Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
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 Crosbyton Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
Resident Council Meeting Held Without Privacy: A resident council meeting was held in the activities room, which had open doorways, hallway noise, and staff passing by and entering during the meeting. Six of eight residents said the room was distracting and not private, and staff could overhear conversations. The AD, ADON, and ADM confirmed the room was usually used for resident council meetings despite lacking doors for privacy, even though the facility policy states the council is to be provided space and privacy for meetings.
Improper Food Storage in Pantry: Surveyors observed multiple pantry items stored open or not properly sealed, including brownie mix, pasta in a damaged bag, sugar, and brown gravy mix. The DM, an A, and the ADM all stated food in the pantry should be sealed and dated, and the facility policy required dry foods and goods to be stored to maintain packaging integrity until use.
Roof Not Kept in Good Repair: The facility failed to maintain the roof in good repair after repeated storm damage and ongoing shingle loss. Staff and leadership described years of roof problems, with leaking rooms, residents moved out of affected rooms, trash cans used to catch brown water, and a ceiling with water staining and hanging material. A large tarp covered much of the roof, and the MS stated there was no policy addressing roof conditions.
Incomplete DNR Advance Directive Documentation: Two residents had DNR status documented in their care plans and physician orders, but their OOH-DNR forms were incomplete. One resident’s form was missing the physician license number, and the other resident’s form was missing dates for the legal guardian declaration and physician signature. The ADON and ADM confirmed the forms were not completed thoroughly, and the facility policy stated advance directives must be honored in accordance with state law and facility policy.
Unsafe and Loose Toilet in Resident Bathroom: A resident with CVA-related weakness, gait instability, and occasional urinary incontinence reported that her toilet was wobbly and moved side to side and front to back. Surveyors observed the toilet was not secure and could be moved several inches with a gentle nudge; the ADM was unaware of the issue, and the MS stated the toilet had become loose previously and was tightened when observed or reported.
A resident with dementia, severe functional dependence, and a history of falling from bed had a scoop mattress ordered and observed in use for fall prevention, but the medical record lacked consent for the device. The ADON stated she did not think about obtaining consent, and the ADM acknowledged the scoop mattress could be a restraint and that staff were responsible for obtaining consent before applying it.
Failure to Provide Scheduled Resident Activities: The facility did not conduct organized group activities and had an incomplete activities calendar, leaving residents without scheduled programming while the AD was on leave. Interviews showed the AD also served as the BOM, the facility lacked a full-time AD due to budget constraints, and the ADM had no backup plan when the AD and a certified AD/housekeeping supervisor were both unavailable. Residents reported they had no activities and, at times, organized their own.
A resident was observed with 1/4 side rails raised on both sides of the head of the bed, but the chart had no physician order, consent, or evaluation for their use. The resident had HTN, radiculopathy, and nutritional anemia, and staff stated the rails had been used for mobility and positioning for years. The DON, ADON, and ADM acknowledged that side rails required an order and consent, and the facility policy required alternatives, interdisciplinary evaluation, resident assessment, and informed consent before use.
Menus were not followed for 2 observed puree lunch meals. A puree lunch tray was served without puree bread on two separate meal observations, and the menu records showed different noon meal items than what was served. Dietary staff stated the bread should have been pureed but was forgotten, and the DM and ADM stated cooks and dietary staff were responsible for following the menu and making appropriate substitutions.
Improperly Pureed Meals Served to a Resident on a Puree Diet: A resident with an order for a pureed diet was served spaghetti, chicken, and vegetables that contained chunks and pieces that had to be chewed. Meal observations and a test tray confirmed the puree was not smooth, and the resident stated she could not swallow food unless it was smooth. Staff stated puree should be pudding-like and free of chunks, and the facility policy required a lump-free final product.
Therapeutic diet not followed for a resident with nutritional risk. A resident with moderate cognitive impairment and an order for puree meals with ice cream at lunch for weight support did not receive the ordered ice cream with noon meals on two observed days. Staff reported the omission was due to forgetting to serve it, lack of stock, and tray card printing issues; the ADM stated the ice cream was intended to boost calories to maintain weight.
Hand Hygiene Not Performed Between Glove Changes During Wound Care: An LVN failed to perform hand hygiene between glove changes while providing wound care to two residents, including one with a chronic RLE ulcer and another with a coccyx pressure wound. The LVN stated she had been trained on hand hygiene but forgot during care, and the ADON, DON, and ADM stated staff were expected to sanitize hands between glove changes.
