Town Hall Estates

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 3 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.1 to 1.8 hours per resident per day.

CMS lists this as a complaint inspection.

• Citation F0609. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

  CMS lists it as corrected on September 24, 2026.

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CMS lists this as a complaint inspection.

• Citation F0641. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on September 23, 2026.

  CMS has cited this home for F0641 2 times since 2025.

• Citation F0844. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Follow rules about disclosure of ownership requirements and tell the state agency about changes in ownership and/or administrative personnel.

  CMS lists it as corrected on September 23, 2026.

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• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 4 of 5.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on July 8, 2026.

  CMS has cited this home for F0689 4 times since 2024.

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• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.5 to 3.0 hours per resident per day.

• Star rating

  The CMS staffing star rating changed from 3 of 5 to 2 of 5.

• Fine

  CMS changed the fine from April 18, 2025 from $20,400 to $13,260.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 3 of 5.

• Fine

  CMS changed the fine from August 29, 2024 from $38,769 to $38,829.

CMS lists this as a standard inspection and a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.

• Citation F0655. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

  CMS lists it as corrected on September 7, 2025.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 7, 2025.

• Citation F0605. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

  CMS lists it as corrected on September 28, 2025.

• Citation F0637. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Assess the resident when there is a significant change in condition

  CMS lists it as corrected on September 28, 2025.

• Citation F0641. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident receives an accurate assessment.

  CMS lists it as corrected on September 28, 2025.

• Citation F0756. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

  CMS lists it as corrected on September 28, 2025.

• Citation F0757. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure each resident’s drug regimen must be free from unnecessary drugs.

  CMS lists it as corrected on September 28, 2025.

• Citation F0761. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on September 28, 2025.

  CMS has cited this home for F0761 2 times since 2024.

• Citation F0812. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on September 28, 2025.

  CMS has cited this home for F0812 4 times since 2023.

• Citation F0842. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on September 28, 2025.

  CMS has cited this home for F0842 2 times since 2024.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on September 28, 2025.

  CMS has cited this home for F0880 2 times since 2023.

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CMS lists this as a standard inspection.

• Citation K0372. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on December 8, 2025.

  CMS has cited this home for K0372 2 times since 2023.

• Citation K0321. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on December 8, 2025.

  CMS has cited this home for K0321 2 times since 2023.

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• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Fine

  CMS changed the fine from August 29, 2024 from $38,327 to $38,769.

• Star rating

  The CMS overall star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 5 of 5 to 3 of 5.

• Fine

  CMS changed the fine from August 29, 2024 from $58,965 to $38,327.

CMS lists this as a complaint inspection.

Severity J is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

407 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2025.

• Citation F0689. Severity J: immediate jeopardy, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on April 19, 2025.

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CMS fine of $13,260 on April 18, 2025.

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CMS lists this as a complaint inspection.

• Citation F0684. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on April 4, 2025.

  CMS has cited this home for F0684 2 times since 2024.

• Citation F0677. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on April 4, 2025.

  CMS has cited this home for F0677 2 times since 2024.

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• Star rating

  The CMS overall star rating changed from 4 of 5 to 2 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS health inspection star rating changed from 4 of 5 to 2 of 5.

• Star rating

  The CMS overall star rating changed from 3 of 5 to 4 of 5.

• Star rating

  The CMS quality measures star rating changed from 4 of 5 to 5 of 5.

CMS lists this as a complaint inspection.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on November 8, 2024.

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CMS stopped payment for new admissions from October 1, 2024, for 38 days.

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CMS lists this as a complaint inspection.

Severity K is the highest of CMS's four levels. CMS uses it when residents' health or safety is at serious risk right away.

411 of 1,177 Texas homes (35%) got a citation at the immediate jeopardy level in 2024.

• Citation F0684. Severity K: immediate jeopardy, pattern.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on September 27, 2024.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 27, 2024.

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CMS fine of $38,829 on August 29, 2024.

