Flower Mound, TX

Cross Timbers Rehabilitation and Healthcare Center

3-star overall rating with 3-star inspections with $8,281 in total fines with 11 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle

3315 Cross Timbers Rd, Flower Mound, TX

(972) 724-0996

Compare this facility

Overall

3 / 5

CMS overall stars

Health inspections

3 / 5

Survey and complaint cycles

Staffing

3 / 5

RN + nurse staffing

Quality measures

4 / 5

Resident outcomes and process measures

Quick facts

Facility snapshot

Beds

120

Certified beds

Average residents

Average occupied residents

Ownership

For-Profit

Publicly displayed owner type

Chain

Nexion Health

Operator or chain grouping

Approved since

1997-07-28

CMS approved date

Coverage

Medicare + Medicaid

Participation flags

Chain footprint

52 facilities

Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars

Changed ownership

Within the last 12 months

Family council

Yes

Resident and family council reported

Sprinklers

Yes

Automatic sprinklers in all required areas

Staffing

Hours and turnover

RN hours / resident day

0.53

Registered nurse staffing · state 0.44 · national 0.68

LPN hours / resident day

0.82

Licensed practical nurse staffing · state 0.95 · national 0.87

Aide hours / resident day

2.28

Nurse aide staffing · state 2.01 · national 2.35

Total nurse hours

3.62

All reported nurse hours · state 3.40 · national 3.89

Licensed hours

1.34

RN + LPN hours · state 1.38 · national 1.54

Weekend hours

3.35

Weekend nurse staffing · state 2.99 · national 3.43

Weekend RN hours

0.57

Weekend registered nurse coverage · state 0.34 · national 0.47

Physical therapist

0.07

Reported PT staffing · state 0.07 · national 0.07

Adjusted RN hours

0.55

CMS adjusted RN staffing hours

Adjusted total hours

3.77

CMS adjusted total nurse staffing hours

Case-mix index

1.31

Higher values indicate more complex resident acuity

RN turnover

46%

Annual RN turnover · state 52% · national 45%

Total nurse turnover

51%

Annual nurse turnover · state 52% · national 46%

SNF VBP

Value-based purchasing

Program rank

13,190

Lower is better among SNFs in the FY 2026 VBP program.

Performance score

7.64

Composite VBP score used to determine payment impact.

Payment multiplier

0.9807

Above 1.000 increases Medicare payment; below 1.000 reduces it.

Program components

How the VBP score is built

Readmission

Baseline 21.44% · Performance 22.52% · Measure score 0 · Achievement 0 · Improvement 0

Healthcare-associated infections

Baseline 7.76% · Performance 8.00% · Measure score 0 · Achievement 0 · Improvement 0

Total nurse turnover

1.93

Baseline 47.95% · Performance 55.79% · Measure score 1.93 · Achievement 1.93 · Improvement 0

Adjusted total nurse staffing

1.13

Baseline 3.59 hours · Performance 3.40 hours · Measure score 1.13 · Achievement 1.13 · Improvement 0

SNF QRP

Medicare quality reporting measures

Measure	Facility	National	Note
Potentially preventable 30-day readmission	10.61%	10.72% 0.1 pts better	No Different than the National Rate · Eligible stays 90 · Observed rate 10% · Lower 95% interval 7.12%
Discharge to community	46.23%	50.57% 4.3 pts worse	No Different than the National Rate · Eligible stays 78 · Observed rate 41.03% · Lower 95% interval 38.03%
Medicare spending per beneficiary	1.12	1.02 0.1 pts worse
Drug regimen review with follow-up	88%	95.27% 7.3 pts worse	Numerator 44 · Denominator 50
Falls with major injury	2%	0.77% 1.2 pts worse	Numerator 1 · Denominator 50
Discharge self-care score	72.97%	53.69% 19.3 pts better	Numerator 27 · Denominator 37
Discharge mobility score	43.24%	50.94% 7.7 pts worse	Numerator 16 · Denominator 37
Pressure ulcers or injuries, new or worsened	0%	2.29% 2.3 pts better	Numerator 0 · Denominator 50 · Adjusted rate 0%
Healthcare-associated infections requiring hospitalization	8%	7.12% 0.9 pts worse	No Different than the National Rate · Eligible stays 49 · Observed rate 10.2% · Lower 95% interval 5.03%
Staff COVID-19 vaccination coverage	28%	8.2% 19.8 pts better	Numerator 28 · Denominator 100
Staff flu vaccination coverage	60.63%	42% 18.6 pts better	Numerator 77 · Denominator 127
Discharge function score	43.24%	56.45% 13.2 pts worse	Numerator 16 · Denominator 37
Transfer of health information to provider	Not Available	95.95%	Numerator Not Available · Denominator 12 · Too few residents or stays to report publicly.
Transfer of health information to patient	77.78%	96.28% 18.5 pts worse	Numerator 21 · Denominator 27
Resident COVID-19 vaccinations up to date	16.67%	25.2% 8.5 pts worse	Numerator 4 · Denominator 24

