Health inspection·June 9, 2023

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few sure if MDD was a mental illness and then changed her answer and said it was. She said the PL1 should have been redone when Resident #8's diagnosis of MDD was made. She said typically, she would be responsible for making sure this was done and said that it may have been overlooked. She said that the risk to a resident with an inaccurate PL1 would be not receiving services they could be eligible for. She said that for example, certain equipment the resident may benefit from. She said that she will be going through the doctor's notes from now on to double check diagnoses and would revise PL1's for residents as needed. Observation and attempted interview on 06/09/23 at 10:26 AM revealed Resident #8 to be sitting in a wheelchair near the lobby of the facility near a staff member, gazing in one direction with a blank expression on his face. An attempted interview with the resident revealed he was unable to converse with the surveyor and was confused. During an interview conducted on 06/09/23 at 11:15 AM, the PASRR Coordinator from the local mental health authority said that she had evaluated Resident #8 earlier today and said that MDS Coordinators should indicate through documentation on the PL1 form if a resident has a diagnosis that qualifies as a mental illness regardless of a diagnosis of dementia or dementia-like symptoms so that an evaluation could be completed. She said that Major Depressive Disorder qualifies as a mental illness. Resident #10: Record review of the Order Summary Report for female Resident #10 dated 6/7/23 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. Diagnoses listed included, major depressive disorder, recurrent, unspecified (mental disorder), schizoaffective disorder, depressive type (mental disorder), and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood, disturbance, and anxiety (mental disorder). Record review of the current face sheet for Resident #10 documented all listed diagnoses, had onset dates of 9/30/21. The Primary diagnosis was unspecified dementia, unspecified, severity, without behavioral disturbance, psychotic disturbance, mood, disturbance, and anxiety. The Classification was Admitting Diagnosis. The second diagnosis listed was schizoaffective disorder, depressive type onset date, 9/30/21 and was classified as an admitting diagnosis. Major depressive disorder, recurrent, unspecified was also listed with an onset date of 9/30/21. Record review of the PASRR Level 1 screening for Resident #10 dated 9/30/21 revealed the following documentation, . Section C. PASRR screen. C0100. Mental illness. Is there evidence or an indicator this is an individual that has a mental illness? No . Record review of the annual MDS assessment for Resident #10 dated 10/13/22 revealed active diagnoses: dementia, depression (other than bipolar), psychotic disorder (other than schizophrenia) and schizophrenia (e.g., Schizoaffective, and schizophreniform disorders). Further record review of this MDS revealed the section titled Preadmission Screening and Resident Review (PASRR), Has the resident been evaluated by a Level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition? revealed a response of No. Under the section titled Level II PASRR Conditions: a. Serious mental illness. reveal no documentation. Record review of the quarterly MDS assessment for Resident #10 dated 5/18/23 revealed the following active diagnoses, dementia, depression (other than bipolar), psychotic disorder (other than schizophrenia) and schizophrenia (e.g., Schizoaffective, and schizophreniform disorders). Further record (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 2 of 20 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 06/09/2023 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few review of the MDS revealed, there was no documentation in the areas, titled, Preadmission Screening and Resident Review (PASRR). Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or mental retardation or a related condition? and titled Level II PASRR Conditions: a. Serious mental illness. Record review of the current care plan for Resident #10 revealed the resident had no care plan related to PASRR. Record review of the Psychiatric Services report for Resident #10 dated 4/18/23 revealed the Problems listed were Psychosis due to general medical condition, hallucinations. Major depressive recurrent, severe without psychotic features. Dementia of Alzheimer's type with late onset. Generalized anxiety disorder . Documented under the Plan Section revealed the following, . Behavioral intervention for psychiatric signs/symptoms . On 6/8/23 at 3:00 PM an interview was conducted with the ADON regarding Resident #10's inaccurate PASRR Level 1 screening related to mental illness. She stated, she found her error (inaccurate assessment for mental illness). She further stated that Resident #10 was negative for mental illness so long that she had overlooked her mental illness diagnosis. On 6/8/23 at 5:02 PM, an interview was conducted with the ADON regarding Resident #10's PASRR. She stated, the resident had been in the facility since approximately 2018. The facility closed, and she went to another facility for a period until the current facility reopened in 2021. She added after the facility reopened; she submitted the same PASRR Level I information from the previous facility without rechecking the diagnoses. On 6/9/23 at 11:05 AM an interview was conducted with the DON regarding issues found in the facility. She stated that the ADON was responsible for ensuring that PASRR screenings were accurate. She added that she expected staff to have reviewed and conducted an accurate PASRR screening. Regarding how this issue could affect residents, she stated residents would not receive the PASRR related services they were eligible for. Review of facility policy titled Admissions Criteria with revision date of March 2019 indicated under policy interpretation and implementation . All new admissions and readmissions are screened for mental disorders (MD), intellectual disabilities (ID) or related disordered (RD) per the Medicaid Preadmission Screening and Resident Review (PASARR) process. Additionally, the policy read If the level one screen indicates that the individual may meet the criteria for MD, ID, or RD, he or she is referred to the state PASARR representative for the Level II (evaluation and determination) screening process. Lastly, the policy read The admitting nurse notifies the social services department when a resident is identified as having a possible (or evident) MD, ID, or RD. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 3 of 20 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 06/09/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to ensure a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one (Resident #23) of three residents reviewed for catheter care. The facility failed to provide appropriate catheter care for Resident #23 The facility failed to have appropriate orders and interventions in place for routine catheter care including cleaning and changing of the catheter for Resident #23. This failure could place residents with urinary catheters at risk for the development and/or worsening of urinary tract infections. Findings include: Record review of Resident #23's admission record revealed he was a [AGE] year-old male admitted the facility on 04/03/2023. Record review of Resident #23's medical diagnosis list revealed diagnoses including obstructive and reflux uropathy and infection and inflammatory reaction due to indwelling urethral catheter both with created dates of 04/03/2023. Record review of Resident 23's MDS dated [DATE] revealed under Section H Bladder and Bowel, subsection H0100 Appliances, documentation which indicated Resident #23 had an indwelling urinary catheter upon admission. Under Section I Active Diagnoses subsection Infections, documentation which indicated Resident #23 was admitted with a urinary tract infection. Additionally, under Section C Cognitive Patterns a BIMS of 11 indicating he was moderately cognitively impaired at the time of assessment. Record review of the care plan dated 04/04/2023 revealed a focus area pertaining to Resident #23's indwelling urinary catheter with interventions in place that did not include daily catheter care. During an interview conducted on 06/07/23 at 11:24 AM, Resident #23 said he has had a urinary catheter for over a year now. He said he has not had it changed out in three or four months. He said he tried to clean it himself. He said the staff do not clean it regularly and said there was maybe one time when a staff member cleaned it. He said he thinks it would be better if staff were cleaning it more often. He said he has had a UTI several times in the past and had to be hospitalized . Review of active physician orders for Resident #23 revealed there were no orders addressing his urinary catheter. Record review of progress notes and the Treatment Administration Record for the months of May and June of 2023 revealed there was no documentation of Resident 23's catheter being cleaned or of him being offered or refusing catheter care. During observation and interview conducted on 06/08/23 at 09:20 AM, Resident #23 said staff did not offer to clean his catheter overnight the previous night or yesterday after speaking with the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 4 of 20 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 06/09/2023 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few surveyor initially. He said his last UTI was 3-4 months ago and he had to be hospitalized for 3-4 days and received antibiotics. His catheter tubing was observed to contain a white, cloudy material in the urine. During an interview conducted on 06/08/23 at 11:17 AM, the DON said Resident #23 was admitted with an indwelling urinary catheter. She said there should be orders for catheter care. She said she expects her staff to clean around the insertion site daily and as needed. She said once per shift cleaning of the insertion site should be completed and documented. She said she did not know why there were no orders for catheter care. She said that the nurses were responsible for putting orders in when Resident #23 came to the facility and the DON was responsible for ensuring that appropriate orders were in place. She said if a resident has no orders for catheter care and is not regularly being offered catheter care, the risk is infections such as a UTI. During an interview conducted on 06/08/23 at 11:29 AM, CNA A said that catheter care is done every two hours. She said that she did not know if this was documented anywhere. She said she was not sure if an order should be in place for catheter care or for changing out the catheter at certain times. She said that if a catheter is not being cleaned regularly there is a risk for infection. She said CNAs and nurses are responsible for catheter care. She said she had only seen one place to document catheters for one resident and there was no option for documenting catheter care offered or completed. During an interview conducted on 06/08/23 at 01:23 PM, LVN A (Charge Nurse) said she expects the CNAs to provide catheter care with every episode of bowel incontinence care. She said that she was not sure if there was a place to document this and said she had been made aware by the DON earlier today that there was an issue with a lack of orders, prompting, and documentation of catheter care. She said that if catheter care is not offered and regularly completed the risk to the resident is a possible urinary tract infection. During an interview conducted on 06/09/23 at 10:04 AM, Resident #23 said staff came to clean his catheter last night, after surveyor intervention, and said staff also finally changed out his catheter this morning sometime. He said staff told him that they were going to start trying some things to see if they could get it out and said that he needed to try to get those muscles working again. Record review of a facility policy titled Catheter Care, Urinary with revision date of August 2022 read under the section titled Purpose, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections. Under the section titled Perineal Care, the policy read Use soap and water or bathing wipes for routine daily hygiene. Antiseptic wipes for daily cleansing are not recommended. Clean the area under the foreskin in uncircumcised males daily. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 5 of 20 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 06/09/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that the menu was followed for 3 of 3 residents (Residents #9, 12 and 31), who consumed 1 of 3 food forms (pureed), in that: The facility failed to ensure 3 residents received the correct portions that were called for on the menu at 1 of 2 meals observed. These resident meal trays had foods omitted and had lesser amounts of food served than called for on the menu. These failures could place residents at risk for unwanted weight loss and hunger. The findings include : Resident #9 Record review of the Order Summary Report for female Resident #9, dated 6/7/23 revealed that the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of Alzheimer's disease with late onset (mental disorder), dysphasia, oropharyngeal, phase (swallowing disorder) and macular degeneration (vision disorder). Further record review of the Order, Summary Report revealed a diet order that stated, regular diet, purée, texture, regular/thin consistency. Order date: 10/29/21. Start date: 10/29/21. Record review of the facility's Diet Type Report dated 6/7/23 revealed that Resident #9 had a diet order for a regular puréed diet with regular/thin liquids. Record review of the 6/8/23 noon meal tray card for Resident #9 revealed the following documentation, Diet order: puréed, regular liquids, super cereal with breakfast. Resident #31 Record review of the Order Summary Report for male Resident #31 dated 6/8/23 documented that the resident was admitted to the facility on [DATE] and was [AGE] years old. Further record review documented a diagnosis of unspecified, severe protein calorie malnutrition (inadequate nutrition). The Order Summary Report further documented a dietary order of NAS (no added salt) diet, puréed, texture, regular, regular/thin consistency. Order date 4/6/23. Start date: 4/6/23. Record review of the facility's Diet Type Report dated 6/7/23 revealed that Resident #31 had an order for NAS (no added salt), puréed diet with regular/thin liquids. Record review of the noon meal tray card for Resident #31 for 6/8/23 revealed the following order, Diet order: Pureed NAS diet, regular liquids. Resident #12 Record review of the Order Summary Report dated 6/8/23 for female Resident #12 revealed the resident was admitted to the facility on [DATE] and was [AGE] years old. The resident had diagnoses of, type II diabetes mellitus without complication (blood sugar disorder), dysphasia, oropharyngeal, phase (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 6 of 20 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 06/09/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some (swallowing disorder), and Alzheimer's disease, unspecified (mental disorder). Further record review of the Order Summary Report revealed a diet order that stated, Regular diet puréed texture, honey, consistency, honey, thick liquids, encourage fluids with meals and snacks. Order date 1/11/22. Start date 1/11/22 . Record review of the facility's Diet Type Report dated 6/7/23 revealed that Resident #12 had a diet type order for regular puréed diet with honey fluid consistency liquids . Record review of the noon meal tray card for 6/8/23 revealed the following documentation for Resident #12, Diet order: puréed, honey, thick liquids. - The following observations were made, and interviews conducted during a kitchen tour on 6/08/23 that began at 11:32 AM and concluded at 12:26 PM: Temperatures were taken on the service line, beginning at 11:32 AM, with the following information on dispensing utensils: Mashed sweet potatoes (also used for pureed sweet potatoes) served with the #6 scoop (2/3 cup) Ham served with tongs Spinach served with a 4 ounce ladle. Rolls on the steam table Swiss steak with gravy Served with tongs Cauliflower served with a 4 ounce ladle. Pasta served with a 4 ounce ladle. Puréed ham served with a #10 scoops (3/8 cup) Puréed spinach served with a #8 Scoop (1/2 cup) Record review of the facility's, Spring Summer, 2023 Menu, Week 1, Day 4 Diet Spreadsheet Lunch meal revealed that residents with orders for puréed diets should have received: #6 scoop of puréed brown sugar glazed ham (2/3 cup) #8 scoop of puréed whipped sweet potatoes (1/2 cup) #12 scoop of puréed, spinach, frozen (1/3 cup) #10 scoop of pureed pineapple cubes and puréed bread (3/8 cup) On 6/08/23 at 11:58 AM meal service began with the Dietary Manager serving. On 6/8/23 at 12:05 PM the Dietary Manager served a pureed tray for Resident #31. He received a #8 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 7 of 20 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 06/09/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some scoop of puréed spinach, #10 scoop of puréed ham, #6 scoop of sweet potatoes, and did not receive any puréed bread. On 6/8/23 at 12:09 PM the Dietary Manager prepared a puréed meal tray for Resident #9, and she receive a #10 scoop of pureed ham, and #8 scoop of pureed spinach and a #6 scoop of pureed sweet potato and did not receive any puréed bread. In the dining room on 6/08/23 at 12:18 PM, Residents #12 and Resident #9 were fed/assisted by a CNA. Both residents had purée diets and had received a #6 scoop of pureed sweet potato, #8 scoop of pureed spinach, #10 scoop of pureed ham, dessert - pureed pineapple, and did not receive any puréed bread. Observation of the hall tray service on 6/08/23 at 12:23 PM, revealed Resident #31 was served a pureed meal tray by CNA A who started to feed him. The resident received a puréed diet which consisted of a #6 scoop of pureed sweet potato, #8 scoop of pureed spinach, #10 scoop of pureed ham, puréed dessert, and did not receive any puréed bread. On 6/8/23 at 12:39 PM an interview was conducted with the Dietary Manager regarding following the menu. Regarding why she served no puréed bread, she stated she made it but forgot to serve it. Regarding why she had used a #10 scoop for the puréed ham and not a #6 scoop, she stated she had no reason why. On 6/9/23 at 10:46 AM an interview was conducted with the Dietary Manager regarding issues in the kitchen. Regarding recent in-services, she stated that an in-service was conducted with the Dietitian over the phone. She stated sanitation, food handling, and scoop sizes were covered. She stated she did not believe she had a signed in-service sheet for that in-service. Regarding training and orientation for the dietary staff, she stated staff were trained three days. Regarding whom was responsible to ensure that residents receive the correct amounts of food and the menu followed, she stated she was. Regarding what could result from residents not receiving the correct amount of foods, she stated residents could starve to death. On 6/9/23 at 11:05 AM an interview was conducted with the DON. Regarding following the menu, she stated that the Dietary Manager was responsible for ensuring that the menu was followed. She stated that she expected the Dietary Manager and staff would ensure that the right amounts of food were given to residents and check the scoop sizes. She added that as a result of not receiving adequate amounts of food, residents could experience weight loss. Record review of the Record of In-Services for the dietary department for April 2023 through May 2023 revealed in-services were held on 4/18/23 and 5/04/23 covering the topics Sanitation/Food Handling and Sanitation/Handwashing respectively. There was no documentation on either form indicating that the subject of scoop sizes or following the menu was covered. Record review of current undated dietary department guidance revealed the following documentation, Criteria for Scoring Meal Appeal Food Quality Survey. 