TERRELL, TX - A federal inspection at Terrell Healthcare Center has documented allegations that multiple staff members, including senior nursing leadership, mocked and encouraged a cognitively impaired resident to injure herself while she was experiencing emotional distress, according to inspection records from a March 2025 survey.
Allegations of Verbal Abuse Against Vulnerable Resident
Federal surveyors documented that on March 19, 2025, a housekeeper reported witnessing registered nurse RN A, registered nurse RN D, and the Director of Nursing (DON) allegedly making statements to Resident #45 while she was banging her head against a wall. According to the housekeeper's written statement, RN A allegedly told the resident "to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself."
The witness statement indicated that RN A, RN D, and the DON demonstrated to Resident #45 how she should hit her head on the wall, while medication aides MA C and MA B reportedly laughed at the situation.
Resident #45 was a resident in her 70s admitted to the facility with diagnoses including bipolar disorder with severe manic episodes and psychotic features, schizoaffective disorder, and paralysis following a stroke. Her cognitive assessment showed severe impairment with a score of 4 out of 15 on the Brief Interview for Mental Status (BIMS). Despite her cognitive limitations, she was usually able to communicate with and understand others.
The resident's care plan documented that she had a pattern of banging her head against walls when frustrated and frequently called 911 requesting transport to a psychiatric hospital. Her behavioral symptoms were noted to place her at significant risk for physical illness or injury. She was receiving multiple psychiatric medications including Seroquel, Zoloft, Clonazepam, and Oxcarbazepine to manage her mental health conditions.
Delayed Reporting Due to Fear of Retaliation
The housekeeper who witnessed the incident did not immediately report what she observed. During interviews with surveyors, Housekeeper E became tearful and explained that she "did not feel comfortable telling the Administrator because of how he had handled other situations in the past and she feared retaliation." She stated she "did not know who she could trust, and she was scared nobody would believe her."
Housekeeper E waited until the following day, March 20, 2025, to report the incident to her supervisor, the Housekeeping/Laundry Manager. That supervisor then took her to the Admissions Coordinator, who brought her to the facility's abuse coordinator—the Administrator—to report the allegations.
In her written witness statement dated March 20, 2025, Housekeeper E wrote: "I witnessed nurses [RN A], nurse [RN D], the D.O.N. making fun of a resident [Resident #45] on hall #1. Banging their heads on the wall in the same like manner as the resident because [Resident #45] was angry about something... I did not know who I could trust to talk to. But I knew that I had to do something. These residents deserve to be treated with the utmost respect."
The delay in reporting represents a significant breakdown in the facility's safety culture. When staff members fear retaliation for reporting concerns about resident care, vulnerable individuals remain at risk. Federal regulations require nursing homes to create environments where staff can report concerns without fear of consequences, as timely reporting is essential for protecting residents from harm.
Administrator Failed to Follow Abuse Reporting Protocols
Once the allegation was reported on March 20, 2025, the facility's Administrator—who served as the abuse coordinator—failed to follow required protocols for investigating and reporting suspected abuse. Federal and state regulations require nursing homes to report allegations of abuse to the state agency within two hours. The Administrator did not report this incident to the Texas Health and Human Services Commission (HHSC) within the required timeframe.
Instead of immediately reporting the allegation, suspending the accused staff members, and conducting a thorough investigation, the Administrator treated the matter as a customer service issue. He conducted an in-service training on "Professionalism/Customer Service" on March 21, 2025, which was signed by MA C, the DON, MA B, RN A, and RN D—the same staff members implicated in the allegation.
Even more concerning, the Administrator took Resident #45 directly to the accused staff members and asked the resident whether those individuals had been mean to her or laughed at her. This violated fundamental principles of abuse investigation. Bringing an alleged victim face-to-face with suspected perpetrators can intimidate the victim, compromise the investigation, and expose the resident to additional emotional harm. Given that Resident #45 had severe cognitive impairment and mental health conditions, this approach was particularly inappropriate.
When interviewed by surveyors, the Administrator stated he believed the allegation was "more of a grievance" rather than abuse. He explained that he had spoken to all the staff involved and "they gave him the same story" and that when he spoke to Resident #45, she said "it did not happen." He concluded it was therefore a grievance rather than an abuse allegation requiring state notification.
