Town Hall Estates

In the surveyor’s words

From the most serious findings on record at Town Hall Estates, in the surveyor’s own words.

• Immediate jeopardy, patternF684Aug 29, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF655Sep 6, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Sep 6, 2025

  Based 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. […]

• Immediate jeopardy, isolatedF689Apr 18, 2025

  Based 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. […]

• Actual harm, isolatedF689Aug 29, 2024

  Based 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. Findings included : Review of Resident #1's quarterly MDS assessment, dated 04/16/24, Section A (Identification Information) reflected a[AGE] year-old female admitted to the facility on [DATE]. […]