Inspection visit
Inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 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
observations, interviews, and record review the facility failed to treat each resident with respect and dignity
and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for
one (Residents #3) of four residents reviewed for resident rights.
The facility did not ensure the Activity Director treated residents with dignity and respect by referring to
Resident #3 as a feeder.
This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality
of life.
Findings included:
Review of Resident #2's face sheet, dated 03/08/24, reflected she was a [AGE] year-old female who
admitted to the facility on [DATE]. Her diagnoses included bipolar disorder (a serious mental illness
characterized by extreme mood swings) and depression (a mood disorder that causes a persistent feeling
of sadness and loss of interest).
Review of Resident #2's admission MDS Assessment, dated 02/14/24, reflected she had a BIMS of 06
indicating severe cognitive impairment.
During a dining observation on 03/08/24 at 11:56 AM, the Activity Director asked an unknown staff if
Resident #2 was a feeder or if Resident #3 could eat on her own. The Activity Director was in the middle of
the dining room where 15 residents were currently seated at different tables.
Interview on 03/08/24 at 12:00 PM with Resident #2 revealed she wanted to know where her lunch tray was
and would not answer any other questions.
Interview on 03/08/24 at 12:15 PM with the Activity Director revealed she had confused Resident #2 with a
different resident who had the same first name when she asked the unknown staff if Resident #2 was a
feeder or not. The Activity Director said she used the word feeder because that was what she was if she
could not eat on her own. The Activity Director said no one had ever talked to her about or trained her to
use a different word or phrase to refer to residents as besides feeder. The Activity Director said it would
probably make residents feel bad and as if they were a baby being referred to as that term especially in
front of other residents. The Activity Director said she should probably refer to residents as needing or
helping to assist them with eating.
(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 6
Event ID:
676080
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
676080
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Town Hall Estates Arlington, Inc.
824 W Mayfield Rd
Arlington, TX 76015
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
Residents Affected - Few
Interview on 03/08/24 at 3:14 PM with the DON revealed staff using the term feeder was not appropriate
and instead they should use the phrase a resident who needs assistance eating. The DON said the
purpose of using this phrase was for resident rights and was a dignity issue. The DON said the risk of
residents being referred to as a feeder was that it could cause depression and they could have emotional
distress. The DON said she had spoken to staff a lot of times about not using the feeder term and it was
everyone's responsibility to use the correct phase.
Review of the facility's policy, revised October 2010, and titled Resident Rights Guidelines for All Nursing
Procedures reflected: .to provide general guidelines for resident rights while caring for the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676080
If continuation sheet
Page 2 of 6
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
676080
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Town Hall Estates Arlington, Inc.
824 W Mayfield Rd
Arlington, TX 76015
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 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and
convey specific information when a resident is transferred or discharged.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record reviews the facility failed to ensure that the transfer or discharge is documented in the
resident's medical record and appropriate information is communicated to the receiving health care
institution or provider for 1 (Resident #1) of 4 residents reviewed for discharge requirements.
The facility failed to provide Resident #1's family with discharge instructions.
This failure could place residents at risk of a disruption of the continuum of care.
Findings included:
Review of Resident #1's undated admission Record revealed the resident was a [AGE] year-old male
admitted to the facility on [DATE] with diagnoses that included pneumonia causing decreased breathing
and oxygen levels, and Parkinson's.
Review of Resident #1's admission MDS, dated [DATE], revealed a BIMS score of 7, indicating severe
cognitive impairment. His Functional Status indicated he required minimal assistance with his ADLs, was
independent in walking, and totally dependent on staff for his cognitive function.
Review of Resident #1's care plan, dated 02/05/24, indicated he was receiving physical and occupational
therapy and would require home health when discharged home.
Review of Resident #1's EHR revealed a signed discharge order by the physician. No discharge
instructions/teaching could be located.
Interview on 03/08/24 at 2:00 PM, the DON stated when a resident was discharged a copy of the discharge
paperwork was sent with the resident and a signed copy stayed with the resident's chart. The DON asked to
locate Resident #1's discharge paperwork not found in his EHR. The DON stated the Medical Records
Clerk was hospitalized and unable to be contacted to help locate the paperwork.
Review of the facility's policy Discharge Summary and Plan, dated December 2016, reflected:
When a resident's discharge is anticipated, a discharge summary and post-discharge plan will be
developed to assist the resident to adjust to his/her new living environment.
The discharge summary will include a recapitulation of the resident's stay at this facility and a final
summary of the resident's status at the time of the discharge in accordance with established regulations
governing release of resident information and as permitted by the resident.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676080
If continuation sheet
Page 3 of 6
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
676080
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Town Hall Estates Arlington, Inc.
824 W Mayfield Rd
Arlington, TX 76015
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 0803
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be
updated, be reviewed by dietician, and meet the needs of the resident.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 out of
2 meals (the lunch meal on 03/08/24) reviewed for food and nutrition services.
The facility failed to ensure residents on a pureed diet were served pureed bread during the lunch meal on
03/08/24.
This failure could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and
metabolic imbalances.
Findings included:
Review of Resident #2's face sheet, dated 03/08/24, reflected she was a [AGE] year-old female who
admitted to the facility on [DATE]. Her diagnoses included bipolar disorder (a serious mental illness
characterized by extreme mood swings) and depression (a mood disorder that causes a persistent feeling
of sadness and loss of interest).
