Terrell Healthcare Center: Narcotic Count Failures - TX
Federal inspectors discovered the violation during an April 3 survey of the 204 W Nash facility. The breakdown in narcotic oversight represented a fundamental failure in medication security protocols designed to prevent controlled substances from disappearing without detection.
The facility's own policy required strict monitoring. According to the undated Controlled Substances policy reviewed by inspectors, "Controlled substance inventory is monitored and reconciled to identify loss or potential diversion in a manner that minimizes the time between loss/diversion and detection/follow-up."
But nurses weren't following through.
During a 5:32 p.m. interview on April 3, the Administrator acknowledged the severity of the problem. He told inspectors that nurses should be counting narcotics every shift, explaining that failure to count medications "could cause a discrepancy, or missing medications."
The Director of Nursing, when questioned about the missing counts, initially defended the practice. She told inspectors she was conducting random checks and claimed she saw no omissions in narcotic sign-out sheets. However, she admitted the current process was inadequate and said she would change how narcotics were checked.
Her response revealed a troubling gap in understanding. Random checks cannot substitute for the systematic shift-by-shift counting that federal regulations and the facility's own policies require. The DON's admission that she would "change the process" confirmed that proper procedures were not in place.
The Administrator placed responsibility squarely on the Director of Nursing's shoulders. He told inspectors the DON was responsible for monitoring and overseeing nurses through regular rounding. Yet the systematic failure to count controlled substances suggested this oversight was not happening effectively.
Federal inspectors classified the violation as causing minimal harm or potential for actual harm, affecting few residents. But the implications extended far beyond the immediate classification. Controlled substances that go uncounted create opportunities for diversion that can affect patient care across the entire facility.
The facility's written policy outlined specific requirements that were being ignored. Beyond the basic counting requirement, the policy mandated that "waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet." This dual-signature requirement exists precisely because controlled substances require heightened security measures.
The policy referenced compliance with "all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications" listed under Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976. These federal classifications cover everything from morphine and oxycodone to lesser controlled substances, all of which require careful tracking.
When nurses skip narcotic counts between shifts, several problems can emerge undetected. Medications can be diverted for personal use or sale. Residents may not receive prescribed pain medication or other controlled substances. Discrepancies in inventory can accumulate over multiple shifts, making it impossible to determine when or how substances went missing.
The Administrator's comment that missing counts "could cause missing medications" understated the regulatory significance. Drug diversion in healthcare settings has led to patient harm, criminal prosecutions, and facility closures. The systematic nature of the counting failure at Terrell Healthcare Center created conditions where such problems could develop and persist.
The Director of Nursing's initial response suggested she may not have fully grasped the scope of the problem. Her focus on "no omits in the narcotic sign out sheets" missed the point entirely. Sign-out sheets document when medications are given to residents, but they cannot verify that the medications were actually available to give in the first place.
Proper narcotic counting involves physically verifying that the number of controlled substances in secure storage matches the number that should be there based on previous counts, new deliveries, and documented administration to residents. This process must happen at every shift change to ensure any discrepancies are identified quickly.
The facility's policy acknowledged this principle by requiring monitoring "in a manner that minimizes the time between loss/diversion and detection/follow-up." When nurses don't count between shifts, the time between potential loss and detection expands dramatically, potentially spanning days or weeks.
The Administrator's statement that the DON was responsible for overseeing nurses "by rounding" suggested a supervisory structure that was not functioning as designed. If the DON was conducting effective rounds, she should have discovered that nurses were not performing required narcotic counts.
Federal regulations require nursing homes to have systems in place to prevent medication errors and ensure proper handling of controlled substances. The failure at Terrell Healthcare Center represented a breakdown in these fundamental safety systems.
The inspection finding highlighted how seemingly simple procedural failures can create significant risks. Counting controlled substances takes only minutes per shift, but skipping these counts can lead to problems that take months to detect and resolve.
The facility's undated policy document itself raised questions about how current the procedures were and whether staff had been properly trained on requirements. Policies that lack dates make it difficult to determine whether they reflect current regulations and best practices.
The DON's promise to "change the process of checking narcotics" suggested recognition that current practices were inadequate. However, the solution was not to change the process but to implement the existing policy that required shift-by-shift counting.
The violation occurred despite clear written policies and administrative awareness of the requirements. This gap between policy and practice indicated either inadequate training, insufficient oversight, or both.
For residents and their families, the narcotic counting failure represented a breach of trust. Families expect that controlled substances prescribed for their loved ones will be properly secured and administered as ordered. When basic counting procedures are skipped, that expectation cannot be met.
The inspection finding serves as a reminder that medication security in nursing homes depends on consistent adherence to established procedures. Even facilities with appropriate policies can fail residents when those policies are not followed in daily practice.
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.
Federal inspectors discovered the violation during an April 3 survey of the 204 W Nash facility.
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?
- Federal inspectors discovered the violation during an April 3 survey of the 204 W Nash facility.
- 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.