Health Inspection - TERRELL HEALTHCARE CENTER

F-Tag F600

Harm Level: serviced. Staff will not be able to work until completed.

Residents Affected: Some On 3/27/2025 the Social Worker will make life safety rounds to all residents that can be interviewed to ensure

F-F600

On 3/25/2025, resident #45 was placed on 1:1 supervision to ensure resident safety.

On 3/27/2025, RN A, RN D, DON, MA C, MA B and Administrator were suspended pending the outcome of

the investigation.

On 3/24/2025 DON referred resident #45 for a psychological evaluation and was seen on 3/25/2025.

On 3/27/2025, Corporate Clinical Specialist in-serviced ADON and MDS nurse regarding Abuse and Neglect policies and procedures. Competency was verified by quiz. Completed on 3/27/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 On 3/27/2025, ADON and MDS nurse in-serviced all staff regarding Abuse and Neglect policies and procedures. Competency was verified by quiz. Started on 3/27/2025 and ongoing until all staff are Level of Harm - Immediate in-serviced. Staff will not be able to work until completed. jeopardy to resident health or safety The above training will continue to be implemented in new hire orientation.

Residents Affected - Some On 3/27/2025 the Social Worker will make life safety rounds to all residents that can be interviewed to ensure free from abuse and neglect. Any abuse or neglect identified will be immediately reported to abuse coordinator and then HHSC. Completed on 3/27/2025

Regional Director of Operations will be the interim Abuse Coordinator. She has received the education on abuse and neglect reporting and policies and procedures with competency quiz. All staff were notified through voice friend messaging and Core staffing system of this change in addition to cell phone contact 3/27/2025. This change, with contact posted for staff, residents and visitors. Completed on 3/28/2025.

To monitor compliance, the Social Worker, or designee, will conduct life safety rounds 1x weekly for 4 weeks and monthly thereafter x3 months.

The QA committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, the facility will continue to monitor as per routine facility QA committee.

On 03/28/2025 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:

During an observation on 03/28/25 at 11:15 AM, it was verified the posting for the abuse coordinators information was updated to reflect the interim abuse coordinator's information.

During an interview on 03/28/2025 at 11:23 AM, the MDS Coordinator said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz.

During an interview on 03/28/2025 at 11:37 AM, the ADON said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz.

During an interview on 03/28/2025 at 12:54 PM, the Social Worker said she would be completing life safety rounds weekly for four weeks and monthly thereafter for 3 months.

During an interview on 03/28/2025 at 1:45 PM, the Corporate Clinical Specialist said she had in-serviced staff on abuse and neglect policies and procedures.

During an interview on 03/28/2025 at 1:45 PM, the Regional Director of Operations said she received education on abuse and neglect and reporting and policies and procedures and completed the competency quiz. The Regional Director of Operations said the staff were notified via a digital system that she was the interim abuse coordinator along with her contact information.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 During interviews conducted on 03/28/2025 beginning at 11:17 AM and ending at 2:12 PM: (Day) the Human Resources, CNA G, CNA H, CNA K, the Maintenance Director, the Dietary Manager, [NAME] N, the Level of Harm - Immediate Business Office Manager, MA C, RN R, the Transportation Driver, Dietary Aide X, the Social Worker, the jeopardy to resident health or Activities Director, Housekeeper Z, Housekeeper AA, the Housekeeper/Laundry Supervisor, Speech safety Therapist BB, COTA CC, the Director of Rehab, and CNA DD, Housekeeper E, LVN F, (Evening) CNA M, CNA O, MA P, LVN S, CNA V, CNA Y, (Nights) LVN T, LVN U, [NAME] W, (Weekend) LVN L, MA Q, were Residents Affected - Some able to properly verbalize the abuse and neglect policies and procedures, and that the Regional Director of Operations was the interim abuse coordinator.

Record review completed of Resident #45's psych evaluation dated 03/25/2025.

Record review completed of Resident #45's 1:1 supervision dated 03/25/2025-03/26/2025.

Record review completed of the life safety rounds completed on 3/27/2025 by the Social Worker.

Record review completed of the Personnel Action Forms dated 03/27/2025 for RN A, RN D, the DON, MA C, MA B and the Administrator's suspension.

Record review completed of the in-service sign in sheet for Abuse and Neglect regarding all allegations of abuse and neglect are to be reported to your abuse coordinator immediately-abuse is the willful infliction of injury, withholding or misappropriating property or money confinement intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families or within their hearing distance regardless of their age ability to comprehend or disability dated 03/27/2025 indicated 32 staff signatures.

