Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Town Hall Estates Keene, Inc. during CMS and state inspections, most recent first.
The facility did not honor the right of residents to organize and participate in resident or family groups, as required. The report does not specify the number of residents affected or detail the circumstances leading to this deficiency.
A deficiency was cited when a resident did not receive enough food or fluids to maintain their health, as required. The report indicates that residents were sampled and at least one was found not to have received adequate nutrition or hydration.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
A resident with dementia and special dietary needs was served her meal 26 minutes after others at her table, despite requiring total assistance with eating. Staff interviews confirmed that all residents should be served together, and delays longer than 5 minutes were considered unreasonable. Facility policies emphasized dignity and respect, but the resident was left waiting while others ate, which staff acknowledged was not acceptable.
The facility did not complete or accurately document PASRR Level 1 screenings for several residents with mental health diagnoses, resulting in missed identification of mental illness and potential lapses in required services. Staff interviews confirmed inconsistencies in the PASRR process, and record reviews showed that residents with significant psychiatric and mood disorders were not properly screened or had inaccurate PASRR documentation.
A deficiency was cited when a resident's care plan did not address all assessed needs and lacked measurable timetables and specific actions, as observed in the care planning documentation.
The facility failed to ensure that two residents had their call lights within reach, violating their right to reasonable accommodations. One resident with moderate cognitive impairment and multiple health conditions was observed with her call light out of reach, while another resident with severe cognitive impairment faced a similar issue. Interviews with CNAs and the DON revealed a lack of awareness and adherence to the facility's policy on call light accessibility.
A facility failed to ensure respectful feeding practices for a resident with moderate cognitive impairment who required substantial assistance with eating. A CNA fed the resident without speaking or engaging, and another CNA removed the meal tray without offering fluids. The facility's DON and ADM acknowledged these actions were unacceptable and did not align with the policy of treating residents with respect and dignity.
A facility failed to update a resident's care plan after a decline in her ability to feed herself. Despite the resident's need for substantial assistance, the care plan inaccurately stated she could feed herself with minimal help. Staff interviews revealed a lack of adherence to care plan updates, with CNAs unaware of changes and the DON and ADM acknowledging the need for regular updates. The facility's policy requires ongoing assessments and revisions, which were not followed.
A resident with multiple health conditions did not receive scheduled showers due to staffing issues, despite requiring substantial assistance and a mechanical lift for transfers. The resident's care plan specified showers three times a week, but documentation showed numerous missed showers over a month. Staff interviews revealed that short staffing and time constraints contributed to the deficiency, impacting the resident's personal hygiene and dignity.
A facility failed to maintain infection control when a CNA entered a resident's room without wearing required PPE, despite the resident being on droplet precautions for Influenza. The CNA believed PPE was unnecessary as she was not providing direct care, leading to a breach in protocol. Interviews with the DON and ADM indicated that training was provided, but the failure was attributed to the CNA's lack of awareness.
Three residents in the facility were found with their call lights out of reach, contrary to their care plans and facility policy. One resident with severe cognitive impairment had her call light six feet away, while another resident's call light was tucked under a mattress, making it invisible. A third resident, despite having no cognitive impairment, could not reach her call light without assistance. Staff interviews confirmed the expectation for call lights to be within reach, yet this was not consistently practiced.
The facility failed to store, prepare, and serve food according to professional standards, as observed in the kitchen. Various food items in the walk-in refrigerator and freezer were found without proper labels or dates, and some were improperly covered. In the dry storage area, bins had smeared and unreadable labels. Interviews with staff revealed a lack of adherence to food safety policies, potentially risking resident health.
The facility failed to maintain an effective infection prevention and control program, as evidenced by an LVN not performing hand hygiene or changing gloves during wound care on a resident with pressure ulcers, and a CNA not changing gloves during peri-care on another resident. These actions were contrary to the facility's infection control policy, which requires hand hygiene and glove changes to prevent cross-contamination.
A resident was incorrectly coded with pneumonia in their Quarterly MDS assessment, despite the condition having been resolved prior to the assessment period. The error was identified as human oversight, and the resident did not receive unnecessary medical interventions. Facility staff acknowledged the importance of accurate MDS assessments for care planning.
Failure to Honor Resident Rights to Organize and Participate in Groups
Penalty
Summary
The facility failed to honor the resident's right to organize and participate in resident or family groups within the facility. The report identifies a deficiency related to this right but does not provide specific details about the number of residents affected, the actions or inactions of staff, or any particular events that led to the deficiency. No information is given regarding the medical history or condition of the residents involved at the time of the deficiency.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids to maintain a resident's health. The report notes that residents were sampled and at least one resident was cited for not receiving sufficient nutrition or hydration as required to support their health status. Specific details about the number of residents involved, their medical history, or their condition at the time of the deficiency are not provided in the report.
