Inspection·February 28, 2024

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to report the results of all investigations to the State Survey Agency (HHSC), within 5 working days of the incident for 1 of 3 facility self-reported incidents (Incident Intake ID: 483847)reviewed for reporting to HHSC. The facility failed to submit a Provider Investigation Report to HHSC within 5 working days of reporting an incident involving allegations of quality of care, administration/personnel, and resident rights regarding Resident #1 on 02/12/24. This failure could place the residents at risk for not having investigations reported within the timeframe as required. Findings included: Record review of the face sheet printed on 02/28/24 indicated Resident #1 was a [AGE] year-old female admitted on [DATE] with diagnoses including vascular dementia severe with agitation (changes to memory, thinking, and behavior resulting from conditions that affect the blood vessels in the brain), cerebral atherosclerosis (build-up of plaque in the blood vessels of the brain), and high blood pressure. Record review of the admission MDS dated [DATE] indicated Resident #1's cognition was severely impaired with a BIMS score of 00. Record review of Resident#1 care plan, dated 02/05/24, indicated Resident #1 had impaired thought process due to dementia and had behaviors. Resident #1 was noted to have behavior problems due to being physically aggressive and resistive to care as evidenced by refusal for staff to provide incontinence care and activities of daily living rule out dementia. The care plan reflected: Intervention: Allow Resident #1 to make decisions about treatment regime, to provide sense of control. Review of TULIP reflected the DON reported an incident (Incident Intake ID: 483847) on 02/12/24 at 5:00 PM. The incident involved Resident #1 and CNA A with allegations of administration/personnel, quality of care, and resident rights. Further review of the TULIP record reflected no evidence a Provider Investigation Report had been submitted for this incident as of 02/28/24. Interview on 02/28/24 at 2:27 PM with the DON revealed she was notified by a family member on 02/12/24 that they heard CNA A walking down the hall with other staff stating she could not wait to get out of the facility because the residents were mean. CNA A was then observed pointing towards (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675703 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 675703 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028 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)