F 0644
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Coordinate assessments with the pre-admission screening and resident review program; and referring for
services as needed.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to coordinate assessments with the PASARR program for 1
(Resident #1) of 4 residents reviewed for PASRR coordination.
The facility failed to meet deadlines for submitting a NFSS for specialized services and customized manual
wheelchair for Resident #1.
This failure could place residents at risk of not receiving qualified specialized services.
Findings included:
Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old female
admitted to the facility on [DATE] with diagnoses that included seizures, Alzheimer's disease, and
Parkinson's disease.
Review of Resident #1's quarterly MDS, dated [DATE], revealed a BIMS score of 9, indicating moderate
cognitive impairment. The assessment revealed she required assistance with all of her ADLs, and she
required the use of a wheelchair for mobility.
Review of Resident #1's care plan, dated 03/06/24, revealed she had the potential for falls related to gait
and balance problems. She was PASRR positive for Intellectual Disability placing the resident at risk of not
having the ordered specialized services provided with interventions of specialized services determined to
be necessary by the IDT will be initiated and request submitted to DADS [HHSC] within 20 business days
after date of IDT. Services will be delivered within 3 days after approval. Dated 08/08/23
Interview on 03/18/24 at 3:38 PM with the PASRR Unit Program Specialist revealed on 02/01/24 the
Administrator was notified via phone and email his facility had to submit a NFSS for Specialized Services
for OT and PT by 02/05/24 and by 02/07/24 for Customized Manual Wheelchair, based on the IDT meeting
in August 2023. As of 02/22/24, the facility was considered delinquent.
Interview on 03/19/24 at 11:00 AM with the MDS Coordinator revealed the request for Specialized Services
was handled by the Rehabilitation Department, so she did not know about the issues.
Interview on 03/19/24 at 11:10 AM with the Director of Rehabilitation Services revealed began working in
her position on 03/04/24, and she did not know what the previous director had done or not done. She stated
the previous director left around 02/14/24. She called the Regional Director of
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 2
Event ID:
675153
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
675153
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/19/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage House at Keller Rehab & Nursing
1150 Whitley Road
Keller, TX 76248
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0644
Level of Harm - Minimal harm
or potential for actual harm
Rehabilitation Services for assistance. The Regional Director was able to reveal the NFSS had been
submitted on 03/01/24. Resident #1 had been on Skilled Nursing Services, following an admission to the
hospital, until 03/16/24, so the NFSS was denied. On 03/19/24, the Regional Director re-submitted the
request. The Regional Director and the Director of Rehabilitation Services understood the re-submission
was considered a late submission.
Residents Affected - Few
Interview on 03/19/24 at 3:00 PM with the Administrator revealed he recalled speaking to someone from
HHSC about Resident #1's MDS, but the caller did not explain the issue very well. He stated he was
confused about what she was talking about. The Administrator stated the caller had been so rude and he
ended the call. The Administrator asked the MDS Coordinator to check Resident #1 to insure everything
had been submitted. The Administrator stated he had not been aware that Rehab Services handled
anything with the MDS so he did not think to follow up with them.
Review of the facility's undated MDS Coordination policy revealed it did not address Specialized Services.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675153
If continuation sheet
Page 2 of 2