Semiprivate Resident Rooms Did Not Meet Required Square Footage: The facility failed to ensure 7 semiprivate resident rooms met the required 80 sq ft per resident. Surveyors observed that rooms 6, 13, 14, 19, 20, 21, and 30 each had less than the required 160 sq ft for 2 residents. The ADM stated the rooms were typically used as private rooms, but not recently because of roof leaks, and noted the facility had no policy for room square footage requirements.
The facility failed to implement its abuse prevention policies, as evidenced by unreported resident-to-resident altercations and undocumented investigations. The ADM did not report abuse allegations to HHSC, and the DON and LVNs did not follow reporting protocols. Residents with cognitive impairments and behavioral issues were involved in incidents that were not reflected in their care plans, placing them at risk for further abuse.
A LTC facility failed to report alleged abuse and injuries of unknown origin involving several residents within the required timeframe. Incidents included resident-to-resident altercations and bruising of unknown origin. Staff interviews revealed confusion and miscommunication regarding the reporting process, leading to non-compliance with regulatory requirements.
The facility failed to investigate allegations of abuse and neglect involving multiple residents. Incidents included resident-to-resident altercations and unexplained bruising, which were not properly documented or investigated by the Abuse Preventionist. Staff interviews revealed a lack of communication and documentation, leaving potential abuse unaddressed.
A resident-to-resident altercation occurred in a facility's dining area, where one resident physically aggressed another by pushing their wheelchair and attempting to hit them. The incident was captured on video, but the facility failed to report it to the appropriate authorities and did not have a care plan addressing aggressive behavior. Staff, including an LVN and the DON, did not follow the facility's abuse prevention protocols, contributing to the deficiency.
A facility failed to develop a baseline care plan within 48 hours for a newly admitted resident with multiple health conditions, including dementia and diabetes. The oversight was due to an issue with the electronic health system not prompting staff to initiate the care plan. Interviews with the ADON and DON revealed that the responsibility for completing care plans lies with nursing administration, and the failure to do so could lead to negative outcomes for the resident.
A resident with multiple health issues, including lung cancer and muscle weakness, did not have a comprehensive care plan developed by the facility. The care plan lacked goals and interventions for ADLs, mobility, cognition, communication, falls, and medications. Facility staff, including the DON and ADM, were unaware of the incomplete care plan until it was identified during a survey. The facility's policy requires a comprehensive care plan to be developed within seven days of the MDS assessment, which was not followed in this case.
The facility failed to create comprehensive care plans for three residents, omitting necessary objectives and timeframes for conditions like cognitive loss, communication, and pressure ulcer risk. The DON and ADM acknowledged the ADON's responsibility for care plans, but the ADON was unavailable. The facility's policy mandates comprehensive care plans, which were not followed, risking inadequate resident care.
The facility failed to properly label and seal food items in the kitchen, posing a risk of foodborne illness. Observations revealed unlabeled and improperly sealed food in the refrigerator, freezer, and pantry. The Dietary Manager acknowledged the issue and the potential risk to residents, despite existing policies on safe food handling.
A long-term care facility failed to maintain an effective infection control program, as staff did not implement contact precautions or use appropriate PPE for residents with COVID-19. Observations showed a lack of PPE and signage outside a resident's room, and staff entered without proper protection. Additionally, CNAs did not sanitize hands between glove changes during incontinent care, increasing infection risk. The facility's policies on transmission-based precautions and hand hygiene were not adequately followed, leading to potential infection spread.
A facility failed to obtain informed consent for a psychotropic medication for a resident with moderately impaired cognition. The resident was prescribed Escitalopram without a signed consent, despite having a consent for another psychotropic medication, Risperidone. Interviews revealed that the DON and ADM were responsible for ensuring consents were completed, but the ADM was unaware of the policy requirements.
A treatment cart containing medications was left unlocked and unsupervised near the nurse's station, despite facility policy requiring it to be locked when unattended. Both LVN A and the DON admitted to leaving the cart unlocked due to being sidetracked and busy, respectively. Interviews confirmed that staff were trained to secure carts, but the cart was observed unlocked, risking unauthorized access by residents.
The facility failed to provide the required 80 square feet per resident in seven semiprivate rooms, with sizes ranging from 152.2 to 156.58 square feet for two residents. The ADM acknowledged the deficiency and noted the absence of a policy on room size requirements, intending to apply for a waiver.
