Inspection·November 19, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few sit on w/c, suddenly resident fell down to floor, right leg twisted, resident c/o severe, another nurse held resident and checked VS: [Blood pressure] 171/62, [Heart rate] 100, [Temperature] 97.0, [Respirations] 18, [Oxygen Saturation] SpO2 96% RA. This nurse called 911, resident left to [the hospital] via 911 at 6:18 PM with documents. Notified DON, [family member] and [Company Name] MD. Called ER to give report to the ER nurse.Record review of Resident #1's hospital records reflected she was admitted on [DATE]. The hospital records reflected the following, This a [AGE] year-old female with a very extensive medical history with known history of essential hypertension history of stroke with weakness and wheelchair-bound, and below other extensive medical history who presents to the emergency room after sustaining a ground-level fall and complaining of right sided rib cage pain as well as pain in the right foot. Patient is non-ambulatory and wheelchair-bound and upon evaluation in the ED patient is noted to have a 10th rib fracture as well as a right tibia and spiral fracture extending to the IM nail as well as proximal and distal right fibular fracture. Orthopedic surgeon has been consulted, and this is felt to be nonoperative mostly admitted for pain management and other supportive treatment. Record review of the Provider Investigation Report, dated 11/10/25 reflected the following, [Resident #1] fell after using the toilet during transfer from toilet to wheelchair and sustained a fracture to 10th rib, right tibia/fibula. Family made an allegation of neglect. Visual assessment and vital signs: Excruciating pain to right lower extremity, 911 called, resident sent to ER for further evaluation: Nondisplaced, nonoperative fracture of right 10th rib and right tibia/fibula. Nonoperative treatment and support, pain management and cast.Interview on 11/19/25 at 9:22 AM with Resident #1 revealed that CNA A was assisting her off the toilet on 11/09/25. She stated CNA A pulled up her brief and pajama bottoms and had her hand resting on the back of her arm. Resident #1 stated to CNA A, Help me, don't let me fall. Resident #1 stated after she said that the next thing she remembered was landing on the floor and screaming due to the excruciating pain in her leg. Resident #1 stated she hit the toilet paper holder, the toilet, and wheelchair before hitting the ground. She stated she did not have a gait belt on. Resident #1 stated the nurse [RN B] came into the room after hearing her screaming and immediately called 911. Resident #1 stated at the hospital they told her she broke her leg in 3 places and broke her ribs. She stated she now had a full leg cast on her right leg and could only use the bathroom in her brief. Resident #1 stated she was feeling better after leaving the hospital, but she did feel upset with having to stay in bed instead of her recliner. Resident #1 stated she understood why she needed to stay in bed for care and agreed to it, but prior to the incident, for the past 12 years, she slept exclusively in her recliner. Resident #1 stated the fall has caused her to have a lot of changes and she felt like the CNA did not know what she was doing. Interview on 11/19/25 at 1:10 PM with Resident #1's RP revealed that he was very upset with the fall and how it happened. Resident #1's RP stated the CNA did not have a gait belt and he felt that no staff should have operated without a gait belt. He stated Resident #1 was wheelchair bound, and staff should have used the gait belt. He said since the fall, staff have been very attentive and have had training. Resident #1's RP stated Resident #1 was now in a lot of pain and tried to keep a positive attitude, but he knew it was affecting her. He stated she was forced to sleep in the bed, and she had never done that. He stated she had tailbone surgery and had slept in the recliner for the last 10-12 years. Resident #1's RP stated Resident #1 did not sleep good in a bed. He stated the facility was doing a good job now and he was very pleased with therapy.Interview on 11/19/25 at 11:27 AM with CNA A revealed on 11/09/25 she answered Resident #1's call light and Resident #1 requested to use the bathroom. CNA A stated Resident #1 did not seem like her normal self. CNA A stated Resident #1 was sleeping more that day and assumed the resident was tired. CNA A stated she assisted (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 2 of 6 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 11/19/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Resident #1 to the toilet with no issues. CNA A stated when the resident finished, Resident #1 pushed the call light, and she went to assist. CNA A stated she assisted Resident #1 to stand and pulled her pants up. CNA A stated when she went to pivot, Resident #1 asked her not to touch her right there . CNA A stated it confused her because it was on the back of Resident #1's arm to steady her. CNA A stated the resident started to fall and stated, Don't let me fall. CNA A stated she started to try and help and did everything she could to get the resident into the wheelchair. CNA A stated the resident may have hit the trash can on the way down. CNA A said Resident #1 was in immediate pain after she fell. CNA A stated RN B came into the room, checked her vital signs, and called 911 since Resident #1 was