Town Hall Estates

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents received care in accordance with professional standards of practice, for 1 (Resident #1) of 4 resident reviewed for resident rights. The facility failed to implement interventions, according to the comprehensive plan of care, to check on and change Resident #1 on rounds, and as needed, to keep Resident #1's and dry, and keep her free from falls. The failure placed residents at risk of falls, injuries, a decline or decrease in their quality of life and quality of care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 2 (Resident's #17, #22) of 6 residents reviewed for baseline care plans. The facility failed to ensure Resident #17's and Resident #22's baseline care plans addressed their mobility abilities. The facility failed to complete Resident #27 and Resident #44's baseline care plans. This failure could place residents at risk of getting insufficient care, not having personal needs not met resulting in hospitalizations and injuries related to falls. An IJ was identified on 09/04/25. The IJ template was provided to the facility on [DATE] at 4:53 pm. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #17 and Resident #22) of 8 residents reviewed for accidents and hazards. The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents in that The facility failed on 08/04/2025 to ensure appropriate supervision and assistive devices were in place for Resident #17 and Resident #22 to prevent falls. This failure could place residents at risk for injury and hospitalizations related to accidents. An IJ was identified on 09/04/25. The IJ template was provided to the facility on [DATE] at 4:53 pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the residents' medical symptoms for 1 of 5 residents (Resident #25) reviewed for unnecessary medications. The facility failed to ensure Resident #25's PRN Lorazepam (medicine used to treat the symptoms of anxiety) was discontinued after 14 days or document a rationale for the continued provision of the medication. This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to complete a Significant Change MDS assessment with 14 days after the facility determined, or should have determined, there has been a significant change in a resident's physical or mental condition for 1 of 5 residents reviewed for assessments (Resident #25). The facility failed to complete a Significant Change MDS for Resident #25 within 14 days of the resident's admission to hospice services. This failure placed residents who had a significant change in condition requiring an MDS assessment at risk of not receiving needed services.

Inspectors wroteBased on interviews, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 4 residents (Resident #26) who were reviewed for accuracy of assessments. The facility failed on 5/16/2025 to accurately document Resident #26's diagnosis of depression on her quarterly MDS assessment. This failure placed residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure all medications that were reviewed by the licensed pharmacist were reported to the attending physician and if there is to be no change in the medication, the attending physician should document his or her rationale in the resident's medical record for 1 of 4 residents (Resident #26) reviewed for unnecessary medications. The facility failed on 04/07/2025 to ensure the medical director documented in Resident #26's medical record the rationale for no action being taken on a GDR recommendation by the licensed pharmacist for Resident #26's Bupropion order (used to treat depression). This deficient practice could affect all residents who have pharmacy recommendations which could place the residents at risk of receiving unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for 1 (Resident #44) of 4 residents reviewed for unnecessary medications. The facility failed on 08/19/2025 to have an adequate indication for use of Midodrine HCl 10mg for Resident #44. This failure could place residents at risk of not receiving the needed monitoring or interventions to prevent potential harm related to adverse side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 (Middle Hall-RN Cart) of 2 medication carts reviewed for drug storage. The facility failed on 08/19/2025 to ensure one medication cart (Middle Hall-RN Cart) was locked and that medications were securely stored. This failure could place residents at risk of obtaining and taking medications not prescribed for them which could result in resident's harm due to adverse medication reactions.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, distribute, and serve food in accordance with professional standards for food safety for 1 of 1 kitchen reviewed for food safety. The facility failed on 08/19/2025 to maintain a properly cleaned ice machine used to serve ice to residents. The facility failed on 08/20/2025 to ensure staff who passed trays to residents properly sanitized their hands in between individual meal set up. This deficient practice could place residents at risk of food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete, accurately documented, and readily accessible for 1 (Resident #26) of 4 residents reviewed for clinical records. The facility failed to document Resident #26's diagnosis of depression in her active diagnoses list in the EHR.This failure could place residents at risk for delays in treatment due to incomplete and inaccurate clinical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 staff reviewed for infection control. (CNA B)The facility failed on 8/20/2025 to practice effective infection control practices when CNA B applied a brief onto Resident #32 after it had been dropped onto the floor during incontinent care. This failure could place residents at risk of being susceptible to bacteria and cross contamination during incontinent care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to Identify and eliminate all known and foreseeable accident hazards in the resident's environment, to the extent possible for 1of 4 residents (Resident #1) reviewed for safety. The facility failed to ensure 1 of 4 residents (Resident #1) was free from risk of accidents and injuries when he was allowed to elope from the facility. The facility failed to properly repair a door for years. An IJ was identified on 04/16/2025. The IJ Template was provided to the facility on [DATE] at 05:09 PM. While the IJ was removed on 04/18/2025, 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. [...]