Resident Council Meeting Held Without Privacy
Penalty
Summary
The facility failed to provide a resident council with private space for its monthly meetings and for a confidential resident group meeting during survey. During observation of the resident council meeting, the meeting was held in the activities room, which had two open doorways without door closures and was located outside the DON's and ADON's offices. Numerous staff members were observed walking past the open room, hallway noise was heard inside the room, and a staff member entered during the meeting and spoke to residents, disrupting the meeting. Staff were also observed sitting in the hallway within hearing distance of the meeting. Six of eight residents attending the meeting stated that resident council meetings were held in the activities room every month and that no more private area was used. Those residents stated the area was distracting, difficult to hear in at times, and not private because staff could overhear their conversations. Interviews with the AD, ADON, and ADM confirmed that the activities room was usually used for resident council meetings, that the room did not have doors to ensure privacy, and that staff should not have been present or interrupting the meeting. The facility's resident council policy stated that the resident council group is provided with space, privacy, and support to conduct meetings.
Improper Food Storage in Pantry
Penalty
Summary
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. During the initial kitchen tour on 09/23/25 at 09:40 AM, surveyors observed a bag of brownie mix in a plastic bag that was not sealed, a bag of pasta in its original bag with a large hole placed in a plastic container that was not covered or sealed, a plastic container of sugar with the lid not sealed, and a bag of brown gravy mix in a plastic bag that was not sealed. The observation also noted that the container lid for the pasta was under the plastic container to the right, and the flour bin had a hole in the lid. During interviews, the DM stated that all food items in plastic bags should be sealed when stored in the pantry and that all plastic container lids should be sealed when stored. She stated it was everyone's responsibility to seal items when storing them in the pantry and that the flour bin should not have a hole in the lid. She also stated kitchen staff had been trained in proper food storage and had safe serve certificates. An A stated all staff were responsible for making sure food put in the pantry was sealed and that she had been trained on proper pantry storage. The ADM stated all food stored in the pantry should be dated and sealed, that he was not aware food was being stored open, and that kitchen staff had been trained to properly store food. He stated his expectations were for staff to follow policy and procedure, and the facility policy required dry foods and goods to be handled and stored in a manner that maintains the integrity of the packaging until they are ready to use.
Roof Not Kept in Good Repair
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment because the roof was not kept in good repair. On entrance to the facility, a large blue tarp was observed covering a large portion of the roof, and the uncovered areas had shingles missing in places. During the entrance conference, the ADM stated several rooms on the front hall and North hall had leaked water during the last storm, residents were moved out of those rooms, and trash cans were used to collect the leaking water. On the front hall, rooms were observed closed and unoccupied, and one room had a large brown ring on the ceiling with some of the ceiling hanging down. A medium-sized trash can was on the floor under the air vent and was half full of brown water. The MS stated the roof had been having problems for about 3 years, that shingles would come off during storms, and that he had repeatedly patched the roof over time. He stated the big storm a few weeks earlier was when the roof started leaking and tarps were placed on the roof to prevent further leaking until the roof could be fixed. The MS stated he could not find a policy related to roof conditions or the environment that included the roof. The Previous ADM stated the roof had issues with shingles coming off during his time at the facility and that storms in spring and summer 2025 caused leaking, with insurance becoming involved after the June storm. The Previous ADM stated emails to the owners about the roof damages went unanswered and that the insurance check had not been provided before he left. Facility Owner A stated a claim had been filed for the June storm damage, an engineer had approved the claim, and the facility was waiting for the insurance check. He also stated he was not aware the roof had been in bad condition for 3 years and that no rooms were leaking at the time of his interview.
Incomplete DNR Advance Directive Documentation
Penalty
Summary
The facility failed to ensure that all residents had complete advance directive documentation for 2 of 16 residents reviewed. Resident #4, a male admitted with diagnoses including muscle weakness, Major Depressive Disorder, and problem related to life management difficulty, had a care plan and physician orders indicating DNR status, but the OOH-DNR form was missing the physician’s license number in the physician’s statement section. Resident #8, a female admitted with diagnoses including vascular dementia, muscle weakness, and problem related to life management difficulty, also had a care plan and physician orders indicating DNR status, but the OOH-DNR form was incomplete because the declaration by the legal guardian/agent/proxy was not dated and the physician signature was not dated. During interview, the ADON stated advance directives were reviewed by the admitting nurse and administrator to ensure accuracy and that they should be completed thoroughly. The ADON verified there were no additional advance directives for either resident and confirmed both current advance directives were not completed because they were missing dates. The ADM stated the admitting nurse was responsible for ensuring advance directives were completed thoroughly within 24 hours of admission, that all nursing staff were responsible for ensuring they were complete and accurate, and that advance directives should be checked regularly. The facility policy stated residents have the right to formulate an advance directive and that DNR orders are honored in accordance with state law and facility policy.