Failure to Follow Professional Standards in Food Procurement and Handling
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, but the report does not provide specific details about the number of residents affected, the nature of the food procurement or handling issues, or any direct observations related to the deficiency. No additional information about the residents involved, their medical history, or their condition at the time of the deficiency is provided in the report.
Resident Meal Service Delay Compromises Dignity
Penalty
Summary
A deficiency was identified when a resident with dementia and significant cognitive and physical impairments was not served her meal at the same time as other residents at her dining table. The resident, who required a pureed, gluten-free diet and total assistance with eating, was observed waiting 26 minutes after the other two residents at her table had received their meals and begun eating. Staff interviews confirmed that the delay was due to the resident's special dietary needs, which sometimes resulted in her meal being delivered later than others. Multiple staff members, including CNAs and LVNs, acknowledged that all residents at a table should be served their meals together, and that waiting more than 5 minutes was considered unreasonable. Staff also stated that such delays could cause residents to feel neglected or upset. The charge nurse and aides were responsible for monitoring meal service and ensuring that all residents at a table received their meals at the same time, with procedures in place to address missing trays promptly. The facility's own policies and resident rights documents emphasized the importance of treating residents with dignity and respect, including during meal service. Despite these policies, the resident was left waiting for an extended period while others ate, which staff and the Director of Nursing agreed was unreasonable and not in line with facility expectations for resident care and dignity.
Failure to Complete Accurate PASRR Screenings for Residents with Mental Disorders
Penalty
Summary
The facility failed to provide accurate Preadmission Screening and Resident Review (PASRR) screenings for six residents with mental disorders or intellectual disabilities. Specifically, the facility did not complete accurate PASRR Level One screenings for three residents who were admitted with negative PASRR Level 1 results despite having mental illness diagnoses. Additionally, the facility did not ensure that three other residents' PASRR Level One screenings accurately reflected their mental illness diagnoses, nor did it submit corrected PASRR Level One screenings for these individuals. Record reviews revealed that the affected residents had various mental health diagnoses, including unspecified dementia, psychotic disturbance, mood disturbance, anxiety, depression, schizoaffective disorder, psychotic disorder, schizophrenia, bipolar disorder, and major depressive disorder. Many of these residents were also prescribed psychotropic medications such as antipsychotics and antidepressants. Care plans for these residents included interventions to monitor for symptoms such as anxiety, agitation, aggression, social withdrawal, and sleeplessness, indicating ongoing mental health concerns that should have been captured in the PASRR process. Interviews with facility staff, including the MDS Coordinator and Social Worker, confirmed that the PASRR process was not consistently followed. The MDS Coordinator acknowledged that residents without a completed PASRR Level 1 screening would not receive necessary services and that the facility would not be reimbursed. The Social Worker described the process for handling PASRR-positive residents and indicated that residents should not be admitted without a PASRR. However, documentation showed that PASRR screenings were either not completed or not accurately reflecting residents' mental health diagnoses, resulting in a lapse in required screenings and potential services.
Incomplete Care Plan Development and Implementation
Penalty
Summary
A deficiency was identified due to the failure to develop and implement a complete care plan that addresses all of a resident's needs. The care plan lacked measurable timetables and specific actions, resulting in incomplete documentation and planning for the resident's care. This omission was observed during the review of resident records and care planning documentation, where it was noted that the care plan did not comprehensively cover the resident's assessed needs.
Failure to Ensure Call Lights Within Reach for Residents
Penalty
Summary
The facility failed to ensure that two residents had their call lights within reach, which is a violation of their right to receive services with reasonable accommodations. Resident #1, an elderly female with moderate cognitive impairment and multiple health conditions, was observed on several occasions with her call light hanging towards the floor, out of her reach. Despite her care plan indicating that the call light should be within reach and answered in a timely manner, Resident #1 stated she could not reach it and had to wait for staff to enter her room for assistance. Similarly, Resident #2, who has severe cognitive impairment and other health issues, was found with her call light tied to the lower part of her bed rail, making it inaccessible. She also expressed that she could not reach the call light and was unsure how long it had been out of reach. Both residents were dependent on staff for assistance, and the inability to access their call lights could prevent them from receiving timely help. Interviews with CNAs and the Director of Nursing (DON) revealed that it was everyone's responsibility to ensure call lights were within reach. However, neither CNA A nor CNA B was aware of the issue with the call lights for Residents #1 and #2. The facility's policy on answering call lights emphasizes the importance of accessibility, yet this was not adhered to, leading to the deficiency noted in the report.
