Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Kerens Care Center during CMS and state inspections, most recent first.
A nurse failed to initiate CPR for a resident with a full code status who was found unresponsive and without vital signs. The nurse incorrectly assumed the resident was DNR due to hospice enrollment and did not verify the code status in the EMR, resulting in no life-saving measures being performed as required by physician orders and facility policy.
A resident with significant cognitive and physical impairments was not provided with a comprehensive care plan that included their physician-ordered mechanical soft diet. Although the resident was observed receiving the correct diet and staff were aware of the dietary order, the care plan was not updated to reflect this need, contrary to facility policy and assessment findings.
Three residents with severe cognitive and mobility impairments did not have their call lights within reach, as observed during surveyor rounds. The call lights were found on the floor, on a roommate's bedside table, or hanging out of reach, and residents confirmed they could not easily access them. Staff interviews revealed awareness of the policy but lapses in practice, with call lights not always returned to accessible positions after care.
The facility did not provide a private area for resident council meetings, instead holding them in the dining room where staff frequently interrupted, preventing residents from speaking freely. Staff acknowledged the need for privacy and their responsibility to ensure it, but the issue persisted, and residents expressed dissatisfaction with the lack of a confidential meeting space.
The facility did not ensure a homelike environment for residents in the memory care unit, as observed by the lack of personal or decorative items in resident rooms. Staff and administration cited resident behaviors as the reason for bare walls and the absence of decor, with personal items provided by families not present in the rooms. Common areas had some decorations, but resident rooms remained institutional and unpersonalized.
Residents in the memory care unit were not provided with organized group or individual activities as required by their care plans. Observations and staff interviews confirmed that residents spent most of their time in the day room with only a television or radio for stimulation, and there was no activity calendar or materials available. The AD did not implement or document activities for the unit, and the facility's policy for a therapeutic activity program was not followed.
Staff failed to consistently perform hand hygiene and sanitize shared equipment between residents during medication administration, and laundry staff transported and delivered linens using uncovered carts, exposing clean linens to contamination. These actions were contrary to facility policy and were acknowledged by staff during interviews.
Two residents' rights to dignity and confidentiality were not upheld when a staff member referred to a dining area as the 'feeder table' in front of others and a sign disclosing a resident's incontinence care needs was posted in a public hallway. Staff interviews confirmed these actions violated facility policy on privacy and respect.
A resident with severe cognitive impairment and multiple health conditions, who required substantial assistance with personal hygiene, was observed with unshaved facial hair despite expressing discomfort about it. Staff interviews revealed inconsistent shaving practices and a lack of available razors, resulting in the resident not receiving regular shaving as outlined in her care plan.
A facility failed to provide adequate pharmaceutical services, resulting in unaccounted for and misplaced medications for several residents. Narcotic audits were not properly conducted, leading to discrepancies in medication counts. LVN A improperly handled medications, including narcotics, and inaccurately documented administration. An incident involving MA A, who was believed to be responsible for missing medications, further contributed to the discrepancies. Despite negative drug test results, the facility's investigation revealed missing medications, and MA A was terminated. Residents were assessed with no adverse effects noted.
A resident with Alzheimer's and other conditions was not allowed to return to the facility after hospitalization due to aggressive behavior. The facility failed to provide the required 30-day written notice for discharge, and the resident was placed in another facility. Interviews and records indicated that the facility informed the family and hospital staff of their decision, contrary to their policy.
A resident with multiple health conditions was care planned for a pureed diet but received a regular diet due to a lack of communication and adherence to dietary orders. Staff interviews revealed that the pureed diet order might have been an error, and the facility's policy to verify food against diet orders was not followed, posing a risk to the resident's health.
A facility failed to maintain an accurate medical record for a resident, resulting in an incorrect pureed diet order being signed by the physician. Despite the order, the resident consistently received a regular diet with regular texture, as confirmed by staff interviews. The discrepancy was acknowledged by the facility's administration, who recognized the potential negative outcomes of serving an incorrect diet.
A resident with dementia was improperly transferred by a student nurse aide without a gait belt, resulting in a rib fracture and pneumothorax. The resident's care plan required two staff and a Hoyer lift for transfers, but this was not followed. The aide was aware of proper techniques but did not have the necessary equipment at the time.
