Cycle 1
Health 2025-09-06 · Fire 2025-09-06
14 health deficiencies
Top issue: Quality of Life and Care (4 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Hillsboro, TX
Town Hall Estates
1-star overall rating with 1-star inspections with $83,494 in total fines with 14 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
300 Happy Ln, Hillsboro, TX
(254) 582-8482
Overall
1 / 5
CMS overall stars
Health inspections
1 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
138
Certified beds
Average residents
37
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
2004-08-26
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.38
Registered nurse staffing
LPN hours / resident day
1.16
Licensed practical nurse staffing
Aide hours / resident day
1.96
Nurse aide staffing
Weekend hours
3.44
Weekend nurse staffing
RN turnover
67%
Annual RN turnover
Total nurse turnover
59%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.9
0.5 pts better
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.8 |
2.1
0.7 pts worse
|
1.8
1 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 73.6% |
97.1%
23.5 pts worse
|
93.4%
19.8 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 90.4% |
97.9%
7.5 pts worse
|
95.5%
5.1 pts worse
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.0% |
3.3%
0.7 pts worse
|
3.3%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 7.0% |
2.7%
4.3 pts worse
|
11.4%
4.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 2.0% |
3.3%
1.3 pts better
|
5.4%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.0% |
18.9%
8.1 pts worse
|
19.6%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 15.3% |
10.8%
4.5 pts worse
|
16.7%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 8.3% |
15.4%
7.1 pts better
|
16.3%
8 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.7% |
16.1%
7.4 pts better
|
14.9%
6.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.5% |
0.5%
About the same
|
1.0%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 24.0% |
15.0%
9 pts worse
|
19.8%
4.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.2%
2 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 42.7% |
89.7%
47 pts worse
|
81.7%
39 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 3.2% |
1.5%
1.7 pts worse
|
1.6%
1.6 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 28.6% |
88.0%
59.4 pts worse
|
79.7%
51.1 pts worse
|
Short Stay · 2024Q3-2025Q2 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-27 · Fire 2024-06-27
9 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
3 fire-safety deficiencies
Top issue: Egress (3 deficiencies)
Cycle 3
Health 2023-06-14 · Fire 2023-06-14
6 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
17 fire-safety deficiencies
Top issue: Smoke (6 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-09-06
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-12-08
D · Potential for more than minimal harm
2025-09-06
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-08
E · Potential for more than minimal harm
2024-06-27
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-02-27
E · Potential for more than minimal harm
2024-06-27
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2025-02-25
E · Potential for more than minimal harm
2024-06-27
K223 · Egress Deficiencies
Fire Safety
Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.
Corrected 2025-02-27
F · Potential for more than minimal harm
2023-06-14
E30 · Emergency Preparedness Deficiencies
Fire Safety
List the names and contact information of those in the facility.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-06-14
E4 · Emergency Preparedness Deficiencies
Fire Safety
Develop and maintain an Emergency Preparedness Program (EP).
Corrected 2023-08-04
F · Potential for more than minimal harm
2023-06-14
E6 · Emergency Preparedness Deficiencies
Fire Safety
Conduct risk assessment and an All-Hazards approach.
Corrected 2023-08-15
F · Potential for more than minimal harm
2023-06-14
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-08-03
F · Potential for more than minimal harm
2023-06-14
K352 · Smoke Deficiencies
Fire Safety
Properly install and monitor supervisory attachments on automatic sprinkler systems.
Corrected 2023-08-09
F · Potential for more than minimal harm
2023-06-14
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-08-07
F · Potential for more than minimal harm
2023-06-14
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-14
F · Potential for more than minimal harm
2023-06-14
K900 · Miscellaneous Deficiencies
Fire Safety
Meet Health Care Facilities Code mechanical requirements.
Corrected 2023-07-21
F · Potential for more than minimal harm
2023-06-14
K916 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have a battery powered remote alarm panel in a location accessible by operating personnel.
Corrected 2023-08-17
F · Potential for more than minimal harm
2023-06-14
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-08-09
E · Potential for more than minimal harm
2023-06-14
K222 · Egress Deficiencies
Fire Safety
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.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-14
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-08-09
E · Potential for more than minimal harm
2023-06-14
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-07-28
E · Potential for more than minimal harm
2023-06-14
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-07-21
D · Potential for more than minimal harm
2023-06-14
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-06-14
K361 · Smoke Deficiencies
Fire Safety
Ensure that waiting areas, nurse’s stations, gift shops, and cooking facilities, open to the corridor are properly protected.