Unsafe and Loose Toilet in Resident Bathroom
Penalty
Summary
The facility failed to ensure Resident #13 had a safe and secure toilet in the bathroom. Resident #13 was a [AGE]-year-old female admitted with diagnoses including unspecified sequelae of nontraumatic intracerebral hemorrhage, unsteadiness on feet, muscle weakness, other abnormalities of gait and mobility, and unspecified lack of coordination. Her annual MDS showed a BIMS score of 15, indicating she was cognitively intact, and she was occasionally urinary incontinent and always continent of bowel. Her care plan addressed ADL self-care performance deficit related to CVA with left hemiparesis and included that she was able to use the toilet with assistance. During interview, Resident #13 stated her toilet was wobbly and moved side to side and front to back, and she had not yet reported it. An observation later confirmed the toilet in her room was not secure and could be moved several inches with a gentle nudge. The ADM stated he was not aware of the concern before it was brought to his attention, and the MS stated the toilet had become loose previously and was tightened when observed or reported. The MS also stated the toilet was still bolted down but the bolts became loose and allowed movement, and he did not feel there was a risk of injury or falling due to the loose toilet.
Missing Consent for Scoop Mattress Used as a Restraint
Penalty
Summary
The facility failed to ensure a resident had the right to be treated with respect and dignity, including being free from physical restraints used for convenience or not required to treat medical symptoms. Resident #2 was an 83-year-old female with dementia, major depression, diabetes, epilepsy, muscle weakness, and hypertension. Her MDS showed she was not cognitively intact with a BIMS score of 00 and required extensive to total assistance for multiple activities, including bed mobility, toileting, dressing, personal hygiene, and transfers. Her care plan documented an actual fall from bed with a forehead wound and included interventions such as a low bed, fall mat, and a scoop mattress. Record review showed a physician order for a scoop mattress to prevent unintentionally rolling off the bed, and observation confirmed the scoop mattress was in place. However, the resident’s medical record did not contain consent for the scoop mattress. During interviews, the ADON stated she did not think about obtaining consent for the scoop mattress and later stated consent for restraints should be obtained when the restraint is applied. The ADM also stated a scoop mattress could be a restraint and that nursing staff were responsible for ensuring consent was obtained before applying it. The facility policy stated that any device attached or adjacent to the resident’s body that restricts movement or normal access to the body could be considered a restraint.
Failure to Provide Scheduled Resident Activities
Penalty
Summary
The facility failed to provide an ongoing program of activities to support residents’ physical, mental, and psychosocial well-being when organized activities were not conducted on 09/23/2025 and 09/24/2025. During observation of the activities area on 09/23/2025 at 10:30 AM, the centrally located activities board had a large print calendar posted, but no month was identified on the calendar. Observations from 10:00 AM to 04:00 PM on 09/23/2025 and from 06:30 AM to 03:30 PM on 09/24/2025 showed no group activities being conducted. During interviews, an anonymous resident stated the activities director was on leave and residents had not had scheduled activities while she was out. The resident also stated the facility did not have a full-time activities director and that residents were organizing their own activities at times because of this. Another resident stated they did not have any activities on either day and was frustrated that the facility did not coordinate activities. The activities director stated she also worked as the business office manager and was on leave during those days, and the ADM stated there was no backup plan for activities while the AD was out. The ADM also stated the facility did not have a full-time AD due to budgeting constraints and that no one was available to organize activities when both the AD and the housekeeping supervisor/certified AD were unavailable.
Side Rails Used Without Order, Consent, or Evaluation
Penalty
Summary
The facility failed to attempt appropriate alternatives before installing side rails and failed to ensure correct installation, use, and maintenance of bed rails for Resident #17. The resident was an 89-year-old female admitted with essential hypertension, radiculopathy, and nutritional anemia. Her MDS assessment dated 03/23/25 showed she required partial assistance from one person for bed mobility, and the assessment did not address bed rails as a restraint. Record review showed no physician order for side rails, and the medical record contained no consent or evaluation for their use. On observation on 09/23/25 at 3:16 PM, Resident #17 was lying in bed with 1/4 side rails raised on both sides of the head of the bed. During interviews, LVN B stated nursing staff were responsible for ensuring a resident had an order for side rails and said the resident had used side rails for mobility and positioning for years. The ADON, DON, and ADM each stated they were responsible for ensuring side rails had a physician order, consent, and evaluation, and they acknowledged that side rails were considered a restraint and carried a risk of entrapment or injury. The facility policy stated bed rails were prohibited unless criteria were met, including attempts at alternatives, interdisciplinary evaluation, resident assessment, and informed consent.