A CNA failed to perform proper hand hygiene during incontinent care for a resident with dementia and incontinence issues, despite being trained on infection control. This oversight occurred when transitioning from a dirty to a clean surface, risking cross-contamination. Interviews revealed a lack of adherence to facility policies on hand hygiene, despite awareness of the procedures.
Failure to Provide CPR to Full Code Resident
Penalty
Summary
A registered nurse (RN) failed to provide basic life support, including CPR, to a resident who was found unresponsive and without vital signs. The resident had a documented full code status, as indicated in the care plan, physician orders, and admission notes. Despite this, the RN did not initiate CPR or arrange for emergency transport, instead contacting hospice and the resident's representative to report the death. The RN stated that she assumed the resident was a Do Not Resuscitate (DNR) because the resident was on hospice care, and did not verify the code status in the electronic medical record (EMR) before making this decision. The resident's representative, who was also the facility administrator, confirmed that there was no DNR on file and that the resident was a full code. The facility's policy required staff to provide CPR to residents with a full code status in the event of cardiac or respiratory arrest. Interviews with other nursing staff indicated that they were trained to check the code status in the EMR if a resident was found unresponsive. The failure to initiate CPR for a resident with a full code status constituted a failure to follow physician orders and facility policy regarding life-saving measures.
Care Plan Lacked Required Dietary Information
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that accurately reflected a resident's needs, specifically omitting the resident's mechanical soft texture diet. The resident, a male with diagnoses including unspecified dementia, seizures, muscle wasting and atrophy, lack of coordination, and muscle weakness, was dependent on staff for multiple activities of daily living and required a mechanically altered diet as indicated in his physician orders and MDS assessment. However, a review of the resident's care plan showed that it did not include the mechanical soft diet, despite this being ordered by the physician and provided during meal observations. Interviews with facility staff, including an LVN, the MDS Coordinator, and the Administrator, confirmed that the care plan should have reflected the resident's mechanical soft diet. The staff relied on meal tickets and physician orders to provide the correct diet but were unaware that the care plan was not updated accordingly. The facility's policy requires that care plans include measurable objectives and timeframes to meet residents' identified needs, but this was not followed in this instance, resulting in an incomplete care plan for the resident.
Failure to Ensure Resident Call Lights Were Accessible
Penalty
Summary
The facility failed to ensure that the call light system was accessible to all residents in their bedside, toilet, and bathing areas, as required for resident safety and communication. Observations revealed that three residents with severe cognitive impairment and significant mobility limitations did not have their call lights within reach. For one resident, the call light was found hanging between the bed and the wall, out of reach while the resident was sitting on the bed. Another resident's call light was placed on a roommate's bedside table, making it inaccessible while the resident was lying in bed. A third resident's call light was observed on the floor approximately 40 feet away from the bed, also out of reach. Interviews with the affected residents confirmed that the call lights were rarely or never within reach, and in some cases, residents had to go to great lengths, such as reaching under furniture, to access them. One resident stated that the call light was always hung straight to the floor and did not use it. The residents involved had diagnoses including severe cognitive impairment, mobility issues, and other complex medical conditions, making them particularly dependent on staff assistance and the ability to summon help when needed. Staff interviews, including those with the ADON, LVN, MA, and ADM, indicated that all were aware of the policy requiring call lights to be within residents' reach and acknowledged the importance of this practice for resident safety. Staff described that call lights should be checked during rounds and that all staff were responsible for ensuring accessibility. However, they also admitted that call lights were sometimes not placed back within reach after care activities, and some staff did not pay adequate attention to this requirement. The facility's policy on call lights and dignity was requested but not provided during the survey.
Failure to Provide Private Space for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private space for resident council meetings, as required by resident rights policies. Interviews with the Activity Director (AD), Assistant Director of Nursing (ADON), and Administrator (ADM) confirmed that resident council meetings were routinely held in the dining room, which was not private. Although the AD attempted to maintain privacy by closing doors and placing signs, staff continued to interrupt the meetings, and residents reported that their meetings were never private. During a confidential group meeting held in a bedroom, residents stated they could not speak freely due to frequent staff interruptions and expressed a desire for a more private meeting space. Staff interviews revealed that they were aware of the requirement for private resident council meetings and acknowledged their responsibility to ensure privacy. However, they also indicated that the resident council had not specifically requested a private space, and the issue had not been addressed. Review of the facility's Resident Rights Policy confirmed residents' rights to privacy and to organize and participate in resident groups. Despite this, the facility did not provide an appropriate private area for these meetings, resulting in a failure to honor residents' rights.
