Terrell Healthcare Center

In the surveyor’s words

From the most serious findings on record at Terrell Healthcare Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Mar 29, 2025

  Based on observation, interview, and record review, the facility failed to ensure the right of the residents to be free from abuse for 1 of 23 residents (Resident #45) reviewed for abuse. The facility failed to protect Resident #45 when an allegation of abuse occurred when RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself on 03/20/2025. The facility failed to protect Resident #45 from abuse when RN A, RN D, and the DON demonstrated to Resident #45 how she should hit her head on the wall to injure herself. The facility failed to prevent abuse when RN A, RN D, the DON, MA C, and MA B laughed at Resident #45 for banging her head on the wall, while she was in emotional distress. […]

• Immediate jeopardy, patternF607Mar 29, 2025

  Based on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 23 residents (Resident #45) reviewed for abuse. The facility failed to ensure Housekeeper E reported an allegation of abuse immediately to the Abuse Coordinator on 03/19/2025 due to fear of retaliation. The Abuse Coordinator failed to follow the facility's abuse policy when he did not report an allegation of abuse to HHSC within 2 hours and did not thoroughly investigate when Housekeeper E reported to him on 03/20/2025 that RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself, RN A, RN D, and the DON demonstrated to Resident #45… […]

• Immediate jeopardy, patternF610Mar 29, 2025

  Based on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property were thoroughly investigated for 1 of 23 residents (Resident #45) reviewed for abuse. The facility failed to investigate/protect/correct when an allegation of abuse allegedly occurred when RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself on 03/20/2025 and prevent potential abuse when RN A, RN D, and the DON demonstrated to Resident #45 how she should hit her head on the wall to injure herself. […]

• Immediate jeopardy, patternF740Mar 29, 2025

  Based on observation, interview and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 3 residents (Resident #45) reviewed for behavioral services. The facility failed to provide Resident #45 with additional psychiatric services until 3/24/25 when the surveyor Intervened. The facility failed to document Resident #45's behaviors on the EMAR accurately reflecting her behavioral status. […]

• Immediate jeopardy, patternF600Feb 15, 2024

  47006 Based on observation, interview and record review, the facility failed to ensure the right of the residents to be free from abuse for 3 of 6 residents (Resident's #23, #43, and #56) reviewed for abuse. 1. The facility failed to protect Resident #56 from physical abuse from Resident #25 on 01/27/2024. Resident #56 stated he did not feel safe in the facility. 2. The facility failed to protect Resident #23 from Resident #25 after the occurrence of physical abuse on 04/11/2023. Resident #23 stated she did not feel safe in the facility. 3. The facility failed to protect Resident #43 from misappropriation from Resident #25 on 01/27/2024. 3a. […]