Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0645
PASARR screening for Mental disorders or Intellectual Disabilities
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review the facility failed to ensure all Pre-admission Screening and Resident Review
(PASRR) level 1 residents with mental illness were provided with a PASRR level 2 evaluation for 1 of 4
residents (Resident #5), reviewed for resident assessment.
Residents Affected - Few
Resident #5's PASRR level 1 screening form did not indicate mental illness and the resident did not have a
PASRR level II evaluation.
This could place residents at risk of not receiving necessary specialized services to meet their individual
needs.
The findings were:
Record review of Resident #5's face sheet dated 11/20/24 revealed the resident was an [AGE] year-old
female admitted to the facility on [DATE]. Her diagnoses included major depressive disorder recurrent
severe with psychotic symptoms (mental health disorder characterized by persistently depressed mood or
loss of interest in activities, causing significant impairment in daily life with hallucinations, delusions,
disorganized thoughts, speech, and actions), psychotic disorder with delusions due to known physiological
condition (severe mental disorders that cause abnormal thinking and perceptions), and unspecified
dementia severe with other behavioral disturbance (general term for loss of memory, language,
problem-solving and other thinking abilities that are severe enough to interfere with daily life).
Record review of Resident #5's EHR on 11/20/24 diagnoses list revealed the primary diagnosis for the
resident was listed as unspecified dementia severe with other behavioral disturbance, but this was not
entered until 6/25/24. Further review revealed psychotic disorder with delusions was entered on the day of
admission to the facility on 3/19/24 indicating the resident had a mental illness not dementia upon
admission to the facility.
Record review of Resident #5's admission MDS assessment dated [DATE] section A1500 indicated the
resident was not considered by the state level II PASRR process to have serious mental illness and section
A1510 serious mental illness was not checked. The resident usually understands and was usually
understood. The resident had a BIMS score of 3 out of 15 indicating the resident was severely cognitively
impaired. The resident had delusions with physical and verbal aggression towards others 4-6 days but less
than daily. The resident was frequently incontinent of urine and always incontinent of bowel and the resident
had a psychotic disorder and unspecified dementia and received antipsychotic medications on a routine
basis.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 7
Event ID:
675071
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
675071
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Yorktown Nursing and Rehabilitation Center
670 W Fourth St
Yorktown, TX 78164
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 0645
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Record review of Resident #5's undated care plan revealed a focus initiated on 3/19/24 for the resident
receiving psychotropic medications and a focus initiated on 3/19/24 for behaviors which include cursing,
hitting during care, yelling during care, refusing care, and exit seeking.
Record review of Resident #5's EHR revealed a PASRR level 1 screening dated 3/19/24 which indicated
the resident had a primary diagnosis of dementia and mental illness was marked 0 indicating no mental
illness.
Record review of Resident #5's EHR revealed no PASRR level 2 evaluation was completed, and no
documents signed by the physician that dementia was the primary diagnosis.
In an interview on 11/21/24 at 1:16 p.m. the DOCC stated resident #5 did not have a level II PASRR
evaluation or form 1012 signed by the physician indicating dementia as the primary diagnosis. The DOCC
stated they were going to contact the physician regarding the PASRR screening form and the resident's
diagnoses. The DOCC stated it was important for residents with mental illness to have a level II PASRR
evaluation, so the residents receive needed or specialized services to meet their needs .
Review of the facility PASRR policy with an effective date of [DATE] revealed (Company name) follows the
Long-Term-Care user guide for Preadmission Screening and Resident Review published by the Texas
Medicaid and Healthcare Partnership (TMHP ).
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675071
If continuation sheet
Page 2 of 7
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
675071
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Yorktown Nursing and Rehabilitation Center
670 W Fourth St
Yorktown, TX 78164
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 0693
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
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.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review the facility failed to ensure a resident who was fed by enteral
means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of
2 residents (Resident #23) reviewed for quality of care.
Resident #23's tube feeding was not labeled with the required information.
This failure could place residents at risk of decreased continuity of care, errors in tube feeding, and
nutritional deficits.
The findings were:
Record review of Resident #23's face sheet dated 11/21/24 revealed the resident was a [AGE] year-old
female admitted to the facility on [DATE]. The resident's diagnoses included anoxic brain damage (damaged
caused by a complete lack of oxygen to the brain), dysphagia following cerebral infarction (difficulty
swallowing following a stroke that disrupted blood flow to the brain due to problems with the blood vessels
that supply it), and aphasia (aphasia is a language disorder that affects your ability to speak and
understand what others say).
Record review of Resident #23's quarterly MDS assessment dated [DATE] revealed the resident had a
BIMS score of 99 which indicated the resident was unable to complete the BIMS assessment and she was
moderately cognitively impaired. The resident had a feeding tube, no significant weight loss or gain, and
received all her nutrition and hydration through her feeding tube.
