Health inspection·April 10, 2023

F 0656 01. Level of Harm - Minimal harm or potential for actual harm Delirium 02. Residents Affected - Some Cognitive Loss 03. Visual 04. Communication 05. Activities of Daily Living 06. Urinary 07. Psychosocial Well-being 08. Mood 09. Behavior 11 Falls 12 Nutritional 16 Pressure ulcer 17. Psychotropic Drug Use 18. Pain (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 2 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crosbyton Nursing and Rehabilitation Center 222 N Farmer Crosbyton, TX 79322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Record Review of Resident #1 Physician Order, dated 04/09/23, revealed the following: Level of Harm - Minimal harm or potential for actual harm Fluoxetine HCl Capsule 10 MG Give 1 capsule by mouth one time a day for depression related to DEPRESSION with an order date of 02/15/23 Residents Affected - Some Record review of Resident #1's care plan, dated 03/05/23, revealed no care plan for delirium, cognitive loss, vision, communication, activities of daily living, urinary, psychosocial well-being, mood, behavior, falls, nutritional, pressure ulcer, psychotropic drug use and pain. Resident #2 Record review of Resident #2's (04/09/23) face sheet revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include urinary tract infection, muscle weakness, and unsteadiness on feet. Record review of Resident #2's admission Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 12, which indicated the resident's cognition was moderately impaired. Section V Care Area Assessment (CAA) Summary: CAA Results: (List the CAA that triggered and not Care Planned) 02. Communication 03. Visual 04. Communication 05. Activities of Daily Living 06. Urinary 07. Psychosocial Well-being 08. Mood 10. Activities 11. Falls 12. Nutritional 16. Pressure Ulcer 19. Pain Record review of Resident #2's care plan, dated 02/21/23, revealed no care plan for cognitive loss, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 3 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crosbyton Nursing and Rehabilitation Center 222 N Farmer Crosbyton, TX 79322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some vision, communication, activities of daily living, urinary, psychosocial wellbeing, mood, activities, falls, nutritional, pressure ulcer and pain. Resident #3 Record review of Resident #3's face sheet dated 04/10/23 revealed an [AGE] year-old-male who was admitted to the facility on [DATE] with diagnoses to include atherosclerotic heart disease (build up in the artery walls), Major depressive disorder and urinary tract infection. Record review of Resident #3's Annual Minimum Data Set, dated [DATE], revealed: Section C Brief Interview for Mental Status score revealed a score of 13, which indicated the resident's cognition was cognitively intact. Record review of Resident #3's care plan, dated 1/31/23, revealed the following: The following care plan focus initiated 02/20/23 did not have a goal: The resident is (SPECIFY: independent/dependent on staff etc.) for meeting emotional, intellectual, physical, and social needs r/t (if dependent) The following care plan focus initiated 02/20/23 did not have any listed interventions: The resident has limited physical mobility r/t The following care plan focus initiated 02/20/23 did not have a goal: The resident is a smoker. The following care plan focus initiated 02/20/23 did not have any listed interventions: The resident has impaired cognitive function/dementia or impaired thought processes r/t The following care plan focus initiated 02/20/23 did not have any listed interventions: The resident is on pain medication therapy The following care plan focus initiated 02/20/23 did not have any listed interventions: The resident has a mood problem r/t The following care plan focus initiated 02/20/23 did not have any listed interventions: The resident has depression r/t The following care plan focus initiated 02/20/23 did not have any listed interventions: The resident has paraplegia r/t (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 4 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crosbyton Nursing and Rehabilitation Center 222 N Farmer Crosbyton, TX 79322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 The following care plan focus initiated 02/20/23 did not have any listed interventions: Level of Harm - Minimal harm or potential for actual harm The resident has nutritional problem or potential nutritional problem (SPECIFY) r/t The following care plan focus initiated 02/20/23 did not have any listed interventions: Residents Affected - Some The resident has an alteration in neurological status (SPECIFY) r/t The following care plan focus initiated 02/20/23 did not have any listed interventions: The resident has (SPECIFY: Condom/Intermittent/Indwelling Suprapubic) Catheter: During an interview on 04/10/23 at 11:46 AM with the DON, she said the ADON was responsible for the care plans in the facility. She said the ADON was not in the building, and she was on vacation and had been on vacation for at least a week. She said everyone uses the care plan. She said a care plan was a baseline of how to care for the patients that resided in the facility. She said she was aware of some issues with the care plans. She said they had some issues with updating them with the electronic medical system that they had. She said the previous DON had gone in and checked something within the system, and now MDS assessment would trigger CAAs that were not relevant. She said that the ADON had to fix each resident manually. When asked how long this issue had been present, she said the issue had been an ongoing process for over a year. She said they contacted their IT worker, and said she was told about the electronic medical record problem. She said they were told to correct the MDS assessment manually. She said they had had many issues with the electronic medical system that needed to be fixed. When asked what efforts had been made to correct the issue, she said she had not contacted anyone from the electronic medical record company because she did not have the number. She said that she had only reached out to the local IT. When asked if she had reported this to her administrator, she said that they had two administrators since she had been employed at the facility, and the current administrator had been out, and she was not sure if she had reported the electronic medical record issue to the current administrator. She said the previous administrator was aware of the issue. When asked about the system to monitor care plans, she said the ADON reviewed them when they were updated. She said the potential negative outcomes for each care are as follows: Delirium: If staff did not realize the resident had that issue, they could have unnecessary hospitalizations. Cognitive loss: She said the resident could decline, and staff could not identify it if they did not know what they were looking for. Visual: She said the lack of a visual care plan could result in increased falls for the resident if the staff does not know how to accommodate the resident. Communication: She said the resident could experience adverse effects, and then staff may not give them the best care that you could give them because of failure to communicate with them. Activities of daily living: She said if not care is planned, then the CNAs could have missed ADLS for residents. Urinary: She said the failure to care plan urinary the resident could have an infection and missed needed care. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 5 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crosbyton Nursing and Rehabilitation Center 222 N Farmer Crosbyton, TX 79322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Psychosocial well-being: She said if not care plan, staff might have missed things like gradual dose reduction or needed psychiatric services. Mood: She said the failure to care plan for a resident's mood, the resident could have been at risk for depression, and the staff would have been unaware of signs and symptoms of a change in mood. Residents Affected - Some Behavior: She said staff might have over-medicated trying to treat an old behavior or might not recognize new behavior. Falls: She said the resident could have had a fall, potential injuries, and precautions may not be in place to prevent falls. Nutritional: She said the failure to care plan could cause the resident to receive the wrong diet and could have placed the resident at risk for aspiration (fluid in the lungs). Pressure ulcer: She said the failure to care plan for a resident at risk for pressure ulcer could have resulted in a worsening pressure ulcer, or the staff might not know they were at risk and have the correct precautions, which could create a pressure ulcer. Psychotropic drug use: She said the staff could miss the adverse effects of the medications that a resident is taking and may be unable to make necessary adjustments if there are issues with the dosage. Pain: She said if the pain is not care planned, then staff would or could not apply the correct pain management, which can result in pain for the resident. When asked if she had been trained regarding care plans? Her response was, Not really. And stated she had no formal training. When asked what her expectation of resident care plans, she said she would have liked for them to improve and give the overall picture of what is needed for the patient. When asked what her expectation of issues to be resolved with her electronic medical system was, she said that she expected them to be resolved in a timely manner. She said that a year is not considered timely. She said a care plan should include the problem, goal, and intervention. She said if it was blank, the triggered item was not being done or addressed. She said the incomplete care plan or a missing problem, goal, or intervention could cause harm because if the care plan did not have an intervention, then staff and the resident were not working toward a goal. She said if the care plan did not have a goal, then the staff or the resident would not know what they were working towards. She said each care plan should be personalized, and if the information is not personalized, there would have been no progression for the patient. She said she was unfamiliar with the MDS assessment, triggered care areas, and how they all went into the care plan. During an interview on 04/10/23 at 12:09 PM, the administrator said the ADON was responsible for care plans in the facility. She said everyone used the resident care plans, including doctors. She said the care plan was a document that included everything about the patient. She said it was specific; for example, if they were prone to falls, that would have been included. She said this information for the care plan came from the residents. She said she was unaware of any issues with care plans or the electronic medical system. She said no one reported issues to her. When asked whether the facility has a process that monitors resident care plans, she stated she does not look at them but would have liked for the DON to keep track. She said she would ask about care plans in stand-up morning meetings, and no one had ever reported issues. She said a potential negative outcome, and she said the problem identified could get worse and could have been overlooked. She said she had not been (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 6 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crosbyton Nursing and Rehabilitation Center 222 N Farmer Crosbyton, TX 79322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some trained formally regarding care plans. When asked what her expectation of resident care plans was, she said she would have liked them to be on point. When asked what was on point, she said the care plan should have had a lot of information in them that is current and specific to that resident. When asked if a care plan consisted of the problem, goal, and intervention, she said Yes and that sometimes the intervention was not a one-day thing. She said incomplete goals or interventions could cause the residents' needs to be overlooked When asked should each of these have personalized data in each space, and she responded yes. When asked if there was no data on what could potentially happen in the problem, goal, or intervention space, she said the staff would be unaware of the resident's issues. She said even though the residents had physician orders, it was still important to have the resident's care plan completed. During an interview on 04/12/23 at 12:35 PM, the IT worker said he was unaware the facility had any issues with the electronic medical record. He said if it had been reported, he would have fixed it. He said he could fix the electronic medical record system, including adding and removing users and just about everything. He said he was not familiar with the nursing side of things. He said the nursing staff had multiple people they could reach out to. To his knowledge, the electronic medical record system was new to [NAME]. At first, there were a lot of problems with the electronic medical record at the beginning but no issues that he knew of at this time, and the system is functioning properly. He said he doubted if the system was having issues because the facility was copying a parent facility from which all the settings within the system were copied. Record review of the facility policy Care Plans, Comprehensive Person-Centered, Revised March 2022, revealed the following documentation: Applicability: this policy sets forth the procedures relating to developing a comprehensive, person-centered care plan. Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the Resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: #7. The comprehensive, person-centered care plan will: (a.) Include measurable objectives and time frames; (b.) Describe the services that are to be furnished to attain or maintain the Residents highest practicable physical, mental, and psychosocial well-being. (c.) includes the resident's stated goals upon admission and desired outcomes; (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 7 of 8 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675291 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Crosbyton Nursing and Rehabilitation Center 222 N Farmer Crosbyton, TX 79322 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 (d.) Level of Harm - Minimal harm or potential for actual harm builds on the resident's strengths; and (e.) Residents Affected - Some reflects currently recognized standards of practice for problem areas and conditions #10. When possible, interventions address the underlying source(s) of the problem area(s) not just symptoms or triggers. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 8 of 8