TERRELL, TX - Federal health inspectors issued immediate jeopardy citations to Terrell Healthcare Center after uncovering evidence that nursing staff mocked a mentally ill resident experiencing a crisis, demonstrating how she should injure herself by hitting her head on the wall harder.
The March 2025 inspection revealed a disturbing incident in which the Director of Nursing, two registered nurses, and medication aides surrounded a resident who was banging her head on the wall in distress and told her to hit the corner of the wall harder to "knock her brain out" and kill herself.
Staff Demonstrate Head-Banging While Resident in Crisis
On March 19, 2025, around 2:00-2:30 PM, Resident #45 was experiencing emotional distress near the nurses' station. The resident, who had diagnoses of bipolar disorder and schizoaffective disorder, began banging her head against the wall—a behavior documented in her care plan as occurring when she became frustrated.
According to a witness statement from Housekeeper E, multiple staff members gathered around the resident at the nurses' station. Rather than intervening to protect the resident from self-harm, RN A reportedly 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."
The housekeeper's written statement described how RN A, RN D, and the Director of Nursing "demonstrated to Resident #45 how she should hit her head on the wall to injure herself." Two medication aides, identified as MA B and MA C, were present and laughing during the incident.
"I witnessed them making fun of her. As if it was funny but it was (is) wrong for them to behave in that manner," Housekeeper E wrote in her statement. "These residents deserve to be treated with the utmost respect. And deserve the best of care."
Vulnerable Resident with Severe Cognitive Impairment
The resident at the center of this incident was particularly vulnerable. Medical records showed she was admitted to the facility with multiple mental health diagnoses including bipolar disorder with severe manic episodes and psychotic features, and schizoaffective disorder.
Her cognitive assessment indicated severe impairment with a BIMS score of 4 out of 15, meaning she had significant difficulty with memory, understanding, and decision-making. The resident also had physical limitations from a previous stroke that caused partial paralysis on her left side.
Her care plan documented behavioral symptoms including talking about killing herself and banging her head on walls or furniture when frustrated. The plan specified that staff should "approach/speak in a calm manner" and "intervene as necessary to protect the rights and safety of others."
The resident was on multiple psychiatric medications including Seroquel for mood regulation, Zoloft for depression, Clonazepam for anxiety, and Oxcarbazepine for bipolar disorder. Despite this documented vulnerability and the clear care plan instructions, staff reportedly encouraged rather than prevented self-harming behavior.
Why Mocking Residents with Mental Illness Causes Harm
When staff ridicule residents experiencing mental health crises, the consequences extend far beyond the immediate emotional distress. Residents with conditions like bipolar disorder and schizoaffective disorder already experience distorted perceptions of reality and heightened emotional states.
Encouraging self-harm in someone with documented suicidal ideation represents a fundamental violation of duty of care. Nursing home staff are trained to de-escalate crisis situations, redirect harmful behaviors, and provide therapeutic interventions. The care plan for this resident specifically outlined approaches including calm interaction, diversion, and removing the resident from triggering situations.
Instead, staff reportedly gathered around the resident while she was in crisis, demonstrated harmful behaviors, and suggested more dangerous methods of self-injury. This approach contradicts every principle of psychiatric care and resident safety.
Residents with severe cognitive impairment, as indicated by Resident #45's BIMS score of 4, have limited ability to distinguish appropriate from inappropriate staff behavior. They may internalize staff suggestions and act on them, particularly when multiple authority figures are providing the same direction.
The psychological impact of being mocked by caregivers can worsen existing mental health conditions. Residents may develop increased anxiety, depression, or paranoia. They may become less likely to report concerns or ask for help, fearing further ridicule.
Administrator Failed to Report Abuse Allegation
The inspection revealed a second critical failure: the facility's abuse coordinator, who was also the Administrator, failed to report the allegation to state authorities within the required two-hour timeframe.
Housekeeper E witnessed the incident on March 19, 2025, but did not immediately report it. During an interview with inspectors, she became tearful and explained that she "feared retaliation" based on how the Administrator had handled previous situations. "I did not know who I could trust, and I was scared nobody would believe her," she stated.
The next morning, March 20, 2025, Housekeeper E reported the incident to her supervisor, the Housekeeping/Laundry Manager. That supervisor took her to the Admissions Coordinator, who then brought her to the Administrator's office where she reported what she witnessed.
Rather than immediately reporting the allegation to the Texas Health and Human Services Commission as required by state law and facility policy, the Administrator conducted his own investigation. He interviewed the accused staff members, who denied the allegations. He also brought Resident #45—the alleged victim—to the accused staff members and asked her if they had been mean to her.
