Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds
bed-hold policy.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review the facility failed to implement a policy that is in accordance with the State
Medicaid Plan to allow a resident to return to his previous room upon discharge from the hospital for 1 of 1
resident reviewed for discharges.
The facility failed to ensure Resident #1 received the services required when they failed to allow Resident
#1 to return to the facility after his hospitalization and they failed to appropriately notify the resident, his
representative, and the LTC Ombudsman of the discharge.
This failure placed residents at risk of an extended, unnecessary hospitalization and a traumatic
psychosocial adjustment to a new facility.
Findings include:
Record review of Resident #1's undated face sheet, reflected he was an [AGE] year-old male that was
admitted to the facility on [DATE] with diagnoses of Alzheimer's, Urinary Tract Infection, Muscle Weakness,
Bipolar (mental illness), and Restlessness and Agitation. He was discharged to the hospital on 6/23/24 to
be evaluated for urinary tract infection and behavior.
Record review of Resident #1's Quarterly MDS reflected a BIMS score of 4, which indicated the resident's
cognition was severely impaired.
Record review of Resident #1's Care Plan, reflected a Focus area was initiated for potential for delirium or
an acute confusion episode on 12/18/23.
In an interview on 7/29/24 at 11:05 a.m., the ADM stated, Resident #1 was not at the facility because he
went to the hospital. The ADM stated that she discussed with his family member that it would be best if he
did not come back to the facility because she did not want a pattern of abuse from resident to resident. The
resident had been aggressive twice with other residents. The ADM stated, the facility would have taken him
back; however, his family member understood and found another place.
In a telephone interview on 7/29/24 at 3:54 p.m. Resident #1's family member stated, she was told by the
ADM that Resident #1 could not return to the facility from the hospital, due to his aggressiveness. She also
stated the discharge planner at the local hospital was also told that the facility would not allow the resident
to return.
In a telephone interview on 7/29/24 at 4:03 p.m. with the local hospital discharge planner stated
(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 6
Event ID:
675867
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
675867
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kerens Care Center
809 NE 4th St
Kerens, TX 75144
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 0626
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
there were multiple notes documented at the hospital stating that the Emergency Room, the family member
and the case managers were told that the resident could not return to the nursing facility. She agreed to
provide the notes to the state.
In an interview on 7/30/24 at 12:01 pm DON stated, 'We told the daughter we would lie to place the
resident elsewhere, but we would take him back. There is no paperwork (discharge or bed release)
because daughter agreed to find him another place.
In an interview with OM the business office manager on 7/30/24 at 1:00 pm, she stated there is no
discharge paperwork for Resident #1.
A record review of the hospital documentation on Resident #1, reflected that the facility refused to allow
Resident 1 to return to the facility from the hospital:
Note on 6/24/24 9:11 a.m. emergency room nurse reflected, Called the nursing home to update on plan of
care - talked to Assistant Director of Nurses, Director of Nurses, and Administrator (ADM) and explained
situation, The ADM said the pt has had two offenses for aggression and cannot return to facility. Informed
that we would have to explore placement at another NH.
Note on 6/24/24 10:19 a.m. by resident's doctor reflected, Nursing home reported that they could not take
care of him anymore and refused to take him back. Patient is intermittently confused. Patient aggressive
with staff at nursing home and was refused back there. Left in our ER.
Note on 6/24/24 1:50 p.m. Discharge Planner's notes reflected, Resident's family member is aware that the
facility has stated Resident #1 cannot return the facility he came from.
Note on 6/24/24 2:13 p.m. Case Manager's notes reflected, Received call from another local nursing home;
they are able to accept patient and report he can come today Resident was discharge to an alternate
facility on 6/25/24 (2-days hospitalization).
A record review of the facility policy named, Nursing Facility Resident Rights dated November 2021 reflects
on page 3 of 4, residents have the right to receive a 30-day written notice sent to them, their legally
authorized representative or a family member for transfers or discharges.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675867
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
675867
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kerens Care Center
809 NE 4th St
Kerens, TX 75144
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop and implement a complete care plan that meets all the resident's needs, with timetables and
actions that can be measured.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review the facility failed to develop and implement a comprehensive person-centered
care plan for 1 of 1 resident (resident #2) reviewed for care plans.