in a lot of pain. CNA A stated she would use the gait belt sometimes with Resident #1, but that day, she forgot to use one. CNA A stated she should have used the gait belt because it may have prevented the fall. CNA A stated the risk of not using a gait belt was the resident could fall. CNA A stated she had been in-serviced on abuse/neglect, gait belt usage, safe transfers, fall prevention, and checking Kardex (CNAs charting system) to see what level of assistance the residents require. Interview on 11/19/25 at 12:54 PM with CNA C revealed she had worked at the facility for 6 years. She stated she was familiar with and cared for Resident #1. CNA C stated Resident #1 always needed assistance with standing. She stated she always used the gait belt because the resident was unsteady. She stated she was not at the facility when Resident #1 fell. She stated Resident #1 was now bedbound and needed total assistance. CNA C stated she knew what level of assistance the residents were based on the Kardex. She stated she would always clarify and ask her nurses if she was ever unsure. She stated she had been in-serviced on transfers, falls, and when to use the gait belt. CNA C stated a gait belt should be used with any transferring or resident walking. She stated gait belts were kept behind each door and were mandatory to use. She stated the risk of not using the gait belt was that the resident could fall and get hurt. Interview on 11/19/25 at 1:22 PM with CNA D revealed she has worked at the facility for 4 years. CNA D stated she worked with Resident #1 before she fell. She stated Resident #1 needed extensive 1-person assist when using the bathroom. CNA D stated she would use the gait belt on her. CNA D stated she was very familiar with Resident #1 and automatically knew how to use the gait belt with her. She stated she had been in-serviced on falls, transfers, and using gait belts. CNA D stated the aides were to check the chart with any new residents and at least once a day. She stated the nurses were also good at educating her with new residents or if they have a change in condition. CNA D stated gait belts should be used for any transfers. She stated the risk of not using a gait belt was the resident could fall. Interview on 11/19/25 at 1:36 PM with CNA E revealed she has worked at the facility since July 2025. She stated she worked with Resident #1 prior to her fall. CNA E stated she always used the gait belt on Resident #1 and used it to assist her with standing. She stated Resident #1 was an extensive 1-person assist. CNA E stated she had been in-serviced on transfers, gait belts, and preventing falls. She stated she knew what assistance a resident needed based on the Kardex. She stated that all transfers needed gait belts. CNA E stated there were gait belts in each room and they were always to be used. CNA E stated the risk of not using a gait belt was injury to the residents. Interview on 11/19/25 at 2:15 PM with RN F revealed he has worked at the facility since 2018. He stated he had worked with Resident #1 but was not present the day she had fallen. He stated that Resident #1 always needed a gait belt and was a 1-person assist before her fall. RN F stated she had one sided weakness and needed extensive assistance. He stated Resident #1 did have previous falls, but not frequently. He stated Resident #1 was now bedbound due to her injuries and physical therapy were the only ones that could get her up. RN F stated he was in-serviced on falls, transfers, and gait belts. He stated all weight bearing transfers should use gait (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 3 of 6 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 11/19/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few belts. He stated CNAs knew what assistance level a resident was based on their charting, and they could always ask him. He stated he always checked the resident rooms to ensure there was a gait belt and would observe transfers. He stated the risk of not using a gait belt was the resident could get fractures from getting dropped or staff could grab them incorrectly and cause injuries. Interview on 11/19/25 at 2:34 PM with LVN G revealed she had worked at the facility for 3 years. She stated she had not worked with Resident #1 and was not aware of the fall. She stated she had been in-serviced on transfers, falls and gait belts. She stated all residents who were transferred without a mechanical lift and needed staff assistance needed a gait belt. She stated that when a resident was admitted to the facility, the nurses and therapists did an assessment to determine what assistance level was needed for transfers. LVN G stated they always let the CNAs know and it was documented in Kardex so they could see. She stated the CNAs should check Kardex daily and talk to the nurses if they had any questions. She stated she was always educating and reminding the aides to use gait belts. LVN G also revealed she would make rounds to check if gait belts were present and being used. She stated the risk of not using gait belts was that the residents could lose their balance and fall. She stated it was a huge safety risk to not use gait belts. Interview on 11/19/25 at 3:25 PM with the Administrator revealed after Resident #1's fall she provided education and in-serviced all staff to follow the care plan regarding fall precautions, safe transfers, and therapy did education and