Failure to Provide Homelike Environment in Memory Care Unit
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for residents in the memory care unit. Observations revealed that resident rooms had grey, barren walls with no personal or homelike decorations, despite the presence of basic furnishings such as beds, dressers, televisions, blinds, over-bed lights, privacy curtains, and occasional recliners. While some paintings were present in common areas like the hallway, dining room, and dayroom, all five resident rooms lacked any personal or decorative items. Interviews with staff indicated that the absence of decorations was due to residents exhibiting behaviors such as tearing items off the walls, leading to a facility rule prohibiting decor in resident rooms. Staff also noted that decor was only placed in supervised common areas where residents could be monitored. Family members reported providing personal items, such as family pictures, for residents, but these were not observed in the rooms. Facility administration acknowledged ongoing challenges in maintaining a homelike environment, citing repeated removal of decorations by residents and the difficulty in keeping items in place. The facility's policy affirms the right of residents to a homelike environment and the use of personal belongings to the extent possible, but this was not reflected in the current state of the memory care unit rooms.
Failure to Provide Activities for Memory Care Residents
Penalty
Summary
The facility failed to provide both group and individual activities for residents in the memory care unit, as required by their comprehensive assessments and care plans. Observations revealed that residents spent extended periods sitting in the day room with only a television or radio for stimulation, and there was no activity calendar or evidence of activity materials such as puzzles, books, or art supplies available in the unit. Staff interviews confirmed that organized activities were not regularly conducted in the memory care unit, and activities were limited to passive options like watching television or listening to the radio. Occasional activities, such as nail painting for two residents, were mentioned, but these were not part of a structured program. The Activity Director (AD) acknowledged that she did not provide activities in the memory care unit and did not maintain an activity log for that area, despite being responsible for doing so. The AD relied on previous activity calendars but did not adapt or implement them for the memory care unit. The Administrator (ADM) also stated that activities in the memory care unit were less frequent than in other parts of the facility and believed that the main activity calendar was not appropriate for the memory care residents. The facility's own policy required a robust, therapeutic activity program tailored to individual needs, including both group and individual activities throughout the week, which was not being followed in the memory care unit.
Failure to Maintain Infection Control During Medication Pass and Linen Delivery
Penalty
Summary
The facility failed to establish and maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in infection control practices involving both medication administration and laundry handling. During medication administration, a medication aide (MA B) was observed repeatedly failing to perform hand hygiene between residents and not sanitizing the blood pressure cuff or the medication cart after use with each resident. Specifically, MA B used the same uncleaned blood pressure cuff on several residents, placed it back on the medication cart without cleaning, and did not consistently perform hand hygiene between residents, contrary to facility policy and infection control standards. Additionally, the facility did not ensure that laundry staff handled and stored linens in a manner that maintained cleanliness and prevented cross-contamination. Laundry staff were observed transporting and delivering linens using carts that were partially or fully uncovered while moving through resident areas and during delivery. This practice left clean linens exposed to potential contamination from the environment and resident contact, which was acknowledged by staff as being against facility policy. Interviews with staff, including laundry staff, medication aides, CNAs, LVNs, and the administrator, confirmed knowledge of the facility's policies requiring hand hygiene between residents, cleaning of equipment between residents, and keeping linen carts covered at all times. Despite this, the observed practices did not align with these policies. Record reviews for the involved residents indicated that they were cognitively impaired and had various medical conditions, including chronic diseases and infections, which could increase their vulnerability to infection. The facility lacked a specific policy for sanitizing equipment between residents, further contributing to the deficiency.
