Inspection·November 18, 2025

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete approximately around 10:00 PM and spoke to LVN A and inquired about Resident #1's bleeding and complained about LVN A's care, specific for urinary indwelling catheter.2. Resident #1's Representative stated on 10/25/2025 at 6:00 AM she called the facility and spoke to LVN A and complained that Resident #1's bedside table was not at the bedside as observed with the in-room camera.Resident #1's Representative stated her grievances were not resolved.During an interview on 11/4/2025 at 5:50 PM LVN A stated she was a nurse for the facility and usually worked the 6:00 PM to 6:00 AM shift and had cared for Resident #1. LVN A stated Resident #1 was a [AGE] year-old male under hospice and facility care. LVN A stated Resident #1 had a need for a urinary indwelling catheter related to his enlarged prostate urinary retention. LVN A stated she was familiar with Resident #1's Representative who had a camera in the resident's' bedroom and often made complaints. LVN A stated she recalled sometime late last month, October 2025, Resident #1's representative called the facility late in the evening and complained she had reviewed the camera footage and saw some blood on the bed linens. LVN A stated she had rounded on Resident #1's several times that evening and redirected him back to bed when she would find him sitting on his bedside. LVN a stated Resident #1 had a history of tugging / pulling on his urinary indwelling catheter and had caused some bleeding. LVN A stated she had assessed Resident #1 without any bleeding to the urinary indwelling catheter and redirected him back to bed. LVN A stated Resident #1's Representative called the morning of 10/25/2025 and spoke with her to complain that Resident #1 was not in his room, and neither was his bedside table. LVN A speculated Resident #1's Representative believed Resident #1 was put aside and not cared for. LVN A stated she reported to Resident #1's Representative that Resident #1 was attending the breakfast service and his bedside table was moved temporarily. LVN A stated she had not documented Resident #1's complaints but had training to help residents and their representatives to generate a grievance report to have their grievances reviewed by the leadership and have their grievances resolved. During a joint interview on 11/05/2025 at 3:20 PM the Administrator and the DON stated the expectation for grievances was for staff who hear a grievance should assist the complainant to generate a grievance form and submit the grievance form to the Administrator and/ or the DON. The Administrator and DON stated LVN A had not generated a grievance form for Resident #1's Representative's complaints. The Administrator and the DON stated the potential negative outcomes for residents was their grievances may go unresolved. A record review of the facility's Resident and Family Grievances policy dated 10/4/2025 revealed, Policy: It is the policy of this facility to support each residents and family members right to voice grievances without discrimination, reprisal or fear of discrimination or reprisal. A resident or family member may voice grievances with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and other residents, and other concerns regarding their long term care facility stay. The staff member receiving the grievance will record the nature and specifics of the grievance on the designated grievance form, or assist the resident or family member to complete the form. Event ID: Facility ID: 675736 If continuation sheet Page 2 of 4 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 11/18/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized for 1 of 3 residents (Resident #1) reviewed for reviewed for accurate records. LVN A and LVN B failed to document the failed attempts to instill a urinary indwelling catheter for Resident #1 and the report to the physician. These failures could place residents at risk for diminished health status. The findings included: A record review of Resident #1's admission record dated 11/4/2025 revealed an admission date of 4/11/2025 and a discharge date of 11/1/2025; with diagnoses which included dementia (a general term for a decline in cognitive function, affecting memory, thinking, and social abilities to the extent that it interferes with daily life). Further review revealed Resident #1 was a [AGE] year-old male admitted for long term care with ADL needs for dementia. A record review of Resident #1's care plan dated 11/4/2025 revealed, (Resident #1) has an ADL self-care performance deficit related to dementia . Resident requires substantial / maximal assistance for personal hygiene. A record review of Resident #1's physicians orders dated 7/5/2025 revealed the physician ordered for Resident to receive care related to his indwelling urinary catheter twice a day and as needed. A record review of Resident #1's physicians orders dated 9/11/2025, revealed, the physician ordered Resident #1 to have a urinary indwelling catheter to support his urinary retention complicated by an enlarged prostate; Foley Catheter: Change 22F with 30ml bulb q month every night shift starting on the 11th and ending on the 11th every month. A record review of Resident #1's medication administration record for October 2025 revealed LVN A documented she instilled Resident #1's urinary indwelling catheter on 11/11/2025. A record review of Resident #1's medical record for the review period of 11/10/2025 through 10/13/2025 revealed no documentation to detail Resident #1's indwelling urinary catheter, nor his change of condition or report to the physician of the change in condition. A record review of Resident #1's nursing progress notes dated 10/12/2025 revealed LVN B at 8:17 AM documented, Note Text: Resident noted with copious amounts of blood clots following having his foley catheter replace 3 hours prior. Dr. (name) on call called for Dr. (name), no answer awaiting response.