Record review completed of the in-service sign in sheet for Abuse and Neglect regarding review of policy-all allegations of abuse are to be reported immediately-free from abuse-resident safety facility has two hours to report to state office perpetrators must be suspended immediately pending investigation-facility is required to investigate/protect resident at all times dated 03/27/2025 indicated 44 signatures.

Record review completed of all the staffs' posttests Post Abuse Training Quiz and Verbal Abuse Competency Quiz dated 03/27/2025 and 03/28/2025.

The Regional Director of Operations was notified the Immediate Jeopardy was removed on 03/28/2025 at 4:14 PM, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Level of Harm - Immediate **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46892 jeopardy to resident health or safety 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) Residents Affected - Some 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 how

she should hit her head on the wall to injure herself, and 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.

The Abuse Coordinator failed to follow the facility's abuse policy when he did not protect Resident #45 from potential abuse when he took her to MA C and asked Resident #45 if she had laughed at her.

The Abuse Coordinator failed to follow the facility's abuse policy when he did not protect Resident #45 from potential abuse when he took her to MA B and asked Resident #45 if she was mean.

The Abuse Coordinator failed to follow the facility's abuse policy when he did not suspend RN A, RN D, the DON, MA C, and MA B after an allegation of abuse was made against them on 03/20/2025.

The Abuse Coordinator failed to identify an allegation of abuse and acknowledge and act upon it to prevent alleged perpetrators to have continued access to Resident #45 and others.

An Immediate Jeopardy (IJ) was identified on 03/27/2025 at 12:30 PM. The IJ template was provided to the facility on [DATE REDACTED] at 2:06 PM. While the IJ was removed on 03/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

These failures could place residents at risk of unreported abuse, neglect, exploitation and a decreased quality of life.

Findings included:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Record review of the facility's Abuse Prohibition Policy, reviewed 05/17/2024 indicated, . Residents, families and staff will be able to report concerns, incidents and grievances without fear of retribution. Staff will be Level of Harm - Immediate instructed to report any signs of stress from individuals involved with the residents that may lead to jeopardy to resident health or (abuse/neglect and intervene appropriately. Facility staff will immediately correct and intervene in reported or safety identified situations in which abuse/neglect is at risk for occurring . Any allegation of abuse/neglect, made by residents/staff/visitors shall be reported to the Abuse Coordinator and investigated immediately . The facility Residents Affected - Some will thoroughly investigate all alleged violations and take appropriate actions. The Abuse Coordinator will report such allegations to the state agency in' accordance with state law. The Abuse Coordinator will 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 of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation .Identification and suspension from employment of the person or persons accused of the abuse allegation(s) is mandatory .1. All residents will be immediately protected from harm. 2. All allegations involving staff will necessitate suspension, without pay, pending investigation .If another resident is the alleged perpetrator, they shall immediately be assessed for treatment options. The safety and protection of other residents is the facility's primary concern. 1. Any employee who becomes aware of an allegation of abuse, neglect or misappropriation of resident property, shall report the incident to the Abuse Coordinator immediately. Failure to do so will result in disciplinary action, up to and including termination. 2. The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary corrective actions depending on the results of the investigation. The Abuse Coordinator will 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 immediately or within two hours of the allegation. The Abuse Coordinator will report all other allegations of neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation .

1. Record review of a face sheet dated 03/29/2025 indicated Resident #45 was a [AGE] year-old female admitted to the facility on [DATE REDACTED] with diagnoses which included bipolar disorder current episode manic severe with psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), schizoaffective disorder bipolar type (a mix of symptoms such as hallucinations, delusions, depression and mania), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial or complete paralysis of the right side of the body due to a stroke that damaged

the left side of the brain).

Record review of Resident #45's Comprehensive MDS assessment dated [DATE REDACTED] indicated she was usually understood by others, and she was usually able to understand others. Resident #45's BIMS score was a 4, which indicated her cognition was severely impaired. The MDS assessment indicated Resident #45 required partial/moderate assistance with showering/bathing self, setup or clean-up assistance with oral, toileting, and personal hygiene and dressing. The MDS assessment indicated Resident #45 exhibited verbal behavioral symptoms towards others (e.g., threatening others, screaming at others, cursing at others) and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS assessment indicated Resident #45's behavioral symptoms placed her at significant risk for physical illness or injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Record review of Resident #45's Order Summary Report dated 03/29/2025 indicated:

Level of Harm - Immediate Seroquel (medication used to treat mood and behaviors) 200 mg give 1 tablet by mouth three times a day jeopardy to resident health or with a start date of 02/13/2025. safety Zoloft (medication for depression) 100 mg give 1 tablet by mouth one time a day with a start date of Residents Affected - Some 03/07/2025.

