Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Keller Oaks Healthcare Center during CMS and state inspections, most recent first.
Failure to provide nail care and personal hygiene assistance: A dependent resident with generalized muscle weakness and impaired self-care had severely contracted hands, long fingernails, and brown matter under a thumb while in the TV area. CNA and RN interviews confirmed nail care was expected on shower days and as needed, and the DON stated residents were to receive nail care during showers, with nurses trimming nails for residents with DM.
Staff failed to consistently follow infection control practices, including enhanced barrier precautions and hand hygiene, during incontinent care and handling of medical devices for three residents. In one case, staff performed high-contact care and a gait-belt transfer for a resident with a pressure ulcer, G-tube, and PICC line while wearing gloves but no gowns, despite posted enhanced barrier precautions. In another case, a CNA changed a resident’s soiled brief and cleansed the perineal area, then changed gloves without performing hand hygiene before applying a clean brief. In a third case, a CNA and the Staffing Coordinator placed a clean brief under a resident before completing cleansing, applied barrier cream with soiled gloves, and the Staffing Coordinator picked an oxygen cannula up from the floor and placed it back on the resident, with both staff leaving the room without performing hand hygiene.
A facility failed to maintain complete and accurate clinical records for a resident with severe cognitive impairment and a history of easy bruising. Weekly skin assessments and follow-up assessments for new bruises were inconsistently documented, with several instances of bruises noted but not properly assessed or communicated to medical staff and family. Staff interviews revealed a lack of awareness and communication about the resident's condition, leading to incomplete records and potential risks for untreated skin conditions.
A resident with severe cognitive impairment and multiple health conditions was found in unsanitary conditions, with flies on his body and a strong foul odor in his room. Despite staff awareness and some cleaning efforts, the issues persisted, compromising the resident's dignity and highlighting a deficiency in care.
The facility failed to ensure that the call lights for four residents were within their reach, which could result in their needs not being met. Observations and interviews revealed that the call lights were out of reach for residents with severe cognitive impairment and those requiring extensive assistance. Staff acknowledged the high risk to residents if call lights were not accessible, as it could prevent them from receiving necessary care.
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety. Observations revealed multiple food items in the walk-in refrigerator and dry storage that were not sealed or dated, personal use items improperly stored, cleaning chemicals near prepared food, and the kitchen door left open. Interviews with staff confirmed these practices were against facility policies and posed significant risks to resident safety.
The facility failed to ensure call lights were within reach for two residents, both with cognitive and mobility impairments. One resident was observed in pain and unable to reach her call light, which was on the floor, while another resident expressed feelings of loneliness due to the same issue. Staff acknowledged the importance of call lights being accessible for residents to communicate their needs.
The facility failed to ensure the medication error rate was below 5%, resulting in an 8% error rate. Two residents had their medications crushed and mixed into pudding without physician orders, contrary to facility policy. This was observed during medication administration by two LVNs, who acted based on verbal reports and judgment rather than verified orders.
A resident was administered a crushed extended-release medication without proper verification, leading to a significant medication error. The LVNs involved did not follow the facility's policy requiring a physician's order to crush medications, and the pharmacist had not reviewed the resident's medication orders. The DON and facility administrator acknowledged the expectation for nurses to follow physician orders and facility policies, which were not adhered to in this case.
A resident with multiple health issues, including a need for assistance with personal care, did not receive scheduled showers since admission. Staff interviews revealed inconsistencies in shower documentation and provision, with some aides failing to document showers. The ADON and Administrator acknowledged documentation issues, emphasizing the importance of offering and documenting showers as scheduled to prevent skin breakdown and maintain resident dignity.
Failure to Provide Nail Care and Personal Hygiene Assistance
Penalty
Summary
Facility failed to provide necessary ADL services to maintain good grooming and personal hygiene for Resident #1, who was dependent for ADLs and had diagnoses including generalized muscle weakness and need for assistance with personal care. The resident’s quarter MDS reflected dependence with ADLs, and the comprehensive care plan dated 05/08/26 identified a self-care performance deficit related to impaired thought process with a goal for the resident to safely perform personal hygiene with limited assistance. On 05/19/26 at 09:50 AM, Resident #1 was observed in a wheelchair in the TV area with both hands severely contracted and supported by sponge pads. The resident had a long fingernail on both hands, approximately 0.6 cm, and brown matter under the left thumb. When asked if she wanted her fingernails trimmed and cleaned, she nodded yes. At 09:55 AM, CNA A physically assessed the fingernails and stated they needed trimming and that the left thumb needed cleaning due to the brown matter underneath. CNA A stated nail care was performed by CNAs on shower days and that nurses and CNAs were responsible for keeping residents’ nails clean and trimmed. RN B stated at 10:25 AM that CNAs and nurses were responsible for nail care and that it should be done on shower days and as needed. The DON stated at 1:22 PM that nail care was expected during shower days, and nurses had to trim nails for residents with diabetes. The facility policy stated residents unable to carry out ADLs would receive necessary services to maintain grooming and personal hygiene.
