The medication violation at Cross Timbers Rehabilitation and Healthcare Center exposed confusion among nursing staff about basic medication safety protocols. Federal inspectors found that Resident #1 had been storing and taking her eye drops without anyone verifying she could safely do so.
Medication Aide D, assigned to the resident on October 7, told inspectors she assumed the resident had proper authorization. "She stated she assumed Resident #1 had an order to self-administer the eyedrops and to keep the eyedrops at her bedside," according to the inspection report.
The aide said the resident had kept the eye drops at her bedside since admission. By bedtime each day, she would check with the resident to confirm the medications had been taken. "MA D stated she should had checked to ensure resident had orders to self-administer," inspectors documented.
Nobody had told the medication aide whether the resident was authorized to keep the drops at her bedside or administer them independently.
LVN C, the evening nurse assigned to the same resident, revealed broader uncertainty about the facility's medication protocols. During her October 8 interview, she said she wasn't sure if any of her residents could self-administer eye drops and keep them at the bedside.
The licensed vocational nurse couldn't recall which medication aide was assigned to Resident #1, and said she didn't observe any eye drops at the resident's bedside during her shift. She acknowledged that medication aides typically administered eye drops to residents, but couldn't identify the specific aide responsible for this resident.
Assistant Director of Nursing B explained the facility's requirements during the inspection. Nurses were expected to assess residents to ensure they could safely self-administer medications before obtaining a physician order. She said there was no potential risk for this particular resident to self-administer, but the eye drops should have been removed until the proper assessment was completed.
The Director of Nursing couldn't recall whether Resident #1 was among those authorized to self-administer medications. She outlined the facility's assessment process: staff must determine if residents know how to correctly administer medications and are aware of proper timing.
"The DON stated if the resident wanted to keep medications at her bedside a physician order had to be obtained," inspectors wrote.
The nursing director identified specific risks of allowing bedside medication storage. Other people could access the medications, or residents might not be capable of proper self-administration.
Facility policy, revised in June 2025, clearly states that residents may only self-administer medications if their attending physician and the interdisciplinary care planning team determine they have the decision-making capacity to do so safely.
The medication aide acknowledged the resident was alert and knew when to administer the eye drops, saying there was no potential risk. But her assumption about proper authorization violated the facility's own protocols requiring formal assessment and physician orders.
The violation affected few residents and caused minimal harm, according to federal inspectors. However, it revealed systemic gaps in medication safety oversight at the 150-bed facility.
Cross Timbers Rehabilitation serves residents requiring skilled nursing care and rehabilitation services in Flower Mound, a suburb north of Dallas. The facility is operated by Foundations Health Solutions.
The inspection occurred following a complaint filed with state health officials. Federal regulators require nursing homes to maintain strict medication administration protocols to prevent adverse drug events and ensure resident safety.
Medication errors rank among the most common violations cited at nursing homes nationwide. The Centers for Medicare and Medicaid Services has increased scrutiny of facilities' medication management systems following studies showing preventable adverse drug events affect hundreds of thousands of nursing home residents annually.
The confusion among Cross Timbers staff about basic medication protocols suggests broader training deficiencies. The medication aide's assumption that proper orders existed, combined with the evening nurse's uncertainty about which residents could self-administer medications, indicates inadequate communication and oversight systems.
Resident #1 continued receiving her eye drops, but the facility was required to implement corrective measures to prevent similar violations. The inspection did not specify whether the resident ultimately received the required assessment and physician order to continue self-administering her medications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Cross Timbers Rehabilitation and Healthcare Center from 2025-11-21 including all violations, facility responses, and corrective action plans.
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