Lytle Nursing Home

In the surveyor’s words

From the most serious findings on record at Lytle Nursing Home, in the surveyor’s own words.

• Immediate jeopardy, patternF921Feb 23, 2022

  Based on observation, interview, and record review, the facility failed to maintain a safe environment for residents, staff, and the public. The facility did not ensure the building was structurally safe and the residents were safe from possible asbestos contamination following the ceiling collapse on 2/16/22. The facility continued to use the main kitchen after the ceiling collapse on 2/16/22. An Immediate Jeopardy {IJ} was identified on 2/18/2022. The immediacy was removed on 2/22/2022, and the facility remained out of compliance at a severity of a pattern with a scope of no actual harm, with the potential for more than minimal harm. This failure could place the residents at risk for injury and health complications. The findings were: During an observation on 2/18/2022 at 12:00 p.m. […]

• Immediate jeopardy, patternF607Jan 30, 2022

  Based on interview and record review the facility failed to implement written policies and procedures to prevent neglect for 3 of 3 residents (Residents #12, #29 and #56) reviewed for neglect, in that: The facility failed to implement a process to obtain and track ordered laboratory results for residents. Labs were not drawn consistently for residents since September 2021 as ordered by their physician. 1. Resident #12's CBC, CMP, FLP, [CONDITION(S)] Panel, A1c, [MEDICATION(S)] and [MEDICATION(S)] were not obtained per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 2. Resident #29's [MEDICATION(S)] level was not obtained per physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] 3. […]

• Immediate jeopardy, isolatedF684May 27, 2024

  Based on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 6 residents (Resident #45) reviewed for notification of changes in that: The facility failed to ensure Resident #45's nephrostomy tube was removed as soon as medically possible. Resident #45 was first documented to have a kidney stone requiring a nephrostomy tube (an opening between the kidney and the skin. A nephrostomy tube is a thin plastic tube that is passed from the back, through the skin and then through the kidney, to the point where the urine collects) and needed to see a urologist on 09/2023. […]

• Immediate jeopardy, isolatedF689Apr 5, 2022

  Based on observation, interview, and record review, the facility failed to ensure resident's received adequate supervision to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents, in that: The facility failed to properly secure the main nurses station construction site to prevent residents from injury. Resident #1 wandered in a wheelchair through closed fire doors into the main nurse's station construction site which resulted in Resident #1 sustaining superficial abrasions from falling debris when the ceiling collapsed above the nurse's station. These failures resulted in identification of Immediate Jeopardy (IJ) on 04/01/2022. […]

• Actual harm, widespreadF644Jan 9, 2024

  Based on interview and record review, the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 2 residents (Resident #1) reviewed for PASRR. The facility failed to submit NFSS forms timely for Resident #1. This failure could place residents at risk for not receiving specialized services in a timely manner. 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). […]