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Inspection visit

Health inspection

Cross Timbers Rehabilitation and Healthcare CenterCMS #6757031 citation on this visit
1 citation recorded

Inspector’s narrative

What the inspector wrote

This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

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

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Citations

1 citation recorded*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

  • 0656GeneralS&S Dpotential for harm

    F656 - Comprehensive Care Plans

    Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

FAQ · About this visit

Common questions about this visit

What happened during the February 26, 2026 survey of Cross Timbers Rehabilitation and Healthcare Center?

This was a inspection survey of Cross Timbers Rehabilitation and Healthcare Center on February 26, 2026. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at Cross Timbers Rehabilitation and Healthcare Center on February 26, 2026?

Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be ..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.