[sic] During an interview on 11/4/2025 at 11:00 AM Resident #1's Representative stated she was unsatisfied with the care provided for Resident #1. Resident #1's Representative stated Resident #1 was hospitalized on [DATE] for bleeding related to his indwelling urinary catheter. Resident #1's Representative stated she learned from LVN B that attempts to change Resident #1's indwelling urinary catheter were unsuccessful, and the physician ordered for Resident #1 to be hospitalized for evaluation and treatment. During an interview on 11/4/2025 at 5:50 PM LVN A stated she was a nurse for the facility and usually worked the 6:00 PM to 6:00 AM shift and had cared for Resident #1. LVN A stated Resident #1 was a [AGE] year-old male under hospice and facility care. LVN A stated Resident #1 had a need for a urinary indwelling catheter related to his enlarged prostate urinary retention. LVN A stated Resident #1 had a history of tugging / pulling on his urinary indwelling catheter and had caused some bleeding. LVN A stated Resident #1's physician had ordered for Resident #1 to have his Indwelling urinary catheter changed once a month beginning on 10/11/2025 during the evening shift. LVN A stated she worked that evening and decided to change the catheter the morning of 10/12/2025 around 5 AM in order to have another nurse available if she had complications. LVN A stated when she attempted to instill the new catheter she met with resistance and had no urine return flow and had reported the finding to the next nurse, LVN B. LVN A stated she had not documented the details of the procedure and stated she believed signing the medication administration record was sufficient. LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675736 If continuation sheet Page 3 of 4 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 11/18/2025 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 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete A stated she had not documented the nurse-to-nurse report either. During an interview on 11/4/2025 at 6:00 PM LVN B stated she was an LVN at the facility and usually worked 6 AM to 6 PM and recalled she received a report from LVN A on the morning of 10/12/2025 where LVN A had a difficult procedure of instilling an indwelling foley catheter for Resident #1 and had received a report from a CNA that Resident #1 had bleeding evidence in his adult brief. LVN B stated she and LVN A assessed Resident #1 with no return urine flow and LVN B re-attempted to instill a fresh indwelling urinary catheter with no success. LVN B stated she could not overcome Resident #1's enlarged prostate to reach the bladder evidenced by no urine return flow. LVN B stated she reported the findings to the physician and received new orders for Resident #1 to be transferred to the hospital for evaluation and treatment. LVN B stated she believed she had documented the details of the incident and upon record review stated she had not documented details to accurately document the chain of events. During a joint interview on 11/05/2025 at 3:20 PM the Administrator and the DON stated the expectation for accurate records was for staff who provided care would document the care provided to include enough details to effectively document the care. The Administrator and the DON stated the facility had a policy for documenting indwelling foley catheterization and followed the [NAME] guidance and procedures (a series of evidence-based, step-by-step clinical resources for healthcare professionals, primarily nurses, created by Wolters Kluwer. These online and print resources provide consistent and safe patient care guidelines at the point of care, offering detailed instructions, skills checklists, and competency assessments for a wide range of procedures and topics, as described on the Wolters Kluwer website.) The Administrator and the DON stated the potential negative outcome for residents could be inaccurate records. A record review of the [NAME] Solutions website https://procedures.lww.com/lnp/view.do?pId=4420096&hits=inserting,urinary,insertion,catheter,catheters,inserted,insert&a= 11/4/2025, titled Procedures: Indwelling urinary catheter (Foley) insertion, assigned male at birth Revised: November 17, 2024, revealed, . Documentation associated with indwelling urinary catheter insertion includes:assessment findingsindication for catheter usedate and time of insertionsize and type of catheteramount of sterile water used to inflate the balloonintake and output (if ordered)characteristics and amount of urinecomplicationsname of the practitioner you notifieddate and time of notificationprescribed interventionspatient's response to those interventionsteaching provided to the patient and family (if applicable)understanding of that teachingfollow-up teaching needed. Event ID: Facility ID: 675736 If continuation sheet Page 4 of 4