Review of Resident #2's admission MDS Assessment, dated 02/14/24, reflected she had a BIMS of 06
indicating severe cognitive impairment.
Review of a list of residents served a pureed diet, dated 03/08/24, reflected the facility had a total of ten
residents on a pureed diet.
Review of the facility's menu for the lunch meal on 03/08/24 revealed crunchy fish, Creole potatoes,
spinach/sauteed onions, roll/margarine, chocolate/yogurt mousse.
Observation and interview on 03/08/24 at 12:10 PM with Resident #2 revealed she was still hungry and
wanted a roll like the other residents had on their plates around her. Resident #2 only had three pureed
items on her plate which were pureed fish, pureed spinach, and mashed potatoes. Resident #2's meal
ticket reflected the following: P crunchy fish, P creole potatoes, P spinach/sauteed onions, P bread/[NAME].
Interview on 03/08/24 at 12:11 PM with [NAME] D revealed there was not pureed bread made or served for
the lunch service today.
Interview on 03/08/24 at 12:25 PM with the Dietary Manager revealed she knew the pureed bread was not
served for the lunch meal today because she never had her staff make the pureed bread for any meal. The
Dietary Manager said she only had her staff make the pureed meat, pureed starch, pureed vegetable, and
pureed dessert for every meal. The Dietary Manager said she was not sure if she was supposed to serve
pureed bread but said that residents on a regular diet always received their bread or roll with each meal.
The Dietary Manager said she expected all residents to receive the same food that was on the menu,
including bread. The Dietary Manager said the risk was that residents could complain about not getting the
same food and become upset or not getting the nutrients needed which could lead to weight loss. The
Dietary Manager said [NAME] D was responsible for making the pureed bread but since the Dietary
Manager did not know about it either it was not made. The Dietary Manager said she was ultimately
responsible for making sure all foods in all forms were prepared for each meal
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676080
If continuation sheet
Page 4 of 6
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
676080
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Town Hall Estates Arlington, Inc.
824 W Mayfield Rd
Arlington, TX 76015
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 0803
though.
Level of Harm - Minimal harm
or potential for actual harm
Interview on 03/08/24 at 3:14 PM with the DON revealed residents on a pureed diet should receive all meal
components as a resident on a regular diet. The DON said the kitchen was responsible for making each
meal component and following the menu and she was not aware the pureed bread was not being made for
each meal. The DON said the risk was that residents could not be receiving enough calories and
carbohydrates and were getting less nutrition which meant they were at risk of weight loss.
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676080
If continuation sheet
Page 5 of 6
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
676080
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
03/08/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Town Hall Estates Arlington, Inc.
824 W Mayfield Rd
Arlington, TX 76015
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 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in
accordance with accepted professional standards.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview and record review, the facility failed to maintain clinical records in accordance with
accepted professional standards and practices that are complete and accurately documented for 1 of 5
residents (Residents #3) reviewed for clinical records.
The facility failed to ensure staff accurately documented on Resident #3's February 2024 MAR that she
received her medications.
This failure could affect residents that received medications and place them at risk of inaccurate or
incomplete clinical records.
Findings included:
Review of Resident #3's face sheet, dated 03/08/24, revealed the resideent was a [AGE] year-old female
who admitted to the facility on [DATE]. Her diagnoses included COVID-19, Type 2 diabetes (a condition
results from insufficient production of insulin, causing high blood sugar), and depression (mood disorder
that causes a persistent feeling of sadness and loss of interest).
Review of Resident #3's admission MDS assessment, reflected she had a BIMS score of 00 indicating
severe cognitive impairment.
Review of Resident #3's physician's orders reflected the following:
- Vitamin E Oral Capsule 450 MG (1000 [units]) (Vitamin E) Give 1 capsule by mouth one time a day for
vitamin
Review of Resident #3's February 2024 MAR revealed blank spots for the following order: Vitamin E Oral
Capsule 450 mg (1000 [units]) give 1 capsule by mouth one time a day for vitamin; on the following dates:
02/08/24 and 02/09/24.
Observation and interview on 03/08/24 at 12:00 PM revealed Resident #3 was sitting in her wheelchair at a
table in the dining room. Resident #3 said she was doing good but was hungry and was wondering when
the food was going to come. Resident #3 was unable to answer additional questions.
Interview on 03/08/24 at 3:14 PM with the DON revealed when staff administered medications to residents
they were supposed to sign off on the MAR. The DON said if the resident refused the medication, they
should use the code to indicate that. The DON said the staff on duty were responsible for documenting the
administration of the medication. The DON said she was supposed to be checking resident MARs to make
sure staff were documenting the administration of the medications. The DON said the purpose was so that
the medication would not be given twice leading to medication duplicates. The DON said the risk was that
residents may not get the proper dosage of the medication if there was no documentation it was
administered.
Review of the facility's policy, revised December 2012, and titled Administering Medications reflected: .19.
The individual administering the medication must initial the resident's MAR on the appropriate line after
giving each medication and before administering the next ones.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676080
If continuation sheet
Page 6 of 6
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Back to topCitations
4 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.
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
F803 - Menus and nutritional adequacy
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the March 8, 2024 survey of TOWN HALL ESTATES ARLINGTON, INC.?
This was a inspection survey of TOWN HALL ESTATES ARLINGTON, INC. on March 8, 2024. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at TOWN HALL ESTATES ARLINGTON, INC. on March 8, 2024?
Yes, 4 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
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.