Inspection·May 30, 2025

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Trulicity fact sheet, accessed on 06/05/2025, revealed, Trulicity is a non-insulin option that helps your body release the insulin it's already making. Record review of Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual, Version 1.19.11, October 2024 revealed, N0350: Insulin. 1. Review the resident's medication administration records for the 7-day look-back period (or since admission/entry or reentry if less than 7 days). 2. Determine if the resident received insulin injections during the look-back period. 3. Determine if the physician (or nurse practitioner, physician assistant, or clinical nurse specialist if allowable under state licensure laws) changed the resident's insulin orders during the look-back period. 4. Count the number of days insulin injections were received and/or insulin orders changed. Coding Instructions for N0350A o Enter in Item N0350A, the number of days during the 7-day look-back period (or since admission/entry or reentry if less than 7 days) that insulin injections were received. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675736 If continuation sheet Page 2 of 12 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 675736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yoakum Nursing and Rehabilitation Center 1300 Carl Ramert Dr Yoakum, TX 77995 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #29) whose comprehensive person-centered care plans were reviewed. The facility failed to ensure that Resident #29's diagnosis of depression was a focus area in the resident's comprehensive care plan. This deficient practice could affect residents by failing to ensure residents received appropriate care for their health conditions. The findings included: Record review of Resident #29's face sheet dated 05/29/2025, revealed the resident was a [AGE] year old female admitted to the facility on [DATE] with diagnoses including: Schizoaffective disorder (a chronic mental illness that combines symptoms of both schizophrenia and a mood disorder, such as depression or mania), major depressive disorder (a mental disorder characterized by persistent feelings of sadness, loss of interest, and difficulty functioning) and dementia (group of symptoms that affect memory, thinking, and other cognitive functions, significantly impacting daily life). Record review of Resident #29's Significant Change MDS dated [DATE] revealed a BIMS score of 09, indicating moderately impaired cognition. Further review of this MDS revealed in Section I - Active Diagnoses, I5800, Depression was checked. Record review of a note from the consultant psychiatric nurse practitioner dated 05/20/2025 revealed under Assessment/Plan the first diagnosis addressed was the resident's major depressive disorder. Record review of Resident #29's comprehensive care plan, updated 02/06/2025, revealed the diagnosis of depression was not listed as a focus area. During an interview on 05/29/2025 at 3:13 PM, MDS LVN C stated the diagnosis of depression was not listed as a focus area in Resident #29's comprehensive care plan and should be there. A possible reason for the omission might be because the resident was not taking any medication for the diagnosis, but the diagnosis should be listed regardless to ensure the resident received proper care. During an interview on 05/29/2025 at 3:15 PM, the Regional Care Manager stated the diagnosis of depression was not in Resident #29's comprehensive care plan and needed to be included in the care plan. During an interview on 05/30/2025 at 12:15 PM, the Administrator stated the diagnosis of depression should have been in Resident #29's comprehensive care plan, and there was no reason for its omission, especially since the resident had been at the facility for a long time. Record review of the facility's policy Comprehensive Care Plans implemented 10/24/2022 revealed: It (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675736 If continuation sheet Page 3 of 12 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 675736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yoakum Nursing and Rehabilitation Center 1300 Carl Ramert Dr Yoakum, TX 77995 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychological needs that are identified in the comprehensive assessment. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 6. The comprehensive care plan will include measurable objectives and timeframes to meet the resident's needs as identified in the resident's comprehensive assessment. The objectives will be utilized to monitor the resident's progress. Alternative interventions will be documented, as needed. Event ID: Facility ID: 675736 If continuation sheet Page 4 of 12 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 675736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yoakum Nursing and Rehabilitation Center 1300 Carl Ramert Dr Yoakum, TX 77995 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 resident (Resident #63) reviewed for incontinent care, in that: While providing incontinent care for Resident #63, CNA B used a back to front motion to clean Resident #63's buttocks. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices. The findings were: Record review of Resident #63's face sheet, dated 05/30/2025, revealed an admission date of 04/17/2023, with diagnoses which included: Dementia (decline in cognitive abilities), Type 2 diabetes mellitus (high level of sugar in the blood), Hypertension (High blood pressure), Hyperlipidemia (Elevated level of any or all lipids(fat) in the blood), Major depressive disorder (mental disorder characterized by at least two weeks of pervasive low mood, low self-esteem, and loss of interest or pleasure). Record review of Resident #'63's Significant change MDS, dated [DATE], revealed the resident had a BIMS score of 12 indicating moderate impairment. Resident #63 required limited to extensive assistance and was frequently incontinent of bladder and bowel. Review of Resident #63''s care plan, dated 05/01/2023, revealed a problem of has occasional bladder incontinence r/t not making it in time and dx of BPH. Uses a urinal at times but will not keep it in a bag. and an intervention of Clean peri-area with each incontinence episode. Observation on 05/29/2025 at 2:30 p.m. revealed while providing incontinent care for Resident #63, CNA B wiped Resident #63's buttocks in a back to front motion. During an interview on 05/29/2025 at 2:40 p.m. with CNA B, she confirmed she had wiped Resident #63's buttocks in a back to front motion She said she thought she was using the correct technique. She confirmed receiving training on incontinent care from the facility. During an interview with the DON on 05/29/2025 at 3:00 p.m., she confirmed the correct motion to clean the residents during perineal care was front to back to prevent fecal matter from contacting the urethra and possibly cause an infection. The DON revealed the staff received training on infection control and incontinent care at least annually. The staff skills were checked yearly. The DON and ADON spot check the staff while they provided care for infection control and quality of care. Review of annual skills check for CNA B revealed CNA B passed competency for Perineal care/incontinent care on 03/06/2025. Review of facility policy, titled Incontinent care skills checklist, undated, revealed Wash from front to towards rectum, front to back, using clean stroke [ .] cleanse the entire buttock area and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675736 If continuation sheet Page 5 of 12 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 675736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yoakum Nursing and Rehabilitation Center 1300 Carl Ramert Dr Yoakum, TX 77995 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 0690 surrounding hip area. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675736 If continuation sheet Page 6 of 12 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 675736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yoakum Nursing and Rehabilitation Center 1300 Carl Ramert Dr Yoakum, TX 77995 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 0801 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician. Based on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 staff (FSS) reviewed for competency and skill sets. The FSS did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition. The findings included: During an interview on 05/27/2025 at 11:20 AM, the FSS stated she was not a certified dietary manager or certified food service manager, and he did not have an associate's or higher degree in food service management or in hospitality. He did not have 2 or more years of experience in the position of director of food and nutrition services in a nursing facility setting. He had completed a course of study in food safety management that included topics integral to managing dietary operations including foodborne illness, sanitation procedures, and food purchasing/receiving, but had not yet taken the exam to become a certified dietary manager and able to apply for certification. He consulted periodically with a registered dietitian, but the dietitian was not employed by the facility full-time. During an interview on 05/29/2025 at 3:12 PM, the HR Director stated the FSS assumed the position of FSS on 03/01/2024. During an interview on 05/29/2025 at 3:30 PM, the Administrator stated she was aware the FSS was not a certified dietary manager, certified food manager, or met the other qualifications to serve as the Director of Food and Nutrition Services for the facility. The Administrator stated the FSS would be taking the exam to become a certified dietary manager shortly. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 1-201.10.10(B) Accredited Program. (1) Accredited program means a food protection manager certification program that has been evaluated and listed by an accrediting agency as conforming to national standards for organizations that certify individuals. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed 2-102.12 Certified Food Protection Manager. (A) The PERSON IN CHARGE shall be a certified FOOD protection manager who has shown proficiency of required information through passing a test that is part of an ACCREDITED PROGRAM. 2-102.20 Food Protection Manager Certification. (B) A FOOD ESTABLISHMENT that has a PERSON IN CHARGE that is certified by a FOOD protection manager certification program that is evaluated and listed by a Conference for FOOD Protection-recognized accrediting agency as conforming to the Conference for FOOD Protection Standard for Accreditation of FOOD Protection Manager Certification Programs is deemed to comply with §2-102.12. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675736 If continuation sheet Page 7 of 12 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 675736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yoakum Nursing and Rehabilitation Center 1300 Carl Ramert Dr Yoakum, TX 77995 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 for 1 of 1 kitchen in accordance with professional standards for food service safety. Residents Affected - Some 1. The facility failed to discard a bag of salad mix dated 03/24/2025 containing brown and rotted leaves in the reach-in cooler. 2. The facility failed to ensure an opened bag of pinto beans in the dry storage room was properly sealed. 