Quality measures

Resident outcomes and process scores

Measure	Facility	State	National	Note
Number of hospitalizations per 1000 long-stay resident days	1.2	2.1 0.9 pts better	1.9 0.7 pts better	Long Stay · 20240701-20250630 · Adjusted 1.2 · Observed 1.6 · Expected 2.5 · Used in QM five-star
Number of outpatient emergency department visits per 1000 long-stay resident days	1.5	2.1 0.6 pts better	1.8 0.3 pts better	Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.8 · Expected 2.0 · Used in QM five-star
Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine	96.8%	97.1% 0.3 pts worse	93.4% 3.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 98.8% · Q2 97.4% · Q3 95.9% · Q4 94.7% · 4Q avg 96.8%
Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine	87.4%	97.9% 10.5 pts worse	95.5% 8.1 pts worse	Long Stay · 2024Q3-2025Q2 · 4Q avg 87.4%
Percentage of long-stay residents experiencing one or more falls with major injury	2.3%	3.3% 1 pts better	3.3% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 2.5% · Q2 3.9% · Q3 1.4% · Q4 1.3% · 4Q avg 2.3% · Used in QM five-star
Percentage of long-stay residents who have depressive symptoms	1.1%	2.7% 1.6 pts better	11.4% 10.3 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.4% · Q3 0.0% · Q4 2.9% · 4Q avg 1.1%
Percentage of long-stay residents who lose too much weight	6.2%	3.3% 2.9 pts worse	5.4% 0.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 7.9% · Q3 6.5% · Q4 6.2% · 4Q avg 6.2%
Percentage of long-stay residents who received an antianxiety or hypnotic medication	23.3%	18.9% 4.4 pts worse	19.6% 3.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 22.9% · Q2 23.4% · Q3 23.8% · Q4 23.1% · 4Q avg 23.3%
Percentage of long-stay residents who received an antipsychotic medication	12.5%	10.8% 1.7 pts worse	16.7% 4.2 pts better	Long Stay · 2024Q4-2025Q3 · Q1 9.4% · Q2 15.7% · Q3 11.3% · Q4 13.7% · 4Q avg 12.5% · Used in QM five-star
Percentage of long-stay residents who were physically restrained	0.0%	0.0% About the same	0.1% 0.1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0%
Percentage of long-stay residents whose ability to walk independently worsened	18.1%	15.4% 2.7 pts worse	16.3% 1.8 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 24.8% · Q2 9.7% · Q3 23.1% · Q4 12.4% · 4Q avg 18.1% · Used in QM five-star
Percentage of long-stay residents whose need for help with daily activities has increased	15.6%	16.1% 0.5 pts better	14.9% 0.7 pts worse	Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 19.4% · Q3 11.7% · Q4 10.8% · 4Q avg 15.6% · Used in QM five-star
Percentage of long-stay residents with a catheter inserted and left in their bladder	0.0%	0.5% 0.5 pts better	1.0% 1 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with a urinary tract infection	0.0%	0.8% 0.8 pts better	1.7% 1.7 pts better	Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star
Percentage of long-stay residents with new or worsened bowel or bladder incontinence	13.8%	15.0% 1.2 pts better	19.8% 6 pts better	Long Stay · 2024Q4-2025Q3 · Q1 12.5% · Q2 15.6% · Q3 16.3% · Q4 10.7% · 4Q avg 13.8%
Percentage of long-stay residents with pressure ulcers	3.7%	4.2% 0.5 pts better	5.1% 1.4 pts better	Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 3.8% · Q3 3.3% · Q4 3.9% · 4Q avg 3.7% · Used in QM five-star
Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine	81.1%	89.7% 8.6 pts worse	81.7% 0.6 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 85.1% · Q2 78.5% · Q3 80.7% · Q4 80.5% · 4Q avg 81.1%
Percentage of short-stay residents who had an outpatient emergency department visit	10.3%	12.0% 1.7 pts better	12.0% 1.7 pts better	Short Stay · 20240701-20250630 · Adjusted 10.3% · Observed 10.9% · Expected 11.7% · Used in QM five-star
Percentage of short-stay residents who newly received an antipsychotic medication	2.0%	1.5% 0.5 pts worse	1.6% 0.4 pts worse	Short Stay · 2024Q4-2025Q3 · Q1 3.7% · Q2 2.9% · Q3 1.1% · Q4 1.2% · 4Q avg 2.0% · Used in QM five-star
Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine	70.6%	88.0% 17.4 pts worse	79.7% 9.1 pts worse	Short Stay · 2024Q3-2025Q2 · 4Q avg 70.6%
Percentage of short-stay residents who were rehospitalized after a nursing home admission	25.4%	25.9% 0.5 pts better	23.9% 1.5 pts worse	Short Stay · 20240701-20250630 · Adjusted 25.4% · Observed 26.1% · Expected 24.5% · Used in QM five-star

