wound management. The resident, who had severe cognitive impairment and was receiving hospice services, had a stage 2 pressure ulcer on her left great toe. The Licensed Vocational Nurse (LVN) responsible for the resident's care did not follow proper wound care procedures, including inadequate hand hygiene and failure to cleanse the wound with normal saline before applying skin prep. The LVN also did not change gloves or sanitize hands between treating different wound sites, which could contribute to infection. The resident's medical records revealed inconsistencies in wound care orders and documentation. The LVN followed a telephone order that did not align with the hospice nurse's progress notes, which specified a different wound care regimen. Additionally, the LVN did not measure or describe the wounds on the resident's left foot and heel, which is essential for tracking healing progress. Interviews with the LVN and the Director of Nursing (DON) highlighted a lack of adherence to standard wound care practices, including the need for hand hygiene and proper wound cleansing. The facility's policy on pressure ulcer prevention did not address specific wound care procedures or hand hygiene, contributing to the deficiency. The DON acknowledged that the LVN should have sought clarification on the wound care orders and communicated with the hospice nurse to ensure accurate treatment. The failure to follow professional standards of practice in wound care could lead to infection and hinder the healing process for residents with pressure ulcers.
Failure to Maintain Oxygen Concentrator for Resident
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident requiring oxygen therapy, as observed in the case of a resident with severe cognitive impairment and multiple health conditions, including congestive heart failure and hypertension. The resident's care plan did not include interventions for oxygen therapy, and the physician orders lacked instructions for maintaining the oxygen concentrator. During observations, the resident was found receiving oxygen at a higher rate than prescribed, and the filter on the oxygen concentrator was covered with lint, indicating it had not been cleaned. Interviews with nursing staff revealed a lack of knowledge and responsibility regarding the maintenance of the oxygen concentrator. An LVN admitted to not knowing how to clean the filter and did not check it during rounds. The DON acknowledged that nursing staff should check and clean the filters regularly, but there were no specific physician orders for this task. The DON also noted that the filter's condition suggested it had not been cleaned as frequently as claimed, potentially leading to respiratory issues for the resident.
Failure to Obtain Physician-Signed Admission Orders
Penalty
Summary
The facility failed to ensure that a physician was notified and provided orders for the immediate care and needs of two residents. For Resident #49, the admission orders were signed by a Nurse Practitioner (NP) instead of the attending physician, who was listed as the Medical Director. The resident, an elderly female with a history of a femur fracture, Alzheimer's disease, and severe asthma, was readmitted from the hospital under hospice care and later expired. Similarly, Resident #200, who had severe cognitive impairment and required assistance with all activities of daily living, had her admission orders signed by an NP rather than the attending physician. Interviews with the Director of Nursing (DON) and the Medical Director revealed that the physician had not signed any of the residents' orders, relying instead on standing orders and lab orders upon admission. The facility's policy stated that the medical care of each resident should be under the supervision of a licensed physician, who is responsible for signing orders and overseeing the resident's care plan. This oversight in obtaining physician-signed orders for the residents' immediate care needs was identified as a deficiency by the surveyors.
Deficiencies in Nursing Competency and Equipment Handling
Penalty
Summary
The facility failed to ensure that two licensed vocational nurses (LVNs) possessed the necessary competencies and skills to provide safe and effective care to residents. LVN A did not adhere to the facility's policy for nephrostomy care, which required the use of sterile gloves and equipment. During an observation, LVN A used contaminated equipment, did not use sterile gloves, and contaminated her hands while providing care to a resident with a nephrostomy tube. This resident had a complex medical history, including a traumatic brain injury, cerebral infarction, and hydronephrosis, and was at risk of infection due to the direct connection of the nephrostomy tube to the kidney. In another instance, LVN H demonstrated a lack of knowledge regarding the calibration of glucometers, which are essential for accurately measuring residents' blood glucose levels. LVN H was observed using glucometers that were not properly calibrated, and she admitted to not having calibrated a glucometer in a long time. During an attempt to calibrate the device, LVN H made errors, resulting in an inaccurate reading. This deficiency could lead to incorrect insulin administration, posing a risk of hypoglycemia to residents. The Director of Nursing (DON) acknowledged the deficiencies in both cases, noting that LVN A should have sanitized equipment and washed her hands before wound care, and that LVN H should have ensured the glucometers were calibrated correctly. The facility's policies on nephrostomy tube care and glucose monitoring were not followed, compromising resident safety and care quality.
Failure to Obtain Consent for Depakote Administration
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs, specifically regarding the administration of Depakote for mood disorder. The nursing staff did not obtain consent from the resident's family representative, who served as the responsible party, for the use of Depakote. Additionally, the medication classification was not indicated on the consent form. This oversight was identified during a review of the resident's records, which showed that the resident, who had moderate cognitive impairment and was receiving hospice services, had signed the consent form themselves, despite being unable to make informed decisions. Interviews conducted during the survey revealed that the Director of Nursing acknowledged the oversight, stating that the nurse should have obtained the responsible party's consent and signature. The resident's family representative confirmed that the nursing staff had not discussed the administration of Depakote with her, and she was not familiar with the medication. The resident was observed to be alert but confused, engaging in limited conversation, which further highlighted the need for proper consent procedures to be followed.
