Above average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Crowley Nursing And Rehabilitation during CMS and state inspections, most recent first.
A resident with multiple comorbidities, including chronic kidney disease and a recent UTI, had an indwelling urinary catheter that was not addressed in the comprehensive care plan. Although physician orders and nursing notes documented catheter care, the care plan lacked measurable objectives and interventions for catheter management, leaving staff without documented guidance.
Staff documented resident care under the EHR credentials of other staff members, resulting in incomplete and inaccurate medical records for multiple residents. CNAs used saved or shared log-ins to document care activities when their own credentials were unavailable, despite facility policy prohibiting this practice. Administrative staff confirmed that such actions were not permitted and led to inaccurate documentation.
The QAA committee did not include the Medical Director or a designee at any of its meetings, as required by facility policy, with sign-in sheets confirming the absence. The Administrator stated it was his responsibility to ensure the Medical Director's attendance, but the Medical Director reported not being invited to any meetings.
A resident with moderate cognitive impairment and mobility limitations was left with a fall mat next to her bed at all times, despite being able to self-transfer to a bedside commode and wheelchair. The mat, which also impeded movement of her bedside table, was identified by both the resident and her family as a trip hazard, but staff refused to remove it, citing fall prevention protocols. Staff interviews confirmed the mat was kept in place continuously, and the physical therapist noted it could be hazardous for ambulatory residents.
A resident with severe cognitive impairment and a history of pulling out her g-tube was provided an abdominal binder to prevent further incidents. However, the binder was used without a physician's order, despite facility policy requiring interventions for enteral feeding to be provided as ordered. Staff and the DON believed an order was unnecessary, but the physician expected one to be in place.
The facility improperly discharged two residents without adequate documentation or attempts to meet their needs. One resident, with severe cognitive impairment, was discharged after a single incident of physical aggression without physician documentation. The second resident, with moderate cognitive impairment, was discharged following an inappropriate touching incident, also without proper documentation or attempted interventions. These actions violated the facility's discharge policy and posed risks to the residents' health.
A resident with severe cognitive impairment was discharged from a facility without proper notification to the resident, their representative, or the State LTC Ombudsman. The discharge followed an incident of physical aggression, but the facility failed to provide a written notice or document the resident's needs and the facility's inability to meet them. The Administrator admitted the discharge was handled improperly without necessary documentation.
Two residents were discharged from a facility without proper preparation or documentation. One resident, with severe cognitive impairment, was discharged the same day as an incident of aggression without a care plan meeting or physician's note. Another resident, with moderate cognitive impairment, was discharged after an inappropriate touching incident without documented interventions or a physician's note. The facility's discharge policy was not followed, leading to potential risks to the residents' health.
The facility failed to ensure that three residents received necessary grooming and personal hygiene services. Residents were observed with several days of facial hair growth and untrimmed fingernails, despite documentation indicating daily hygiene care. Interviews revealed inconsistencies in the provision of care, and the DON confirmed that daily hygiene was not consistently performed according to residents' preferences.
The facility failed to maintain an effective training program for 8 of 12 staff members, missing critical training on Resident Rights, Dementia, HIV, Falls, Restraints, and ANE. Interviews with the ADON and DON confirmed the oversight, with night shift staff frequently missing required in-services.
The facility failed to develop a comprehensive care plan for a resident with multiple medical conditions, including contractures. Despite the resident's non-compliance with keeping devices in her hands for contracture management, the care plan lacked measurable objectives and timeframes. Staff interviews confirmed the resident's refusal was known but not documented, leading to inadequate and non-individualized care.
A facility failed to administer medications as prescribed when the ADON left a medication cup with two pills on a resident's shelf and forgot to return to administer them. The resident, who has conditions including hypothyroidism and GERD, was found holding the medication cup and unaware of its contents. This incident was confirmed by interviews with the MA and DON, highlighting a lapse in following the facility's medication administration policy.
A facility failed to securely store medications when the ADON left a medication cup with two pills on a resident's shelf. The resident, who has moderate cognition and various medical conditions, was later found holding the medication cup. The ADON admitted to forgetting to administer the medications after the resident was transferred into her wheelchair.
A resident with severe cognitive impairment and multiple diagnoses was inaccurately documented as being on antibiotic therapy for five days after the treatment had ended. This error was confirmed through interviews with nursing staff and the DON, who acknowledged the mistake and emphasized the importance of accurate documentation.