Survey summary

Recent inspection cycles

Cycle 1 Health 2025-01-24 · Fire 2025-01-24

11 health deficiencies

Top issue: Pharmacy Service (4 deficiencies)

4 fire-safety deficiencies

Top issue: Smoke (2 deficiencies)

Cycle 2 Health 2023-11-29 · Fire 2023-11-29

4 health deficiencies

Top issue: Nutrition and Dietary (1 deficiency)

1 fire-safety deficiencies

Top issue: Miscellaneous (1 deficiency)

Cycle 3 Health 2022-09-22 · Fire 2022-09-22

13 health deficiencies

Top issue: Environmental (3 deficiencies)

4 fire-safety deficiencies

Top issue: Egress (1 deficiency)

Fire safety

Fire-safety citations

F · Potential for more than minimal harm 2025-01-24

K293 · Egress Deficiencies

Fire Safety

Have properly located and lighted "Exit" signs.

Corrected 2025-02-17

F · Potential for more than minimal harm 2025-01-24

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2025-02-17

F · Potential for more than minimal harm 2025-01-24

K351 · Smoke Deficiencies

Fire Safety

Install an approved automatic sprinkler system.

Corrected 2025-02-17

F · Potential for more than minimal harm 2025-01-24

K918 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have generator or other power source capable of supplying service within 10 seconds.

Corrected 2025-02-17

E · Potential for more than minimal harm 2023-11-29

K712 · Miscellaneous Deficiencies

Fire Safety

Have simulated fire drills held at unexpected times.

Corrected 2023-11-29

F · Potential for more than minimal harm 2022-09-22

K324 · Smoke Deficiencies

Fire Safety

Provide properly protected cooking facilities.

Corrected 2022-10-22

F · Potential for more than minimal harm 2022-09-22

K761 · Miscellaneous Deficiencies

Fire Safety

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Corrected 2022-10-22

C · Minimal harm 2022-09-22

K222 · Egress Deficiencies

Fire Safety

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.

Corrected 2022-10-22

C · Minimal harm 2022-09-22

K916 · Gas, Vacuum, and Electrical Systems Deficiencies

Fire Safety

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Corrected 2022-10-22

Inspection history

Recent health citations

D · Potential for more than minimal harm 2025-11-21

F554 · Resident Rights Deficiencies

Health

Allow residents to self-administer drugs if determined clinically appropriate.

