Inspection·October 14, 2024

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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. The findings included: Kitchen observation on 10/14/2024 at 12:07 pm of a dry storage cabinet, revealed an open bag of brown powder with brown powder on the shelf. The open bag was labeled cumin and there was no date on the bag. Kitchen observation on 10/14/2024 at 12:10 pm in the walk-in fridge, revealed a container labeled applesauce 8/30/24|9-4 and a container labeled prunes 9/29. During an interview on 10/14/2024 at 12:10 pm the DM stated the applesauce with a date of 8/30/24|9-4, should have been thrown out after 9/4/2024 and the prunes should have been discarded after 9/29/24. Kitchen observation on 10/14/2024 at 12:11 pm outside the walk-in fridge, revealed a tray of partially frozen hotdogs sitting outside the walk-in fridge. Inside the walk-in fridge, an observation of a tub of covered drink glasses with a white liquid in them. The tub was not labeled or dated. During an interview on 10/14/2024 at 12:12 pm the DM stated the hotdogs had been taken out of the freezer in preparation for another meal the next day. The DM stated the hotdogs should not be sitting out but should have been put in the fridge. The DM identified the glasses of liquid as milk and noted they should have been labeled and dated. Kitchen observation on 10/14/2024 at 12:12 pm in the walk-in fridge revealed a plastic container of plastic wrapped items not labeled or dated. During an interview on 10/14/2024 at 12:12 pm the DM stated the items were sliced cheeses and lunch meat and should have been labeled and dated before being put away. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 676033 Printed: 05/15/2026 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 676033 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/14/2024 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)