Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Yorktown Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
MDS assessments for three residents did not accurately reflect key clinical information. One resident’s quarterly MDS missed an active depression diagnosis and undercounted falls despite antidepressant therapy, psych notes, and documented falls. Another resident’s Significant Change MDS did not code oxygen therapy even though the resident had an O2 order and was observed wearing a nasal cannula with oxygen documented in the record. A third resident’s quarterly MDS did not include dysphagia despite a mechanically altered diet, swallowing history, and meal observations showing soft-texture food.
Infection control practices were not maintained for two residents. A resident with a urinary catheter, colostomy, and Stage 4 sacral pressure injury was observed during catheter care when a CNA removed a dirty brief and applied a clean brief without changing soiled gloves or sanitizing hands. The report also states an ADON did not remove and replace her gown after leaving the room during wound care, and another resident with a diabetic ulcer did not have EBP PPE or signage outside the door.
Failure to Follow Ordered Wound Treatment: A resident with a diabetic heel ulcer and severe cognitive impairment did not receive wound care as ordered when an ADON cleaned the wound, applied the collagen dressing, and rewrapped the foot but omitted the ordered Betadine-moistened gauze. The ADON stated she did not know why she skipped the step, and the DON and ADM acknowledged that staff must follow MD orders and that missing the ordered treatment could delay healing or compromise care.
Unlocked housekeeping carts with cleaning chemicals were left in an unsecured storage room near resident rooms. Surveyors observed 2 carts containing antibacterial hand foam, glass cleaner, biowaste degrader, odor neutralizer, and cream cleanser, with one cart keyed in the door and the other unlocked with no key present. The Housekeeping Supervisor, DON, and Administrator all stated the carts and chemicals should have been locked when not in staff view, and the facility policy required carts and chemicals to be locked when not within eyesight of staff.
Improper Oxygen Delivery and Dirty Concentrator Filter: A resident with COPD was observed receiving oxygen from a concentrator set above the ordered 2 LPM until an LPN adjusted it, and another resident with COPD had an oxygen concentrator filter repeatedly observed covered in dust and dirt despite a weekly cleaning order. The DON, ADM, and LPN all acknowledged that nurses were responsible for following the oxygen orders and keeping the filter clean.
Expired Medi-honey was found on Station II medication cart during observation. LVN C stated expired substances should not remain on the cart and nurses were responsible for checking and removing them. The DON said Station II was missed during cart checks, and the ADM stated nurses needed to continually check carts and medication rooms for expired medications. The facility policy required medications to be rotated and/or reviewed on a consistent basis to prevent expired medications from being in the facility.
Incomplete and inaccurate oxygen documentation was found for two residents. One resident had an O2 order for 2 L/min via NC, but the MAR/TAR did not initially include the order for staff to monitor the concentrator setting and cannula placement, and the concentrator was observed set between 3 and 4 LPM. Another resident’s TAR was initialed to show the oxygen concentrator filter had been cleaned, but repeated observations showed the filter was still covered with dust and dirt, and the LPN stated she had not cleaned it.
The facility's kitchen ice machine, used for resident beverages, was found with visible rust and large sections of yellow and brown ice. Multiple staff, including dietary and nursing, were aware of the issue but did not consistently report or address it, citing unclear responsibilities. There was no established cleaning schedule or adequate staff training, leading to ongoing unsanitary conditions in the ice machine.
The facility failed to maintain proper hand hygiene during meal preparation, as observed when a Dietary Manager did not change gloves or wash hands after handling meal tickets and before continuing food preparation. This lapse in protocol was confirmed through interviews, highlighting a risk of cross-contamination.
A facility failed to conduct a PASRR level 2 evaluation for a resident with mental illness, despite her diagnoses of major depressive disorder with psychotic symptoms and psychotic disorder with delusions. The resident's PASRR level 1 screening incorrectly indicated no mental illness, and her admission MDS assessment did not recognize her as having a serious mental illness. The DOCC acknowledged the oversight, which could prevent the resident from receiving necessary specialized services.
A resident receiving enteral feeding had a tube feeding bag that was improperly labeled, lacking the formula name and correct date, which could lead to errors in care. The LVN trusted the night nurse's report despite these discrepancies, and the facility's policy did not adequately cover labeling procedures.