Failure to Ensure Respectful Feeding Practices
Penalty
Summary
The facility failed to ensure that staff interacted with a resident in a manner that assured communication, maintained respect, and enhanced the resident's quality of life. Specifically, the facility did not treat a resident with respect and dignity during feeding. The resident, who had moderate cognitive impairment and required substantial assistance with eating, was fed by a CNA who did not speak to or engage with the resident. The CNA placed a spoonful of food in the resident's mouth and left the room without further interaction. This lack of communication and engagement was corroborated by a family member's video, which showed the CNA's actions and the resident's verbal expression of dissatisfaction. Further observations revealed that another CNA removed the resident's meal tray without offering any fluids, and the resident appeared not to have eaten the meal. The facility's Director of Nursing and Administrator both acknowledged that the staff's actions were unacceptable and did not meet the facility's policy of treating residents with kindness, respect, and dignity. The facility's policy, revised in February 2021, emphasizes the importance of treating all residents with respect and ensuring their right to a dignified existence.
Failure to Update Care Plan After Resident's Decline
Penalty
Summary
The facility failed to ensure the comprehensive care plan for a resident was reviewed and revised by the interdisciplinary team following a change in the resident's condition. The resident, a female with diagnoses including Parkinson's, unspecified dementia, and protein-calorie malnutrition, was observed to have a decline in her ability to feed herself. Despite this decline, the care plan continued to state that the resident was able to feed herself with only set-up or supervision assistance. This discrepancy was noted during an observation where the resident was unable to feed herself and required assistance from a CNA. Interviews with facility staff revealed a lack of awareness and adherence to care plan updates. CNA A admitted to not reviewing care plans, while CNA B highlighted the risks of not updating care plans, such as potential harm from dietary changes. The DON and ADM acknowledged that care plans should be updated regularly, especially after significant changes in a resident's condition. The facility's policy mandates ongoing assessments and revisions of care plans as resident conditions change, which was not adhered to in this case.
Failure to Provide Scheduled Showers to Resident
Penalty
Summary
The facility failed to ensure that a resident, who required assistance with activities of daily living, received necessary services to maintain personal hygiene. The resident, a female with multiple diagnoses including coronary artery disease, end-stage renal disease, diabetes, and dementia, required substantial assistance for showers and was totally dependent on staff for shower transfers. Despite having a care plan that specified she should receive showers three times a week, the resident did not receive showers according to her schedule, with documentation showing missed showers on numerous occasions over a month-long period. Interviews with staff revealed that the resident's showers were often not conducted due to staffing issues, as the resident required a mechanical lift and two staff members for transfers. CNAs reported that they were sometimes short-staffed or ran out of time during their shifts, which contributed to the failure to provide scheduled showers. The resident expressed dissatisfaction with the infrequency of her showers, stating that it made her feel dirty and that there were often not enough aides available to assist her. The facility's policy on bathing and showering emphasized the importance of maintaining cleanliness and observing skin condition, yet the documentation and reporting procedures were not consistently followed. The ADON acknowledged the importance of adhering to the shower schedule for residents' skin integrity and overall health, but the facility's staffing challenges and documentation inconsistencies led to the deficiency in care for the resident.
Infection Control Breach Due to PPE Non-Compliance
Penalty
Summary
The facility failed to maintain proper infection prevention and control measures, specifically in the case of a resident diagnosed with Influenza. The resident was placed on droplet precautions, which required staff to wear personal protective equipment (PPE) such as gowns, masks, goggles, and gloves when entering the resident's room. However, on January 15, 2025, a Certified Nursing Assistant (CNA) entered the resident's room without wearing any PPE, despite the presence of a sign on the door indicating the need for droplet precautions. The CNA acknowledged that she was aware of the droplet isolation sign but believed that PPE was unnecessary since she was not providing direct care that involved touching the resident. This misunderstanding led to a breach in infection control protocols, potentially exposing other residents and staff to the influenza virus. The CNA admitted to sanitizing her hands before entering the room but did not follow the required protocol of donning the appropriate PPE. Interviews with the Director of Nursing (DON) and the Administrator (ADM) revealed that the facility had policies and training in place to ensure staff compliance with infection control measures. The facility conducted in-service training on January 3, 2025, which the CNA attended. Despite these measures, the failure to adhere to infection control protocols was attributed to the individual staff member's lack of awareness, highlighting a gap in the effective implementation of the facility's infection control program.
