Town Hall Estates

F-F689 The facility failed to ensure Resident #1 was free from risk of accidents and injuries.

l. Immediate Action Taken

A. Resident # 1 is currently in the facility.

B. On 4/9/25 Resident #1 was returned to the facility via private vehicle by staff and placed on q15 minute monitoring which entails the following: staff visually confirming the resident's location, a log sheet for documenting the resident's location, including space for staff signatures, and timestamp for each

observation.

C. On 4/16/2025 The DON/ Designee completed a head-to-toe physical assessment on Resident #1 with no negative findings noted

D. On 4/16/25 The DON/ Designee updated Resident #1 care plan for wandering/exit seeking

E. On 4/16/25 The DON/ Designee completed elopement assessments on all facility residents with no changes noted.

F. On 4/16/25 The maintenance director/ Designee completed environmental assessments to include checks

on all door alarms. These checks identified 3 nonfunctioning door alarms (100 hall door, west hall door that faces the facility parking lot, and downstairs hallway office door).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 8 676033 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 G. On 4/16/25 The administrator/Designee assigned facility staff to monitor identified nonfunctioning doors and the elevator will be locked during non-business overnight hours to allow no access without facility code Level of Harm - Immediate to ensure that no resident exits the facility. Upstairs assigned staff will be physically present at the area that jeopardy to resident health or accesses the two doors waiting for repair. Department Head staff downstairs will be rotated to ensure visual safety observation of that door between 8a-5p. After 5p, elevators will be locked and only accessible via key access. Elevators will only be accessible via key access on the weekends. Residents Affected - Few H. On 4/11/25 The Social Worker/Designee checked the wander guard appliances utilized by residents to ensure they were functioning properly with the doors that are currently functioning. No issues were identified with the appliances, and they were identified to be currently functioning properly.

I. On 4/16/25 The DON/ Designee completed in-service education with facility direct care staff on the elopement policy. No employee will be allowed to work until they receive this education with drill and posttest.

J. On 4/16/25 The DON/ Designee completed a Missing Resident Drill with facility direct care staff to ensure staff know the proper procedure for locating missing residents to include when a staff member hears the alarm sound they will initiate the code silver alert via overhead paging to notify all other staff members of the missing resident and to not turn the alarm sound off until all staff are notified of the missing resident and headcount guidelines which requires visual confirmation and documentation regarding the location of each resident in the center. The designated head count coordinator will be the Administrator or DON during business hours (8a-5p) and the designated charge nurse and/or the Manager on Duty during non-business hours. (5p-8a).On 4/16/25 The facility administrator spoke with alarm company in regard to the nonfunctioning door alarm who stated they would have a tech support person to the facility on [DATE REDACTED] to repair the nonfunctioning door alarms.

K. 2. Identification of Residents Affected or Likely to be Affected:

A. No other residents identified, on 4/16/25, the DON/Designee completed elopement assessments on all facility residents with no new changes noted.

3. Actions to Prevent Occurrence/Recurrence:

A. On 4/16/25, the DON/Designee provided education to facility direct care staff on facility's elopement Policy including missing resident drill.

B. On 4/17/25, the DON/Designee provided missing resident posttest to facility direct care staff.

These in-services will be accessible via our communications platform (online information system for staff with

a required 85% passing score). This will be completed at 6:00 pm on 4/17/2025 and no employee will be allowed to work until they receive this education with drill. Agency staff will be provided these trainings through access from our online communications platform as well.

C. Results of facility missing resident drills will be discussed with Facility Administrator/ Designee during the facility recurring daily morning start up meetings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 8 676033 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 On 4/16/2025 the facility's Administrator notified the Medical Director regarding the Immediate Jeopardy the facility received related to Accidents/Hazards/Supervision and reviewed plan to sustain compliance with no Level of Harm - Immediate new orders received. jeopardy to resident health or safety Likelihood for Serious Harm No Longer Exists: 4/17/2025.

Residents Affected - Few Signature of ADM on 4/17/2025

On 4/17/25 and 4/18/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by:

4/17/25 Monitoring:

Observation on 4/17/25 at 11:30 the ENG company at the facility working on the 3 broken doors. Office staff were turning staff away from the OHD door to prevent alarms from sounding when there was not a problem and therefore making a problem very noticeable if it occurred.

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 8 676033 Department of Health & Human Services Printed: 08/28/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

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

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 4/18/25 Monitoring:

Level of Harm - Immediate Observation on 4/18/25 at 10:50 AM revealed no residents in rooms or halls on WHD and WLD. Staff were jeopardy to resident health or posted specifically at these entrance points and intersections to disallow residents from accessing these safety doorways. Observed a staff member also posted near the nurse's station (unused station) to ensure residents did not enter that area without staff accompanying them. Residents Affected - Few

Observation on 4/18/25 at 11:00 AM revealed the Office Hall where the OHD was located, contained offices

in which staff members were observed working with the doors open, monitoring traffic in and out.

In an interview on 4/18/25 at 10:48 AM the DON stated the Elopement Drill had been completed and she would provide the documentation for that exercise. The DON stated the 3 doors that were out of service were being monitored and they were disallowing resident traffic on those halls.

In an interview on 4/18/25 at 10:53 AM AL stated her role to prevent further elopements until doors were fixed was to sit at the intersection of the 2 [NAME] Halls and not allow anyone to access the malfunctioning doors. She stated this was being done for the safety and protection of the residents.

In an interview on 4/18/25 at 11:00 AM the DON stated part of the plan was for staff on this hallway to monitor. She stated the staff were to communicate if they were leaving the hallway with each other to ensure someone was always downstairs. She stated the OHD would sound if opened but not for long, so staff were not to use those doors either to avoid monitoring staff from becoming accustomed to the alarm and unknowingly ignoring the alarm.

Record review on 4/18/25 reflected 16 staff signatures on an Elopement Drill Sign-in form.

The administrator was notified the IJ was removed on 04/18/2025 at 08:30 AM, however the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to complete repairs and evaluate the effectiveness of the corrective systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 8 676033