This approach violated multiple protocols. Taking a vulnerable resident with severe cognitive impairment to the alleged perpetrators exposes them to potential intimidation and further harm. Federal regulations require that alleged perpetrators be immediately suspended pending investigation to protect resident safety.
The Administrator characterized the allegation as a "grievance" rather than abuse. He told inspectors he did not consider staff laughing at a resident to be reportable, even though he later acknowledged that such behavior "could cause psychological issues and it was emotional abuse."
The Administrator provided the accused staff with a brief in-service on "Professionalism/Customer Service" on March 21, 2025. No staff were suspended. No report was made to state authorities. The allegation was not properly investigated until state inspectors arrived for a routine survey on March 27, 2025—eight days after the incident occurred.
Immediate Jeopardy Identified by Federal Inspectors
When inspectors uncovered the unreported allegation during their March 27, 2025 survey, they immediately recognized the serious threat to resident safety. At 12:30 PM that day, they issued an immediate jeopardy determination—the most serious category of nursing home violations.
Immediate jeopardy means the facility's noncompliance has caused, or is likely to cause, serious injury, harm, impairment, or death to a resident. In this case, inspectors identified two immediate jeopardy situations: failure to protect residents from abuse (F607) and failure to report abuse allegations (F609).
The Regional Director of Operations, who had not been informed of the incident by the Administrator, stated the allegation should have been reported within two hours and staff should have been suspended pending investigation. "Taking the victim of an abuse allegation [to] the perpetrator" exposed the resident to harm, she confirmed.
The facility's own Abuse Prohibition Policy, reviewed in May 2024, clearly stated: "Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately." The policy required reporting allegations of abuse within two hours and mandated that "identification and suspension from employment of the person or persons accused of the abuse allegation(s) is mandatory."
Emergency Corrective Actions Required
On March 27, 2025, the facility implemented emergency corrective measures. The Administrator, Director of Nursing, both registered nurses involved in the incident, and both medication aides were suspended pending investigation. Resident #45 was placed on one-to-one supervision to ensure her safety.
The facility's corporate clinical specialist conducted immediate training for the Assistant Director of Nursing and MDS Nurse on abuse and neglect policies and procedures. Those two staff members then trained all other employees, with staff required to complete competency quizzes before being allowed to work.
The Regional Director of Operations became the interim abuse coordinator. Contact information was posted throughout the facility. The Social Worker conducted life safety rounds, interviewing all residents capable of being interviewed to identify any other instances of abuse or neglect.
By March 28, 2025, inspectors verified the facility had implemented sufficient corrective actions to remove the immediate jeopardy. However, the facility remained cited for violations at a lower level of harm due to the need to complete staff training and evaluate the effectiveness of new systems.
What Federal Regulations Require
Federal regulations mandate that nursing homes develop and implement written policies and procedures prohibiting abuse, neglect, and exploitation. All alleged violations must be reported immediately to the administrator and to other officials in accordance with state law.
Facilities must have evidence that all alleged violations are thoroughly investigated and must prevent further potential abuse while the investigation is in progress. Staff members who are the subject of an investigation must be prevented from coming into contact with residents until the investigation is complete.
The regulations require reporting to the state agency and to other agencies as required by law within specific timeframes. In Texas, allegations of abuse must be reported to the Health and Human Services Commission within two hours.
Facilities must also ensure that employees are trained on abuse and neglect policies during orientation and through ongoing education. Staff must know how to identify abuse, how to report it, and understand that retaliation against those who report is prohibited.
Impact on Resident Trust and Safety
This incident occurred in a facility with 99 beds caring for vulnerable individuals who depend on staff for their daily needs and safety. When staff mock residents experiencing mental health crises, it creates an environment where abuse can flourish unchecked.
The housekeeper's fear of retaliation prevented immediate reporting of the incident. This suggests a facility culture where staff did not feel safe reporting concerns about clinical leadership, including the Director of Nursing and the Administrator himself.
When other employees witnessed the incident—including medication aides who were reportedly laughing—and did not intervene or report it, the failure extended beyond the individuals directly involved. The systemic breakdown in abuse prevention and reporting placed all residents at risk.
Following the inspection, Terrell Healthcare Center faced the task of rebuilding systems to prevent abuse, training staff on proper reporting procedures, and creating a culture where employees feel safe reporting concerns without fear of retaliation. The facility implemented weekly Quality Assurance committee meetings for eight weeks to monitor compliance with corrective actions.
For complete details of the inspection findings and the facility's plan of correction, the full inspection report is available through the Texas Health and Human Services Commission and the Centers for Medicare & Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrell Healthcare Center from 2025-03-29 including all violations, facility responses, and corrective action plans.
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