A facility failed to ensure proper pharmaceutical services when an LVN pre-popped a tramadol tablet for a resident and left it unsupervised in a medication cart. The resident, with severe cognitive impairment and pain management needs, had a care plan requiring pain medication as ordered. The DON confirmed that medications should not be pre-popped, as it could lead to errors. The facility's policy outlined proper medication administration steps, which were not followed in this instance.
A resident with severe cognitive impairment and multiple medical conditions was injured during a transfer when a CNA used a mechanical lift with the wrong-sized sling and without the required two-person assistance. The resident fell, sustaining a fracture and a laceration, after the CNA attempted the transfer alone, contrary to the care plan.
MDS Assessments Did Not Accurately Reflect Depression, Oxygen Use, or Dysphagia
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected resident status for three residents reviewed. For one resident with diagnoses including major depressive disorder, anxiety, dysphagia, and anoxic brain damage, the quarterly MDS dated 01/12/2026 did not code depression and reflected only one fall since the prior assessment, even though the record showed an active antidepressant order, a psychological services note documenting major depressive disorder with depressed and anxious mood, and two falls occurring between the assessment periods. The resident’s care plan also included antidepressant medication and fall-risk interventions. For another resident, the Significant Change MDS dated 01/16/2026 did not code oxygen therapy in Section O even though the resident had an order for O2 via nasal cannula at 2 L/min for shortness of breath/O2 >89, and records showed oxygen use documented in the vitals/O2 saturation summary on multiple days during the look-back period. Staff observed the resident wearing a nasal cannula, and the resident care plan included oxygen therapy as ordered. During interviews, the MDS Coordinator stated she did not code oxygen because she believed there was no order at the time and said she did not typically review vitals when completing MDS assessments. For a third resident with diagnoses including Alzheimer’s disease, dysphagia, COPD, and major depressive disorder, the quarterly MDS dated 12/29/2025 did not note dysphagia as an active diagnosis even though the resident was on a mechanically altered diet and records referenced swallowing difficulty and an esophageal stricture history. The resident was observed eating a mechanically soft meal, and the lunch ticket reflected a mechanically soft diet with thin liquids. The MDS Coordinator stated she was not aware of the missed diagnosis for the resident, and the DON and Administrator stated the MDS assessment needed to accurately reflect the resident and the care being provided.
Infection Control Lapses During Catheter and Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 of 7 residents reviewed for infection control. Resident #6 was admitted with diagnoses including pressure ulcer of the sacral region, neuromuscular dysfunction of the bladder, urinary tract infection, cerebral infarction, aphasia, anxiety, anoxic brain damage, dysphagia, and major depressive disorder. Her record showed she was severely cognitively impaired, dependent on staff for ADLs, had an indwelling urinary catheter and a colostomy, and had a Stage 4 pressure injury to the sacrum. Her care plan and active orders included indwelling catheter care, wound care, and enhanced barrier precautions related to her PEG tube, urinary catheter, and wound. During observation, CNA B performed catheter care for Resident #6 and cross contaminated the field by removing the resident's dirty brief and applying a clean brief without changing soiled gloves, sanitizing hands, or putting on clean gloves. In interview, CNA B stated she forgot and then realized she had not removed her soiled gloves, sanitized her hands, or put on the clean brief correctly, and acknowledged that her actions could cause transmission of bacteria and infection. The report also states the facility failed to ensure the ADON removed and replaced her gown after leaving the room to get more gloves while performing wound care for Resident #6 on EBP, and failed to ensure Resident #10 was on EBP by not having PPE outside the door and a sign on the door when he had a diabetic ulcer requiring a dressing.
Failure to Follow Ordered Wound Treatment
Penalty
Summary
The facility failed to ensure that a resident with a diabetic foot ulcer received treatment consistent with the physician’s orders. Resident #10 was a [AGE]-year-old male admitted with diagnoses including unspecified dementia, COPD, major depressive disorder, and type 2 diabetes mellitus. His quarterly MDS showed a BIMS score of 4 out of 15, indicating severe cognitive impairment, and he required moderate to extensive assistance with ADLs. His care plan identified a diabetic ulcer on the right heel and directed wound treatment per facility protocol. The weekly ulcer assessment documented the right heel ulcer as not resolved and measured 1.40 cm x 1.40 cm x 1.96 cm. The active order for the wound directed staff to clean the right heel with wound cleanser, apply Promogran Prisma, then apply Betadine-moistened gauze and wrap with kerlix every other day and as needed. During observation, the ADON performed the treatment by sanitizing her hands, wearing gloves, removing the old dressing, cleaning the wound, applying the collagen dressing, and rewrapping the foot with kerlix, but she did not apply the ordered Betadine-moistened gauze even though it was present with the treatment supplies. In interview, the ADON stated she did not know why she did not use the Betadine as ordered and acknowledged she was trained to follow physician orders. The DON and ADM also stated that nurses needed to follow physician orders and that missing the ordered Betadine could delay healing or compromise care.
