Health inspection·April 24, 2025

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many where it is not yellow or brown. I just get ice around it. LVN A stated she had not reported the discolored ice because everybody has seen it and it's been like that for a long time. During an interview with LVN C, 04/23/2025 at 12:00 p.m., LVN C stated she had observed facility residents being served yellow or brown ice and had observed yellow and brown ice in the ice machine. LVN C stated she had not reported the discolored ice because I know it is something they are aware of. LVN C stated, I noticed it when I started working here and I thought it was kind of gross. LVN C stated she had been working at the facility for 1 ½ months. During an interview with the Dietary Supervisor, 04/24/2025 at 9:37 a.m., the Dietary Supervisor stated the Maintenance Director and Dietary Supervisor were responsible for ensuring the ice machine was cleaned and stated it should have been cleaned on a weekly basis. The Dietary Supervisor said, the cleaning schedule was in the Maintenance Director's computer program as a weekly task and said, But are all responsible for pulling out that yellowish looking ice and not serving it to our residents. The Dietary Manager stated the ice machine was cleaned on 4/22/2025 and stated it was important for the ice machine to be clean, because it is about sanitation and infection control and keeping our residents safe and happy. The Dietary Supervisor stated a resident who received ice from a dirty or contaminated ice machine could get sick if their immune system is down. The Dietary Supervisor stated the ice discoloration was due to the city water and occurred when the city flushed the fire hydrants. The Dietary Supervisor stated the city would notify the facility when they were flushing the hydrants, and this notification would give the facility the ability to make a plan to clean the ice machine according to the city notification. During an interview with the Maintenance Director, 04/24/2025 at 12:34 p.m., the Maintenance Director stated he was responsible for cleaning the ice machine and stated, I pulled out the filters and clean them and then I check for the yellow ice due to the city water and I scoop it out and throw it in the sink in the kitchen and wipe the inside down but sometimes I forget, that is probably why there was rust on it. The Maintenance Director stated there was no specific clean schedule but stated he cleaned the filters on the ice machine once a month and said, The yellow ice, if I think about it when I walk by, I will scoop it out. It is usually worse when the city flushes the hydrants on every other Thursday. The Maintenance Director stated there was not an assigned task in the maintenance program and stated he had not received any training on how to clean the ice machine. The Maintenance Director stated it was important to clean the ice machine so the residents would have clean ice. During an interview with the facility Administrator, 04/24/2025 at 1:24 p.m., the Administrator stated the facility Maintenance Director was responsible for cleaning the ice machine and said he thought the ice machine should be cleaned monthly. The Administrator stated it was important for the ice machine to be cleaned for sanitation and we don't want to grow any bacteria and for health and safety. The Administrator stated he was not sure what harm could occur to a resident who received ice from a contaminated or dirty ice machine but stated, I know it would not be healthy. The Administrator stated the Dietary Supervisor and Maintenance Director probably had training on cleaning the ice machine. During an observation of the ice machine, 04/24/2025 at 3:15 p.m., the outside and inside of the ice machine walled surfaces had been cleaned and there was no rust observed. Yellow ice was observed in the middle of the ice in the ice machine. Record review of a facility document titled, Environment (Dining Services Policy and Procedure Manual, Copyright Original 5/2014, Revised 9/2017), revealed a policy statement, All food preparation (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675071 If continuation sheet Page 2 of 3 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 04/24/2025 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 Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete areas, food service areas, and dining areas will be maintained in a clean and sanitary condition. The procedures for the policy included, 1. The Dining Services Director will ensure that the kitchen is maintained in a clean and sanitary manner 2. The Dining Services Director will ensures that all employees are knowledgeable in the proper procedures for cleaning and sanitizing of all food services equipment and surfaces .4. The Dining Services Director will ensure that a routine cleaning schedule is in place for all cooking equipment, food storage areas, and surfaces. Event ID: Facility ID: 675071 If continuation sheet Page 3 of 3