Improper Storage and Labeling of Drugs and Biologicals
Penalty
Summary
The facility failed to ensure proper storage and labeling of drugs and biologicals, as well as maintaining appropriate access controls. During an observation, it was found that the nurse supply room's patient nourishment refrigerator contained staff food, expired products, unlabeled, and unsealed food items. The refrigerator, intended for resident use only, was improperly used by staff, and lacked a thermometer in the freezer section. Additionally, the crash cart in the nursing supply room contained expired saline and alcohol prep pads, which were not removed by the night shift responsible for checking the cart. Furthermore, the C hall medication cart was found to contain loose pills and expired medications. An LVN was unaware of the origin of the loose pills and improperly disposed of one by throwing it in the trash. The DON acknowledged that the refrigerator should only contain resident supplements and that loose pills pose a concern as they could lead to residents not receiving their prescribed medications. The facility's policies on food storage and medication labeling were not adhered to, contributing to these deficiencies.
Failure to Provide Prescribed Mechanical Soft Diet
Penalty
Summary
The facility failed to provide a therapeutic diet in the appropriate form as prescribed by a physician for a resident observed for therapeutic diets. The resident, a male with a history of acute cerebrovascular insufficiency, major depressive disorder, and hemiplegia, was ordered a mechanical soft diet due to missing teeth and potential swallowing difficulties. However, during an observation, the resident was seen eating a piece of beef brisket, which was not in the mechanical soft form as prescribed. The resident expressed difficulty in chewing due to missing teeth, indicating that the diet provided did not align with the physician's order. Interviews with facility staff revealed a lack of proper communication and verification of the resident's dietary needs. The Director of Nursing (DON) acknowledged that the resident should be on a mechanical soft diet due to a previous medical condition, but there was no documentation of the resident's refusal to attend follow-up medical appointments. The Speech-Language Pathologist (SLP) noted that the resident was observed eating regular textured food without issues, but was under the impression that the resident was prescribed a regular diet. The Dietary Manager (DM) admitted that the meal ticket checks were not conducted properly, leading to the resident receiving an incorrect diet texture, which posed a risk of aspiration or choking.
Lack of QAPI Plan and Procedures in Facility
Penalty
Summary
The facility failed to establish and implement written policies and procedures for feedback, data collection systems, and monitoring, including adverse event monitoring. The facility did not have a Quality Assurance and Performance Improvement (QAPI) plan, policies, or procedures in place for systematic analysis and systemic action. This deficiency could potentially affect all residents' overall quality of life and quality of care due to the lack of systems to improve direct care nursing staff performance. During an interview, the Director of Nursing (DON) revealed that while the facility had a Quality Assurance Committee, it did not have a QAPI Program because they did not utilize Performance Improvement Projects (PIPs). The DON stated that there was no written plan, policies, or procedures in place. Meetings were held monthly with all department heads and the Medical Director to discuss effective systems in the facility, but direct care staff were not involved in the process. Additionally, the facility did not complete written comparative analyses to determine root causes or assess the effectiveness of new systems implemented.
Failure to Post Survey Results in Accessible Location
Penalty
Summary
The facility failed to make the results of the most recent survey readily accessible to residents, family members, and legal representatives for four out of seven survey days. This deficiency was identified through observation, interviews, and record reviews. Several residents reported being unaware of the location of the survey results binder. During an interview, the Administrator (ADM) was unable to locate the binder in the lobby, where it was supposed to be available. The Assistant Director of Nursing (ADON) later provided the binder, which was found on her desk, and admitted to not knowing its intended location. Upon review, the binder contained outdated survey results from 2022. The facility's policy, revised in September 2004, mandates that the most recent survey results be maintained in a binder located in a common area frequented by residents, such as the main lobby or resident activity room.
Failure to Update Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment for the past three years, which is necessary to determine the resources required to care for residents competently during both day-to-day operations and emergencies. The last completed facility assessment was in 2021, and it had not been updated since then. During an interview and record review on May 26, 2024, the Administrator acknowledged that no facility assessment had been conducted since his arrival in September 2023. A notebook found in the Administrator's office contained a basic facility assessment form completed in 2019, 2020, and 2021, but no updates had been made since 2021. This oversight could potentially place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.
Inadequate Living Space in Double Occupancy Rooms
Penalty
Summary
The facility failed to provide adequate living space for residents in four of its double occupancy rooms, specifically Rooms 27, 28, 34, and 35. These rooms did not meet the required minimum of 80 square feet per resident, with measurements showing that the space per resident ranged from 70.97 to 79.62 square feet. This deficiency was identified during an observation by the life safety code on May 21, 2024, which revealed that the rooms were not in compliance with the space requirements. The facility's Bed Classifications form, dated March 20, 2023, confirmed that each of these rooms was intended for two residents. The Room Census List from May 21, 2024, indicated varying occupancy statuses for these rooms, with some beds unoccupied. During an interview, the Administrator acknowledged the deficiency and expressed a desire to continue with a room size waiver, although it was noted that one bed needed to be de-licensed or de-certified as it did not meet the minimum square footage required for a waiver.
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Illustrative
What surveyors actually found near you
We read the 561 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lytle
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Devine Health & Rehabilitation | 7.6 mi | ★★★★★ | 6 | 0 |
| Medina Valley Health & Rehabilitation Center | 9.6 mi | ★★★★★ | 11 | 0 |
| Harbor Valley Health And Rehabilitation | 13.6 mi | ★★★★★ | 19 | 1 |
| The Mission At Blue Skies Of Texas East | 14.1 mi | ★★★★★ | 0 | 0 |
| Legend Oaks Healthcare And Rehabilitation - West S | 14.8 mi | ★★★★★ | 11 | 0 |
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