Inspectors wroteBased on observation , interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three of ten (Resident #1, Resident #2 and Resident #3) residents reviewed for quality of care. 1. The facility failed to ensure skin assessment orders for Resident #1 and Resident #2 were followed. 2. The facility failed to ensure Resident #3 was not left in bedding saturated with urine. 3. The facility failed to ensure Resident #3 received incontinent care for over two hours from 3:12 PM until 5:13 PM on 03/06/25. These failures could place residents at risk of skin breakdown, infection, and injury.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 8 residents (Resident #4) reviewed for ADL care. The facility failed to ensure toenails for diabetic Resident #4 were smooth and trimmed. This failure could place residents at risk of skin tears and infection.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for one (1) of one kitchen reviewed for food storage and sanitation. The facility failed to ensure food and beverages were labeled and dated in the dry storage, walk-in refrigerator, and freezer. This deficient practice could place all 57 residents at risk of food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for three (Resident #1, Resident #2, and Resident #4) of five residents reviewed for quality of care. The facility failed to conduct a fall assessment or skin assessment after Resident #1 had a fall on 05/06/24. The facility failed to utilize a two person assist for Resident #1 while providing care, Resident #1 slipped out of bed causing an abrasion to her back and bruising on her face on 05/06/24. The facility failed to document a fall, conduct a fall assessment or a skin assessment after Resident #2 had an unwitnessed fall on 06/23/24 resulting in fractured ribs. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility failed to ensure Resident #1 received 2-person assistance, as specified in the care plan, when CNA D provided incontinent care independently resulting in Resident #1 falling out of bed on 05/06/24, causing an abrasion on her back and bruising on her face . This failure could place residents at risk of injuries, falls, and a decline in quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 3 residents (Resident #8, Resident #12 and Resident #13) reviewed for activities of daily living . The facility failed to document Resident #8, Resident #12 and Resident #13 received showers as scheduled. The facility failed to assist Resident #8 with hygiene and Resident #12 with grooming. The facility failed to provide Resident #13 with showers as scheduled. This failure could place residents at risk of embarrassment, injury, skin breakdown and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1) of 2 medication carts (East Hall medication cart) and 1 of 1 medication refrigerator (Middle Hall medication refrigerator) reviewed for medication storage. 1. The facility failed to ensure the middle hall medication refrigerator was within an acceptable temperature range by not checking the temperature on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE]. [DATE] and [DATE]. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record contain an accurate representation of the actual experiences of the resident and include enough information to provide a picture of the resident's progress, including his/her response to treatments and/or services, and changes in his/her condition for 1 (Resident #1) of 4 residents reviewed for resident assessments. This failure could place residents at risk of embarrassment, injury, skin breakdown and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights, which included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 residents (Resident #16) reviewed for care plans. The facility failed to ensure Resident #16's comprehensive care plan, dated 05/02/2024, reflected the resident received routine and as needed pain medication for a diagnosis of low back pain . This deficient practice could place residents at risk of not receiving proper care for pain management and other services due to inaccurate care plans.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for the only facility kitchen reviewed for food storage and sanitation. The facility failed to ensure food and beverages were labeled and dated in the refrigerator and freezer. This deficient practice could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the nurse staffing information was posted on a daily basis and included the total number and the actual hours worked by licensed and unlicensed nursing staff for 2 of 3 days (6/25/24 and 6/26/24) reviewed for nurse staffing and the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater, for the last 18 months. 1. The facility failed to ensure the Daily Staffing log contained the total number and actual hours worked of licensed and unlicensed nursing staff directly responsible for resident care per shift for registered nurses, licensed practical or vocational nurses, and certified nurse aides on 6/25/24 and 6/26/24. 2. The facility failed to maintain the nurse staffing data from December 2022 through June 26, 2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 2 out of 14 residents (Residents #28, and #40) reviewed for respiratory care. 1- The facility failed to change and/or label Resident # 28's oxygen equipment and handheld nebulizer equipment in accordance with professional standards of practice and the facility policy and procedure. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen. 1. The facility failed to ensure that food was properly stored in the kitchen's dry storage, refrigerator, and freezer. 2. The facility failed to ensure that kitchen's expired foods were discarded. 3. The facility failed to label and date food in the kitchen refrigerator. These failures could place residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 6 of 6 residents observed (Resident #5, Resident# 11, Resident#21, Resident# 28, Resident #30, Resident#41) for infection control. The facility failed to ensure CMA A disinfect the blood pressure cuff in between blood pressure checks for Resident #5, Resident# 11, Resident #30, and Residnet#41 The facility failed to ensure LVN C change glove and perform hand hygiene, after dropping on the floor, then picking up, and putting in the trash a blood sugar lancet (the device used to stick resident finger to get the blood sample); then get a new lancet from the medication cart, and proceed to check Resident#28 blood pressure with the same glove. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the call system was accessible to the resident at each toilet and bath or shower located in the facility. The call system should be accessible to a resident lying on the floor. The facility failed to ensure the call light system in 2 showers rooms (shower A and Shower B) in the facility are accessible to a resident lying on the floor. This failure could place residents in the shower facility at risk of being unable to obtain assistance in the event of an emergency.

Inspectors wroteBased on interviews and record reviews the facility failed to coordinate assessments with the PASARR program for 1 (Resident #8) of 5 residents reviewed for PASARR. The MDS Coordinator failed to ensure Resident #8 was referred to the local authority for evaluation of a positive PASRR I. This failure placed the residents at risk of not receiving specialized services for their mental illness.

Inspectors wroteBased in observations, record reviews, and interviews the facility failed to ensure that residents received proper treatment and care to maintain mobility by assisting 1 (Resident #39) of 5 residents reviewed for foot care in making an appointment with the podiatrist. The facility failed to ensure Resident #39 was treated by the podiatrist when he visited the facility. This failure placed residents at risk of developing foot issues that could impede their mobility. Review of Resident #39's admission Record revealed he was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included prostate cancer, weight loss, and reflux. Review of Resident #39's quarterly MDS, dated [DATE], revealed his BIMS score was 7, indicating severe cognitive impairment. His Functional Status indicated he required extensive assistance with his personal hygiene. [...]