Corrected 2023-08-03
D · Potential for more than minimal harm
2023-06-14
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-08-08
Inspection history
Recent health citations
J · Immediate jeopardy
2025-09-06
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-09-07
J · Immediate jeopardy
2025-09-06
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-09-07
D · Potential for more than minimal harm
2025-09-06
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2025-09-28
D · Potential for more than minimal harm
2025-09-06
F637 · Resident Assessment and Care Planning Deficiencies
Health
Assess the resident when there is a significant change in condition
Corrected 2025-09-28
D · Potential for more than minimal harm
2025-09-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-28
D · Potential for more than minimal harm
2025-09-06
F756 · Pharmacy Service Deficiencies
Health
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Corrected 2025-09-28
D · Potential for more than minimal harm
2025-09-06
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2025-09-28
D · Potential for more than minimal harm
2025-09-06
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2025-09-28
D · Potential for more than minimal harm
2025-09-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-09-28
D · Potential for more than minimal harm
2025-09-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2025-09-28
D · Potential for more than minimal harm
2025-09-06
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-09-28
J · Immediate jeopardy
2025-04-18
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-04-19
E · Potential for more than minimal harm
2025-03-07
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-04-04
D · Potential for more than minimal harm
2025-03-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2025-04-04
E · Potential for more than minimal harm
2024-10-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-11-08
K · Immediate jeopardy
2024-08-29
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-09-27
G · Actual harm
2024-08-29
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-09-27
E · Potential for more than minimal harm
2024-06-27
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2024-07-10
E · Potential for more than minimal harm
2024-06-27
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-06-30
E · Potential for more than minimal harm
2024-06-27
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-07-10
D · Potential for more than minimal harm
2024-06-27
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-06-30
D · Potential for more than minimal harm
2024-06-27
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-06-28
C · Minimal harm
2024-06-27
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-06-30
E · Potential for more than minimal harm
2023-06-14
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-06-18
E · Potential for more than minimal harm
2023-06-14
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-14
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-11
E · Potential for more than minimal harm
2023-06-14
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-06-21
D · Potential for more than minimal harm
2023-06-14
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2023-07-06
D · Potential for more than minimal harm
2023-06-14
F687 · Quality of Life and Care Deficiencies
Health
Provide appropriate foot care.
Corrected 2023-06-15
Penalties and ownership
What sits behind the stars
$13,260
2025-04-18
Fine
Fine · fine $13,260
Fine
$38,829
2024-08-29
Fine
Fine · fine $38,829
Fine
$0
2024-08-29
Payment Denial
Payment Denial · denial start 2024-10-01 · 38 days
38 day denial
$4,587
2023-09-05
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-28
Fine
Fine · fine $4,587
Fine
$4,587
2023-08-21
Fine
Fine · fine $4,587
Fine
$4,235
2023-08-14
Fine
Fine · fine $4,235
Fine
$3,882
2023-08-07
Fine
Fine · fine $3,882
Fine
$9,527
2023-07-17
Fine
Fine · fine $9,527
Fine
Ownership
American Religious Town Hall Meeting Inc
5% Or Greater Direct Ownership Interest · Organization
Tandy, Steven
5% Or Greater Indirect Ownership Interest · Individual
Ecord, Barbara
5% Or Greater Indirect Ownership Interest · Individual
Caviness, Glen
Corporate Director · Individual
Ecord, Barbara
Corporate Director · Individual
Fautheree, Stacie
Corporate Director · Individual
Fautheree, Stacie
Corporate Officer · Individual
Fautheree, William
Corporate Director · Individual
Peters, Robin
Corporate Director · Individual
Tandy, Robert
Corporate Director · Individual
Tandy, Steven
Corporate Director · Individual
Tandy, Vicky
Corporate Director · Individual
Tubbs, John
Corporate Director · Individual
Tubbs, John
Corporate Officer · Individual
Tubbs, John
W-2 Managing Employee · Individual
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#3
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