Menus Not Followed for Puree Lunch Meals
Penalty
Summary
The facility failed to ensure menus were followed for 2 of 2 lunch meals observed. On 09/23/25 at 11:45 AM, dining room puree lunch trays were observed being served with spaghetti with white gravy and green beans, and no puree bread was on the plate. On 09/24/25 at 11:45 AM, dining room puree lunch trays were observed being served with roasted thyme chicken with gravy, mashed potatoes with gravy, and mixed vegetable florets, and no puree bread was on the plate. Record review showed the Tuesday Week 1 menu dated 05/07/25 listed the noon meal as spaghetti with meatballs, green beans, and garlic bread, and the Wednesday Week 2 menu dated 05/07/25 listed the noon meal as roasted thyme chicken, mushroom rice, broccoli florets, wheat dinner roll, margarine, confetti cake, 2 percent milk, and coffee. During interviews, dietary staff stated puree bread should have been served with the noon meals and that the bread was not pureed because it was forgotten. The DM stated cooks were responsible for properly preparing puree diets and following the menu, and the ADM stated dietary staff should follow the menu and make appropriate substitutions.
Improperly Pureed Meals Served to Resident on Puree Diet
Penalty
Summary
The facility failed to ensure that food was prepared in a form designed to meet individual needs for 1 of 2 residents reviewed for meals. Resident #11, a female admitted on 07/06/2023 with diagnoses including gastro-esophageal reflux disease, problem related to life management, and weakness, had a physician order dated 10/19/24 for a regular diet with pureed texture and regular thin liquids. During meal observations, she was served pureed spaghetti meat, chicken, and vegetables that contained large chunks and pieces that had to be chewed. The resident was observed picking chunks out of the food from her mouth and placing them on the edge of the plate, and she stated she could not chew food and could not swallow it unless it was smooth. Additional observations confirmed the puree consistency was not proper: a test tray showed pureed spaghetti with large chunks of noodles and meat, and pureed chicken and vegetables also contained chunks that had to be chewed. The resident stated the texture depended on the cook and that some cooks pureed the food well while others did not. Staff interviews stated puree should be smooth, pudding-like, and without chunks, and that staff were responsible for ensuring the food was properly pureed. The facility policy on diet definitions stated pureed foods should be blended until there are no small pieces or lumps and should have a fluffy, moist consistency with no lumps.
Therapeutic Diet Not Followed for Resident With Weight Loss Risk
Penalty
Summary
The facility failed to ensure Resident #11 received the therapeutic diet ordered by the attending physician. The physician's order dated 09/24/25 specified a regular diet with puree texture, regular/thin consistency, and ice cream with the noon meal for unplanned weight loss. Resident #11's record also showed a BIMS score of 10, indicating moderate cognitive impairment, and documentation noted no significant recent weight loss or gain. Nutrition records identified the resident as having a nutritional risk and stated that ice cream with the noon meal and supplements were being used to help promote stable weight. During observation on 09/23/25 and 09/24/25 at the noon meal, Resident #11 was served puree meals with dessert, but no ice cream was provided. The resident stated she liked ice cream but did not always receive it with lunch. A staff member stated she forgot to serve the ice cream on both days, and the DM stated the resident did not receive ice cream because the facility was out of ice cream and magic cups and because the tray cards for those days could not be printed due to lack of printer ink. The ADM stated the purpose of the ice cream order was to boost calories to maintain weight.
Hand Hygiene Not Performed Between Glove Changes During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 2 residents reviewed for infection control because LVN B did not perform hand hygiene between all glove changes while providing wound care. Resident #13 was a female with diagnoses including unspecified dementia, schizoaffective disorder, depressive type, and peripheral vascular disease, and she had a chronic venous and arterial ulcer of the right lower extremity with an order for daily wound care. During wound care, LVN B removed gloves and a gown, did not perform hand hygiene, left the room to retrieve calcium alginate from the wound cart, then returned to the room after applying hand sanitizer and putting on a clean gown and gloves to finish the dressing change. Resident #20 was a female with diagnoses including heart failure, osteoarthritis, and edema, and she was at risk for developing pressure ulcers/injuries with an order for daily coccyx wound care. During the wound care observation, LVN B used hand sanitizer before entering the room, donned clean gloves, prepared supplies, removed gloves and used hand sanitizer, then donned another pair of clean gloves to cleanse and dress the coccyx wound. LVN B then removed her gloves and put on a clean pair of gloves without performing hand hygiene. During interview, LVN B stated she had been trained to perform hand hygiene with glove changes and that she received an in-service on infection control and hand washing a few weeks earlier, but she could not remember the exact date. She stated it slipped her mind during wound care for both residents and acknowledged there was a risk of spreading infection. The ADON, DON, and ADM each stated they expected staff to sanitize their hands between glove changes, and the ADON and DON stated the residents had a risk for infection spreading or cross-contamination.