A medical assistant failed to disinfect a reusable blood pressure cuff between its use on two residents, despite knowing the importance of this practice and having received multiple in-services on infection control. This failure occurred in a facility where the policy mandates decontamination of reusable equipment between residents.
Failure to Develop Comprehensive Care Plan for Indwelling Catheter
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident who had an indwelling urinary catheter from late January to early April. Despite the resident's complex medical history, including chronic kidney disease stage 4, type 2 diabetes mellitus, hypertensive heart disease with heart failure, and a recent urinary tract infection, the comprehensive care plan did not address the presence or management of the indwelling catheter. The baseline care plan and MDS assessment noted the catheter, but this information was not carried over to the comprehensive care plan, leaving a gap in documented interventions and measurable objectives related to catheter care. Physician orders during the period specified detailed specific catheter care, including flushing, monitoring output, and changing the catheter as needed. Nursing progress notes confirmed the presence and management of the catheter, and staff interviews revealed that the catheter was in place due to urinary retention. However, the comprehensive care plan, which is intended to guide all staff in providing consistent and appropriate care, did not include any care area or interventions related to the catheter. This omission was confirmed by the MDS Nurse, who acknowledged that the catheter was not addressed in the comprehensive care plan and that this information should have been included to inform staff. Interviews with facility leadership, including the DON and the MDS Nurse, confirmed that the catheter was not included in the care plan and that this was an oversight. The facility's own policy requires that comprehensive care plans include measurable objectives and timeframes for all identified needs, and that care plans be updated with any significant change in condition or upon readmission. The lack of a care plan addressing the indwelling catheter meant that staff did not have documented guidance on catheter care, which could have led to inconsistent care practices.
Inaccurate Medical Record Documentation Due to Shared EHR Credentials
Penalty
Summary
The facility failed to maintain complete and accurate medical records for all 15 residents reviewed, as required by professional standards. Certified Nursing Assistants (CNAs) documented care activities such as personal hygiene, bathing, incontinent care, oral care, and positioning under the electronic health record (EHR) credentials of other staff members, including Licensed Vocational Nurses (LVNs) and other CNAs. This occurred because some staff members' credentials were not working, and they either used saved log-ins on facility computers or obtained credentials from coworkers. For example, one CNA documented care under an LVN's credentials, which were saved on the computer, while another CNA used a coworker's credentials after requesting them directly. Staffing schedules confirmed that the staff members whose credentials were used were not present during the times the documentation was entered. Interviews with staff and administration revealed that staff were aware they were not permitted to use another person's credentials, but some did not realize this constituted false documentation. The facility's policy required documentation to be objective, complete, and accurate, and prohibited sharing or saving credentials in a way that would allow others to document under the wrong name. The Director of Nursing (DON) and Administrator confirmed that sharing or saving credentials for others to use was not acceptable practice, and that the facility's policy did not allow for such actions.
QAA Committee Lacked Required Medical Director Attendance
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee met the regulatory requirements for membership and meeting frequency. Specifically, the Medical Director or a designated representative did not attend any of the 11 QAA meetings reviewed, as evidenced by sign-in sheets for each meeting date. The Administrator acknowledged that it was his responsibility to follow up with the Medical Director to ensure attendance, but stated that the Medical Director rarely attended despite being notified of meeting dates and times. In contrast, the Medical Director reported not being invited to any QAA meetings and confirmed non-attendance. The facility's QAA policy requires the committee to include, at a minimum, the Committee Chairperson, Administrator, Director of Nursing, and Medical Director.
Failure to Remove Trip Hazard for Ambulatory Resident
Penalty
Summary
The facility failed to ensure that a resident received adequate supervision and assistance devices to prevent accidents, specifically by not removing a fall mat that posed a trip hazard. The resident, an elderly female with a history of stroke, non-Alzheimer's dementia, muscle weakness, and moderately impaired cognition, was able to self-transfer to her bedside commode and wheelchair. Despite her ability to ambulate short distances, a fall mat was kept on the floor next to her bed at all times, with three wheels of her bedside table resting on it, making it difficult for her to move the table and increasing her fear of tripping. Both the resident and her family expressed concerns about the mat being a trip hazard, but staff insisted it remain in place as a fall prevention measure. Multiple staff interviews confirmed that the fall mat was kept in place continuously, regardless of the resident's mobility, and that the family’s requests to remove it were denied. The physical therapist noted that fall mats could be a trip hazard for ambulatory residents and recommended they be removed when not in use. The facility's care plan and policy emphasized providing a safe environment free from hazards, but the mat's placement contradicted this by creating a potential obstacle during transfers. The resident had not experienced recent falls, but the persistent use of the fall mat, despite voiced concerns and observed difficulties, constituted a failure to maintain an environment free from accident hazards.