3. The facility failed to properly sanitize the compartments of the blender used to puree food for modified diets in accordance with manufacturer's instructions. These failures could place residents at risk for food borne illness. The findings included: 1. Observation on 05/27/2025 at 11:29 AM in the reach-in cooler revealed 5-lb. bag of salad mix with a label indicating it was received on 05/22/2025 and opened 05/23/2025. The bag was sealed and approximately 15% of the salad leaves had turned brown or were rotten. During an interview on 05/27/2025 at 11:30 AM, the FSS stated the salad mix should have been discarded. All dietary staff were responsible for properly labeling and dating food items stored in the cooler and discarding items past their use-by dates. 2. Observation on 05/27/2025 at 11:36 AM in the dry storage room revealed a 50-lb. bag of pinto beans on a rack. The bag had been opened and was rolled over. The bag was not sealed or placed in a sealed bin or container. During an interview 05/27/2025 at 11:37 AM the FSS stated the bag of pinto beans should have been placed in a sealed container, and failing to ensure food was properly sealed could result in deterioration in food quality and potential contamination from pests. 3. Observation on 05/29/2025 at 10:35 AM revealed [NAME] D used the high-speed blender to puree bread for the lunch meal for residents on a modified consistency (pureed) diet. After emptying the contents of the blender in a pan, [NAME] D took the blender to the preparation sink and rinsed the components in hot water. [NAME] D did not use hot, soapy water to wash the blender components or sanitize the components in a sink containing a sanitizing solution or use the dish machine to wash/sanitize the components. During an interview on 05/29/2025 at 10:36 AM, [NAME] D stated she was told she just needed to rinse the blender components in very hot water, almost too hot to touch, between the preparation of different foods for residents on a pureed diet. [NAME] D stated she had not used soap or sanitizing solution for the blender components after preparing pureed roast pork, pureed sweet potatoes or pureed cauliflower. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675736 If continuation sheet Page 8 of 12 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 675736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yoakum Nursing and Rehabilitation Center 1300 Carl Ramert Dr Yoakum, TX 77995 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 - Some During an interview on 05/29/2025 at 10:37 AM, the consultant RD stated utensils needed to be sanitized in the sink with sanitizing solution or in the dish machine. During an interview on 05/29/2025 at 10:55 AM, the FSS stated the dietary staff had been trained by his predecessor, and he would ensure the staff was retrained on proper sanitizing procedures for equipment and utensils. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 3-501.17 Ready-to-Eat/Time Temperature Control for Safety Food, Date Marking. (B) Except as specified in (E) - (G) of this section, refrigerated, ready-to-eat, time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, based on the temperature and time combinations specified in (A) of this section and: (1) The day the original container is opened in the food establishment shall be counted as Day 1; and (2) The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, O. Retail Food Protection Program Information Manual: Recommendations to Food Establishments for Serving or Selling Cut Leafy Greens. Following 24 multi-state outbreaks between 1998 and 2008, cut leafy greens was added to the definition of time/temperature for safety food requiring time-temperature control for safety (TCS). The term used in the definition includes a variety of cut lettuces and leafy greens. Record review of facility policy 03.003 Food Storage revised 06/01/2019 reveled, Policy: To ensure that all food served by the facility is of good quality and safe for consumption, all food will be stored according to the state, federal and US Food Codes and HACCP guidelines. 1. Dry storage rooms. d. To ensure freshness, store opened and bulk items in tightly covered containers. Record review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed: 3-305.11, Food Storage, (A) Food shall be protected from contamination by storing the food: (1) in a clean, dry location; (2) Where it is not exposed to splash, dust, or other contamination. Record review of facility policy 04.005 Manual Cleaning and Sanitizing of Utensils and Portable Equipment approved 10/01/2018 revealed, Policy: The facility will follow the cleaning and sanitizing requirements of the state and US Food Codes for manual cleaning in order to ensure that all utensils and equipment are thoroughly cleaned and sanitized to minimize the risk of food hazards. 1. Use a three-compartment sink with running hot and cold water for cleaning, rinsing and sanitizing. 5. Prior to washing, pre-flush or pre-scrape all equipment and multi-use utensils. When necessary, presoak to remove gross food particles and soil. 6. In the first sink, immerse the equipment or utensils in a hot, clean detergent solution at a temperature of no less than 120°F. 7. Rinse in the second sink using clear, clean water between 120 °F and 140 °F to remove all traces of food, debris, and detergent. 