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Complaint Investigation

Town Hall Estates

September 6, 2025 · Hillsboro, TX · 300 Happy Ln
Citations 2
CMS Rating 2/5
Beds 138
Provider ID 676033
Healthcare Facility
Town Hall Estates
Hillsboro, TX  ·  View full profile →
Inspection Summary

Town Hall Estates in Hillsboro, TX — inspection on September 6, 2025.

Found 2 citations. 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.

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Inspection Findings

FF0655
Resident Assessment and Care Planning Deficiencies
Immediate Jeopardy

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.

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

09/06/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Town Hall Estates

300 Happy LN Hillsboro, TX 76645

SUMMARY STATEMENT OF DEFICIENCIES

jeopardy to resident health or safety

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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Hillsboro, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Town Hall Estates or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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