Lack of Physician Order for Abdominal Binder Used to Secure G-Tube
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and dependent on a gastrostomy tube (g-tube) for nutrition did not have a physician's order for an abdominal binder that was being used to secure and protect the g-tube. The resident had a history of pulling out her g-tube during care, as documented in progress notes and confirmed by staff interviews. The abdominal binder was implemented to prevent further incidents of the resident pulling out her g-tube, and staff reported that no further incidents occurred after its use. Despite the use of the abdominal binder as an intervention, review of the resident's medical records and physician orders revealed that there was no physician's order for the binder. The Director of Nursing stated that an order was not required because the binder was considered protective rather than a treatment, while the physician indicated that an order should have been in place. The facility's policy required that enteral nutrition and related interventions be provided as ordered, but the lack of a physician's order for the abdominal binder constituted a failure to ensure appropriate treatment and services for the resident receiving enteral feeding.
Improper Discharge Procedures for Two Residents
Penalty
Summary
The facility failed to adhere to proper discharge protocols for two residents, leading to deficiencies in the discharge process. For the first resident, a female with severe cognitive impairment and a history of verbal aggression, the facility discharged her without adequate documentation from a physician regarding the necessity of the discharge. The incident that led to her discharge involved a single occurrence of physical aggression, where she hit another resident with her shoe. Despite this, there was no evidence of a care plan addressing physical aggression, nor was there documentation of attempts to meet her needs within the facility before deciding on discharge. The second resident, a male with moderate cognitive impairment and no prior behavioral issues, was discharged following an incident where he was observed touching another resident inappropriately. The facility issued a 48-hour emergency discharge notice citing safety concerns, but again, there was no physician documentation supporting the discharge decision. Interviews with staff revealed that this was the first known incident of inappropriate behavior by the resident, and there were no documented interventions attempted to address the behavior before discharge. In both cases, the facility's failure to document the specific needs that could not be met, attempts to meet those needs, and the services available at the receiving facility, as required by their policy, resulted in unsafe discharges. The lack of proper documentation and communication with the receiving facilities posed a risk to the residents' physical and mental health, as acknowledged by the facility's administration.
Improper Emergency Discharge Notification
Penalty
Summary
The facility failed to properly notify a resident, their representative, and the State Long-Term Care Ombudsman about an emergency discharge. The resident, an elderly female with severe cognitive impairment and multiple medical conditions, was discharged without receiving a written notice or an emergency discharge letter that included necessary information and resources. The facility only informed the resident's representative by phone, which did not comply with the required procedures for discharge notifications. The incident leading to the discharge involved the resident hitting another resident with a shoe, which was the first known physical aggression incident for this resident. Despite this, the facility did not document any physician's note or care plan adjustments to address the resident's behavior. Interviews with staff revealed that the resident was known for verbal aggression but not physical aggression, and there were no injuries reported from the incident. The decision to discharge was made quickly, without a formal discharge process or proper documentation. The facility's policy required a care plan meeting and documentation of the resident's needs and the inability of the facility to meet those needs before discharge. However, these steps were not followed, and the discharge was executed without setting up necessary resources for the resident. The Administrator, who was on vacation at the time, acknowledged that the discharge was handled improperly and without the required documentation from the Medical Director.
