Crosbyton Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident or family group with private space for the residents' monthly council meetings and the confidential resident group meeting during survey (09/24/2025) for eight of eight confidential residents reviewed for resident council. The facility did not provide private space for resident council meetings. This failure could place residents at risk of not being able to exercise their rights of being able to voice their grievances in private, without uninvited staff being present. Findings Included:Observation and interviews on 09/24/2025 at 2:00 PM in a Resident Council meeting, conducted during survey, revealed the following: The Resident Council meeting was held in the activities room. The area contained two open doorways that did not have a door closure. [...]

Inspectors wroteBased 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, in that: The facility failed on 09/23/25 to seal food stored in pantry. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 facility roof. The facility failed to ensure the roof of the facility was in good repair. This failure could cause leaking and water damage and cause the facility to have an unsightly appearance.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 2 of 16 residents (Residents #4, and #8) reviewed for advanced directives. Residents #4, and #8 were listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were missing required information. This failure could place residents at risk of not having their end of life wishes honored and incomplete records.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident has a right to a safe, clean, comfortable, and homelike environment for 1 of 16 residents (Resident #13) reviewed for physical environment. The facility failed to ensure Resident #13 had a safe and secure toilet in the bathroom. This failure could place residents at risk for injuries and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 1 of 15 residents (Resident #2) observed for physical restraints in that; The facility failed to ensure Resident #2 had a consent and an evaluation for scoop mattress for fall prevention. This failure could place residents at risk of injuries or entrapment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for 1 of 16 residents reviewed for activities, in that: The facility failed to ensure there were organized activities available to residents on 09/23/2025 and 09/24/2025. This failure placed residents at risk for a diminished quality of life, isolation, and lack of stimulation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail and ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements: Assess the resident for risk of entrapment from bed rails prior to installation and/or Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1 of 15 residents (Resident #17) observed for physical restraints in that; The facility failed to ensure Resident #17 had a physician order, consent and evaluation for side rails used for positioning and mobility. This failure could place residents at risk of injuries or entrapment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure menus were followed for 2 of 2 meals observed. (Lunch meal 9/23/25 and 9/24/25) The facility failed to follow the week 1 menu for two lunch services served at the facility on Tuesday 09/23/25 and Wednesday 09/24/25. These failures could place residents that eat food from the kitchen at risk of poor intake, and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 2 residents (Resident #11) reviewed for meals. The facility failed to ensure that Resident #11 was served pureed spaghetti meat, chicken and vegetables that were the proper texture. This deficient practice could affect residents by placing them at risk for choking and weight loss.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident bedroom measured at least 80 square feet per resident in multiple resident bedrooms for 7 of 26 resident semiprivate rooms (Rooms #6, 13, 14, 19, 20, 21 and 30), in that, The facility failed to provide 80 square feet per resident in resident rooms #6, 13, 14, 19, 20, 21 and 30. This failure could result in crowding, cause difficulty in providing ADL services, and place residents at risk for decreased quality of life.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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). [...]

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident bedroom measured at least 80 square feet per resident in multiple resident bedrooms for 7 of 26 resident semiprivate rooms (Rooms #6, 13, 14, 19, 20, 21 and 30), in that, The facility failed to provide 80 square feet per resident in 7 of 26 semiprivate resident rooms. This failure could result in crowding, cause difficulty in providing ADL services, and placing residents at risk for decreased quality of life.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident bedroom measured at least 80 square feet per resident in multiple resident bedrooms for 7 of 26 resident semiprivate rooms (Rooms #6, 13, 14, 19, 20, 21 and 30), in that, The facility failed to provide 80 square feet per resident in 7 of 26 semiprivate resident rooms. This failure could result in crowding, cause difficulty in providing ADL services, and placing residents at risk for decreased quality of life.