Department of Health & Human Services

Centers for Medicare & Medicaid Services
Form Approved

OMB No. 0938-0391
Statement of Deficiencies (X1) Provider/Supplier/CLIA Identification Number 673074 (X3) Date Survey Completed 02/01/2022
Name of Provider or Supplier Temple Rehabilitation Hospital Street Address, City, State 23621 Se H.K. Dodgen Loop, Temple, TX
For information on the provider's plan to correct this deficiency, please contact the provider or the state survey agency.
(X4) ID Prefix Tag Summary Statement of Deficiencies

(Each deficiency should be preceded by full regulatory or LSC identifying information)
A0000 The CMS-2567 (Statement of Deficiencies) is an official, legal document. All information must remain unchanged except for entering the plan of correction, correction dates, and the signature space. Any discrepancy in the original deficiency citation(s) will be reported to the Dallas Regional Office (RO) for referral to the Office of the Inspector General (OIG) for possible fraud. If information is inadvertently changed by the provider/supplier, the State Survey Agency (SA) should be notified immediately. An entrance conference was held with the CEO, Director of Quality Management and VP of Corporate Compliance on 2-1-22. The purpose and process of the complaint survey were discussed, and an opportunity given for questions. Complaint TX00396745 is substantiated with related Federal deficiencies cited. An exit conference was held with the facility CEO, Director of Quality Management and VP of Corporate Compliance on 2-1-22. Preliminary findings of the survey were discussed, and an opportunity given for questions.