Semiprivate Resident Rooms Did Not Meet Required Square Footage
Penalty
Summary
The facility failed to ensure that 7 of 26 semiprivate resident rooms met the required 80 square feet per resident. During observation and record review, rooms 6, 13, 14, 19, 20, 21, and 30 were identified as having less than the required 160 square feet for 2 residents, with measured room sizes of 158.22, 156.44, 151.55, 152.41, 151.18, 154, and 156.10 square feet, respectively. The deficiency was identified during the survey process through observation, interview, and record review. At the entrance conference, the ADM stated the facility wanted to apply for a room square footage waiver for the semiprivate rooms that did not meet the 80 square foot requirement. During a later interview, the ADM stated the semiprivate rooms that did not meet the requirement were typically used as private rooms, but not recently because of water leaking from the roof. The ADM also stated the residents were at risk for a lower quality of life and could feel like there was not enough room to move around, and that the facility did not have a policy related to room square footage requirements for residents.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prevent abuse and neglect, as evidenced by multiple incidents involving four residents. The Abuse Preventionist (ADM) did not report allegations of abuse to the Health and Human Services Commission (HHSC) and failed to document investigations into resident-to-resident altercations. Specifically, an altercation between two residents was not reported, and the ADM did not document the investigation of bruising identified on a resident, which was considered an injury of unknown origin. The facility's policies require immediate reporting of abuse allegations to the administrator and relevant authorities, but these protocols were not followed. The Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) involved did not report incidents as required, and the ADM did not ensure that the necessary investigations were conducted. The DON was unaware of physical contact between residents during an altercation and did not observe video footage of the incident, relying instead on second-hand reports. Residents involved in the incidents had cognitive impairments and behavioral issues, which were not adequately addressed in their care plans. One resident, with a history of wandering and aggression, was involved in multiple altercations, yet her care plan did not reflect these behaviors until after the incidents occurred. The facility's failure to adhere to its abuse prevention policies and procedures placed residents at risk for further abuse and neglect.
Failure to Report Abuse and Injuries in a Timely Manner
Penalty
Summary
The facility failed to report alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, within the required timeframe. Specifically, incidents involving four residents were not reported to the appropriate authorities, including the State Agency and the Abuse Preventionist, within two hours if the alleged violation involved abuse or neglect and resulted in bodily injury. This failure was observed in incidents involving resident-to-resident altercations and injuries of unknown origin. In one incident, a resident-to-resident altercation occurred, where one resident initiated physical aggression towards another resident by pushing their wheelchair and swinging a fist. Although the incident was observed on video, it was not reported to the Health and Human Services Commission (HHSC) because the staff believed no physical contact was made. However, the video footage showed that there was physical contact, and the incident was not reported within the required timeframe. Additionally, the facility's staff failed to report bruising of unknown origin found on a resident, which was also not reported to HHSC as required. Interviews with staff revealed a lack of clarity and communication regarding the reporting process. The Director of Nursing (DON) and the Abuse Preventionist (ADM) did not report the incidents to HHSC, believing they did not meet the definition of abuse or were not suspicious. The staff involved in the incidents were trained to report such events, but the reporting process was not followed correctly, leading to a deficiency in the facility's compliance with reporting requirements.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to thoroughly investigate allegations of abuse, neglect, or mistreatment involving several residents. Specifically, the Abuse Preventionist did not document or conduct investigations into multiple resident-to-resident altercations and an incident of bruising. On one occasion, a resident was reported to have initiated physical aggression towards another resident in the dining area, but the incident was not properly investigated or documented by the Abuse Preventionist. The facility's incident report noted that no injuries were observed at the time, but the lack of a thorough investigation could have left potential abuse unaddressed. Another incident involved a resident who was reported to have bruising on her arms, which was identified during a shower. The bruising was not investigated by the Abuse Preventionist, and there was no documentation to explain the cause of the bruising. The resident had a history of wandering and self-transferring, which could have contributed to the bruising, but without a proper investigation, the exact cause remained unknown. The facility staff, including the DON and ADON, were aware of the bruising but did not conduct a thorough investigation to determine its origin. Interviews with facility staff revealed a lack of communication and documentation regarding these incidents. The DON and ADM were informed of the altercations and bruising but did not take appropriate steps to investigate or document the incidents thoroughly. The facility's failure to investigate these allegations of abuse and neglect could place residents at risk, as potential abuse or mistreatment may go unaddressed.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically in an incident involving two residents. On the date of the incident, a resident-to-resident altercation occurred in the dining area where one resident physically aggressed another by pushing their wheelchair and swinging a fist. The incident was captured on video, which showed the aggressor making physical contact with the other resident's wheelchair and attempting to hit them. Despite the altercation, the facility did not have a care plan addressing aggressive behavior for the aggressor, and the incident was not reported to the appropriate authorities as required by the facility's abuse prevention policy. The staff involved, including an LVN and the DON, did not take adequate steps to address the incident according to the facility's abuse prevention protocols. The LVN, who was not present during the altercation, reviewed the video footage but did not report the incident to the ADM, who was the designated abuse preventionist. The DON was informed of the incident but did not observe the video footage herself and did not report the incident to the Health and Human Services Commission (HHSC) because she believed no physical contact occurred. The ADM also did not review the footage and concluded that the incident did not meet the definition of abuse, despite the video evidence. The facility's failure to report and address the incident properly highlights a lack of adherence to their abuse prevention policies. The staff's actions and inactions, including the lack of a care plan for aggressive behavior and the failure to report the incident to the appropriate authorities, contributed to the deficiency. The facility's policies require that all staff follow procedures to protect residents from abuse, but in this case, the protocols were not followed, leaving residents vulnerable to further incidents.