Unlocked housekeeping carts with cleaning chemicals left in unsecured storage room
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible in room [ROOM NUMBER], which was being used as storage on a hallway with 6 residents. During observation on 02/17/2026 at 11:20 a.m., the room was found with no lock on the door and contained 2 housekeeping carts that were not locked. The carts held potentially unsafe cleaning chemicals, including antibacterial hand foam refills on the bottom shelves and multiple bottles of cleaners and disinfectants. Housekeeping cart #1 had the key in the door and was unlocked with Bold Power hard surface & glass cleaner and Biowaste Degrader, and housekeeping cart #2 was unlocked with Biowaste Degrader, Oder Neutralizer spray, and Cream Cleanser. During interview, the Housekeeping Supervisor stated housekeeping had been given the room to store items, but the carts were supposed to be locked. The supervisor also stated the soap and antibacterial hand foam should have been locked up and removed from the carts, and that a resident could come into the room and drink or spray the chemicals. The DON stated that leaving housekeeping carts unattended and unlocked could allow residents to access the chemicals, and the Administrator stated the carts should have been stored locked and chemicals should not have been left out and unlocked when not in view of staff. The facility policy stated housekeeping carts and chemicals must be locked when not within eyesight of a staff member.
Improper Oxygen Delivery and Dirty Concentrator Filter
Penalty
Summary
Resident #28, who had COPD and intact cognition, had a physician order for oxygen via nasal cannula at 2 L/min for shortness of breath/O2 >89. During observations, the resident was seen wearing oxygen while the concentrator was set between 3 and 4 LPM. When the LVN entered the room, she stated the concentrator was supposed to be set at 2 liters per minute continuously and adjusted it to 2 LPM, stating it should not be set higher without an order. The DON and Administrator later stated the nurse was responsible for ensuring the concentrator was at the proper setting and that the incorrect setting could affect the oxygen the resident received. Resident #36, who had diagnoses including heart failure, acute bronchitis, dysphagia, psychotic disorder, and COPD, was ordered to use oxygen at 2 L/min via nasal cannula every night shift. The care plan and active orders also directed that the oxygen concentrator filter be cleaned weekly every Sunday. Although the TAR showed the filter was cleaned on 02/15/2026, repeated observations on multiple days showed the concentrator's black foam filter covered with a thick gray coat of dust and dirt. The DON observed the same condition and stated oxygen concentrator filters needed to be cleaned and changed as needed because not cleaning the oxygen he received could result in respiratory difficulty. During interview, the LVN stated she had initialed the oxygen-related tasks but did not remember to clean the oxygen filter and had not actually done so, despite initialing it off. She stated it was important for the oxygen filter to be clean and that respiratory compromise could happen if it was not. The ADM stated nurses needed to follow physician orders and clean oxygen filters on concentrators to prevent complications and respiratory distress. The facility's oxygen administration policy stated oxygen administration, monitoring, responses, and safety precautions are performed by the nurse, and the concentrator manual described the intake and cabinet filters and warned not to operate the concentrator without the filters installed.
Expired Medi-honey Left on Medication Cart
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate handling of drugs and biologicals on Station II medication cart. During observation on 02/18/2026 at 12:37 PM, surveyors found a small tube of Medi-honey in Station II medication cart with an expiration date of 07/01/2025. The product was identified as house stock used for residents, and it remained on the cart despite being expired. During interviews, LVN C stated expired substances should not be left on the medication cart and should be removed because they could be less potent after they expire, and that nurses were responsible for checking the cart and removing expired medications. The DON stated she checked Station I's medication cart but did not get to Station II's, and that the expired Medi-honey was missed and needed to be discarded and replaced. The ADM stated nurses needed to continually check carts and medication rooms for expired medications. The facility policy titled Expired Medications and Medications with Shortened Expiration Dates stated that all medications should be rotated and/or reviewed on a consistent basis to prevent expired medications from being in the facility.