Failure to Follow Enhanced Barrier Precautions and Hand Hygiene During Incontinent Care and Device Handling
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective Infection Prevention and Control Program, including proper use of enhanced barrier precautions and hand hygiene, for three residents observed for infection control practices. For one resident with a sacral pressure ulcer, dysphagia, a G-tube, and a PICC line, an enhanced barrier precautions sign was posted indicating the need for gown and gloves during high-contact care. During incontinent care and preparation for transfer to a wheelchair, a PTA, a CNA, and an RN all wore gloves but did not don gowns, despite performing high-contact activities such as changing briefs, disconnecting a feeding tube, and using a gait belt to transfer the resident. In interviews, these staff members acknowledged they had been trained on enhanced barrier precautions, recognized that residents with wounds or medically inserted devices required such precautions, and admitted they should have worn gowns during this high-contact care. For a second resident with diagnoses including type 2 diabetes mellitus, COPD, and overactive bladder, a CNA entered the room to provide incontinent care after performing hand hygiene and donning gloves. The CNA unfastened a wet brief, cleansed the resident’s perineal and buttocks areas, then changed gloves without performing hand hygiene before placing a clean brief under the resident and completing the brief change and repositioning. Hand hygiene was only performed after the gloves were removed at the end of care. In a subsequent interview, the CNA stated she was supposed to perform hand hygiene before and after incontinent care and further acknowledged she should have performed hand hygiene after cleaning the resident and changing gloves. For a third resident with dementia and COPD, a CNA and the Staffing Coordinator provided incontinent care while the resident’s oxygen concentrator was on and the oxygen cannula was observed lying on the floor. Both staff performed hand hygiene and donned gloves before care. The CNA unfastened the brief, placed a clean brief beside the resident, cleansed the perineal area, and, with assistance, removed the soiled brief and placed the clean brief under the resident before cleaning the buttocks, thereby placing a clean item under the resident prior to completing cleansing. Without changing gloves, the CNA then applied barrier cream using the same gloves that had been used for cleaning. After fastening the brief and repositioning the resident, the Staffing Coordinator picked up the oxygen cannula from the floor and placed it back on the resident’s nose. Both staff then removed their gloves, collected trash, left the room without performing hand hygiene, and only washed their hands later at a sink behind the nurse’s station. In interviews, both the CNA and the Staffing Coordinator acknowledged they had not followed required hand hygiene and glove-change practices and described the expected protocols as taught by the facility’s infection control policies.
Incomplete Documentation of Resident's Skin Assessments
Penalty
Summary
The facility failed to maintain complete and accurate clinical records for a resident, specifically regarding weekly skin assessments and follow-up assessments for new bruises. The resident, an elderly female with severe cognitive impairment and a history of bruising easily due to blood thinners, was admitted with multiple bruises. Despite this, the facility's documentation was inconsistent and incomplete, with several instances of bruises being noted on shower sheets but not followed up with proper assessments or notifications to medical staff and family. On multiple occasions, the resident's skin assessments failed to document new bruises, and there was a lack of communication between staff members regarding these findings. For example, a significant bruise on the resident's right arm was noted by a therapist and reported to a nurse, who then completed an incident report. However, other bruises on the resident's thighs were not documented or reported, leading to incomplete records. Interviews with staff revealed a lack of awareness and communication about the resident's condition, with some staff members unaware of the extent of the bruising. The facility's policy required thorough documentation and communication of any changes in a resident's condition, but this was not adhered to in the case of this resident. The Director of Nursing and the Administrator acknowledged the importance of accurate documentation and the risks associated with incomplete records, yet the facility's practices did not reflect these standards. This deficiency in documentation and communication could potentially lead to untreated skin conditions and inadequate care for residents.