However, when questioned by surveyors about whether Resident #45—with her BIMS score of 4 indicating severe cognitive impairment—was a reliable source for determining whether abuse occurred, "the Administrator was silent and did not answer the question," according to the inspection report.
Understanding the Severity of Psychological Abuse
Verbal abuse and psychological mistreatment in nursing homes can cause significant harm to residents, particularly those with cognitive impairment and mental health conditions. When staff members mock residents who are experiencing emotional distress, it creates an environment of humiliation and fear rather than therapeutic care.
For a resident with severe mental illness who already experiences thoughts of self-harm, having staff members encourage her to injure herself more severely represents a profound betrayal of the duty of care. Nursing home staff are expected to de-escalate situations, redirect residents experiencing distress, and implement interventions designed to keep residents safe from harming themselves.
The resident's care plan outlined appropriate interventions including administering prescribed medications, anticipating and meeting her needs, providing opportunities for positive interaction, approaching her in a calm manner, and diverting her attention when necessary. The documented care plan specifically noted staff should "intervene as necessary to protect the rights and safety of others" and "monitor behavior episodes and attempt to determine underlying cause."
Mocking a resident's self-injurious behavior and allegedly instructing her on how to hurt herself more effectively directly contradicts these care plan interventions. Such actions can reinforce harmful behaviors, increase psychological distress, and potentially lead to serious physical injury.
Immediate Jeopardy Determination and Corrective Actions
Federal surveyors determined on March 27, 2025, that the facility's failures created a situation of "immediate jeopardy"—the most serious level of noncompliance, indicating a situation where the facility's practices have caused or are likely to cause serious injury, harm, impairment, or death to residents.
The immediate jeopardy was based on multiple system failures: staff members allegedly engaging in verbal abuse, a housekeeper fearing retaliation for reporting concerns, and the abuse coordinator failing to recognize an abuse allegation, failing to report it to the state within required timeframes, failing to suspend accused staff members pending investigation, and taking actions that exposed the alleged victim to the accused perpetrators.
Once notified of the immediate jeopardy determination, the facility implemented several corrective measures. On March 25, 2025, Resident #45 was placed on one-to-one supervision to ensure her safety and referred for a psychological evaluation. On March 27, 2025, the facility suspended RN A, RN D, the DON, MA C, MA B, and the Administrator pending the outcome of the investigation.
The facility conducted extensive staff training on abuse and neglect policies and procedures on March 27-28, 2025. Training emphasized that all allegations of abuse must be reported immediately to the abuse coordinator, that abuse includes willful infliction of injury and verbal abuse defined as disparaging or derogatory language, and that suspected perpetrators must be suspended immediately pending investigation.
The Regional Director of Operations was designated as the interim abuse coordinator and received education on abuse reporting requirements and protocols. All staff were notified of this change and the interim coordinator's contact information was posted throughout the facility. The Social Worker conducted life safety rounds with all residents who could be interviewed to ensure they were free from abuse and neglect.
Surveyors verified on March 28, 2025, that the facility had implemented sufficient corrective measures to remove the immediate jeopardy, though the facility remained out of compliance and subject to ongoing monitoring.
Additional Issues Identified
The inspection also documented that the facility failed to develop and implement adequate policies and procedures to prevent abuse, neglect, and theft. While the facility had written policies stating that residents, families, and staff should be able to report concerns without fear of retribution and that all allegations must be reported immediately to the abuse coordinator and investigated, these policies were not consistently followed.
The facility's abuse policy required the abuse coordinator to report all allegations of abuse, neglect with serious bodily injury, mistreatment with serious bodily injury, exploitation with serious bodily injury, and injuries of unknown source with serious bodily injury within two hours. Other allegations were to be reported within 24 hours. The policy also mandated that identification and suspension of accused persons is mandatory and that all residents must be immediately protected from harm.
Federal regulations require nursing homes to have zero tolerance for abuse. This means facilities must create cultures where abuse is prevented through proper hiring, training, and supervision; where staff feel safe reporting concerns; where allegations are taken seriously and investigated thoroughly; and where residents are protected throughout the investigative process.
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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