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 673077 (X3) Date Survey Completed 06/05/2026
Name of Provider or Supplier Texas Rehabilitation Hospital Of Keller Street Address, City, State 791 S Main Street, Keller, 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)
A0396 NURSING CARE PLAN
CFR(s): 482.23(b)(4)

The hospital must ensure that the nursing staff develops, and keeps current, a nursing care plan for each patient that reflects the patient's goals and the nursing care to be provided to meet the patient's needs. The nursing care plan may be part of an interdisciplinary care plan.


This STANDARD is not met as evidenced by:
Based on interviews and record reviews, the facility failed to ensure the nursing staff developed and kept current a nursing care plan for each patient that reflected the nursing care to be provided to meet the patient's needs for 1 (Patient #1) of five patients reviewed for dysphagia and aspiration risks. Patient #1 was identified on admission as high risk for silent aspiration and respiratory compromise with orders for aspiration precautions. The risks were not included in her Care Plan and no individualized nursing interventions were identified or documented to meet her needs. Findings included: Record review of Patient #1's History and Physical Report dated 04/03/2026 reflected an 86-year-old female admitted to the facility on 04/03/2026 after hospitalization following a fall from a ladder at home. She had sustained injuries including right arm fractures, rib fractures, two fractured vertebrae and a brain hemorrhage and a recommendation was made for a cervical collar at all times. She was found to have dysphagia after failing swallow studies and was " ...at HIGH risk for ongoing silent aspiration with all PO intake, placing the patient at increased risk for aspiration pneumonia, respiratory compromise/occlusion ...". She received a PEG [percutaneous endoscopic gastrostomy] tube placement while hospitalized. Patient #1's Admission Orders, dated 04/03/2026 included: -NPO [nothing by mouth] -Aspiration Precautions. Order Details: Elevate head of bed (HOB) 30-45 degrees, unless contraindicated; For bolus administration elevate HOB 90 degrees during feeding and for at least 1 hour after or according to provider order. -Oxygen Therapy. Order Details: Routine, Flow Rate (L/min): 4, SpO2 [oxygen saturation] goal 90% or greater, Nasal Cannula -Cervical Collar Application (C-Collar) Patient #1's Rehabilitation Nursing Goals, dated 04/03/2026 reflected the following: Nursing Goal #1: Patient will verbalize pain levels that allow participation in the rehabilitation program. Nursing Goal #1 Intervention: Patient will receive pain medication prior to participating in therapy. Nursing Goal #1 Status: Initial. Nursing Goal #1 Date Met: 04/03/2026 Nursing Goal #2: Patient will maintain normal blood pressure and heart rate. Nursing Goal #2: Intervention: Monitor vital signs every shift and as needed. Nursing Goal #2 Status: Initial Nursing Goal #2 Date Met: 04/03/2026 No other nursing goals were included. During an interview and record review on 06/03/2026 at 2:25 PM, Staff D stated when a patient was on aspiration precautions, they received a speech therapy evaluation. She stated the head of the bed should be elevated whenever continuous or bolus feeding was in place. She stated Patient #1 wore a cervical collar and the head of her bed should have been elevated at least 30-45 degrees at all times. She stated other care including ensuring the patients were repositioned properly, stop any feeding during care, and maintaining oral care. She stated oxygen and suction with a yaunkar was placed in the room as well as oral swabs. Staff D stated new patient care plans began with the nursing assessment then, the following day, OT, PT, and ST. When asked to display Patient #1's nursing Care Plan, Staff D displayed the clinical record which reflected the only goals listed were for pain and blood pressure. She stated the nurses selected a couple of key issues initially and her other precautions were addressed in her orders. During an interview and record review on 06/04/2026 at 12:25 PM, Staff K stated she had completed the admission assessment for Patient #1 and knew about her by reviewing her preadmission screening documents. She stated she was aware of Patient #1's aspiration precautions. She stated the order to keep the head of the bed up was generated when the diagnoses were entered. Staff K demonstrated the process for entering initial Care Plan goals on the computer and stated, "we put in the goals, on this day, I did not put in aspiration goal or oxygen goals in and I should have." She stated she selected pain with the interventions to assess pain and give medications in a timely manner, and vital signs to be monitored every shift. She stated they were supposed to prioritize the condition of the patient at the time of the assessment, and at that time, Patient #1 had been in a lot of pain from her transfer. She stated the nurses could add to the goals throughout a patient's stay Staff K stated she did write about the PEG tube and keeping the head of the bed up on the patient's white board in her room, but she did not add the areas to her Care Plan. Record review of the facility's policy and procedure titled, Assessment and Reassessment, dated 04/01/2021 reflected: POLICY "Patients are assessed upon admission and reassessed as needed in order to determine the appropriate care, treatment and services to meet the needs of the patient. PROCEDURE ...A complete assessment shall include physical, psychological, pain management, functional, visual and hearing, nutritional, spiritual needs, social status including social barriers such as language or culture, communication, educational and discharge planning ...The initial Nursing Assessment is completed on each patient by a Registered Nurse within twenty four (24) hours of admission, in order to assess the patient's nursing care needs and obtain information for initiating the rehabilitation nursing plan of care; to identify patients who are at functional or nutritional risk; to determine potential discharge planning needs; and to orient the patient and family members to the Hospital environment and routine activities ...".