Resident Dignity Compromised by Unsanitary Conditions
Penalty
Summary
The facility failed to uphold the dignity and respect of a resident, identified as Resident #1, by allowing unsanitary conditions to persist in his room. Observations revealed that the resident, who was non-verbal and required maximum support for activities of daily living, was found lying on a mattress on the floor with his gastrostomy tube exposed. The room had a strong foul odor, and multiple flies were observed on the resident and in the room, which the resident attempted to swat away. The presence of flies and the odor were reported to have been ongoing issues, with staff aware of the situation but failing to resolve it effectively. Interviews with staff, including an LVN, the Housekeeping Supervisor, and the Maintenance Director, indicated that the problem had been reported and some actions were taken, such as increased cleaning and pest control measures. However, these actions were insufficient to eliminate the flies and odor. The LVN acknowledged the dignity issue and the potential health risks posed by flies, while the Housekeeping Supervisor and Maintenance Director noted the need for more effective pest control and cleanliness measures. Despite these acknowledgments, the problem persisted, indicating a lack of timely and effective intervention. The resident's medical history included severe cognitive impairment, Down syndrome, and other health conditions requiring specialized care, such as a feeding tube. The facility's failure to maintain a clean and dignified environment for the resident, despite being aware of the issues, highlights a significant deficiency in care. The report does not mention any corrective actions taken by the facility to address the deficiency after the incident, focusing solely on the events and inactions that led to the situation.
Failure to Ensure Call Lights Within Residents' Reach
Penalty
Summary
The facility failed to ensure that the call lights for four residents were within their reach, which could result in their needs not being met. Resident #1, who had severe cognitive impairment and a history of falls, was observed with her call light on the floor against the wall, out of her reach. She was unaware of the call light's location and needed assistance with showering. Resident #2, who had moderate cognitive impairment and was totally dependent on assistance for various activities, was found with her call light hanging just above the floor, out of her reach. She also did not know where her call light was and needed it for assistance. Resident #3, who had severe cognitive impairment and was always incontinent, was observed with her call light underneath her bed, out of her reach. Despite her communication challenges, she indicated that she needed her call light. Resident #4, who had severe cognitive impairment and required extensive assistance, was found with her call light touching the floor and out of her reach. She did not respond to questions due to a language barrier and her dementia. Interviews with staff, including a CNA/CMA, an LVN, the DON, and the Administrator, revealed that there was an expectation for call lights to be within residents' reach and for staff to make rounds to ensure this. The staff acknowledged the high risk to residents if call lights were not accessible, as it could prevent them from receiving the necessary care. The facility's call light policy also stated that call devices should be placed within residents' reach before leaving the room.
Food Safety Violations in Facility Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. Observations revealed multiple food items in the walk-in refrigerator and dry storage that were not sealed or dated, including sliced cheese, onions, tomatoes, pickles, lettuce, ham, lemon pudding, watermelon spears, a tomato, dried mushrooms, and crumbled cookies. Additionally, personal use items such as a lunch bag and a small container of watermelon spears were improperly stored in the walk-in refrigerator. Cleaning chemicals were found near prepared food, and the kitchen door opening to the outside was left open, posing a risk of contamination from insects and other external elements. Personal use cups were also observed on the counter while food was being prepared, further increasing the risk of cross-contamination and food-borne illness. Interviews with kitchen staff and the Dietary Manager confirmed that these practices were against the facility's policies and posed significant risks to resident safety. The staff acknowledged that food items should be labeled and dated to prevent cross-contamination and that personal items should not be stored in the facility refrigerator. The Dietary Manager emphasized the importance of proper food storage and the risks associated with improper practices, including infection control issues and potential food poisoning. The DON and ADM also highlighted the risks of food poisoning and food-borne illness due to improper food storage and handling practices. Record reviews of the facility's policies and the Food Code from the U.S. Public Health Service and FDA further supported the need for proper labeling, dating, and storage of food items, as well as the separation of cleaning chemicals from food storage areas.
Failure to Ensure Call Lights Within Reach
Penalty
Summary
The facility failed to provide services to residents with reasonable accommodation of their needs and preferences by not ensuring that call lights were within reach for two residents. Resident #1, a female with moderate cognitive impairment and multiple health issues, was observed in pain and unable to reach her call light, which was found on the floor. This resident had recently undergone surgery and had a history of falls, including one just 10 hours prior to the observation. The staff, including a CNA and the ADON, acknowledged the issue and the importance of call lights being within reach for residents to communicate their needs effectively. Similarly, Resident #2, a female with significant cognitive impairment and mobility issues, was observed unable to locate her call light, which was also found on the floor. This resident required extensive assistance with daily activities and expressed feelings of loneliness due to the inability to find her call light. The RN and DON both recognized the concern that residents could be in distress and unable to contact nursing staff for help if their call lights were not within reach. Interviews with the DON and the Administrator revealed that the facility's policy mandates that call lights be within reach of residents before staff leave the room. The Administrator emphasized that CNAs work under the license of nurses, who are responsible for ensuring call lights are properly placed. The facility's call light policy outlines specific steps for staff to follow, including ensuring the call device is within the resident's reach before leaving the room.
