Yoakum Nursing and Rehab: Care Plan Failures Put Resident at Risk - TX
The resident, identified in inspection records only as Resident #1, is a man with normal pressure hydrocephalus, a condition that causes unsteady gait and problems with thinking and reasoning. He was also diagnosed with bipolar disorder and schizoaffective disorder. His own facility had assessed him as high risk for falls. His care plan, written in March 2026, specifically listed keeping his call light within reach as a fall prevention intervention.
When a federal inspector visited Yoakum Nursing and Rehabilitation Center on the morning of May 29, 2026, accompanied by the assistant director of nursing, the resident was sitting in a chair near the window. His walker was in front of him. His call light was hooked to the room divider curtain roughly six feet away.
The assistant director of nursing was standing right there.
When inspectors interviewed the resident that afternoon, he said he would have to cross the room to reach his call light if he needed help. He said he would use it if it were closer. He also mentioned something else: he had never used a wheelchair since the day he was admitted. He had always walked with a walker.
His care plan said otherwise. The fall prevention section listed a wheelchair as his mobility aid, not a walker. The MDS nurse, interviewed the same day, said she did not know how that error got into the care plan. She added that the care plan existed precisely to give aides accurate information about what residents needed, and that without accurate information, care could be missed.
It had been missed.
The certified nursing assistant who cared for the resident said she did not realize the call light was out of reach and had overlooked it. She confirmed he had never had a wheelchair and always used a walker. The medication aide who administered his medications that morning said she had seen him sitting up in the chair but had not thought about the call light being too far away. She acknowledged he needed it within reach to call for help.
The assistant director of nursing, when interviewed at 1:34 in the afternoon, said she had not thought to move the call light when she was in the room earlier that morning, during the inspection itself. She said the resident had fallen previously and that having the call light within reach was important so he could call for assistance rather than attempt to move on his own.
The director of nursing confirmed the care plan intervention had not been implemented. She said the resident used a rollator and had never used a wheelchair.
What the inspection found, in plain terms, was a care plan with the wrong equipment listed and a safety intervention that no one had followed. Multiple staff members, including the facility's own assistant director of nursing, had been in the room that day and left the call light where it was.
The resident had already told inspectors what he would do if he needed help and the call light was six feet away. He would have to get up and cross the room to reach it.
He was high risk for falls. He had a condition that made walking unsteady. He had a history of falling. And on the morning of the inspection, he sat near a window with a walker in front of him and a call light he could not reach.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Yoakum Nursing and Rehabilitation Center from 2026-05-29 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 21, 2026 · Our methodology
YOAKUM NURSING AND REHABILITATION CENTER in YOAKUM, TX was cited for violations during a health inspection on May 29, 2026.
He was also diagnosed with bipolar disorder and schizoaffective disorder.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.