Cross Timbers Rehabilitation And Healthcare Center
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
resident safety.B. Interdisciplinary Interventions:.2. When a door alarm sounds, staff shall respond immediately and determine cause of the alarm. The staff member responding to the alarm clock shall check
the outside of the building to determine if a resident has left the building. If upon investigation, no apparent cause is determined for the sounding of the alarm, the charge nurse shall immediately initiate an accounting of whereabouts of all residents at risk for elopement. The Administrator was notified on 09/11/25 at 4:50 PM that a past non-compliance IJ had been identified related to the facility's failure to provide adequate supervision to prevent an elopement. It was determined this failure placed Resident #1 in an IJ situation on 05/05/25. The facility had implemented the following corrective measures prior to the HHSC
investigation
Observation on 09/11/25 at 1:55 PM of Resident #2 revealed she was wearing a Wander Guard and her nurse brought her near the front door, setting the alarm off which indicated the Wander Guard was working. Record review of an Elopement Drill Evaluation Form, dated 05/09/25, reflected the facility completed an elopement drill with staff. Record review of an in-service, dated 05/09/25, and titled Elopement Drill reflected 23 staff participated. Record review of an in-service, dated 05/05/25, and titled Elopement Policy reflected 76 staff were educated on the facility's elopement policy. Record review of an Elopement Policy Quiz, dated 05/06/25, reflected that 76 staff completed the quiz and passed. Record
review of a QIPP QAPI Worksheet, dated 05/06/25, reflected a meeting was held to discuss Resident #1's elopement on 05/05/25. Record review of a sheet of paper, dated 05/06/25, and titled Wander guard Individual Checks reflected staff had ensured all 4 residents who used Wander Guards at the time were secured and operational. Record review of a sheet of paper, dated 05/06/25, and titled Exit Door Checks reflected all exit doors were locked and operational. Record review of a Logbook Report, dated 05/07/25, revealed the Maintenance Director had completed a check of residents with Wander Guards on 05/03/25.
Record review of the facility's incident/accident log from 05/01/25 to 09/11/25 reflected there were no other elopement incidents that occurred. Record review of a Disciplinary Action Record, dated 05/06/25, reflected LVN A was terminated.
Event ID:
Facility ID:
If continuation sheet
Cross Timbers Rehabilitation and Healthcare Center in Flower Mound, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Flower Mound, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Cross Timbers Rehabilitation and Healthcare Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.