Corrected 2025-11-24

J · Immediate jeopardy 2025-09-11

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Not marked corrected

E · Potential for more than minimal harm 2025-01-24

F698 · Quality of Life and Care Deficiencies

Health

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-24

F755 · Pharmacy Service Deficiencies

Health

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-24

F756 · Pharmacy Service Deficiencies

Health

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Corrected 2025-02-23

E · Potential for more than minimal harm 2025-01-24

F761 · Pharmacy Service Deficiencies

Health

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Corrected 2025-02-17

E · Potential for more than minimal harm 2025-01-24

F804 · Nutrition and Dietary Deficiencies

Health

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Corrected 2025-02-17

D · Potential for more than minimal harm 2025-01-24

F690 · Quality of Life and Care Deficiencies

Health

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Corrected 2025-02-17

D · Potential for more than minimal harm 2025-01-24

F692 · Quality of Life and Care Deficiencies

Health

Provide enough food/fluids to maintain a resident's health.

Corrected 2025-02-17

D · Potential for more than minimal harm 2025-01-24

F758 · Pharmacy Service Deficiencies

Health

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.

Corrected 2025-02-26

D · Potential for more than minimal harm 2025-01-24

F919 · Environmental Deficiencies

Health

Make sure that a working call system is available in each resident's bathroom and bathing area.

Corrected 2025-02-17

D · Potential for more than minimal harm 2024-02-28

F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies

Health

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Corrected 2024-03-20

F · Potential for more than minimal harm 2023-11-29

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2023-12-18

E · Potential for more than minimal harm 2023-11-29

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2023-12-18

D · Potential for more than minimal harm 2023-11-29

F657 · Resident Assessment and Care Planning Deficiencies

Health

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Corrected 2023-12-18

D · Potential for more than minimal harm 2023-11-29

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-12-18

D · Potential for more than minimal harm 2023-08-15

F689 · Quality of Life and Care Deficiencies

Health

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Corrected 2023-09-20

D · Potential for more than minimal harm 2023-07-13

F761 · Pharmacy Service Deficiencies

Health

Corrected 2023-08-10

D · Potential for more than minimal harm 2023-07-13

F908 · Environmental Deficiencies

Health

Keep all essential equipment working safely.

Corrected 2023-08-10

D · Potential for more than minimal harm 2023-07-11

F921 · Environmental Deficiencies

Health

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Corrected 2023-08-06

D · Potential for more than minimal harm 2023-05-05

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2023-05-30

F · Potential for more than minimal harm 2022-09-22

F812 · Nutrition and Dietary Deficiencies

Health

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Corrected 2022-10-22

E · Potential for more than minimal harm 2022-09-22

F584 · Resident Rights Deficiencies

Health

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.

Corrected 2022-10-22

E · Potential for more than minimal harm 2022-09-22

F677 · Quality of Life and Care Deficiencies

Health

Provide care and assistance to perform activities of daily living for any resident who is unable.

Corrected 2022-10-22

E · Potential for more than minimal harm 2022-09-22

F880 · Infection Control Deficiencies

Health

Provide and implement an infection prevention and control program.

Corrected 2022-10-22

E · Potential for more than minimal harm 2022-09-22

F925 · Environmental Deficiencies

Health

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

Corrected 2022-10-22

D · Potential for more than minimal harm 2022-09-22

F583 · Resident Rights Deficiencies

Health

Keep residents' personal and medical records private and confidential.

Corrected 2022-10-22

D · Potential for more than minimal harm 2022-09-22

F693 · Quality of Life and Care Deficiencies

Health

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.

Corrected 2022-10-22

Penalties and ownership

What sits behind the stars

$8,281 2025-09-11

Fine

Fine · fine $8,281

Fine

Ownership

Eastland Memorial Hospital District

5% Or Greater Direct Ownership Interest · Organization

100% 34 facilities 2017-04-01

Fallon, John