Medication Administration Errors Due to Crushing Without Physician Orders
Penalty
Summary
The facility failed to ensure the medication error rate was not 5 percent or greater, resulting in an 8 percent medication error rate for two of six residents reviewed for medication administration. Specifically, the facility did not administer medications as ordered by the physician for two residents. Resident #80 and Resident #223 had their medications crushed and mixed into a cocktail without a physician's order, which is against the facility's policy and standard medical practice. This failure was observed during medication administration by LVN A and LVN B, who both admitted to crushing the medications based on verbal reports and their judgment rather than verified physician orders. Resident #80, a female with multiple diagnoses including major depressive disorder, dementia, and a hip fracture, had her medications crushed and mixed into pudding by LVN B. LVN B assumed there was an order to crush the medications because it had been done since the resident's readmission. Similarly, Resident #223, a male with conditions such as heart disease, stroke, and hypertension, had his medications crushed and mixed into pudding by LVN A. LVN A stated she crushed the medications because the resident was on a mechanical soft diet, despite knowing that extended-release medications should not be crushed. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) revealed a misunderstanding and misapplication of the facility's policy on medication administration. The DON believed that nurses should use their judgment to crush medications unless explicitly contraindicated, while the ADON expected nurses to verify orders before crushing any medications. The facility's policy requires a physician's order to crush medications, which was not followed in these instances, leading to the medication errors observed by the surveyors.
Failure to Verify Medication Orders
Penalty
Summary
The facility failed to ensure that residents are free from significant medication errors, specifically for one resident who was administered a crushed extended-release medication without proper verification. The resident, a 75-year-old male with multiple diagnoses including hypertension, stroke, and heart disease, was given Nifedipine Extended Release in a crushed form by a Licensed Vocational Nurse (LVN) who had been working at the facility for three weeks. The LVN crushed all medications and mixed them with pudding, despite knowing that extended-release medications should not be crushed without proper authorization. She stated that she was told in a report that the resident's medications were to be crushed but did not verify this with a physician's order or pharmacist review. Another LVN also admitted to crushing the resident's medications based on verbal instructions without verifying the orders, indicating a lack of adherence to proper medication administration protocols. The pharmacist confirmed that crushing extended-release medications could result in adverse effects and that she had not reviewed the resident's medication orders since he was a new admission. The Director of Nursing (DON) and the facility administrator both acknowledged the expectation for nurses to follow physician orders and facility policies, which were not adhered to in this case. The facility's policy clearly states that a physician's order is required to crush medications, and this was not followed, leading to the significant medication error. The report highlights the failure to verify medication orders and the improper administration of a crushed extended-release medication, which could jeopardize the resident's health and safety.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADLs) independently received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not provide scheduled showers to a resident since her admission in December 2023. The resident, who had diagnoses including an unspecified open wound, lower back pain, generalized muscle weakness, and a need for assistance with personal care, was scheduled to receive showers three times a week but reported only receiving one shower and one bed bath since admission. Interviews with staff revealed inconsistencies in the documentation and provision of showers. A Licensed Vocational Nurse (LVN) stated that aides were supposed to document showers in both a physical log and electronically, but acknowledged that the resident sometimes refused showers due to back pain. Certified Nursing Assistants (CNAs) provided conflicting accounts, with one CNA stating that showers were often given but not documented, while another CNA, who was an agency nurse, confirmed the resident's shower schedule but noted that documentation was the aides' responsibility. The Assistant Director of Nursing (ADON) and the Administrator both acknowledged issues with shower documentation and emphasized the importance of offering and documenting showers as scheduled. The ADON noted that the lack of documentation could not be explained and highlighted the risk of skin breakdown and dignity issues for residents not receiving proper personal care. The facility's policy required that residents be offered showers at least twice weekly and that all ADL care be documented, but these procedures were not consistently followed for the resident in question.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Keller
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Discovery Village At Southlake | 1.5 mi | ★★★★★ | 2 | 0 |
| The Carlyle At Stonebridge Park | 1.7 mi | ★★★★★ | 14 | 1 |
| Oakmont Guest Care Center | 3.2 mi | ★★★★★ | 2 | 1 |
| Bear Creek Nursing And Rehabilitation | 3.5 mi | ★★★★★ | 14 | 2 |
| Heritage House At Keller Rehab & Nursing | 3.8 mi | ★★★★★ | 7 | 1 |
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