Failure to Implement Baseline Care Plan Within 48 Hours
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for a resident, which is a requirement to ensure effective and person-centered care. The resident, a female with multiple diagnoses including vascular dementia, cerebral infarction sequelae, and type 2 diabetes, was admitted without a baseline care plan being completed. This oversight was discovered during a record review and interviews with facility staff, revealing that the electronic health system failed to prompt nurses to initiate the baseline care plan, a known issue that had not been resolved. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) confirmed that the responsibility for completing baseline care plans lies with nursing administration and charge nurses. The DON was unaware of the missing care plan until it was brought to her attention, and the ADON acknowledged the potential negative outcomes of not having a care plan, such as falls or elopement. The facility's policy requires a baseline care plan to be developed within 48 hours of admission, but this was not adhered to, placing the resident at risk of not receiving necessary care and services.
Incomplete Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, identified as Resident #2, which is consistent with the resident's rights and includes measurable objectives and timeframes. The care plan was incomplete in several areas, including activities of daily living (ADLs), mobility, disease process, cognition, communication, falls, and medications. This deficiency was identified during a review of the resident's records and interviews with facility staff. Resident #2, a male with diagnoses including lung cancer, generalized muscle weakness, unsteadiness on feet, and lack of coordination, was admitted to the facility. The initial Minimum Data Set (MDS) assessment indicated that the resident required assistance with eating, bathing, and transfers, and was taking an antidepressant medication. The Care Area Assessment Summary highlighted communication and falls as areas needing to be addressed in the care plan. However, the comprehensive care plan for Resident #2 was found to be incomplete, with missing goals and interventions in several focus areas. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that they were unaware of the incomplete care plan until the survey. The DON acknowledged that the comprehensive care plan should be completed within 48 hours of admission and updated regularly. The facility's policy requires the interdisciplinary team to develop a comprehensive care plan within seven days of the MDS assessment, but this was not adhered to in Resident #2's case. The lack of a complete care plan could potentially result in the resident not receiving the necessary care to meet their individualized needs.
Failure to Develop Comprehensive Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for three residents, which were necessary to address their medical, nursing, mental, and psychosocial needs as identified in their comprehensive assessments. Specifically, the care plans for these residents did not include measurable objectives and timeframes for various conditions. For one resident, there was no care plan addressing cognitive loss, communication, psychosocial well-being, and pressure ulcer risk. Another resident lacked a care plan for cognitive loss, vision, falls, nutrition, and psychotropic drug use. The third resident did not have a care plan for delirium, communication, urinary function, psychosocial well-being, mood, dental care, pressure ulcer risk, and pain. The Director of Nursing (DON) and the Administrator (ADM) acknowledged that the Assistant Director of Nursing (ADON) was responsible for completing the care plans, but the ADON was on vacation and unavailable for comment. The DON admitted to not knowing why the care plans were incomplete and could not recall the last time care plans were audited. The facility's policy requires comprehensive, person-centered care plans with measurable objectives and timetables, but this was not adhered to, potentially leading to residents not receiving the necessary care.
