Health inspection·February 26, 2026

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 Page 1 of 2 675703 675703 02/26/2026 Cross Timbers Rehabilitation and Healthcare Center 3315 Cross Timbers Rd Flower Mound, TX 75028

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 675703 Page 2 of 2