Crosbyton Nursing and Rehabilitation Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure residents were provided with the therapeutic diets as prescribed by the attending physician for 1 of 2 residents (Resident #11) reviewed for therapeutic diets and food and nutrition services. The facility failed to ensure Resident #11 received ice cream with noon meals on 09/23/25 and 09/24/25 as ordered by the physician. This failure could place residents with diet needs at risk for weight loss and potential decline in health.The findings included:Record review of Resident #11's admission record dated 09/25/25 revealed she was [AGE] years old and admitted on [DATE] with muscle weakness, gastro esophageal reflux disease (stomach acid flows back into the esophagus), and problem related to life management difficulty.Record review of the physician's orders dated 09/24/25 revealed Resident #11's diet was Regular, puree texture, regular/thin consistency, ice cream with noon meal for unplanned weight loss with a start date of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #13 and Resident #20) reviewed for infection control. 1. LVN B did not perform hand hygiene between all glove changes when providing wound care to Resident #13 and Resident #20. These failures could place residents at risk for cross contamination and infection.The findings include: Resident #13 Record review of the admission record for Resident #13, dated 10/01/25 revealed a [AGE] year-old female who was admitted to the facility on [DATE] with the following diagnoses: unspecified dementia (a group of conditions that cause a decline in cognitive abilities), schizoaffective disorder, depressive type (mental health disorder) and peripheral vascular disease (a slow and progressive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 4 of 7 residents (Resident #1, #2, #3 and #4) reviewed for abuse. The ADM (Abuse Preventionist) failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC and documenting his investigation regarding the Resident-to-Resident altercation (Between Resident #1 and Resident #2) that occurred and was reported on 1/08/25 by the DON and LVN A. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC and documenting his investigation regarding the Resident-to-Resident altercation (Between Resident #2, #3 and #4) that occurred and was reported on 1/12/25 by LVN B to the ADON. The ADM (Abuse Preventionist) failed to follow the facility's abuse policy by not reporting the allegation of abuse to include injury of unknown origin to HHSC and documenting his investigation regarding the bruising that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Preventionist for 4 of 7 residents (Resident #1, #2, #3 and #4) reviewed for abuse. The ADM (Abuse Preventionist) failed to report the allegation of abuse to HHSC regarding the Resident-to-Resident altercation (Between Resident #1 and Resident #2) that occurred and was reported on 1/08/25 by the DON and LVN A within the appropriate time frame. The ADON and LVN B failed to report the allegation of abuse to the ADM (Abuse Preventionist) regarding the Resident-to-Resident altercation (Between Resident #2, #3 and #4) that occurred and was reported on 1/12/25 by LVN B to the ADON within the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated for 3 of 7 residents (Resident #1, #2, #3 and #4) reviewed for abuse. The ADM (Abuse Preventionist) failed to document and conduct an investigation regarding the Resident-to-Resident altercation (Between Resident #1 and Resident #2) that occurred and was reported on 1/08/25 by the DON and LVN A. The ADM (Abuse Preventionist) failed to document and conduct an investigation regarding the Resident-to-Resident altercation (Between Resident #2, #3 and #4) that occurred and was reported on 1/12/25 by LVN B to the ADON. The ADM (Abuse Preventionist) failed to document and investigate regarding the bruising that was identified on Resident #2 on 1/14/25. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment. Findings included: Resident #1 Record Review of Resident #1's face…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse for 2 of 7 residents (Resident #1 and #2) reviewed for abuse. The facility failed to keep Resident #2 safe from Resident #1 on 1/08/25 when a resident-to-resident altercation occurred resulting in Resident #1 hitting Resident #2. This failure could place residents at risk for serious psychosocial harm from abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life. Findings included: Resident #1 Record Review of Resident #1's face sheet, dated 02/04/25, revealed a [AGE] year-old male that was admitted to the facility on [DATE], with a diagnosis of Hepatitis C (a contagious viral liver infection). Record Review of Resident #1's Comprehensive MDS assessment dated [DATE], revealed under Section C, Cognitive Patterns, a BIMS score of 07, indicating the resident was severely cognitively impaired. Section E revealed Resident #1 did not exhibit physical behavior…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, and record review, the facility failed to develop and implement a baseline care plan within 48 