Terrell Healthcare Center: Call Light Violations - TX
The woman, identified as Resident #64, required total assistance with toileting, personal hygiene, transfers and bathing. Despite having intact cognition and being able to communicate clearly, she told inspectors she "usually had to holler out if she needed assistance."
Inspectors observed the problem over multiple days. On March 31 at 11:10 a.m., they found the resident in bed with her call light sitting on the bedside table, not within reach. Later that same day at 3:53 p.m., inspectors returned to find the call light still on the table, out of reach.
When CNA H entered the room during the second observation, she acknowledged the call light was not accessible. The nursing assistant said all residents should have their call lights within reach in case they needed something, but explained that this resident's call light cord was not long enough. She placed the call light on the bed temporarily.
The resident's care plan, dated March 15, 2021, specifically identified her as a fall risk due to deconditioning, psychoactive drug use, and being unaware of safety needs. The plan's interventions required staff to anticipate and meet her needs, ensure the call light was within reach, and respond promptly to all requests for assistance.
LVN K, the charge nurse responsible for Resident #64, confirmed the problem during an interview on April 1. She explained that while the resident did have a call light, the pull cord was too short for her to reach it. The nurse noted that the resident could move her right and left hands slightly despite contractures, but would benefit from a push pad call light system.
"The risk of not having a call light could be Resident #64 would not get the help she needed in a timely manner," LVN K told inspectors. She promised to obtain a push pad call light system for the resident.
The next day, inspectors observed that a push pad call light system had been placed within the resident's reach.
The facility's Director of Nursing said she was unaware that Resident #64 could not use her call light. She acknowledged that all staff should be checking on residents and ensuring call lights remain within reach, stating she expected call lights to always be accessible.
"Failure to have or keep call lights within reach could cause a resident to fall, receive a bump, bruise, or even a fracture," the DON told inspectors.
The Administrator echoed similar expectations during his interview, saying he required call lights to work properly, have cords long enough for residents to use, and that residents should receive special call light systems when needed.
"If call lights were not in reach of residents, then their needs would not be met, and it could place them at a greater risk of falling," the Administrator said. He emphasized that all staff were responsible for ensuring residents had accessible call lights.
The resident's medical records revealed she was admitted to the facility with diagnoses including dementia, depression, and muscle weakness. Her quarterly assessment showed she understood others and made herself understood, with a cognitive score indicating her mental faculties remained intact.
Despite requiring maximal assistance with eating and total assistance with most daily activities, the resident's cognitive awareness meant she understood when she needed help but had no reliable way to summon staff.
The facility's own policy, titled "Call System, Residents" and dated September 2022, states that residents must be provided with a means to call staff for assistance through a communication system that directly contacts staff or a centralized workstation. The policy specifically requires that each resident be provided with a way to call staff directly from their bed, from toileting and bathing facilities, and from the floor.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. However, they noted the failure could place residents at risk of delayed assistance and decreased quality of life, self-worth, and dignity.
The inspection revealed a gap between written policies and daily practice. While the facility had clear protocols requiring accessible call lights and staff specifically trained on the resident's fall risk and need for prompt assistance, the basic accommodation of ensuring she could actually request help went unaddressed for an unknown period.
For a resident who depended entirely on staff for toileting, hygiene, and transfers, the inability to reliably summon assistance represented more than an inconvenience. With her documented fall risk and physical limitations, being forced to shout for help left her vulnerable during the times when no staff member happened to be within earshot.
The case highlighted how seemingly minor oversights can compound the challenges faced by residents with multiple diagnoses. Despite having dementia, depression, and muscle weakness, this resident retained enough cognitive function to recognize her predicament and articulate it to inspectors.
Her situation improved only after federal inspectors discovered the problem and staff obtained appropriate equipment. The push pad call light system installed on April 2 finally gave her the independence to request assistance without having to shout and hope someone would hear.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terrell Healthcare Center from 2026-04-03 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 15, 2026 · Our methodology
Terrell Healthcare Center in Terrell, TX was cited for violations during a health inspection on April 3, 2026.
The woman, identified as Resident #64, required total assistance with toileting, personal hygiene, transfers and bathing.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.
Frequently Asked Questions
- What happened at Terrell Healthcare Center?
- The woman, identified as Resident #64, required total assistance with toileting, personal hygiene, transfers and bathing.
- How serious are these violations?
- Violation severity varies from minor documentation issues to serious safety concerns. Review the inspection report for specific deficiency codes and scope. All violations must be corrected within required timeframes and are subject to follow-up verification inspections.
- What should families do?
- Families should: (1) Ask facility administration about specific corrective actions taken, (2) Request to see the follow-up inspection report verifying corrections, (3) Check if this represents a pattern by reviewing prior inspection reports, (4) Compare this facility's ratings with other nursing homes in Terrell, TX, (5) Report any new concerns directly to state authorities.
- Where can I see the full inspection report?
- The complete inspection report is available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request a copy directly from Terrell Healthcare Center or from the state Department of Health. The report includes specific deficiency codes, facility responses, and correction timelines. This facility's federal provider number is 675879.
- Has this facility had violations before?
- To check Terrell Healthcare Center's history, visit Medicare.gov's Care Compare and review their inspection history, quality ratings, and staffing levels. Look for patterns of repeated violations, especially in critical areas like abuse prevention, medication management, infection control, and resident safety.