demonstration with staff on transferring. She stated the ADONs did check-offs for gait belts and transfers as well. The Administrator stated she had done audits to make sure each room had a gait belt present. She stated they in-serviced on abuse, neglect, exploitation, updating care plans after each fall and with any changes. The Administrator stated she suspended the perpetrator after finding out a gait belt was not used. She said before suspending they did education and in-service. The Administrator stated she brought CNA A back on 11/13/25 to monitor her gait belt usage and reinstated the education. She stated CNA A did follow the care plans and used gait belts correctly that day, but she still had not officially brought her back. The Administrator stated she was waiting to discuss it with Resident #1 and the resident's RP to decide if she would continue working on that hall or be moved to a different one. Interview on 11/19/25 at 3:36 PM with LVN H revealed she had worked at the facility for 5 years. She stated she had worked with Resident #1 but was not present the day she had fallen. LVN H stated Resident #1 did need a gait belt with all transfers because she needed staff assistance. LVN H stated Resident #1 has more pain, was now bedbound and sleeps most of the day. She stated she had been in-serviced on falls and transfers. She stated the CNAs go to the plan of care and Kardex to review the residents and their needs. She stated the CNAs could always go to the nurses as well. LVN H stated every room had a gait belt and she would round to make sure gait belts were used during transfers. She stated if any rooms did not have a gait belt, the nurses could get one. LVN H stated all transfers required a gait belt. She stated the risk of not using a gait belt was the resident could fall. Interview on 11/19/25 at 4:26 PM with RN B revealed she was present on 11/09/25 when Resident #1 had a fall. She stated she went to the room when she heard screaming, and the emergency call light was on. RN B stated when she went into the bathroom, she found the resident right in front of the toilet with her back against the wall and facing the toilet. She stated her wheelchair was present as well. RN B stated Resident #1 was screaming and had severe pain in her right leg. She stated she did not observe the gait belt on Resident #1. RN B stated Resident #1 normally did wear a gait belt. RN B stated she only worked the weekends, so she was not as familiar with Resident #1, but she checked her vital signs at the start of her shift, as well as blood sugar with no concerns. She stated Resident #1 appeared her normal self. She stated she could not recall if there were any other staff (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 4 of 6 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 11/19/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few present during the incident. RN B stated she immediately called 911 due to Resident #1's pain and the paramedics were there within a couple minutes. RN B stated she checked her vital signs and did not see any wounds or open areas. RN B stated she had been in-serviced on transfers, gait belts, and fall prevention. She stated all transfers should have a gait belt. She stated the gait belts were in every room, and she was monitoring the transfers to ensure they were used. RN B stated it was a safety risk if a gait belt was not used and puts the residents at a high risk of falling. Interview on 11/19/25 at 5:33 PM with ADON I revealed she had worked at the facility for 2 years. She stated she was not at the facility the day Resident #1 fell and went to the hospital. She stated it was a weekend, and the DON was made aware immediately after it happened. ADON I stated CNA A should have used a gait belt when transferring Resident #1. She stated Resident #1 had one sided weakness but would sometimes refused the gait belt. ADON I stated on the date of the incident Resident #1 did not refuse the gait belt, so it should have been used. ADON I stated any residents that needed assistance and was weight bearing with transfers should have a gait belt. ADON I stated Resident #1 did always sleep in her recliner. She stated when Resident #1 came back from the hospital, she really wanted to be back in the recliner. ADON I stated the staff could not change her in the recliner so Resident #1 finally agreed, but she did not like to use the bed. ADON I stated staff were in-serviced on everything regarding abuse/neglect, falls, transfers, and using the gait belts. She stated she did spot checks and audits to ensure staff were using the gait belts. She stated the risk of not using a gait belt was a fall and injuries. Interview on 11/19/25 at 5:51 PM with the Administrator revealed she expected all her staff to use gait belts during transfers. She stated that was why the gait belts were kept in the room, so they were easily accessible. The Administrator stated she reinforced that education and has ensured that the gait belts were all present. The Administrator stated there had been no other recent falls related to gait belt usage. The Administrator stated the risk when not using the gait belt was an increased risk of falls and injury to both the residents and staff. Record review of the facility's undated CNA onboarding training revealed it included Using a Gait/Transfer Belt, which reflected the following, . There are several advantages to using a gait/transfer belt: 1. It reduces the chance of injury to either the resident or nursing assistance. 