Town Hall Estates

F 0655 Level of Harm - Immediate jeopardy to resident health or safety

assistive devices needed. Record review of education provided to nurses, direct care staff and agencies on

the revised admission process and policy to require baseline care plan initiation within 48 hours. Nurses, direct care staff and agencies staff were required to read, acknowledge understanding and sign the in-services before the start of their shift. A competency check (test) had been implemented to ensure understanding. The competency check (test) was completed and signed by 5 LVNs and 2 RNs from both day and night shifts.

Residents Affected - Few

Record review completed on 09/05/25 of an Implemented admission checklist and new 'admission Quality Check' form was verified to include care plan and fall risk completion. An Inservice given to Nursing staff was completed to include an updated report sheet located at the nurses' desk directing care staff and agencies staff to look at the report sheet located at the nurses' desk before start of the shift requiring a signature acknowledging that the changes had been reviewed by the staff. Education verification and acknowledgement of understanding per the competency check was signed by 5 LVNs and 2 RNs from both day and night shifts.

Record review completed on 09/05/25 of new Monitoring tools was conducted to capture ongoing audits of all new admits' baseline care plans (daily for 30 days, weekly for 60 days, then monthly ongoing). The tool included Baseline care plan initiated within 48 hours of admission.

Interviews conducted on 09/06/25 between 6:00am and 8:00am with DON, ADON, LVN C, LCN D, LVN I, LVN E, RN F, from both day and night shifts reflected They had been instructed on baseline care plans ensuring residents' mobility, transfers and supervision needs were included. They stated Nurses, direct care staff and agencies staff were required to read, acknowledge understanding and sign the in-services before

the start of their shift. The staff stated agencies they were to look at the report sheet located at the nurses' desk before start of the shift and sign it acknowledging that the resident changes had been reviewed by the staff. The staff verified they were given competency test on their education.

On 09/06/2025 at 8:18am, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with

a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

09/06/2025

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 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

assessments were initiated on residents with new falls. Neuro checks were initiated immediately for two residents identified with recent falls verified with record review. Nursing staff were educated on performing neurological check on resident post fall as evidenced by an in-service signed and dated for 09/05/25.

Record review of an audit completed on 09/05/25 for all residents for admission fall risk assessment and quarterly fall risk assessments was signed completed by the ADON. Residents had current completed fall risk assessments as evidenced by a review of medical records for 7 residents within the facility. Record

review completed on 09/05/25 of an Inservice verified that license nurses including PRN and agency nurses were re-educated on completing fall risk assessments within 24 hours of admission and ensuring proper supervision. The Director of Nursing and the Assistant director of Nursing on monitoring that the fall risk assessments are being completed by the charge nurses within 24 hours of admission and ensuring proper supervision by the Nurse Consultant on 09/05/25. Education was verified for 6 of 8 nursing staff

Record review completed on 09/05/25 of new admission Monitoring tools was conducted. The tool included resident name, date of admission, verifying the fall risk assessment was completed along with a baseline care plan. The facility did not have any new admission as of time of exit. The [NAME] stated the tool will be reviewed daily in their morning meeting for verification of completion. Interviews conducted on 09/06/25 between 6:00am and 8:00am with DON, ADON, LVN C, LCN D, LVN I, LVN E, RN F, from both day and night shifts reflected They had been instructed on Fall Policy, Fall Risk Assessments, including assessment of neurological status. The staff stated they had been educated on need for assistive devices and fall prevention measures including keeping beds in low positions, more frequent rounding, and call light placement. The staff were able to identify the report sheet located at the nurses' station to be signed each shift verifying resident changes in condition had been reviewed from one shift to the next. On 09/06/2025 at 8:18am, the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a level of no actual harm with the potential for more than minimal harm with a scope identified as isolated due to the facility's need to monitor the implementation and effectiveness of its POR.

Event ID:

Facility ID:

If continuation sheet