Incomplete and inaccurate oxygen documentation
Penalty
Summary
The facility failed to maintain complete and accurate medical records for two residents by not documenting oxygen-related orders and care correctly. Resident #28 had a physician order for oxygen at 2 L/min via nasal cannula, but the January MAR/TAR did not include the order for nurses to monitor the oxygen concentrator setting and nasal cannula placement. The February MAR/TAR later added the oxygen order on 02/19/2026, after the order had already been in place, and the MDS Coordinator stated she had not seen oxygen documented on the MAR/TAR when completing the Significant Change MDS assessment. Observations showed Resident #28 wearing oxygen while the concentrator was set between 3 and 4 LPM. The resident stated she did not know what the oxygen concentrator was supposed to be set at. During an observation and interview, LVN D stated the resident was supposed to have the concentrator set at 2 liters per minute continuously and adjusted it to 2 LPM, stating it should not be set higher without an order. The DON stated oxygen use should have been on the TAR when the physician order was written so the nurse would be prompted to verify the setting, tubing, and related equipment each shift. For Resident #36, the record showed an order to clean the oxygen concentrator filter weekly every Sunday, and LVN A initialed the TAR indicating the filter was cleaned on 02/15/2026. However, repeated observations on 02/17/2026, 02/18/2026, 02/19/2026, and 02/20/2026 showed the oxygen concentrator’s black foam filter covered with a thick gray coat of dust and dirt. LVN A stated she did not clean the oxygen filter and that her documentation was not accurate. The DON stated LVN A should not have initialed that the filter was cleaned when it was not, and the ADM stated accurate documentation was important to reflect the care provided.
Failure to Maintain Sanitary Ice Machine for Resident Beverages
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, specifically related to the condition and maintenance of the kitchen's ice machine. Observations revealed that the ice machine, which provided ice for resident beverages at meals, had visible rust on both the inside and outside surfaces and contained large sections of yellow and brown colored ice. Multiple staff members, including dietary and nursing staff, acknowledged awareness of the discolored ice and rust, with some stating they avoided using the affected ice but did not report the issue, assuming it was already known or not their responsibility. Interviews with dietary staff indicated a lack of clarity regarding responsibility and procedures for cleaning the ice machine. The Dietary Cook reported seeing the rust and discolored ice and stated she had informed the Dietary Supervisor but not the Maintenance Director, as she believed it was not her role. The Dietary Supervisor confirmed that both she and the Maintenance Director were responsible for ensuring the ice machine was cleaned, and that a cleaning schedule was supposed to be in place, but also stated that staff were expected to remove discolored ice as needed. The Maintenance Director admitted to cleaning the filters monthly and removing yellow ice when he noticed it, but there was no specific cleaning schedule or training provided for cleaning the ice machine. Further review of facility policy revealed that the Dining Services Director was responsible for maintaining a clean and sanitary kitchen environment and ensuring staff were knowledgeable about proper cleaning procedures. However, the lack of a consistent cleaning schedule, insufficient staff training, and unclear lines of responsibility contributed to the ongoing presence of rust and discolored ice in the machine, resulting in the deficiency.
Improper Hand Hygiene During Meal Preparation
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in the kitchen, specifically regarding proper hand hygiene during meal preparation. An observation revealed that the Dietary Manager (DM) did not change gloves or wash hands after handling meal tickets and before continuing to prepare food. The DM initially washed her hands and put on gloves to cut bread, but then assisted with placing plates on trays and handled meal tickets without changing gloves or washing hands. This action was identified as a potential cause of cross-contamination. Interviews with the DM and the Assistant Dietary Manager (ADM) confirmed the lapse in proper hand hygiene practices. The DM acknowledged that she should have completed cutting the bread before assisting with other tasks and recognized the risk of cross-contamination due to not changing gloves and washing hands. The ADM emphasized the importance of changing gloves and washing hands to prevent contamination, especially after touching meal tickets. The facility's policy on meal distribution and the U.S. FDA Food Code were reviewed, highlighting the requirement for food employees to wash hands during food preparation to prevent cross-contamination.
