Deficiency Records for Cross Timbers Nursing and Rehabilitation
Updated as of March 01, 2024
A list of the most recent deficiencies for Cross Timbers Nursing and Rehabilitation. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-01-31 | 2024-03-04 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-11-16 | 2023-12-28 | N |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-11-16 | 2023-12-28 | N |
| Ensure that residents are free from significant medication errors. | Health | 2023-11-16 | 2023-12-28 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-11-16 | 2023-12-28 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-11-16 | 2023-12-28 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-11-16 | 2023-12-08 | N |
| Honor the resident's right to organize and participate in resident/family groups in the facility. | Health | 2023-08-04 | 2023-09-06 | Y |
| Honor the resident's right to manage his or her financial affairs. | Health | 2023-08-04 | 2023-09-06 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-08-04 | 2023-09-06 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-04 | 2023-09-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-08-04 | 2023-09-06 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-08-04 | 2023-09-06 | Y |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-04 | 2023-09-06 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-04 | 2023-09-06 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-08-04 | 2023-09-06 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-08-04 | 2023-09-06 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2023-08-04 | 2023-09-06 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-17 | 2023-09-06 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-05-17 | 2023-09-06 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-09 | 2023-04-07 | Y |
| Protect each resident from the wrongful use of the resident's belongings or money. | Health | 2023-03-09 | 2023-04-07 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-03-09 | 2023-04-07 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-09-21 | 2022-11-17 | Y |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2022-09-22 | 2022-11-11 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-09-22 | 2022-11-11 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-09-22 | 2022-11-11 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-09-22 | 2022-11-11 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-09-21 | 2022-10-10 | Y |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2022-09-21 | 2022-10-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-09-21 | 2022-10-07 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-09-21 | 2022-10-07 | N |
| Ensure that residents are free from significant medication errors. | Health | 2022-09-21 | 2022-10-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-09-21 | 2022-10-07 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-09-21 | 2022-10-07 | Y |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-09-21 | 2022-10-07 | Y |
| Provide timely, quality laboratory services/tests to meet the needs of residents. | Health | 2022-09-21 | 2022-10-07 | Y |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-09-22 | 2022-10-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-09-22 | 2022-10-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-09-22 | 2022-10-07 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-11-18 | 2022-01-18 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2021-11-18 | 2022-01-18 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-18 | 2022-01-18 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2021-11-18 | 2022-01-18 | N |
| Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-11-18 | 2022-01-18 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-11-18 | 2022-01-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-11-18 | 2022-01-18 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-11-18 | 2022-01-18 | N |
| Hire a qualified full-time social worker in a facility with more than 120 beds. | Health | 2021-11-18 | 2022-01-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-11-18 | 2022-01-18 | N |
| Perform COVID19 testing on residents and staff. | Health | 2021-11-18 | 2022-01-18 | N |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-18 | 2022-01-18 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-11-18 | 2022-01-18 | Y |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-11-16 | 2022-01-18 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-11-16 | 2022-01-18 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2021-11-16 | 2022-01-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-11-16 | 2021-12-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-11-16 | 2021-12-22 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2021-11-16 | 2021-12-16 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2021-11-16 | 2021-12-16 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-11-16 | 2021-12-13 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-11-16 | 2021-12-09 | N |
| Properly provide smoke detection systems in areas open to corridors. | Fire Safety | 2021-11-16 | 2021-11-22 | N |