The facility failed to ensure Resident #2 had a care plan to reflect the accurate diet she was on. Resident
#2 was care planned for pureed textured diet when she was receiving regular diet.
This failure could place residents at risk of getting insufficient nutrition with the wrong diet order which could
have diminished her physical and psychosocial well-being.
Findings include:
Review of Resident #2's undated face sheet reflected that she was a [AGE] year-old female admitted with
diagnoses of Malnutrition, Encephalopathy, Chronic Ulcer of Right Calf, Chronic Kidney Disease, Dementia
and Anemia.
Review of 7/29/24 of Resident #2's Quarterly MDS reflected her BIMS score was 99, which indicates they
could not fully evaluate her cognitive abilities.
Review of resident #2's 7/5/24 Care Plan reflected she was on a pureed texture diet order with a goal to
maintain weight and proper nutrition. The care plan also reflected in the Activities of Daily Living section
that on 5/31/24 an intervention was initiated that she required one staff assisting her for eating.
Review of Resident #2's orders reflected a diet order on 6/8/24 of a Regular Diet, Pureed Texture, Regular
Consistency. The order was signed by PCP on 6/10/24.
In an interview on 7/30/24 at 12:20 pm, the LVN stated that on 7/27/24 resident #2 ate whole pieces of
shrimp that her family had brought to her. She stated that she thought the resident was on a regular soft
diet and that she had never seen the resident eat a pureed diet.
In an interview on 7/30/24 at 12:55 with the DS, she stated that resident #2 has received a Regular diet
with regular texture (not pureed) for the whole time she has been at the facility. She further stated that she
thinks the pureed diet order was an error and that the resident can also feed herself without assistance.
In an interview on 7/30/24 at 1:15 pm with PCP regarding the Regular pureed diet order signed on 6/10/24
by PCP, he stated that he was not familiar with the patient as he has so many patients, he can't remember
them all. He was not sure if he had seen the resident. He referred surveyor to speak to his Nurse
Practitioner.
In an interview on 7/30/24 at 1:48 pm the NP stated, the pureed diet was not a diet she would have ordered
and that it must have come from when the resident was in the hospital. She further stated that she had
seen the resident eating and the correct order for this resident would have been a regular diet with regular
texture (not pureed). She also stated the resident was able to feed herself without assistance.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675867
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
675867
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kerens Care Center
809 NE 4th St
Kerens, TX 75144
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 0656
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
In an interview on 7/30/24 at 2:12 pm with the CNA, she stated on 7/27/24 at 3:00 pm resident #2 was
eating rice with bite size shrimp. She further stated that she had never seen the resident eat anything, but
regular texture diet and she had no problem feeding herself.
In an interview on 7/30/24 at 2:30 pm with the ADM she stated, the policy was to serve the diet as ordered
by the physician. She also stated that now she was aware that Resident #2 had a Regular pureed diet
ordered but was getting a Regular diet with regular texture instead. The ADM stated the negative outcome
to an incorrect diet can be as severe as death.
In an interview on 7/30/24 at 2:59 pm with the DON she stated, the policy was to serve the diet as ordered
and to check the food against the diet order. She further stated that she knew Resident #2 had a pureed
diet order but didn't know until now that she wasn't getting that diet. She stated the negative outcome to an
incorrect diet can be choking and aspiration (food going into the lungs).
In an interview on 7/30/24 at 3:10 pm with the ADON he stated, the policy on serving the diet was that the
food should be checked and verified when passing the food to the residents. He stated that he knew
resident #2 had a pureed diet ordered but he was not sure what was served to her. He stated the negative
outcome to an incorrect diet can be aspiration (food going into the lungs).
Record Review of the facility policy titled, Diet Orders/Diet Manual and dated 2012, reflect The Physician
will prescribe diets in accordance with the approved Diet Manual and a written order must appear on the
medical record before the resident can be served.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675867
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
675867
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kerens Care Center
809 NE 4th St
Kerens, TX 75144
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview, and record review the facility failed to ensure medical records were complete and accurate in
accordance with accepted professional standards and practices when the facility to maintain a correct
medical record for 1of 1 resident (resident #2) reviewed for diet orders. Evidence supports the resident
medical record was not accurate.
