Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0550
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or
her rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure staff interacted with residents in a
manner that assures communication, maintains respect, and enhances his/her quality of life for one
(Resident #1) of six residents reviewed for resident rights.
The facility failed to ensure Resident #1 was treated with respect and dignity while being fed by staff.
These failures could place residents at risk for poor nutrition and hydration and diminished quality of life.
Findings included:
Record Review of the undated Face Sheet for Resident #1 reflected a [AGE] year-old female who was
admitted to the facility on [DATE] with the following diagnoses: Parkinson (conditions that affect movement),
Unspecified Dementia (group of symptoms affecting memory), Unspecified Protein-Calorie Malnutrition
(lack of sufficient energy or protein to meet the body's metabolic demands, and Senile Degeneration of the
Brain (age related cognitive decline).
Record Review of Resident #1's MDS, dated [DATE] reflected a BIMS score of 9, which indicated the
resident had moderate cognitive impairment. Resident #1's MDS Section GG also reflected the resident's
functional ability for eating was coded as:
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk
or limbs and provides more than half the effort.
During an interview on 2/24/2025 at 10:35 AM with Resident #1's family member, they stated, They are not
taking care of her. I have a video that showed the aide walked into her room with her lunch, took a spoon,
jabbed it into her mouth and walked out of the room. Then another aide came in and said, 'I guess you are
done now.' She had not eaten.
During an observation on 2/24/2024 at 12:35 PM of electronic monitoring video dated 2/23/2025 at 12:48
PM provided (via email) by family member, revealed a CNA had brought a lunch tray into the room of
Resident #1. The CNA appeared to have been [NAME] or Hispanic and had dark hair, pulled into a ponytail,
approximately four inches past the shoulders. The CNA was wearing dark pants with a light-colored draw
string and a white t-shirt that had a graphic on the front. The gender of the CNA was not identifiable from
the video. The CNA slid the rolling bedside table over the resident who was lying
(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 4
Event ID:
676047
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
676047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Town Hall Estates Keene, Inc.
207 S Old Betsy Rd
Keene, TX 76059
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)
F 0550
Level of Harm - Minimal harm
or potential for actual harm
in a slightly inclined, bed. The CNA was standing with their back to the resident, then turned sideways,
placed food on a spoon and put it into Resident #1's mouth. Then put the spoon down and walked out of
Resident #1's room. The CNA did not speak to the resident during this interaction, did not smile, nor did
they bend over to look Resident #1 in the face. Resident #1 was heard to say, I guess you aren't going to
help me either.
Residents Affected - Few
During an observation on 2/24/2025 at 2:41pm of electronic monitoring video dated 2/23/2025 at 2:19 PM
provided (via email) by family member, revealed a female CNA, who wore navy blue scrubs and had hair
that was either short or pulled on top of her head. The CNA took the residents tray away and did not offer
any fluids. It appeared Resident #1 had not eaten the meal. The fortified shake in a red bottle appeared to
be unopened.
During an interview on 2/24/2025 at 4:35 PM with the DON he stated when feeding residents, Interaction is
very crucial. You would get feedback if the meals were good, were they full or if they wanted more. He said it
was not acceptable for any staff to have walked into a resident's room, fed the resident one spoonful of
food, exited the room, and never have spoken to the resident.
During an interview on 2/24/2025 at 4:45 PM with the ADM she stated, it was not acceptable for any staff to
have walked into a resident's room, fed the resident one spoonful of food, exited the room, and never have
spoken to the resident. She stated, My expectation was that staff would have interacted with residents.
A Record Review of the facility's policy Resident Rights, Revised February 2021, reflected:
Policy Statement
Employees shall treat all residents with kindness, respect, and dignity.
1.
Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the
resident's right to:
a.
A dignified existence;
b.
Be treated with respect, kindness, and dignity.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676047
If continuation sheet
Page 2 of 4
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
676047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Town Hall Estates Keene, Inc.
207 S Old Betsy Rd
Keene, TX 76059
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)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed,
and revised by a team of health professionals.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and
revised by the interdisciplinary team after a change of condition for 1 of 6 residents (Resident #1) reviewed
for care plans.