Improper Food Storage and Labeling in Dietary Services
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen tour. Several food items in the refrigerator, freezer, and pantry were not properly labeled or sealed. Specifically, a pitcher of orange liquid in the refrigerator was found without a label or date, and a bag of oven-roasted turkey breast sandwich meat was not sealed properly, although it was dated. In the freezer, a bag of fried chicken and a bag of three biscuits were not sealed properly, with dates noted on them. Additionally, a bag of brown gravy mix in the pantry was not sealed properly and was dated. Interviews with the Dietary Manager (DM) and Assistant Dietary Manager (ADM) revealed that all dietary staff were responsible for labeling and storing food items correctly, with the DM ultimately accountable for ensuring compliance. The DM admitted to not knowing why the food items were improperly stored and acknowledged the potential risk of foodborne illness due to cross-contamination or spoilage. The facility's policy on safe food handling, dated 2009, emphasized the importance of proper food handling to prevent foodborne illness, yet the observed practices did not align with these guidelines.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple deficiencies observed during the survey. The facility did not implement and maintain contact precautions for residents who tested positive for COVID-19, specifically failing to ensure that staff utilized appropriate personal protective equipment (PPE) to prevent cross-contamination. Observations revealed that there was no visible PPE or signage indicating transmission-based precautions outside the room of a resident who tested positive for COVID-19. Both the administrator and the Director of Nursing (DON) entered the resident's room without wearing the necessary PPE, which included gowns and gloves, despite the facility's policy requiring such precautions. Additionally, the facility's staff failed to perform proper hand hygiene during incontinent care for several residents. Certified Nursing Assistants (CNAs) were observed changing gloves without sanitizing their hands in between, which is a critical step in preventing the spread of infection. This lapse in protocol was acknowledged by the CNAs, who attributed their failure to forgetfulness and nervousness. The DON confirmed that staff should perform hand hygiene between glove changes and recognized the potential risk of infection due to this oversight. The facility's policies on transmission-based precautions and hand hygiene were not adequately followed, leading to a risk of infection spread among residents and staff. The DON and the administrator admitted that the facility's policy had not been updated to reflect changes in procedures for residents with COVID-19, and there was a lack of clarity and communication regarding the necessary precautions. The absence of proper signage, PPE availability, and adherence to hand hygiene protocols contributed to the deficiencies identified during the survey.
Failure to Obtain Informed Consent for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the administration of psychotropic medications. This deficiency was identified for one resident who did not have a signed informed consent for the administration of Escitalopram, a psychotropic medication. The resident, a female with a moderately impaired cognition as indicated by a BIMS score of 12, was admitted with diagnoses including mood disorder with depressive features. Although there was a consent for Risperidone, another psychotropic medication, no consent was found for Escitalopram. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed a lack of adherence to the facility's policy requiring completed consents for psychotropic medications. The DON acknowledged the oversight and stated that both she and the Assistant Director of Nursing (ADON) were responsible for ensuring consents were completed at admission and when new medications were prescribed. The ADM was unaware of the specific policy requirements and noted that nursing staff were responsible for obtaining and updating consents. The facility's policy on resident rights emphasized the importance of informing residents about their medical conditions and involving them in care planning and treatment decisions.
Failure to Secure Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly secured, as observed during a state survey. A treatment cart containing medications was left unlocked and unsupervised in the hallway near the nurse's station on multiple occasions. LVN A, who was responsible for the cart, admitted to leaving it unlocked due to being sidetracked. Similarly, the DON, who was covering for a sick nurse, also left the cart unlocked, citing being busy and distracted as reasons for the oversight. Interviews with the DON and ADM confirmed that all nursing staff were trained and expected to keep treatment carts locked when unattended. The facility's policy, revised in November 2020, mandates that all drugs and biologicals be stored in locked compartments, and that unlocked medication carts should not be left unattended. Despite this policy, the treatment cart was observed to be unlocked and unattended, posing a risk of unauthorized access to medications by residents.
Deficiency in Room Size Requirements
Penalty
Summary
The facility failed to ensure that resident bedrooms met the required square footage per resident in multiple semiprivate rooms. Specifically, seven out of twenty-six semiprivate rooms did not provide the minimum 80 square feet per resident. The rooms in question had square footage ranging from 152.2 to 156.58 square feet for two residents, falling short of the required 160 square feet. This deficiency was identified through observations and interviews conducted during a survey. During an interview, the Administrator (ADM) acknowledged the lack of compliance with room size requirements and mentioned the facility's intention to apply for a waiver. The ADM also noted that there had been no recent changes to the floor plan and admitted that the facility did not have a policy related to room square footage requirements. The potential negative outcomes of this deficiency, as stated by the ADM, included issues related to crowding and clutter, which could affect the residents' quality of life.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — including the 3 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Crosbyton
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ralls Nursing Home | 7.6 mi | ★★★★★ | 14 | 3 |
| Slaton Care Center | 28.9 mi | ★★★★★ | 8 | 0 |
| Post Nursing & Rehab Center | 33.7 mi | ★★★★★ | 6 | 0 |
| Windmill Village Rehabilitation & Care Center | 33.7 mi | ★★★★★ | 2 | 0 |
| Matador Health And Rehabilitation Center | 34.8 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.