Record review of Resident #23's undated care plan revealed a focus revised on 10/22/24 for tube feedings
with interventions that included Resident #23 is NPO (Nothing by Mouth). Enteral formula and feedings as
ordered. Osmolite 1.5 (Formula) at 55 ml/hr (milliliters per hour) to provide 1800 KCALS (kilocalories) 76
grams protein, 800ml of water per 22 hours. Flush feeding tube with 200ml H2O Q 4 hours (water every 4
hours).
Record review of Resident #23's physician orders revealed an order with a start date of 11/19/24 for
osmolite 1.5 at 55ml/hr to provide 1800 KCALS, 76gms of protein, 800ml of water per 24 Hours. Via G-tube.
In an observation on 11/18/24 at 12:10pm Resident #23 was in bed, head of bed was elevated, the resident
was non-verbal but made eye contact and would nod her head slightly when asked a question and was
smiling. The tube feeding bag was clear and had approximately 500ml of an unidentified formula in it. A
label affixed to the tube feeding bag had Resident#23's last name, no room#, dated 11/16/24 at 8:00 p.m.
and the number 55 all written in black marker. No formula name was listed. The label also had areas to
record any additions to the bag with amount, time, and initials slots that were all blank. The tube feeding
was running via enteral feeding pump at 55ml/hr with a flush of 200ml water every 4 hours. The pump
indicated the resident had already received 4307mls of the formula feeding and 5053mls of water flush.
In an observation and interview on 11/18/24 at 12:14 p.m. LVN A was examining the tube feeding bag and
stated that the night nurse told her in report that she had hung it last night despite being
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675071
If continuation sheet
Page 3 of 7
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
675071
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Yorktown Nursing and Rehabilitation Center
670 W Fourth St
Yorktown, TX 78164
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 0693
Level of Harm - Minimal harm
or potential for actual harm
dated 11/16/24 and the date was just written in error and should have been 11/17/24. LVN A further stated
she trusted the night nurse and the formula was osmolite as ordered but admitted she had no proof but
trusted the night nurse. When asked why it was important the label be filled out correctly, LVN A stated
because when state walks in and then stated so that other nursing staff were aware of the feeding and
when it was hung.
Residents Affected - Few
In an interview on 11/21/24 at 11:15 a.m. the DON stated the tube feeding label should have the name of
the formula used, rate, date, and time hung. The DON further stated the resident's orders state to hang new
tubing every 2 days or 48 hours .
The facility policy and procedure for hanging and labeling a tube feeding was requested in an email sent to
the Administrator on 11/21/24 at 10:32 a.m.
Review of the facility provided enteral nutrition policy revised August 1, 2012, was from the food service
manual regarding assessment, orders, and documentation. This policy did not cover nursing procedures for
hanging a tube feeding and or labeling the tube feeding bag.
Review of Texas Health and Human Services Evidence-Based Best Practice for Nutritional Support revised
8/2023 revealed . These processes include ensuring timely turnover of enteral formula inventory well within
the product expiration dates and appropriate labeling . Formula labels should include the following: person's
name and room number, formula name and strength, date and time formula prepared and hung .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675071
If continuation sheet
Page 4 of 7
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
675071
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Yorktown Nursing and Rehabilitation Center
670 W Fourth St
Yorktown, TX 78164
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review the facility failed to provide pharmaceutical services (including
procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and
biologicals) to meet the needs of each resident for 1 of 8 residents (Resident #18) reviewed for pharmacy
services.
Resident #18's Tramadol (narcotic) medication was left unsupervised in the top drawer of the medication
cart in a paper pill cup after it was popped out of the medication card.
This could put residents at risk of pain, medication errors, and drug diversion.
The findings were:
Record review of Resident #18's face sheet dated 11/21/24 revealed the resident was a [AGE] year-old
female admitted to the facility on [DATE]. The resident's diagnoses included unspecified dementia
unspecified severity with agitation (general term for loss of memory, language, problem-solving, and other
thinking abilities that are severe enough to interfere with daily life and include agitation), muscle wasting
and atrophy not elsewhere classified multiple sites (wasting or loss of muscle tissue), and hemiplegia and
hemiparesis following cerebral infarction affecting right dominant side (weakness or paralysis of right side of
the body following a stroke due to damage to tissues in the brain due to a loss of oxygen to the area).
Record review of Resident #18's annual MDS assessment dated [DATE] revealed the resident had a BIMS
score of 3 out of 15 indicating the resident was severely cognitively impaired. The resident had unclear
speech and was sometimes understood and usually understands. The resident was continent of urine and
usually continent of bowel. The resident had frequent pain up to a 5 on a scale of 1-10 with 10 being worst
pain and received routine and PRN pain medication.
Record review of Resident #18's undated care plan revealed a focus for pain revised on 2/19/24 and
interventions included to administer pain medication as ordered.
Record review of Resident #18's physician orders revealed an order dated 11/14/24 for tramadol 100 mg
(milligram) 1 tablet by mouth every 6 hours for pain. (Give at 12 a.m., 6:00 a.m., 12 noon, and 6:00 p.m.)
