Deficiency Records for Lytle Nursing Home
Updated as of April 01, 2021
This is not the most recent data for Lytle Nursing Home. For the most recent information, click here.
A list of the most recent deficiencies for Lytle Nursing Home. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2021-01-28 | 2021-02-08 | Y |
| Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. | Health | 2021-01-28 | 2021-02-08 | Y |
| Post nurse staffing information every day. | Health | 2021-01-28 | 2021-02-08 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-01-28 | 2021-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2020-11-26 | 2020-12-17 | Y |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2020-10-21 | 2020-11-30 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2020-10-21 | 2020-11-30 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2020-10-21 | 2020-11-30 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2020-10-21 | 2020-11-30 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2020-10-21 | 2020-11-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2020-10-21 | 2020-11-30 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2020-10-21 | 2020-11-30 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2020-10-21 | 2020-11-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2020-10-21 | 2020-11-30 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2020-10-21 | 2020-11-30 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2020-10-20 | 2020-11-27 | N |
| Construct fire resistant interior walls. | Fire Safety | 2020-10-20 | 2020-11-27 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2020-10-20 | 2020-11-27 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2020-10-20 | 2020-11-27 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-10-20 | 2020-11-27 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2020-09-25 | 2020-11-06 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2020-09-25 | 2020-11-06 | Y |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-04-10 | 2019-05-24 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2019-04-10 | 2019-05-17 | N |
| Ensure that building systems meet requirements determined by risk assessment procedures performed by qualified personnel. | Fire Safety | 2019-04-10 | 2019-05-03 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-04-10 | 2019-04-30 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-04-10 | 2019-04-29 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2019-04-12 | 2019-04-19 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-04-12 | 2019-04-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2019-04-12 | 2019-04-19 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2019-04-12 | 2019-04-19 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2019-04-12 | 2019-04-19 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-04-12 | 2019-04-19 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-04-12 | 2019-04-19 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2019-04-12 | 2019-04-19 | N |
| 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. | Health | 2019-04-12 | 2019-04-19 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2019-04-12 | 2019-04-19 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2019-04-12 | 2019-04-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-04-12 | 2019-04-19 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2019-04-12 | 2019-04-19 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-04-12 | 2019-04-15 | Y |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2018-03-28 | 2018-04-09 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-03-28 | 2018-04-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2018-03-28 | 2018-04-06 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2018-03-28 | 2018-04-06 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2018-03-28 | 2018-04-06 | N |
| Have a battery powered remote alarm panel in a location accessible by operating personnel. | Fire Safety | 2018-03-28 | 2018-04-06 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-03-28 | 2018-04-06 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2018-04-05 | 2018-04-06 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2018-04-05 | 2018-04-06 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-04-05 | 2018-04-06 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2018-04-05 | 2018-04-06 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-04-05 | 2018-04-06 | N |
| Ensure each resident receives an accurate assessment. | Health | 2018-04-05 | 2018-04-06 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-04-05 | 2018-04-06 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2018-04-05 | 2018-04-06 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-04-05 | 2018-04-06 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2018-04-05 | 2018-04-06 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2018-04-05 | 2018-04-06 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-04-05 | 2018-04-06 | N |
| Ensure that the resident and his/her doctor meet face-to-face at all required visits. | Health | 2018-04-05 | 2018-04-06 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2018-04-05 | 2018-04-06 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2018-04-05 | 2018-04-06 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2018-04-05 | 2018-04-06 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2018-04-05 | 2018-04-06 | N |
| 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. | Health | 2018-04-05 | 2018-04-06 | N |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2018-04-05 | 2018-04-06 | N |
| Provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs. | Health | 2018-04-05 | 2018-04-06 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-04-05 | 2018-04-06 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-04-05 | 2018-04-06 | N |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2018-04-05 | 2018-04-06 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-04-05 | 2018-04-06 | N |
| Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Health | 2018-04-05 | 2018-04-06 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2018-04-05 | 2018-04-06 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-04-05 | 2018-04-06 | N |
| Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility. | Health | 2018-04-05 | 2018-04-06 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2018-04-05 | 2018-04-06 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2018-04-05 | 2018-04-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-04-05 | 2018-04-06 | N |
| Implement a program that monitors antibiotic use. | Health | 2018-04-05 | 2018-04-06 | N |
| Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. | Health | 2018-04-05 | 2018-04-06 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-04-05 | 2018-04-06 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2018-04-05 | 2018-04-06 | N |