2. It helps minimize fall related injuries. 3. As you have the belt to hold on to, you will feel more in control of the situation. 4. This provides a feeling of security and helps maintain the resident's strength. The gait belt is used with residents who require assistance in moving. This includes those who are weak, unsteady, or prone to falling.Record review of the facility's Transfer: Bed-chair/wheelchair policy, dated 02/05/15, reflected the following, Purpose: To move safely from bed to chair or wheelchair and back again. Equipment: Wheelchair with locks or sturdy chair, Shoes or slipper with nonskid soles, Gait belt, if necessary, Pillows, if necessary, Slide board, if necessary. Procedure . ONE PERSON - STAND-PIVOT: .4. Assist to sitting position on side of bed - refer to Dangling procedure for specific instructions 5. Apply gait belt to resident, if necessary. 12. Align in chair/wheelchair using pillows to support proper positioning. 13. Remove gait belt. The facility implemented the following corrective measures prior to the HHSC investigation:Record review of a facility in-service completed on 11/10/25 revealed the following, Transfers: 1. Gait belts must be used for ALL transfers. 2. When a resident is a standby assist, staff must use gait belt for resident safety. 3. Staff must ensure that each resident has a gait belt in their room behind the door. 41 staff signatures were present, all from the nursing department. Record review of the facility Gait Belt Check off, dated 11/11/25 reflected the ADONs completed gait belt checkoffs with 26 staff members, who were able to demonstrate correct use of gait belts. Record review of the facility's gait belt transfer audit completed between the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675153 If continuation sheet Page 5 of 6 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 11/19/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dates of 11/10/25 - 11/14/25 reflected that the ADONs audited 23 gait belt gate belt transfers. Staff were able to demonstrate and perform safe gait belt transfers. Record review of a facility in-service, Preventing, recognizing, and reporting abuse, neglect, exploitation/misappropriation, completed on 11/10/25 revealed the following, 1. When suspecting abuse, neglect, exploitation/misappropriation, you must report to the abuse coordinator immediately. 2. The abuse coordinator is [The Administrator]. 45 staff signatures were present from various departments.Record review of a facility in-service record, dated 11/10/25, reflected 24 staff members from the nursing department attended the in-service which covered the following: In the event when a resident falls, a CNA may NOT move the resident or any part of the resident's body until the resident is evaluated by the nurse. When a resident had an incident that requires medical care (fall, code blue, etc), the first responder may NOT leave the resident alone. The first responder calls (shouts) for help and stays with the resident until help arrives. Record review of a facility in-service record, dated 11/10/25, reflected 26 staff members from the nursing department received training on the facility's Fall Management System Policy.Record review of an individual in-service completed on 11/10/25 with CNA A reflected the following: Safe Transfer. CNA must use gait belt for all transfers. CNA must ensure that they are familiar with each resident's Kardex to learn how to care for them. If resident declines use of gait belt or declines assistance, change nurse must be notified immediately. Record review of an individual in-service completed on 11/10/25 with CNA A revealed the following, Falls and Safety. CNA may not move any part of the resident's body after a fall unless instructed by the nurse after assessment. CNA must remain with the resident until the nurse arrives to assess the resident.Record review of a Quality Assurance Agreement Patient Questionnaire with 6 residents on 11/10/25 revealed none of the 6 residents had concerns.Observation on 11/19/25 at 10:56 AM with CNA C and Resident #2 revealed the resident being transferred from her wheelchair to the bathroom. A gait belt was noted to have been stored on the back of the bedroom door and another in the bathroom. The gait belt was used appropriately throughout the observation, and no concerns were noted with the transfer. Observation on 11/19/25 at 11:10 AM with CNA J and Resident #3 revealed the resident being transferred from his wheelchair to the toilet. A gait belt was stored on the back of the bedroom door and used throughout the transfer. No concerns were noted with the transfer, and the gait belt was properly used. Observation on 11/19/25 at 11:52 AM with CNA K and Resident #4 revealed the resident being transferred from her wheelchair to the bathroom. The gait belt was stored on the back of the door, and another was present in the bathroom. Resident #4 was safely transferred by CNA K using the gait belt. No issues were noted with the transfer. Observation on 11/19/25 at 4:47 PM with CNA L and Resident #5 revealed the resident being transferred from her bed to the wheelchair. The gait belt was used properly, and no concerns were noted with the transfer. Another gait belt was noted in bathroom. Event ID: Facility ID: 675153 If continuation sheet Page 6 of 6