Failure to Ensure Safe and Orderly Discharge of Residents
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation for the safe and orderly transfer or discharge of two residents. Resident #1, a female with severe cognitive impairment and a history of verbal aggression, was discharged the same day as an incident where she hit another resident with a shoe. The discharge was executed without a care plan meeting or a 48-hour discharge notice, and there was no documentation from a physician stating that the resident was a harm to herself or others. The Administrator, who was on vacation at the time, later acknowledged that the discharge was handled too quickly and without proper resources set up for the resident. Resident #2, a male with moderate cognitive impairment and a history of Alzheimer's disease, was discharged following an incident where he was reported to have touched another resident inappropriately. Despite being placed on one-on-one supervision, the discharge was carried out without documented interventions or a physician's note indicating that the resident was a threat. The Administrator admitted to determining the discharge without consulting the medical director or the resident's physician, and there was no oversight of the discharge process. The facility's policy required documentation of specific resident needs that could not be met, attempts to meet those needs, and communication of necessary information to the receiving facility. However, these procedures were not followed, leading to the risk of unsafe discharges for both residents. The lack of proper documentation and communication created potential risks to the residents' physical and mental health.
Failure to Maintain Grooming and Personal Hygiene
Penalty
Summary
The facility failed to ensure that three residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, Residents #82, #37, and #26 were not shaved regularly, and their fingernails were not kept trimmed according to their wishes. Resident #82, a cognitively intact male with a self-care deficit, was observed with several days of facial hair growth and overgrown fingernails. Despite documentation indicating daily personal hygiene, Resident #82 reported not being showered since his last interview. Similarly, Resident #37, who required assistance with hygiene, was observed with several days of facial hair growth and untrimmed fingernails. He expressed that his appearance was important to him and that CNAs did not trim nails unless specifically asked. Resident #26, who was moderately cognitively impaired and required assistance with personal hygiene, was also observed with several days of facial hair growth. Interviews with CNAs and the DON revealed inconsistencies in the provision of daily hygiene care. CNA L stated that Resident #82's shower days were scheduled on the evening shift, and she was unaware of his last shower. The DON confirmed that her expectation was for all residents to have basic hygiene performed daily, including trimming fingernails and shaving male residents according to their preferences. The DON acknowledged that not performing daily hygiene could lead to infections and expressed concern over CNAs documenting hygiene care without completing all necessary steps. The facility's policy on the care of fingernails and toenails emphasized the importance of cleaning the nail bed, keeping nails trimmed, and preventing infections, which was not adhered to in these cases.
Failure to Maintain Effective Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for 8 of 12 staff members reviewed for training. Specifically, the facility did not ensure that training on Resident Rights, Dementia, HIV, Falls, Restraints, and Abuse, Neglect, and Exploitation (ANE) were completed during orientation and prior to the start date. This deficiency was identified through record reviews and interviews, revealing that several staff members, including CNAs, MAs, RNs, and LVNs, had incomplete training transcripts. For instance, CNA D, CNA E, CNA F, MA G, CNA H, RN I, LVN C, and LVN J had missing records of required training, such as restraint training, falls, dementia, HIV, and ANE. The lack of proper training could place residents at risk for abuse and neglect due to staff not being adequately prepared to handle these critical aspects of care. Interviews with the ADON and DON confirmed the oversight in training. The ADON acknowledged that improper training on restraints could result in physical or psychosocial harm to residents. The DON admitted awareness of the incomplete annual restraint training and other required trainings, emphasizing the risk of harm to residents when staff are not fully trained. The DON also noted that night shift staff, such as LVN J and CNA F, often missed required in-services, and it was the ADON's responsibility to monitor these trainings. The facility's policy on mandatory in-service training classes, including HIV, Resident Rights, and Resident Abuse, was not adhered to, contributing to the deficiency.
Failure to Develop Comprehensive Care Plan for Resident with Contractures
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #59, who had multiple medical conditions including CVA, hemiplegia, paraplegia, and a seizure disorder. The resident had moderately impaired cognition and was dependent on staff for all activities of daily living (ADLs). Despite the resident's need for contracture management, the care plan did not include measurable objectives and timeframes to address her non-compliance with keeping a device in her hand for contractures. Observations and interviews revealed that the resident frequently removed the carrots or wash rags placed in her hands, complaining of pain, and there was no alternative plan documented to manage her contractures effectively. Interviews with staff, including a CNA, LVN, Director of Rehab, and the MDS Nurse, confirmed that the resident's refusal to keep the devices in her hands was known but not adequately addressed in her care plan. The hospice doctor had also noted that the resident's hands could not be rehabbed and recommended keeping her comfortable. Despite this, the care plan lacked specific interventions to manage the resident's contractures and pain, and there was no documentation of her refusal to comply with the recommended interventions. This oversight could lead to inadequate and non-individualized care for the resident.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of a resident, specifically in the accurate administration of medications. The Assistant Director of Nursing (ADON) left a medication cup containing two pills on a resident's shelf and forgot to administer them. This incident was discovered when the resident was found holding the medication cup and stated she did not know who left the pills or if they were hers. The medications in question were Omeprazole and Levothyroxine, which were crucial for managing the resident's health conditions, including hypothyroidism and gastro-esophageal reflux disease (GERD). Interviews with the Medication Aide (MA) and the Director of Nursing (DON) confirmed that the ADON had intended to return to administer the medications after the resident was transferred into her wheelchair but forgot to do so. The facility's policy on administering medications, which mandates that medications be administered in a safe and timely manner as prescribed, was not followed. This lapse in procedure placed the resident at risk of not receiving essential medications, potentially compromising her health status.