8. Sanitize all multi-use eating and drinking utensils and the food-contact surfaces of other equipment in the third compartment by one of the following methods: a. Immerse for at least 30 seconds in clean, hot water at a temperature of 170°F or above. b. Immerse for at least 60 seconds in a clean sanitizing solution containing: i. A minimum of 50 parts per million of available chlorine at a temperature not less than 75°F. c. Be sure to cover all surfaces of the utensils (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675736 If continuation sheet Page 9 of 12 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 675736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yoakum Nursing and Rehabilitation Center 1300 Carl Ramert Dr Yoakum, TX 77995 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete and/or equipment with hot water or the sanitizing solution and keep them in contact with it for the appropriate amount of time. Review of the Food Code, U.S. Public Health Service, U.S. FDA, 2022, U.S. Department of H&HS, revealed, 4-702.11 Before Use After Cleaning. UTENSILS and FOOD-CONTACT SURFACES of EQUIPMENT shall be SANITIZED before use after cleaning. Event ID: Facility ID: 675736 If continuation sheet Page 10 of 12 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 675736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yoakum Nursing and Rehabilitation Center 1300 Carl Ramert Dr Yoakum, TX 77995 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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #1) of 8 residents reviewed, in that: Residents Affected - Few The facility failed to ensure the thermometer inside Resident #1's personal refrigerator was functioning properly and the staff recorded the accurate temperatures of the refrigerator for five months. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled. The findings included: Record review of Resident #1's face sheet, dated 05/27/2025, reflected the resident was a [AGE] year-old female and was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses included: Alzheimer's disease (the most common type of dementia, a progressive brain disorder that damages memory, thinking, and other cognitive abilities), dementia (a decline in mental abilities severe enough to interfere with daily life, and it is caused by damage to the brain), hypertension (high blood pressure), and depression (a persistent feeling of sadness, loss of interest, and changes in thinking, sleeping, eating, and acting). Record review of Resident #1's quarterly MDS, dated [DATE], reflected the resident's BIMS score was 08 out of 15, indicating moderately impaired cognition. The resident required supervision or touching assistance with eating (helper provided verbal cues or touching/steadying assistance as resident completed activity). Observation on 05/27/2025 at 2:30 PM revealed Resident #1 was sitting in her wheelchair in her room. The resident had a personal refrigerator, and inside the refrigerator was an analogue thermometer. The interior temperature of the refrigerator according to the thermometer was 26 degrees F. Further observation inside the refrigerator revealed an open can of soda approximately half-full. Shaking the can revealed the soda was not frozen, indicating the thermometer was not accurate. Record review of the temperature log attached to the side of the refrigerator revealed temperatures taken for the months of January through May 2025. The temperatures ranged from 32 - 12 degrees F in January, 26 - 22 degrees F in February, 32 - 18 degrees F in March, 20 - 12 degrees F in April and 34 -12 degrees F in May 2025. During an interview on 05/27/2025 at 2:35 PM, LVN E stated Housekeeping was responsible for recording the temperatures of the refrigerator on the temperature log. During an interview on 05/27/2025 at 2:40 PM, the DON stated the thermometer inside Resident #1's read 26 degrees F, indicating it was not working properly, as the contents of the refrigerator were not frozen. The Housekeeping staff recorded the temperatures of this thermometer on a Temperature log placed in a document protector and posted on the left side of the refrigerator from January - May 2025 without noting the thermometer was broken and failed to bring the situation to the attention of nursing staff. She would ensure a new thermometer was placed in the refrigerator. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675736 If continuation sheet Page 11 of 12 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 675736 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/30/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Yoakum Nursing and Rehabilitation Center 1300 Carl Ramert Dr Yoakum, TX 77995 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 0813 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Observation on 05/27/2025 at 3:30 PM inside Resident #1's refrigerator revealed the new analogue thermometer read 40 degrees F, indicating the previous thermometer was broken and the refrigerator was functioning properly. During an interview on 05/27/2025 at 3:20 PM, the Housekeeping Director and Administrator stated they understood the thermometer in Resident #1's facility was not functioning properly and had not been for several months. The facility's policy needed to be clearer, as it stated at the top of the temperature log form Resident Room or nourishment refrigerators should have temperatures 40 degrees F or lower. Housekeeping staff needed education on the proper range for refrigerator temperatures. Record review of https://www.kitchenaid.com/pinch-of-help/major-appliances/refrigerator-temperature.html accessed on 06/05/2025 revealed, .the ideal refrigerator temperature is around 37°F (3°C). That said, a range of 33-40°F (0-4°C) is typically considered safe for most purposes. Temperatures that fall below 33°F can freeze foods while temperatures above 40°F may contribute to food spoilage. Record review of facility policy 02.005 Potluck Meals and Foods from Home approved 10/18/2018 revealed, Policy: Residents have a right to participate in potluck events and consume foods brought into the facility from outside sources. The facility will provide the resident and family education on the basics of food safety and the use and storage of food to ensure safe consumption. 2. The facility must ensure safe food handling techniques once the food is brought into the facility including safe reheating to 165 degrees for 15 seconds, holding cold items <41 degrees . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675736 If continuation sheet Page 12 of 12