1. Menu followed. a. Menu followed as written. If a substitute was made, the correct procedure was followed, such as the substitution being in the substitution book and substitute was appropriate. c. Proper serving sizes were followed. One point should be deducted for each food not served properly. d. If an item is omitted from the menu completely, the score should be at three or fair at the highest. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 8 of 20 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 06/09/2023 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 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Record review of the facility policy, titled Operational Policy and Procedure Manual for Long-Term Care, Revised October 2017, Dietary Services - Meals, Snacks and Service, Menus, revealed the following documentation, Policy Statement. Menus are developed and prepared to meet resident choices, including religious, cultural and ethnic needs following establish national guidelines for nutritional adequacy. Policy Interpretation and Implementation. 1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences) . Event ID: Facility ID: 675291 If continuation sheet Page 9 of 20 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 06/09/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 2 of 2 staff (Dietary Manager and Dietary staff A) in 1 of 1 kitchen, in that: 1) Dietary staff failed to ensure pasteurized eggs were used in under cooked egg dishes (soft cooked/sunny side up/over easy eggs), 2) Dietary staff failed to handle food contact equipment in a manner to prevent contamination, 3) Dietary staff failed to maintain adequate chlorine sanitizer levels in the low temperature dish machine. 4) Dietary staff failed to ensure food contact surfaces were clean, 5) Dietary staff failed to perform sanitary handwashing between the handling of soiled and clean food equipment during dishwashing, 6) Dietary staff failed to use good hygienic practices, 7) Dietary staff failed to store personal items in a manner to prevent contamination of food contact equipment. These failures could place residents at risk for food contamination and foodborne illness. The findings include : - The following observations were made, and interviews conducted during a kitchen tour on 6/07/23 that began at 10:19 AM and concluded at 11:03AM: Dietary staff A was observed washing dishes in the dish machine. She tested the dishwasher, and the rinse temperature was 125°F and there was no detectable chlorine being dispensed in the final rinse cycle per the chlorine test strip. On 6/7/23 at 10:22 AM an interview was conducted with Dietary staff A. She stated that she looked for 50 to 100 ppm chlorine as being the correct level of sanitizer in the dishwasher. On 6/7/23 at 10:24 AM an observation and interview were conducted with the Dietary Manager. Regarding the chlorine level, she stated she recently changed the sanitizer bucket on the dishwasher. The sanitizer level was then checked two more times and there was still no detectable chlorine being dispensed. At this time the Dietary Manager stated that if the chlorine sanitizer was not dispensing then, staff would use the three compartment sink. Regarding how often the dishwasher was primed (flushing the dishwasher sanitizer line/system with sanitizer), she stated, staff primed the dishwasher one time a week. She added the Dishwasher Representative, told them to make sure to mix/stir the sanitizer, when changing the sanitizer bucket, to make sure that the contents of the bucket were being mixed before using. She further stated the Dishwasher Representative told them priming was used to run the sanitizer through the dishwasher system. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 10 of 20 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 06/09/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Dietary staff A handled soiled dishes from the dishwashing area, and then handled and stored clean plates using her bare hands. She failed to wash her hands between the soiled and clean duties. She then donned a pair of gloves and stored more clean dishes without washing her hands prior to donning the gloves. She then handled and stacked more clean glasses. Residents Affected - Some The kitchen refrigerator had approximately one and a half cases of raw eggs that were not pasteurized. On 6/7/23 at 10:44 AM an interview was conducted with the Dietary Manager. She stated there were five residents that liked, requested and were served sunny side up/over easy eggs (not fully cooked) each morning. She stated those eating in the dining room were Residents #5, 11, 13, 23 and 29. She stated that Resident #23 asked for over easy eggs but wants them cooked through. She stated she had two or three more residents that also requested the sunny side up/over easy eggs. She added, she had difficulty getting liquid eggs from her supplier and that the boxed/cases of raw eggs were her backup. She stated that the raw unpasteurized shelled eggs that were in the refrigerator were used for serving over easy and Sunnyside up eggs for residents. She further stated that she was not aware that unpasteurized shelled eggs could not be used for nursing home residents /highly susceptible population when making Sunnyside up/over easy eggs (eggs that were not fully cooked). Dietary staff A was washing soiled dishes with her gloves on. She then removed the gloves and then she handled clean dishes. She failed to wash her hands prior to handling the clean dishes. The dishwasher was tested again after the sanitizer was primed by staff and the final rinse tested at 50 ppm chlorine sanitizer after priming. - The following observations were made during a kitchen tour on 6/07/23 that began at 11:32 AM and concluded at 12:15 PM: The Dietary Manager placed chicken tetrazzini in the processor and puréed it with chicken broth and milk. She then washed the processor parts in the dishwasher. The surveyor checked the processor blade after the processor was cleaned in the dishwasher prior to her preparing to purée the peas. The blade was dirty and had bits of food on the interior portion of the blade housing. She re-washed the processor parts and checked it, and the blade was still soiled with food on the interior portion of the blade. The can opener blade had a buildup of dried food and was soiled. Three of the six cutting boards were soiled with brown/black smears. The Dietary Manager coughed twice in the food preparation area and did not cover her mouth effectively. - The following observations were made during a kitchen tour on 6/08/23 that began at 10:01 AM and concluded at 10:10 AM: The can opener blade was still dirty with a buildup of dried food. There were a set of keys and soiled lanyard left on the center prep table next to stacked clean dishes. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 11 of 20 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 06/09/2023 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 0812 Three of the six cutting boards were still dirty with black/brown smears. Level of Harm - Minimal harm or potential for actual harm - The following observations were made, and interviews conducted during a kitchen tour on 6/08/23 that began at 11:00 AM and concluded at 11:02 AM: Residents Affected - Some There was a personal phone on the prep table next to the stove next to other food equipment. - The following observations were made, and interviews conducted during a kitchen tour on 6/08/23 that began at 11:32 AM and concluded at 12:26 PM: The Dietary Manager coughed in the area of the service line. She did not cover her mouth effectively. She raised her elbow to approximately her brow level and coughed downward but did not cover her mouth. On 6/9/23 at 10:41 AM an observation was made in the kitchen and the can opener blade was still dirty with dried food buildup and three of six cutting boards were dirty with smears. On 6/9/23 at 10:29 AM an interview was conducted with Dietary staff A. She stated, she had worked in the facility for a year previously and had retuned in April 2023. She stated dietary staff orientation was three days. There was paperwork one day, a morning shift worked, and then an afternoon/evening shift worked one day. Regarding priming the dishwasher, she stated, she was not aware she had to prime the sanitizer after a new bucket of sanitizer was installed. She stated she received training on priming on 6/08/23. Regarding handwashing and not washing hands between gloves changes and soiled and clean duties, she stated she changed gloves when she thought she had completed all of her duties. She stated that she had received training regarding gloves at a previous job. She added that she was told just to change gloves and there was no mention of anything about hand washing associated with the gloves. Regarding what could result from her actions related to the inadequate dishwashing sanitizer levels, glove changes and handwashing, she stated she could transfer germs and items would not be sanitized or clean. On 6/9/23 at 10:46 AM an interview was conducted with the Dietary Manager regarding issues in the kitchen. She stated, staff had a weekly cleaning schedule for extra things. She was unsure the last time she had pasteurized eggs in the facility. She further stated she that she had not conducted any training regarding priming the dishwasher. She added, dietary staff A was new. She stated she would conduct an in-service on handwashing. Regarding whom was responsible for ensuring dietary sanitation duties were conducted correctly, she stated, she was ultimately responsible, but so was everyone. Regarding what could result from the dietary sanitation issues found, she stated, these issues could make residents sick. Regarding when she conducted the last in-service, she stated that there was an in-service conducted with the Dietitian over the phone. She stated sanitation, and food handling was covered. She stated she did not believe she had a signed in-service sheet for that in-service. Regarding training and orientation for the dietary staff, she stated the training was three days and eight hours. On 6/9/23 at 11:05 AM an interview was conducted with the DON regarding issues found in the facility. Regarding dietary sanitation, she stated that the Dietary Manager was responsible for ensuring that dietary duties were carried out correctly. As far as staff expectations, she stated she expected for staff not to leave their personal items on food prep counters, to conduct education with the staff and to ensure that food contact equipment was clean. Regarding how these issues could affect the residents, she stated these issues could cause resident infections. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 12 of 20 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 06/09/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the record of in-services for the dietary department for April through May 2023 revealed the following in-services were held on 4/18/23 and 5/04/23: 4/18/23 - The Dietary Manager conducted an in-service for staff regarding Sanitation/Food Handling. The summary documented the following: Discussed the proper way to handle food with gloves changing and proper handwashing. 5/4/23 - The Dietary Manager conducted an in-service for staff that had a subject of Sanitation/Handwashing. The contents of the in-service were listed as, Dietary Manager watched each employee wash hands at sink, and also have employees watch to see the proper handwashing. Sanitation, (Dietician) spoke to the girls (dietary staff) over the phone on proper sanitation. Know how to change gloves, wash hands in between changing gloves. Dietary staff A attended both in-services. Record review of the June 2023 dietary Cleaning Schedule revealed the following documentation, Everyone is responsible for the cleaning!! . (Clean) After each use: . food processor. Can opener . Record review of the facility policy titled DP - F - 17, Nutrition, Policies, and Procedures, Complete Revision: 8/1/2022, revealed the following documentation, Subject: Safe Egg, Storage, and Preparation. Policy: All foods are cooked and held at the appropriate temperatures to prevent the outbreak of foodborne illness. Facility will use and serve only pasteurized liquid or frozen egg products or uncracked/uncompromised pasteurized shelled eggs. The population we serve is considered a highly susceptible population, and, as a result, the FDA and CMS have strongly recommended that we use only pasteurized liquid or frozen egg products or uncracked/uncompromised, pasteurized, shelled eggs, which are deemed safe for consumption and properly handled and cooked/held at appropriate temperatures. Procedures: 1. If a patient/resident and/or his/her legal representative request, soft cooked eggs, to the extent, the yolk is not firmly set, facility will prepare and serve using only pasteurized shell eggs. 2. The Food and Nutrition Services Director/Designee will educate the patient/resident and/or legal representative that uncracked/compromise pasteurized shell eggs are being used to eliminate the risk of foodborne illnesses when soft cooked eggs are ordered/served. Record review of the facility policy, titled Operational Policy and Procedure Manual for Long-Term Care, Dietary Services - Kitchen Operations, Revised November 2022, revealed the following documentation, Sanitization. Policy Statement. The food service area is maintained in a clean and sanitary manner. Policy Interpretation and Implementation. 