The facility failed to ensure Resident #2 had an accurate medical record when the physician signed an
incorrect diet order for a pureed diet that the resident wasn't getting and did not need.
This failure could place residents at risk of getting insufficient nutrition with the wrong diet order which could
have diminished her physical and psychosocial well-being.
Findings include:
Review of Resident #2's undated face sheet reflected that she was a [AGE] year-old female admitted with
diagnoses of Malnutrition, Encephalopathy, Chronic Ulcer of Right Calf, Chronic Kidney Disease, Dementia
and Anemia.
Review of 7/29/24 of Resident #2's Quarterly MDS reflected her BIMS score was 99, which indicates they
could not fully evaluate her cognitive abilities.
Review of resident #2's 7/5/24 Care Plan reflected she was on a pureed texture diet order with a goal to
maintain weight and proper nutrition. The care plan also reflected in the Activities of Daily Living section
that on 5/31/24 an intervention was initiated that she required one staff assisting her for eating.
Review of Resident #2's orders reflected a diet order on 6/8/24 of a Regular Diet, Pureed Texture, Regular
Consistency. The order was signed by PCP on 6/10/24.
In an interview on 7/30/24 at 12:20 pm, the LVN stated that on 7/27/24 resident #2 ate whole pieces of
shrimp that her family had brought to her. She stated that she thought the resident was on a regular soft
diet and that she had never seen the resident eat a pureed diet.
In an interview on 7/30/24 at 12:55 with the DS, she stated that resident #2 has received a Regular diet
with regular texture (not pureed) for the whole time she has been at the facility. She further stated that she
thinks the pureed diet order was an error and that the resident can also feed herself without assistance.
In an interview on 7/30/24 at 1:15 pm with PCP regarding the Regular pureed diet order signed on 6/10/24
by PCP, he stated that he was not familiar with the patient as he has so many patients, he can't remember
them all. He was not sure if he had seen the resident. He referred surveyor to speak to his Nurse
Practitioner.
In an interview on 7/30/24 at 1:48 pm the NP stated, the pureed diet was not a diet she would have ordered
and that it must have come from when the resident was in the hospital. She further stated that she had
seen the resident eating and the correct order for this resident would have been a
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675867
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
675867
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Kerens Care Center
809 NE 4th St
Kerens, TX 75144
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
regular diet with regular texture (not pureed). She also stated the resident was able to feed herself without
assistance.
In an interview on 7/30/24 at 2:12 pm with the CNA, she stated on 7/27/24 at 3:00 pm resident #2 was
eating rice with bite size shrimp. She further stated that she had never seen the resident eat anything, but
regular texture diet and she had no problem feeding herself.
In an interview on 7/30/24 at 2:30 pm with the ADM she stated, the policy was to serve the diet as ordered
by the physician. She also stated that now she was aware that Resident #2 had a Regular pureed diet
ordered but was getting a Regular diet with regular texture instead. The ADM stated the negative outcome
to an incorrect diet can be as severe as death.
In an interview on 7/30/24 at 2:59 pm with the DON she stated, the policy was to serve the diet as ordered
and to check the food against the diet order. She further stated that she knew Resident #2 had a pureed
diet order but didn't know until now that she wasn't getting that diet. She stated the negative outcome to an
incorrect diet can be choking and aspiration (food going into the lungs).
In an interview on 7/30/24 at 3:10 pm with the ADON he stated, the policy on serving the diet was that the
food should be checked and verified when passing the food to the residents. He stated that he knew
resident #2 had a pureed diet ordered but he was not sure what was served to her. He stated the negative
outcome to an incorrect diet can be aspiration (food going into the lungs).
Record Review of the facility policy titled, Diet Orders/Diet Manual and dated 2012, reflect The Physician
will prescribe diets in accordance with the approved Diet Manual and a written order must appear on the
medical record before the resident can be served.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675867
If continuation sheet
Page 6 of 6
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F626 - Transfer and discharge-
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
FAQ · About this visit
Common questions about this visit
What happened during the July 30, 2024 survey of Kerens Care Center?
This was a inspection survey of Kerens Care Center on July 30, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Kerens Care Center on July 30, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.