Town Hall Estates
Town Hall Estates in Hillsboro, TX — inspection on April 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Observation on 4/17/25 at 04:45 PM revealed the OHD hall staff coordinating if they leave the Office Hall to ensure staff were present to hear the alarm on OHD and to monitor the hall for residents.
Observed 1 staff member assigned to the unused nurses station located between WHD and LHD with constant visual monitoring of the doors that weren't working.
In an interview on 4/17/25 at 12:48 PM, the DON stated the following steps had been completed:
QAPI Meeting held on 4/16/25 at 08:30 PM with the ADM, the DON, and the MD.
In-services were done on 4/16/25 and 2 in-services were done on 4/17/25.
Another in-service and Elopement Drill were planned for 4/17/25 on the night shift.
The ENG company just left, and they confirmed doors not working and ordered the parts.
They were supposed to return Monday.
She further stated it was important to monitor Dementia residents because they were unaware of their own safety needs and the facility had to keep them safe.
She stated the negative outcome to residents if they wander could be injury and death.
She stated if alarms sound too often it becomes background noise and that was why they were now coordinating staff to not use the OHD at all so the alarm will not sound if there was not a problem.
She stated they were also coordinating the office staff to make sure someone was on the hall.
During the business hours the hall was accessible.
Record review reflected 3 completed in-services on elopements and alarms with staff signatures attached and dated 4/1625 and 4/17/25.
Record review reflected an invoice from the ENG showing doors were worked on and parts were ordered and dated 4/17/25.
Record review on 4/17/25 reflected the typed minutes of the QAPI meeting held on 4/16/25 listed topics as facility elopement and the follow-up plan to sustain compliance.
Attendees shown as the ADM, the DON, and the MD.
676033
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676033 B.
Wing 04/18/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Town Hall Estates 300 Happy LN Hillsboro, TX 76645
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.