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• Star rating

  The CMS quality measures star rating changed from 3 of 5 to 4 of 5.

• Staffing

  Total nurse staffing reported to CMS went from 3.2 to 2.6 hours per resident per day.

CMS lists this as a standard inspection.

• Citation F0677. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide care and assistance to perform activities of daily living for any resident who is unable.

  CMS lists it as corrected on July 10, 2024.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on June 30, 2024.

• Citation F0842. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

  CMS lists it as corrected on July 10, 2024.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on June 30, 2024.

• Citation F0812. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on June 28, 2024.

• Citation F0732. Severity C: potential for minimal harm, widespread.

  The rule CMS cited: Post nurse staffing information every day.

  CMS lists it as corrected on June 30, 2024.

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CMS lists this as a standard inspection.

• Citation K0211. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on February 27, 2025.

  CMS has cited this home for K0211 2 times since 2023.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on February 25, 2025.

  CMS has cited this home for K0222 2 times since 2023.

• Citation K0223. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

  CMS lists it as corrected on February 27, 2025.

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• Fine

  CMS changed the fine from August 14, 2023 from $4,196 to $4,235.

• Fine

  CMS changed the fine from August 21, 2023 from $4,545 to $4,587.

• Fine

  CMS changed the fine from July 17, 2023 from $9,440 to $9,527.

• Fine

  CMS changed the fine from August 7, 2023 from $3,846 to $3,882.

• Fine

  CMS changed the fine from August 28, 2023 from $4,545 to $4,587.

• Fine

  CMS changed the fine from September 5, 2023 from $4,545 to $4,587.

• Star rating

  The CMS overall star rating changed from 4 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 3 of 5.

CMS lists this as a standard inspection.

• Citation F0695. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on June 18, 2023.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on July 11, 2023.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on July 11, 2023.

• Citation F0919. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that a working call system is available in each resident's bathroom and bathing area.

  CMS lists it as corrected on June 21, 2023.

• Citation F0644. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

  CMS lists it as corrected on July 6, 2023.

• Citation F0687. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate foot care.

  CMS lists it as corrected on June 15, 2023.

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CMS lists this as a standard inspection.

• Citation E0004. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Develop and maintain an Emergency Preparedness Program (EP).

  CMS lists it as corrected on August 4, 2023.

• Citation E0006. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Conduct risk assessment and an All-Hazards approach.

  CMS lists it as corrected on August 15, 2023.

• Citation E0030. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: List the names and contact information of those in the facility.

  CMS lists it as corrected on August 15, 2023.

• Citation K0324. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide properly protected cooking facilities.

  CMS lists it as corrected on August 3, 2023.

• Citation K0352. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Properly install and monitor supervisory attachments on automatic sprinkler systems.

  CMS lists it as corrected on August 9, 2023.

• Citation K0511. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have properly installed electrical wiring and gas equipment.

  CMS lists it as corrected on August 7, 2023.

• Citation K0712. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have simulated fire drills held at unexpected times.

  CMS lists it as corrected on August 14, 2023.

• Citation K0900. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Meet Health Care Facilities Code mechanical requirements.

  CMS lists it as corrected on July 21, 2023.

• Citation K0916. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have a battery powered remote alarm panel in a location accessible by operating personnel.

  CMS lists it as corrected on August 17, 2023.

• Citation K0918. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on August 9, 2023.

• Citation K0222. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

  CMS lists it as corrected on July 28, 2023.

• Citation K0291. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install emergency lighting that can last at least 1 1/2 hours.

  CMS lists it as corrected on August 9, 2023.

• Citation K0321. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

  CMS lists it as corrected on July 28, 2023.

• Citation K0355. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on July 21, 2023.

• Citation K0211. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Keep aisles, corridors, and exits free of obstruction in case of emergency.

  CMS lists it as corrected on July 19, 2023.

• Citation K0361. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.

  CMS lists it as corrected on August 3, 2023.

• Citation K0372. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on August 8, 2023.

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