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Complaint Investigation

Cross Timbers Rehabilitation And Healthcare Center

Inspection Date: November 21, 2025
Total Violations 1
Facility ID 675703
Location Flower Mound, TX
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Inspection Findings

F-Tag F0554

Resident Rights Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0554 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

stated expectations were for nurses to assess the residents to ensure residents were able to self-administer and obtain an order. ADON B stated there was no potential risk for the resident to self-administer and to keep eye drops at the bedside; however, the eye drops would need to be removed until the assessment was completed on the resident. Interview on 10/08/25 at 2:39 PM, LVN C revealed she was the 2:00 PM-10:00 PM nurse assigned to Resident #1 on 10/07/25. She stated she was not sure if she had any residents who could self-administer eye drops and keep them at the bedside. She stated the Medication Aides administered eye drops to residents, but she could not recall which Medication Aide was assigned to Resident #1. LVN C stated they had to first determine if a resident could self-administer eye drops. She stated she did not observe any eye drops at the resident's bedside during her shift for Resident #1.

Interview on 10/08/25 at 2:45 PM, MA D revealed she was the 2:00 PM-10:00PM Medication Aide assigned to Resident #1 on 10/07/25. She stated Resident #1 kept her eye drops at her bedside and kept them at her bedside since admission. MA D stated Resident #1 had an order for the eyedrops, and the resident self-administered her own eye drops. She stated by the time she followed-up with Resident #1 at bedtime to ensure she administered the eyedrops the resident confirmed she had administered them. MA D stated no one had mentioned anything to her regarding whether Resident #1 could keep the eyedrops at her bedside or if she could self-administer them. She stated she assumed Resident #1 had an order to self-administer

the eyedrops and to keep the eyedrops at her bedside. MA D stated she should had checked to ensure resident had orders to self-administer. She stated there was no potential risk to the resident because she was alert and knew when to administer. Interview on 10/08/25 at 3:13 PM, the DON revealed she had residents who could self-administer medications; however, she could not recall if Resident #1 was one who could self-administer. The DON stated the expectation was for the residents to be assessed first to ensure

they were capable of self-administering, and then they would obtain a physician order. She stated the assessment was for them to know if the resident knew how to correctly administer medications and be aware of the times. The DON stated if the resident wanted to keep medications at her bedside a physician order had to be obtained. She stated the potential risk of keeping medications at the bedside would be someone else could get the medications or the residents not being able to self-administer. Record review of

the facility Medication Administration policy, revised June 2025 reflected the following: .27. Residents may self-administer their own medications only if the attending physician, in conjunction with the interdisciplinary care planning team, has determined that they have the decision-making capacity to do so safely

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📋 Inspection Summary

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.

What this means: Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. All deficiencies must be corrected within required timeframes and are subject to follow-up verification.

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.
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