Failure to Conduct PASRR Level 2 Evaluation for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASRR) level 1 residents with mental illness received a PASRR level 2 evaluation, specifically for one resident. Resident #5, a female with diagnoses including major depressive disorder with psychotic symptoms, psychotic disorder with delusions, and unspecified severe dementia, was admitted to the facility without a PASRR level 2 evaluation. The resident's PASRR level 1 screening form incorrectly indicated no mental illness, despite the presence of a psychotic disorder diagnosis upon admission. The resident's admission Minimum Data Set (MDS) assessment did not recognize her as having a serious mental illness, and her care plan included focuses on psychotropic medication and behavioral issues. The Director of Clinical Care (DOCC) acknowledged the absence of a level II PASRR evaluation and the lack of a physician-signed form confirming dementia as the primary diagnosis. This oversight could potentially prevent the resident from receiving necessary specialized services to address her mental health needs.
Improper Labeling of Enteral Feeding Bag
Penalty
Summary
The facility failed to ensure that a resident receiving enteral feeding was provided with appropriate treatment and services to prevent complications. Specifically, the tube feeding for a resident was not labeled with the required information, which could lead to decreased continuity of care, errors in tube feeding, and nutritional deficits. The resident, a female with anoxic brain damage, dysphagia following cerebral infarction, and aphasia, was moderately cognitively impaired and received all nutrition and hydration through a feeding tube. Observations revealed that the tube feeding bag was not properly labeled with the formula name, and the date was incorrect, leading to potential confusion among staff. During an interview, an LVN admitted to trusting the night nurse's report about the feeding bag despite the incorrect date and lack of formula identification. The Director of Nursing (DON) confirmed that the label should include the formula name, rate, date, and time hung, and that new tubing should be hung every 48 hours. The facility's policy did not cover the specific procedures for hanging and labeling tube feeding bags, and the Texas Health and Human Services guidelines emphasize the importance of proper labeling. This oversight in labeling could compromise the resident's care and safety.
Medication Administration Deficiency
Penalty
Summary
The facility failed to provide pharmaceutical services that ensure the accurate acquiring, receiving, dispensing, and administering of drugs for a resident. During a medication cart check, a Licensed Vocational Nurse (LVN) was observed to have pre-popped a tramadol tablet for a resident and left it unsupervised in the top drawer of the medication cart. The LVN admitted to pre-popping the medication and acknowledged that it was not standard practice, expressing uncertainty about why it was done in this instance. The Director of Nursing (DON) confirmed that medications should not be pre-popped and stored for later use, as this could lead to medication being lost, taken by someone else, or forgotten. The resident involved was a female with a history of severe cognitive impairment, dementia with agitation, muscle wasting, and hemiplegia following a stroke. The resident's care plan included administering pain medication as ordered, and her physician had prescribed tramadol for pain management. The facility's medication administration policy, as reviewed, included steps for proper medication administration, such as observing the resident swallow the medication and documenting after administration. However, the LVN's actions deviated from these procedures, leading to a deficiency in pharmaceutical services.
Inadequate Supervision and Incorrect Equipment Use During Resident Transfer
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for a resident who required two-person assistance during transfers. The resident, who had severe cognitive impairment and multiple medical conditions including osteoporosis, dementia, and congestive heart failure, was transferred by a CNA using a mechanical lift with the wrong-sized sling. This transfer was conducted independently by the CNA, contrary to the care plan that specified the need for two aides and a medium-sized sling. During the transfer, the resident's bottom bumped the bed, causing the lift to jolt and the resident to slide out of the sling, resulting in a fall. The resident sustained a zygomatic fracture and a laceration to the right temporal region. The incident occurred when the CNA was the only aide on the floor and did not seek assistance from the nursing staff, despite knowing the requirement for two-person assistance. The incident was reported by the nursing staff, and the resident was assessed and sent to the hospital for evaluation. The CNA involved had previously received training on the use of mechanical lifts, but failed to adhere to the established protocols, leading to the resident's fall and injury.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Yorktown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whispering Oaks Rehab & Nursing | 16.5 mi | ★★★★★ | 0 | 0 |
| Cuero Nursing And Rehabilitation Center | 16.6 mi | ★★★★★ | 5 | 0 |
| La Bahia Nursing And Rehabilitation | 21.9 mi | ★★★★★ | 8 | 0 |
| John Paul Ii Nursing Home | 23.2 mi | ★★★★★ | 5 | 0 |
| Kenedy Health & Rehabilitation | 23.4 mi | ★★★★★ | 12 | 0 |
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