The facility failed to ensure Resident #1's care plan was revised to reflect the resident's decline and inability
to feed themselves.
This failure could place residents at risk of not receiving appropriate care to meet their current needs,
compromised nutritional intake, aspiration, and choking.
Findings included:
Record Review of the undated Face Sheet for Resident #1 reflected a [AGE] year-old female who was
admitted to the facility on [DATE] with the following diagnoses: Parkinson (conditions that affect movement),
Unspecified Dementia (group of symptoms affecting memory), Unspecified Protein-Calorie Malnutrition
(lack of sufficient energy or protein to meet the body's metabolic demands, and Senile Degeneration of the
Brain (age related cognitive decline).
Record Review of Resident #1's MDS, dated [DATE] reflected a BIMS score of 9, which indicated the
resident had moderate cognitive impairment. Resident #1's MDS Section GG also reflected the resident's
functional ability for eating is coded as:
02. Substantial/maximal assistance - Helper does MORE THAN HALF the effort. Helper lifts or holds trunk
or limbs and provides more than half the effort.
Record Review of the Comprehensive Care Plan for Resident #1 reflected the following:
Focus:
ADLs [eating, dressing, mobility, transfer, toilet, hygiene, bed mobility, bath], Date Initiated and Created
[DATE].
Interventions:
*EATING: Resident is able to feeding self each meal daily. Resident may need set-up/supervision
assistance. Date Initiated [DATE].
During an observation on [DATE] at 8:30 AM, revealed the resident was lying in bed with a breakfast tray on
rolling, bedside table. The resident did not speak and turned head slightly when spoken to. A CNA came
into the resident's room and said, I'll be back to feed her in a moment and then was gone quickly.
During an interview on [DATE] at 4:15 PM with CNA A stated she was made aware of residents change of
condition each day when she arrived at work. She stated she has never looked at care plans.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676047
If continuation sheet
Page 3 of 4
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
676047
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
02/24/2025
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Town Hall Estates Keene, Inc.
207 S Old Betsy Rd
Keene, TX 76059
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)
F 0657
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on [DATE] at 4:27 PM with CNA B stated she was given a full report when she began
her shift and she always gave a full report to the next shift, when her shift ended. She stated the residents'
chart should have indicated changes with incontinent status and when eating status (i.e., thickened liquids,
feeding assistance) changed. She identified risks for residents who care plans were not updated as, If
someone switched to mechanical soft [diet] and I didn't know about it or thickened liquids, they could get
hurt or die.
During an interview on [DATE] at 4:35 PM with the DON, he revealed care plans should have been updated
every day. He said social services was responsible to ensure care plans were updated. He said his
expectation was for the care plan to have been updated for a resident who experienced a significant decline
within the last month. He identified potential negative outcomes for residents without updated care plans as,
Multiple negative outcomes, they could have gone downhill, died, or any other consequences that neglect
may have caused.
During an interview on [DATE] at 4:45 PM with the ADM, she stated, care plans should have been updated
quarterly, at a minimum. She said the two ADONs and the two MDS staff were responsible to update the
nursing components of the care plans. She said she would have hoped a care plan would have been
updated for a resident who had declined within the last month. She said the negative outcome for residents
was that the nursing staff would not have known what they needed to do for the resident.
Record Review of the facility's policy titled, Care Plans, Comprehensive Person-Centered, Revised [DATE],
reflected:
Policy Statement
A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet
the resident's physical, psychosocial and functional needs is developed and implemented for each resident.
Policy Interpretation and Implementation
11. Assessments of residents are ongoing and care plans are revised as information about the resident and
the resident's
conditions change.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676047
If continuation sheet
Page 4 of 4
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F550 - Resident Rights
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
F657 - Comprehensive Care Plans
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
FAQ · About this visit
Common questions about this visit
What happened during the February 24, 2025 survey of Town Hall Estates Keene, Inc.?
This was a inspection survey of Town Hall Estates Keene, Inc. on February 24, 2025. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Town Hall Estates Keene, Inc. on February 24, 2025?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her right..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.