Failure to Protect Resident Dignity and Confidentiality
Penalty
Summary
The facility failed to ensure a dignified environment and protect resident rights for two residents. For one resident with a history of pneumonitis, epilepsy, stroke, malnutrition, right-sided muscle weakness, dementia, and anxiety, the Assistant Director of Nursing (ADON) referred to the resident's dining area as the 'feeder table' in the presence of another resident and a state surveyor. The ADON later acknowledged that this terminology was inappropriate and recognized it as a dignity issue, but was unsure of the correct term to use. For another resident with diagnoses including diabetes type 2, depression, anxiety, stroke, falls, and muscle weakness, a sign was posted on her door in a public hallway indicating her use of pull-ups and referencing her incontinence care needs. Interviews with staff, including a CNA, LVN, and the administrator, confirmed that facility policy requires confidentiality regarding incontinence and that such information should not be publicly displayed, as it could lead to embarrassment and loss of dignity for the resident.
Failure to Provide Necessary Assistance with Personal Hygiene (Shaving)
Penalty
Summary
A deficiency was identified when a resident with severe cognitive impairment and multiple diagnoses, including dementia, anxiety, depression, muscle wasting, and unsteadiness, did not receive necessary assistance with personal hygiene. The resident required substantial to maximal assistance for personal hygiene tasks, as documented in her care plan, which included interventions for assistance with hair care, shaving, and oral care. During an observation, the resident was found with facial hair along her chin approximately 1 cm in length. The resident expressed that the facial hair bothered her and could not recall the last time it had been shaved by staff. Interviews with staff revealed that shaving was typically performed during shower times, but could also be done outside of those times. A CNA reported difficulty recalling the last time the resident was shaved and noted that razors had not been available in the memory care unit. The facility's policy indicated that shaving should be part of daily personal hygiene or at least every other day, depending on beard growth. The failure to provide regular shaving assistance as required by the resident's care plan led to the resident not being well-groomed, as observed during the survey.
Medication Mismanagement and Missing Narcotics
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, resulting in unaccounted for, misplaced, and/or misappropriated medications for several residents. Narcotic audits were not properly conducted, leading to discrepancies in medication counts, including missing tablets of Lorazepam, Tylenol #3, Phenobarbital, and Amoxicillin. This failure affected seven residents, with specific instances of delayed medication administration for two residents and improper handling of medications by LVN A. LVN A did not adhere to the facility's Medication Administration Procedures policy, as they withdrew and prepared scheduled medications, including narcotics, for future administration but failed to administer or properly dispose of them. Additionally, LVN A did not sign the narcotic count sheets after removing medications, creating discrepancies in the medication counts. Furthermore, LVN A inaccurately documented the administration of a Fentanyl patch for a resident, signing it out before actual administration and causing a discrepancy in the count. The report also highlights an incident involving MA A, who was believed to be responsible for the missing medications. MA A was involved in an argument with staff and refused to count the medication cart with the DON, leading to further discrepancies. Despite the negative drug test results for MA A, DON, and LVN A, the facility's investigation revealed that medications were missing or unaccounted for, and MA A was ultimately terminated. The residents involved were assessed, and no adverse effects were noted, but the facility's failure to ensure proper medication management placed residents at risk of not receiving necessary therapeutic benefits.
Failure to Allow Resident Return After Hospitalization
Penalty
Summary
The facility failed to implement a policy in accordance with the State Medicaid Plan, which resulted in a resident not being allowed to return to his previous room after hospitalization. The resident, an elderly male with Alzheimer's, urinary tract infection, muscle weakness, bipolar disorder, and restlessness, was discharged to the hospital for evaluation. Despite the facility's policy requiring a 30-day written notice for transfers or discharges, the resident was not allowed to return, and there was no discharge paperwork completed. Interviews and record reviews revealed that the facility's administrator informed the resident's family and the hospital that the resident could not return due to aggressive behavior. The family member and hospital staff were told that the facility would not accept the resident back, leading to the resident being placed in another facility. The facility's actions were not in compliance with their policy, as they failed to notify the resident, his representative, and the LTC Ombudsman appropriately, placing the resident at risk of unnecessary hospitalization and a traumatic adjustment to a new facility.
Failure to Implement Accurate Dietary Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, specifically regarding her dietary needs. The resident, a female with multiple diagnoses including malnutrition, encephalopathy, and dementia, was care planned for a pureed textured diet, but was actually receiving a regular diet. This discrepancy was not identified by the facility staff, leading to a situation where the resident was consuming food inconsistent with her care plan. Interviews with various staff members, including an LVN, DS, PCP, NP, CNA, ADM, DON, and ADON, revealed a lack of awareness and communication regarding the resident's correct diet order. The resident's care plan and dietary orders were inconsistent, with the care plan indicating a pureed diet while the actual diet provided was regular. The facility's policy required serving diets as ordered by the physician, but this was not adhered to in the case of the resident. Staff interviews indicated that the pureed diet order might have been an error, possibly originating from a previous hospital stay. Despite the policy to verify food against diet orders, the resident continued to receive a regular diet, which was not aligned with the documented care plan. This failure in communication and adherence to dietary orders posed a risk to the resident's health and well-being.