Failure to Securely Store Medications
Penalty
Summary
The facility failed to ensure all drugs and biologicals were stored securely for one resident. The Assistant Director of Nursing (ADON) administered medications to a resident but left the medication cup with two pills on the resident's shelf in the room. The resident, who has moderate cognition and various medical conditions including hypertension, diabetes, and hypothyroidism, was later found holding the medication cup with the two pills inside. The resident did not know who left the pills or if they were her medications. Interviews with the Medication Aide (MA) and the ADON revealed that the ADON had intended to return to administer the medications after the aides had transferred the resident into her wheelchair but forgot to do so. The Director of Nursing (DON) confirmed that the pills were omeprazole and levothyroxine and emphasized the importance of not leaving medications unattended due to the potential danger to other residents. The facility's policy on the storage of medications requires that all drugs and biologicals be stored in a safe, secure, and orderly manner.
Inaccurate Nursing Documentation for Antibiotic Therapy
Penalty
Summary
The facility failed to ensure medical records were accurately documented in accordance with accepted professional standards for one resident. Specifically, the nursing documentation for a resident with severe cognitive impairment and multiple diagnoses, including stroke, liver disease, and cystic fibrosis, was found to be inaccurate. The resident had developed a UTI and was prescribed a three-day course of antibiotics. However, nursing documentation incorrectly indicated that the resident continued to be on antibiotic therapy for an additional five days after the treatment had ended. This discrepancy was confirmed through interviews with the nursing staff and the Director of Nursing (DON), who acknowledged the mistake and emphasized the importance of accurate documentation. The resident's medical records showed that the last dose of antibiotics was administered on the correct date, but subsequent nursing notes inaccurately documented ongoing antibiotic therapy. This error was identified during a review of the resident's electronic health record (EHR) and medication administration record (MAR). The facility's policy on charting and documentation, which mandates that all services provided to the resident be documented accurately and objectively, was not followed. The DON stated that there was no excuse for such errors, as accurate documentation is a basic expectation for professional nurses and is crucial for providing accurate information to other healthcare providers.
Failure to Disinfect Reusable Medical Equipment
Penalty
Summary
The facility failed to ensure staff followed an infection control program designed to provide a safe, sanitary, and comfortable environment, which could prevent the development and transmission of communicable diseases and infections. Specifically, a medical assistant (MA) did not sanitize a reusable blood pressure cuff between its use on two residents. This failure was observed during blood pressure checks on two residents, one with diagnoses including brain disorder, senile degeneration of the brain, and diabetes, and the other with diagnoses including stroke, liver disease, and cystic fibrosis. The MA admitted to knowing the importance of disinfecting the equipment but failed to do so due to nervousness. The Director of Nursing (DON) confirmed that all staff had been repeatedly in-serviced on infection control practices, including the disinfection of reusable medical equipment. The facility's policy, dated August 2009, mandates that reusable resident care equipment be decontaminated and/or sterilized between residents. Despite this policy and the training provided, the MA did not follow the required procedures, leading to a potential risk of disease transmission between residents.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Crowley
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Allegiant Wellness And Rehab | 1 mi | ★★★★★ | 0 | 0 |
| Park Bend Rehabilitation And Healthcare Center | 2 mi | ★★★★★ | 7 | 2 |
| Avir At Burleson | 2.6 mi | ★★★★★ | 3 | 0 |
| Advanced Rehabilitation & Healthcare Of Burleson | 3.6 mi | ★★★★★ | 13 | 1 |
| Estates Healthcare And Rehabilitation Center | 4.7 mi | ★★★★★ | 29 | 3 |
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