Inaccessible Call Lights for Residents
Penalty
Summary
The facility failed to ensure that the call lights for three residents were within reach, which is a critical aspect of accommodating resident needs and preferences. Resident #64, a female with severe cognitive impairment and physical dependencies, was observed in her wheelchair with her call light six feet away, wrapped around her bed rail, making it inaccessible. Despite the care plan indicating that the call light should always be within reach, staff failed to adhere to this requirement, as confirmed by a CNA who acknowledged the incorrect placement. Resident #43, a male with severe cognitive impairment and physical limitations, was found in his Geri-Chair with the call light five feet away, tucked under his mattress, and not visible. This placement rendered the call light inaccessible, contrary to the care plan's stipulations. During an interview, the resident expressed a desire to have the call light next to him, and a CNA confirmed that the resident needed to be handed the call light to use it. Resident #21, a female with a BIMS score indicating no cognitive impairment, was observed in her wheelchair with the call light four feet away, making it unreachable. Although the resident attempted to reach the call light, she was unable to do so without assistance. A CNA later repositioned the resident closer to the call light, acknowledging the training to keep call lights within reach. The facility's policy and staff interviews confirmed that call lights should always be accessible, yet this standard was not consistently met, placing residents at risk.
Food Safety and Sanitation Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food safety and sanitation in their kitchen, as observed during a survey. In the walk-in refrigerator, various food items such as coleslaw, mushrooms, pineapple, cucumber, onions, chopped hard-boiled eggs, and pickles were found without labels or dates. Additionally, in the walk-in freezer, an opened box of uncooked lasagna noodles with ice on them was dated from the previous year, and cooked lasagna was improperly covered and exposed to freezing air, with unreadable labels. In the dry storage area, bins labeled as flour and sugar had smeared and unreadable use-by dates, and another bin's label was completely unreadable. Interviews with staff, including the Dietary Manager and the Administrator, revealed a lack of proper labeling and sealing of food items, which could lead to residents consuming potentially unsafe food. The Dietary Manager acknowledged the issue and mentioned that new staff had been hired, and the importance of labeling was frequently communicated. The facility's policies on food safety and receiving deliveries were reviewed, indicating that open food should be labeled, dated, and safely stored, but these practices were not consistently followed.
Infection Control Lapses in Wound and Peri-Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A and CNA E. LVN A did not perform hand hygiene or change gloves while providing wound care to a resident with a history of stroke, sepsis, and pressure ulcers. During the wound care procedure, LVN A removed dressings from two wounds located on the resident's gluteal folds without changing gloves or performing hand hygiene between the two sites. This action was contrary to the facility's infection control policy, which requires hand hygiene and glove changes to prevent cross-contamination. Similarly, CNA E did not conduct hand hygiene or change gloves while performing peri-care on another resident. Despite having received training on proper peri-care techniques, CNA E failed to change gloves when moving from cleaning the front to the back of the resident. This lapse in infection control practices was acknowledged by CNA E during an interview. The facility's Director of Nursing confirmed that staff are expected to follow infection control measures, including hand hygiene and glove changes, to prevent the spread of infectious bacteria.
Inaccurate MDS Coding for Pneumonia
Penalty
Summary
The facility failed to ensure the resident assessment accurately reflected the resident's status for one resident who was reviewed for accuracy of assessments. Specifically, the facility incorrectly coded a resident with pneumonia in their Quarterly MDS assessment, despite the condition having been resolved prior to the assessment period. The resident, a female with a history of cerebral infarction and post-traumatic stress disorder, was diagnosed with pneumonia in February and treated with Benzonatate for an upper respiratory infection, which was completed by March. By the time of the assessment, the resident no longer exhibited symptoms of pneumonia, and the coding error was identified as a result of human oversight. Interviews with facility staff, including the MDS Coordinator and the Administrator, revealed that the error was due to human oversight and not a systemic failure. The MDS Coordinator acknowledged that the resident's MDS did not accurately reflect her current health status, as the pneumonia diagnosis was no longer active during the seven-day lookback period prior to the assessment. The Administrator emphasized the importance of accurate MDS assessments for developing appropriate care plans and acknowledged the error, noting that the resident did not receive unnecessary medical interventions as a result of the miscoding.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Keene
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Colonial Manor Nursing Center | 4.8 mi | ★★★★★ | 3 | 0 |
| Heritage Trails Nursing And Rehabilitation Center | 5.7 mi | ★★★★★ | 4 | 0 |
| Alvarado Meadows Nursing & Rehabilitation | 6.7 mi | ★★★★★ | 4 | 0 |
| Ridgeview Rehabilitation And Skilled Nursing | 7.7 mi | ★★★★★ | 6 | 0 |
| Advanced Rehabilitation & Healthcare Of Burleson | 8.5 mi | ★★★★★ | 13 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.