Inaccurate Medical Record Leads to Incorrect Diet Order
Penalty
Summary
The facility failed to maintain an accurate medical record for a resident, leading to an incorrect diet order being signed by the physician. The resident, who was admitted with diagnoses including malnutrition, encephalopathy, and dementia, was documented to be on a pureed diet according to her care plan. However, interviews with staff revealed that the resident had been receiving a regular diet with regular texture, contrary to the pureed diet order. The Licensed Vocational Nurse (LVN) and Dietary Supervisor (DS) both confirmed that the resident had been eating regular textured food, and the DS suggested that the pureed diet order was an error. Further interviews with the Primary Care Physician (PCP) and Nurse Practitioner (NP) indicated a lack of familiarity with the resident's diet needs, with the NP stating that the pureed diet order likely originated from a hospital stay and was not appropriate for the resident's current condition. The facility's administration, including the Administrator (ADM), Director of Nursing (DON), and Assistant Director of Nursing (ADON), acknowledged the discrepancy between the diet order and what was being served, recognizing the potential negative outcomes of such an error. The facility's policy required diets to be served as ordered by the physician, but this was not adhered to in this case.
Improper Transfer Leads to Resident Injury
Penalty
Summary
The facility failed to ensure adequate supervision and the use of assistance devices during the transfer of a resident, leading to a significant injury. Specifically, a resident was transferred from her bed to a wheelchair by a student nurse aide without the use of a gait belt, which is against the facility's policy. This improper transfer resulted in the resident sustaining a 10th rib fracture and a pneumothorax, as confirmed by subsequent medical evaluations and x-rays. The resident involved was an elderly female with a diagnosis of unspecified dementia, which severely impaired her cognition. She was dependent on staff for transfers, as indicated in her care plan, which required the assistance of two staff members and the use of a Hoyer lift. However, at the time of the incident, the care plan had not been updated to reflect this requirement, and the student nurse aide performed the transfer alone without the necessary equipment. Interviews with the staff revealed that the student nurse aide was aware of the proper transfer techniques, including the use of a gait belt, but did not have one available at the time of the transfer. The Director of Nursing confirmed that it was the facility's policy to use a gait belt for all transfers and that staff were trained accordingly. Despite this, the resident was transferred improperly, leading to her injuries.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, specifically during the provision of incontinent care for a resident. During an observation, it was noted that a Certified Nursing Assistant (CNA) did not perform proper hand hygiene when transitioning from a dirty to a clean surface while changing a resident's brief. This lapse in protocol occurred despite the CNA having been trained on infection control and hand hygiene practices. The resident involved was an elderly female with a history of dementia, cerebrovascular disease, anxiety, and hypertension. She was noted to be always incontinent of bladder and frequently incontinent of bowel, requiring regular incontinent care. The resident's care plan included specific interventions to prevent skin breakdown and complications related to incontinence, such as applying a moisture barrier and performing perineal care after each episode. Interviews with the CNAs involved and facility administration revealed that while staff were aware of the need for hand hygiene, they did not apply this knowledge correctly during the incontinent care process. The facility's policy clearly outlined the need for hand hygiene before and after contact with soiled materials, yet this was not adhered to during the observed incident, leading to a risk of cross-contamination and infection spread.
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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 Kerens
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cedar Lake Nursing Home | 13.5 mi | ★★★★★ | 6 | 0 |
| Twilight Home | 16.1 mi | ★★★★★ | 0 | 0 |
| The Village At Heritage Oaks | 16.2 mi | ★★★★★ | 1 | 0 |
| Meadows Of Corsicana, Llc | 16.3 mi | ★★★★★ | 4 | 0 |
| Legacy At Corsicana Rehabilitation And Healthcare | 16.5 mi | ★★★★★ | 7 | 0 |
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