hours for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #1) of 5 residents reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #1. This failure could place newly admitted residents at risk for not receiving the necessary care and services needed. The findings included: Record review of the face sheet, dated 11/06/2024, revealed Resident #1 was a [AGE] year-old female who admitted to the facility on [DATE] with the following diagnoses: vascular dementia (memory loss caused by impaired blood supply to the brain), unspecified sequelae of cerebral infarction (alteration of sensation following stroke), receptive-expressive language disorder (difficulty understanding and expressing self through…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #2) of 5 residents reviewed for care plans. The facility failed to develop an accurate, consistent, and complete care plan for Resident #2's activities of daily living (ADL's), mobility, disease process, cognition, communication, falls, and medications. This failure could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Record review of the face sheet, dated 11/05/2024, revealed Resident #2 was a [AGE] year-old male who admitted to the facility on [DATE] with the following diagnoses: malignant neoplasm of unspecified bronchus or lung (lung cancer), generalized muscle weakness…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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, that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 of 14 residents (Residents #1, #8 and #21) reviewed for care plans. The facility failed to develop a care plan for Resident #1's cognitive loss, communication, psychosocial well-being and pressure ulcer risk. The facility failed to develop a care plan for Resident #8's cognitive loss, vision, falls, nutrition and psychotropic drug use. The facility failed to develop a care plan for Resident #21's delirium, communication, urinary function, psychosocial well-being, mood, dental care, pressure ulcer risk and pain. These failures could place residents at risk of not receiving the care required to meet their individualized needs. Findings included: Resident #1…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to keep food properly labeled and sealed in the refrigerator, freezer and pantry. These failures could place residents at risk for food contamination and foodborne illness. The findings included: Observation during a kitchen tour on 07/29/24 at 7:45 AM revealed the following in the refrigerator: 1 pitcher of orange liquid, no label and no date noted on the pitcher and 1 bag of oven roasted turkey breast sandwich meat not sealed properly, dated 7/23/24. The following was noted in the freezer: 1 bag of fried chicken not sealed properly, dated 6/19/24 and 1 bag of 3 biscuits not sealed properly, dated 7/23/24. The following was noted in the pantry: 1 bag of brown gravy mix not sealed properly, dated 7/15/24. Interview on 07/31/24 at 10:02 AM, the DM stated all the dietary staff were responsible for properly labeling and storing food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 4 of 4 (Residents #17, #2, #6, #7) and 4 of 4 staff (ADM, DON, CNA A, CNA B) reviewed for infection control. 1. The facility failed to implement and maintain contact precautions and ensure staff utilized Personal Protective Equipment (PPE) appropriately to prevent cross contamination from residents positive with COVID-19. 2. The facility failed to place readily visible signage on the door of Resident #17 who was actively on contact precautions. 3. The administrator entered the room of a resident who was on transmission-based precautions without proper PPE. 4. The DON entered the room of a resident who was on transmission-based precautions without proper PPE. 5. CNA A failed to sanitize hands between glove changes during incontinent care for Resident #2 and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure the residents had the right to participate in his or her treatment, which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment, and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 15 residents (Resident #20) reviewed for resident rights. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Resident #20, prior to administering psychotropic medications (a psychoactive drug taken to exert an effect on the chemical make-up of the brain and nervous system). This failure could place residents at risk of receiving medications without their prior knowledge or consent, or that of their responsible party or being aware of the benefits and risks of the medications prescribed. Findings included: Record review of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were properly secured for 1 of 1 treatment carts reviewed for proper medication storage. LVN A left the treatment cart containing medications unlocked and unsupervised in the hallway near the nurse's station. The DON left the treatment cart containing medications unlocked and unsupervised in the hallway near the nurse's station. These failures could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversions. Findings included: During an observation