F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record reviews, the facility failed to develop and implement a comprehensive
person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a
resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive
assessment for 1 of 8 residents (Resident #1) reviewed for care plans.The facility failed to develop a
comprehensive person-centered care plan for Resident #1 that addressed her religious dietary
restrictions.This failure could lead to the residents' personal choices and desires not being met. Findings
included:Record review of Resident #1's quarterly MDS assessment, dated 12/18/25, reflected that
Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included
stroke affecting the resident's vision, Asperger's syndrome (form of Autism with social and communication
issues), and diabetes. Her Functional Abilities assessment indicated she used a wheelchair for mobility, and
she required staff assistance with her ADLs. Record review of Resident #1's care plan, dated 12/27/25,
reflected she was PASRR positive and during an IDT meeting on 05/13/25, Resident #1's Kosher (Jewish)
diet was discussed but there were no interventions addressing this specific issue. In an interview on
02/26/26 at 10:00 AM, Resident #1 stated she was blind in her left eye and had 15% vision in her right eye
because of a stroke. She stated she had in the last few months begun to return to her religious roots and
follow her religious teachings. Resident #1 stated she did not expect the facility to have a Kosher kitchen;
she just asked them to try to accommodate her restrictions. She stated the Dietary Manager had met with
her to go over the standard menu and she indicated what she could and could not have, and what she
wanted for an alternative. Food service was much improved now. In an interview on 02/26/26 at 2:30 PM,
the Dietary Manager stated Resident #1 just recently decided to follow a Kosher light diet in the last few
months of no dairy on the same plate as meat. The Dietary Manager stated Resident #1 is the only resident
with religious dietary restrictions, but she made accommodations. The Dietary Manager stated she had
taken the facility's 5-week menu cycle to the resident and reviewed what was scheduled each day, allowing
the resident to pick what she could and could not eat, and what she wanted as an alternative. In an
interview on 02/26/26 at 2:50 PM, the Social Worker stated care plans were developed in a combination of
care plan meetings and IDT meetings. She stated the MDS Coordinator created and maintained the care
plan. She stated the facility did not currently have an MDS Coordinator, and she was not sure who was
responsible for care plans until a new coordinator could be hired. The Social Worker was not aware of
Resident #1's religious beliefs. In an interview and record review on 02/26/26 at 3:30 PM, the DON stated
Resident #1 did not follow the Jewish lifestyle when she first admitted . She stated it had only been in the
last few months that Resident #1 decided to return to the Jewish religion and lifestyle. After the DON
reviewed Resident #1's care plan, she stated there were no dietary restrictions based on the resident's
religious beliefs in the care plan. The DON stated during
(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
02/26/2026
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)
F 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
an IDT meeting on 05/13/25, documented in the care plan, Resident #1's religious and dietary restrictions
were discussed but no interventions were documented. The DON agreed there were no specific
interventions in place to address the resident's dietary needs, but staff could access the IDT meeting notes.
She stated the Social Worker arranged the care plan meetings and notified the IDT team. She stated the
risk of not respecting Resident #1's wishes and beliefs was the resident feeling isolated and belittled.
Record review of the facility's Care Plans, Comprehensive Person-Centered policy, dated January 2023,
reflected: .1. The Interdisciplinary team (IDT) in conjunction with the resident and his/her family or legal
representative, develops and implements a comprehensive person-centered care plan for each resident.8.
Each resident's comprehensive person-centered care plan will:.b. Describe the services that are to be
furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial
well-being.
Event ID:
Facility ID:
675703
If continuation sheet
Page 2 of 2