1. All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris, and protected from rodents and insects. 2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair, and are free from breaks, corrosions, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. 3. All equipment, food contact surfaces and utensils are cleaned and sanitize using heat or chemical sanitizing solutions. 4. Cutting boards are washed and sanitized between uses. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 13 of 20 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 06/09/2023 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 5. Dishwashing machines are operated according to manufacturer's instructions. General recommendations for heat and chemical sanitization are. b. Low temperature dishwasher (chemical, sanitization): 1. Wash temperature (120°F); 2. Final rinse with 50 ppm (PPM) hypochlorite (chlorine) on dish surface and final rinse; and 3. The chemical solution is maintained at the correct concentration, based on periodic testing, at least once per shift, and for the effective contact time, according to manufacturer's guidelines . Record review of the facility policy, titled Operational Policy and Procedure Manual for Long-Term Care, Dietary Services - Food and Nutrition Services, Food, Preparation and Service Revised November 2022 revealed the following documentation, Policy Statement. Food and nutrition services employees prepare, distribute and serve food in a manner that complies with safe food handling practices. Policy Interpretation and Implementation. General Guidelines. 1. Identification of potential hazards in the food preparation process and adhering to critical control points can reduce the risk of food contamination and thereby minimize the risk of foodborne illness. 2. Cross-contamination can occur when harmful substances, i.e., Chemical or disease, causing microorganisms are transferred to food by hands, (including gloved hands), food contact surfaces, sponges, cloth towels, or utensils that are not adequately cleaned. Cross-contamination can also occur when raw food touches or drips onto cooked or ready to eat foods. 3. Food preparation staff adhere to proper hygiene and sanitary practices to prevent the spread of foodborne illness. Food Preparation Area . 4. Appropriate measures are used to prevent cross contamination. These include: . d. Cleaning and sanitizing work surfaces (including cutting boards) and food contact equipment between uses, following food code guidelines . Food Preparation, Cooking and Holding Time/Temperatures . 12. Only pasteurized shell eggs are cooked and serve when: a. Resident request undercooked, soft serve or sunny side up eggs; and b. Preparing foods that will not be thoroughly cooked (e.g., Hollandaise sauce, French, toast, ice cream, etc.) . Food Distribution and Service. 5. Food and nutrition service staff, including nursing services personnel, wash their hands before serving food to residents. Employees also wash their hands after collecting soiled plates and food waste prior to handling food trays. 7. Bare hand contact with food is prohibited. Gloves are worn when handling food directly and changed between tasks. Disposable gloves or single use items are discarded after each use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 14 of 20 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 06/09/2023 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 0812 15. All food service equipment and utensils will be sanitized. According to current guidelines and manufacturers recommendations. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 15 of 20 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 06/09/2023 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 0912 Level of Harm - Potential for minimal harm Residents Affected - Some Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure the resident bedroom measured at least 80 square feet per resident in multiple resident bedrooms for 7 of 26 resident semiprivate rooms (Rooms #6, 13, 14, 19, 20, 21 and 30), in that, The facility failed to provide 80 square feet per resident in 7 of 26 semiprivate resident rooms. This failure could result in crowding, cause difficulty in providing ADL services, and placing residents at risk for decreased quality of life. Findings included: Observations were made during a general observation tour on 06/08/23 beginning at 4:45 PM and indicated the following: room [ROOM NUMBER] had 156.54 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 156.58 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 152.37 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 154.03 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 152.2 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 154.03 square feet for 2 residents instead of the required 160 square feet. room [ROOM NUMBER] had 155.25 square feet for 2 residents instead of the required 160 square feet. On 6/7/23 at 9:35 AM an interview was conducted with DON, at the time of the entrance conference. She 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. On 6/9/23 at 11:05 AM an interview was conducted with the DON. Regarding inadequate room square footage in semiprivate rooms, she stated that it could affect residents related to crowding, clutter, and it could cause a fall risk with the rooms being too small. She also requested a waiver at this time. Record review of facility untitled guidelines document dated November 28, 2017, revealed the following documentation related to resident room square footage, Measure at least 80 ft.² per resident in multiple resident bedrooms, and at least 100 ft.² in single resident rooms. unless a variation has been applied for and approved. Are there at least 80 ft.² per resident in multiple resident rooms and at least 100 ft.² for single resident rooms? . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 16 of 20 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 06/09/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public, in 1 of 1 common resident bath (Central) and 6 of 16 resident rooms (15, 17, 25, 27, 30 and 32) in that: 1) The facility failed to ensure resident use water was maintained at comfortable and safe temperatures (resident use hot water ranged from 93.2 degrees F to 117.4 degrees F), and 2) The facility failed to ensure resident use equipment was maintained in a sanitary manner (shower chairs). These failures could lead to resident injuries, spread of infections, and cause the facility to have an unsightly appearance. The findings include : 1. During an observation on 6/07/23 at 11:10 AM, room [ROOM NUMBER] had hot water in the shared restroom at 93.2°F (room [ROOM NUMBER]/27). During an observation on 6/7/23 at 4:10 PM in room [ROOM NUMBER], the hot water in the shared restroom (Rooms 30/32) was 117.4°Fahrenheit where it peaked and then declined. During an observation on 6/7/23 at 4:11 PM, the Dietary Manager also witnessed the hot water in rooms 30/32 shared restroom peaking at 116.9°F and decreased. During an observation on 06/08/23 12:53 PM, a water temperature check was conducted in rooms 15/17's shared restroom. The hot water temperature was 95.6 degrees Fahrenheit During an observation on 06/09/23 09:31 AM, a water temperature check was conducted in rooms 15/17's shared restroom. The hot water temperature was 95.0 degrees Fahrenheit. On 6/7/23 at 4:22 PM an interview was conducted with the Maintenance Supervisor. Regarding the elevated water temperatures, he stated, the facility water system ran on a recirculating pump and that was why it spiked (in room [ROOM NUMBER]/32 on 6/07/23 at 4:10 PM). He added he was working on tweaking the water temperatures. He further stated he had not contacted a repairman/plumber to assist with adjusting or finding a solution for the water temperature issues. He stated there was on one tankless water heater in the facility and there was another (regular) one for the whole facility (resident use water). He stated that he had installed a new water heater at the end of April or early May (2023) that controlled resident use hot water. He also added that he tried to keep the resident use hot water between 100 and 110°F. He stated that was the temperature range that he would shoot for water temperatures. He added, if he attempted to adjust the hot water temperature up or down it goes too high or too low. He stated that he took water temperatures in the facility weekly and added that he usually tested the hot water in the facility between 9:45 AM and 10:30 AM on Tuesdays. He stated that he checks all the resident rooms hot water at that time. The surveyor then explained that taking temperatures during high water usage times, such as showers, could deplete hot water supply and abnormally lower the hot water temperatures taken. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 17 of 20 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 06/09/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the Water Temps Weekly Logs from 4/4/23 through 6/6/23 revealed that the documented temperatures for hot water in resident rooms ranged between 101-109°F with most temperatures ranging between 101 and 103°F. On 6/9/23 at 9:57 AM an interview was conducted with charge nurse LVN B. Regarding shower times, she stated showers were normally conducted after the kitchen finished dishwashing at approximately 9:00 AM or 9:30AM. She added that CNAs normally finish showers around 10:00 AM before lunch. She stated that the CNAs waited to give showers after the kitchen finishes their dishes because the hot water pressure is low if they do not. She added if everything was running smoothly, CNAs would start showers before breakfast. On 6/7/23 at 5:06 PM an interview was conducted with the Maintenance Supervisor. Regarding his method of taking temperatures in the facility, he stated he documents the temperature when the temperature stops moving on the thermometer. He stated he did not document the temperatures when it peaked, only documented the temperature when the thermometer stopped registering any differences. During a confidential resident interview, one Resident stated the water takes a long time to get warm and added that even when it does get warm, it was not that warm. During another confidential resident interview, the resident voiced concerns with the hot water temperature. The resident stated residents received cold showers often. The most recent was when the new water heater was recently installed. The resident stated this was not a good situation and other residents had complained. On 6/9/23 at 9:17 AM an interview was conducted with the Maintenance Supervisor regarding solutions implemented for the cold water/hot water issues discovered during the survey. He stated, he turned the temperature down a bit on the water heater. He added he planned to install a mixing valve at the sink in that room (room [ROOM NUMBER]/32 restroom). He also stated that the idea to install a mixing valve on the sink in that restroom was brought to his attention by another maintenance employee. Regarding documentation of the peak water temperatures, he stated the peak was usually 109°F. He stated he kept his eye on the water temperatures. He added that the new water heater now had more gallons than the one before. It increased from 50 to 73 gallons. He stated that the facility added the new water heater to increase the amount of hot water available. He added, the facility had a tankless water heater and another water heater for the facility. The other water heater was for resident use water. He further stated the resident use water heater was the one that was changed out recently. Regarding whom was responsible for ensuring that the water temperatures remained within safe ranges, he stated, he was. Regarding what could result if resident use water that was too hot or too cold, he stated if the water was too hot, residents could sustain scalding and if it was too cold residents could get sick. On 6/9/23 at 9:33 AM an interview was conducted with the Maintenance Supervisor regarding the facility's current water temperature policy (2006). The Maintenance Supervisor stated that was the only policy and procedure that he had available regarding water temperatures. He stated when he was hired, that was the policy that was available. Regarding how he determined that resident use water should be between 100 and 110°F, he stated, historically he knew from past experience. The water temperature should be maintained between 100 and 110°F. 2. During an observation on 6/7/23 at 3:52 PM, two of two shower chairs in the central bath had dirt buildup on the mesh back . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 18 of 20 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 06/09/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some On 6/8/23 at 4:11 PM an interview was conducted with the Housekeeping Supervisor regarding the cleaning of shower chairs. She stated the CNAs were responsible for cleaning the shower chairs. On 6/9/23 at 10:15 AM interviews were conducted with NA A, and CNA B regarding cleaning of the shower chairs. NA A stated that they clean the shower chairs after each shower. She was unsure if or when they did deep cleaning of the shower chairs. CNA B stated she was not sure when deep cleaning was conducted and added the shower chairs deep cleaning could occur at night or possibly housekeeping did it. Regarding what could result from residents using shower chairs that were not clean, CNA B, stated this could cause resident skin irritation. NA A stated this issue could cause infections, especially if residents had open wounds. Regarding how staff cleaned the shower chairs, CNA B and NA A both stated that they spray a chemical on the shower chair and let it set a while, then rinse it off and let it air dry for 45 minutes. On 6/9/23 at 11:05 AM an interview was conducted with the DON regarding issues found in the facility. Regarding environmental issues, she stated that the Maintenance Supervisor was responsible for ensuring that the water temperatures were within the correct range and that the nursing was responsible for ensuring that the shower chairs were clean. Regarding what she expected of her staff, she stated she expected staff to report water temperature issues to the Maintenance Supervisor and maintenance was expected to fix the issue. Regarding the soiled shower chairs, she stated she expected the nursing staff to ensure that they scrubbed the shower chairs daily and deep clean them daily. Regarding how the water temperatures could affect the residents, she stated high temperatures could cause burns and low temperatures could cause residents to have chills and to refuse showers. Regarding shower chairs being dirty, she stated that this could affect residents by causing or leading to infections. Record review of the current American Burn Association Scald Injury Prevention Educator's Guide revealed the following information. .although scald burns can happen to anyone, .older adults and people with disabilities are the most likely to incur such injuries .High Risk groups .Older Adults .Older adults, .have thinner skin so hot liquids cause deeper burns with even brief exposure. Their ability to feel heat may be decreased due to certain medical conditions or medications so they may not realize water is too hot until injury has occurred. Because they have poor microcirculation, heat is removed from burned tissue rather slowly compared to younger adults . People With Disabilities or Special Needs .Individuals who may have physical, mental or emotional challenges or require some type of assistance from caregivers are at high risk for all types of burn injuries including scalds sensory impairments can result in decreased sensation especially to the hands .so the person may not realize if something is too hot. Changes in a person ' s perception, memory, judgment or awareness may hinder the person ' s ability to recognize a dangerous situation .or respond appropriately to remove themselves from danger . Further record review of the Guide revealed that 100 degree F. water was a safe temperature for bathing. Water at 120 degrees F. would cause a third degree burn (full thickness burn) in 5 minutes . Record review of the website, Neuroscience Online and Electronic Textbook For Neurosciences, UT Health, the University of Texas Health Science Center at Houston (https://nba.[NAME].tmc.edu/neuroscience/m/s2/chapter06.html#:~:text=When%20the%20temperature%20of%20the,all%2 . Chapter 6: Pain Principles, reviewed and revised 07 October 2020, revealed the following documentation, .6.3 Pain Threshold and Just Noticeable Differences. When the temperature of the skin reaches 45+ -1°C (111.2F - 114.8F), subjects report pain . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 19 of 20 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 06/09/2023 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 0921 Level of Harm - Minimal harm or potential for actual harm Record review of the National Center for Cold Water Safety website (https://www.coldwatersafety.org/what-is-cold-water) revealed the following documentation, What Is Cold Water? . Interesting Temperature Facts. 98.6°F. Normal body temperature measured with an oral thermometer. Residents Affected - Some 95°F. Medical definition of hypothermia. Record review of the facility policy titled Maintenance/Housekeeping, Policies and Procedures, Equipment Management Program, Original: 3/2006, revealed the following documentation, Subject: Domestic Hot Water Temperature. Purpose: to ensure safety and comfort of the patient's/residents. Procedures: 1. The facility shall maintain domestic hot water temperature at 105-120° at the outlet, or per state regulations. Record review revealed the facility presented another water temperature related policy dated/signed 6/9/23 which documented of the following, Nursing Services, Policy and Procedure, Manual for Long-Term Care, Resident, Safety, Water Temperatures, Safety Of, Revised December 2009, revealed of the following documentation, Policy Statement. Tap water in the facility shall be kept within a temperature range to prevent scalding of residents. Policy Interpretation and Implementation. 1. Water heaters that service resident rooms, bathrooms, common areas, and tub/shower areas shall be set to temperatures of no more than 110°F, or the maximum allowable temperature per state regulation. 2. Maintenance staff is responsible for checking thermostats and temperature controls in the facility and recording these checks in a maintenance log. 3. Maintenance staff shall conduct periodic tap water, temperature checks, and record the water temperatures in a safety log. 4. If at any tap water temperatures feel excessive to the touch (i.e. Hot enough to be painful or cause reddening of the skin after removal of the hand from the water), staff will report this finding to the immediate supervisor. Record review of the facility policy, titled Operational Policy and Procedure Manual for Long-Term Care, Revised September 2022, Cleaning and Disinfection of Resident, Care, Items and Equipment, revealed the following documentation, Policy Statement. Resident care equipment, including reusable items, and durable medical equipment will be cleaned and disinfected. According to current CDC recommendations for disinfection and the OSHA blood-borne pathogen standard. Policy Interpretation, and Implementation. 6. Reusable resident care equipment is decontaminated and/or sterilize between residents according to manufacturer's instructions. 7. Only equipment that is designated reusable is used for more than one resident. 9. Durable medical equipment (DME) is cleaned and disinfected before re-used by another resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675291 If continuation sheet Page 20 of 20