on 07/29/2024 at 06:58 AM the treatment cart across from the nurse's station and across from the resident living area was observed to be unlocked and unattended. This state surveyor observed residents in close proximity to the treatment cart and no staff were present to supervise the cart. Upon inspection of the second drawer of the cart with LVN A, several prescription medications and creams were observed. During an observation and an interview on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that the menu was followed for 3 of 3 residents (Residents #9, 12 and 31), who consumed 1 of 3 food forms (pureed), in that: The facility failed to ensure 3 residents received the correct portions that were called for on the menu at 1 of 2 meals observed. These resident meal trays had foods omitted and had lesser amounts of food served than called for on the menu. These failures could place residents at risk for unwanted weight loss and hunger. The findings include : Resident #9 Record review of the Order Summary Report for female Resident #9, dated 6/7/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Alzheimer's disease with late onset (mental disorder), dysphasia, oropharyngeal, phase (swallowing disorder) and macular degeneration (vision disorder). Further record review of the Order, Summary Report revealed a diet order that stated, regular diet, purée,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 staff (Dietary Manager and Dietary staff A) in 1 of 1 kitchen, in that: 1) Dietary staff failed to ensure pasteurized eggs were used in under cooked egg dishes (soft cooked/sunny side up/over easy eggs), 2) Dietary staff failed to handle food contact equipment in a manner to prevent contamination, 3) Dietary staff failed to maintain adequate chlorine sanitizer levels in the low temperature dish machine. 4) Dietary staff failed to ensure food contact surfaces were clean, 5) Dietary staff failed to perform sanitary handwashing between the handling of soiled and clean food equipment during dishwashing, 6) Dietary staff failed to use good hygienic practices, 7) Dietary staff failed to store personal items in a manner to prevent contamination of food contact equipment. These failures could place residents at risk for food contamination and foodborne illness. The findings include : - The following…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in 1 of 1 common resident bath (Central) and 6 of 16 resident rooms (15, 17, 25, 27, 30 and 32) in that: 1) The facility failed to ensure resident use water was maintained at comfortable and safe temperatures (resident use hot water ranged from 93.2 degrees F to 117.4 degrees F), and 2) The facility failed to ensure resident use equipment was maintained in a sanitary manner (shower chairs). These failures could lead to resident injuries, spread of infections, and cause the facility to have an unsightly appearance. The findings include : 1. During an observation on 6/07/23 at 11:10 AM, room [ROOM NUMBER] had hot water in the shared restroom at 93.2°F (room [ROOM NUMBER]/27). During an observation on 6/7/23 at 4:10 PM in room [ROOM NUMBER], the hot water in the shared restroom (Rooms 30/32) was 117.4°Fahrenheit where it peaked and then…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to refer all residents with newly a evident or possible serious mental disorder for PASRR level II evaluation for 2 of 12 residents (Resident #8 and Resident #10) reviewed for PASRR. 1. The facility failed to ensure that Resident #8 was accurately assessed for PASRR services related to hi diagnoses of major depressive disorder, psychotic disorder, and anxiety disorder. 2. The facility failed to ensure that Resident #10 was accurately assessed for PASRR services related to her diagnoses which included major depressive disorder and schizoaffective disorder. These failures could place residents at risk for not receiving the specialized PASRR care and services required to meet their individual needs and could result in a decrease in quality of life. The findings were: Resident #8: Record review of Resident #8's admission record revealed an [AGE] year-old male admitted to the facility on [DATE]. Record review of medical diagnoses for Resident #8…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to ensure a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #23) of three residents reviewed for catheter care. The facility failed to provide appropriate catheter care for Resident #23 The facility failed to have appropriate orders and interventions in place for routine catheter care including cleaning and changing of the catheter for Resident #23. This failure could place residents with urinary catheters at risk for the development and/or worsening of urinary tract infections. Findings include: Record review of Resident #23's admission record revealed he was a [AGE] year-old male admitted the facility on 04/03/2023. Record review of Resident #23's medical diagnosis list revealed diagnoses including obstructive and reflux uropathy and infection and inflammatory reaction due to indwelling urethral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.