Record review of Resident #18's EMAR for November 2024 revealed the resident had pain levels from 0 up
to 2 with most days being none.
In an observation and interview during station 2 medication cart check on 11/19/24 at 5:05 p.m. witnessed
by LVN A in the top drawer of the medication cart, a paper medication cup with an oblong white pill in it, and
the bottom of the paper cup written in pen was Resident #18's last name. LVN A stated it was a tramadol
100mg tab for Resident #18's 5pm dose and she had pre-popped it and signed out for it. LVN A further
stated she never does that, and she was unsure why she did it this time. LVN A stated she was not
supposed to pre-pop the medication and leave it in the cart and apologized. When asked why it was
important not to pre-pop the medications from the cards, LVN A stated because you can accidently give it
to the wrong resident or wrong time. The narcotic count sheet for tramadol
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675071
If continuation sheet
Page 5 of 7
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
675071
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Yorktown Nursing and Rehabilitation Center
670 W Fourth St
Yorktown, TX 78164
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
indicated LVN A signed out the tramadol at 5pm, the narcotic count was correct. LVN A wasted the tramadol
with another nurse and documented it as wasted and signed by both nurses on the narcotic count sheet.
In an interview on 11/21/24 at 11:05 a.m. the DON stated medications should be popped out of the card at
the time they were given and not to be stored for later. The DON stated it was important not to pre-pop
medications and store for later because it could get lost, the medication might be taken by someone else,
or the nurse could forget to give it.
The facility policy on medication administration was requested in an email sent to the Administrator on
11/21/24 at 10:32 a.m. A medication competency check off was provided .
Review of the facility provided medication administration competency audit for oral meds undated revealed
steps in administration of medications included . 3. punching med into cup using proper infection control
technique . 10. Observe resident swallow medications 11. Documents after administration of meds .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675071
If continuation sheet
Page 6 of 7
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
675071
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
11/21/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Yorktown Nursing and Rehabilitation Center
670 W Fourth St
Yorktown, TX 78164
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
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve
food in accordance with professional standards for food service safety for the kitchen.
Residents Affected - Some
The facility failed to ensure dietary staff used proper hand hygiene during meal preparation.
This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne
illness.
The findings included:
Observation on 11/20/2024 at 11:20 a.m. revealed the DM assisting with the meal tray preparation. The DM
had washed her hands and put on gloves for cutting the bread, after cutting the bread she assisted with
taking plates from the cook and placed them on trays. The cook asked for diet tickets on the other side of
the DM in which the DM reached and grabbed tickets handed them to the cook, and continued to assist
with putting plates on trays and placing bread on plates using tongs. The DM then proceeded to reach in a
bread bag, grabbed a large stack of bread, placed her gloved hand on the bread, cut the bread in half and
continued to place bread on trays. The DM did all this without changing gloves and washing hands.
During an interview on 11/20/2024 at 11:28 a.m. the DM stated she should have cut all the bread first
before helping with the plates. The DM further stated by not changing her gloves and washing her hands it
could cause cross contamination.
During an interview on 11/21/2024 at 1:05 p.m. the ADM stated the DM should have changed her gloves
once she finished what she was doing with the use of the gloves. The ADM further stated she should have
removed the gloves and before touching the bread again she should have washed her hands and put new
gloves on. The ADM stated once the DM had touched the meal tickets, she should have taken her gloves
off. The ADM stated the importance of removing the gloves and washing her hands was to prevent cross
contamination. The ADM further stated by touching the tickets the DM risked the contamination of the food
and it could be passed on to the residents.
Review of the facility's policy Meal Distribution, revised 2/2023, read Policy Statements: Meals are
transported to the dining locations in a manner that ensures proper temperature maintenance, protects
against contamination, and are delivered in a timely and accurate manner., Procedures: 6. Proper food
handling techniques to prevent contamination and temperature maintenance controls will be used for
point-of service-dining.
Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed,
2-301.14, When to Wash, FOOD EMPLOYEES shall clean their hands and exposed portions of their arms
as specified under 2-301.12 immediately before engaging in FOOD preparation including working with
exposed FOOD, clean EQUIPMENT and UTNESILS, and unwrapped SINGLE-SERVICE and SINGLE-USE
ARTICLES and: (F) During FOOD preparation, as often as necessary to remove soil and contamination
and to prevent cross contamination when changing tasks;.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675071
If continuation sheet
Page 7 of 7
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F645 - Preadmission Screening for individuals with a mental disorder and individuals
PASARR screening for Mental disorders or Intellectual Disabilities
F693 - Assisted nutrition and hydration
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.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the November 21, 2024 survey of YORKTOWN NURSING AND REHABILITATION CENTER?
This was a inspection survey of YORKTOWN NURSING AND REHABILITATION CENTER on November 21, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at YORKTOWN NURSING AND REHABILITATION CENTER on November 21, 2024?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "PASARR screening for Mental disorders or Intellectual Disabilities"
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.