Clonazepam (medication for anxiety) 1 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025.

Oxcarbazepine (used to treat bipolar disorder) 300 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025.

Record review of Resident #45's care plan with a date initiated 01/15/2025 indicated she had a behavior problem and banged her head against the wall when she got frustrated, called 911 multiple times a shift, and when they arrived, she banged her head on the walls or furniture and demanded to be taken to a psychiatric hospital and 911 refused to take her. The interventions for Resident #45 included administer medications as ordered, anticipate, and meet the resident's needs, caregivers to provided opportunity for positive interaction and attention, stop and talk with her as passing by, explain all procedures to the resident before starting and allow the resident a few minutes to adjust to changes, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention remove from situation and take to alternate location as needed, and monitor behavior episodes and attempt to determine underlying cause consider location, time of day, persons involved, and situations document behavior and potential causes.

Record review of a witness statement signed by Housekeeper E dated 03/20/2025 indicated, To whom it may concern: I [Housekeeper E] 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. [MA C] the med ade [sic] was laughing and [MA B] was laughing. I witnessed them making fun of her. As if it was funny but it was (is) wrong for them to behave in that manner. 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. And deserve the best of care. I believe in telling the truth. It is unprofessional to behave the way that they did. Thank you! [Housekeeper E] (housekeeper).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 During an interview on 03/27/2025 at 8:48 AM, Housekeeper E said on March the 20th or 21st, towards the end of her shift, she witnessed the DON, RN D, and RN A making fun of Resident #45. Housekeeper E Level of Harm - Immediate became teary-eyed and started crying. Housekeeper E said the DON, RN D and RN A were at the nurses' jeopardy to resident health or station, and Resident #45 was upset and had wheeled up and was banging her head on the wall. safety Housekeeper E said the DON, RN D, and RN A were telling Resident #45 where to bang her head on the wall to hurt herself. Each one of them were taking turns telling Resident #45 where she should hit her head Residents Affected - Some on the wall. 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. Housekeeper E said MA B and MA C were watching and laughing. Housekeeper E said Resident #45 often banged her head on the wall and RN A would get irritated with her. Housekeeper E said Resident #45 always talks about killing herself. Housekeeper E said she did not feel comfortable telling the Administrator because of how he had handled other situations in the past and she feared retaliation. Housekeeper E said she did not know who she could trust, and she was scared nobody would believe her. Housekeeper E said she wished she would have recorded the incident because she did not have any witnesses. Housekeeper E said the next morning she reported the incident to her boss, the Housekeeping/Laundry Supervisor, and she had taken her to the Admissions Coordinator. Housekeeper E said the Admissions Coordinator listened to her and took her to the ADON's office where she reported the incident to the ADON and Administrator.

During an interview on 03/27/2025 at 9:17 AM, the Housekeeping/Laundry Manager said Housekeeper E had come to her the day after she witnessed an incident maybe a couple days ago or last week. The Housekeeping/Laundry Manager said Housekeeper E told her the staff was laughing and making fun of Resident #45. She said Housekeeper E said they were gathered around Resident #45 and were telling her just hit your head on the corner if you really want to hit your head and hurt yourself hit your head on the corner. The Housekeeping/Laundry Manager said she reported it to the Admissions Coordinator because

she was the department head available. The Housekeeping/Laundry Manager said she did not think she could write a grievance because she was contracted. The Housekeeping/Laundry Manager said she could not remember the staff members names, but she knew it was a nurse, the DON, and some CNAs. The Housekeeping/Laundry Manager said the incident reported to her by Housekeeper E could be considered abuse.

During an interview on 03/27/2025 at 9:33 AM, the Admissions Coordinator said last week some day she did not remember the day, the Housekeeping/Laundry Manager told her that Housekeeper E had a concern about what happened the day before. Then, Housekeeper E went to her office and told her there were a couple of the nurses that were laughing at Resident #45 because she was hitting her head on the wall and said something to her. The Admissions Coordinator said Housekeeper E told her the nurses were gathered around Resident #45 laughing at her while she was hitting her head. The Admissions Coordinator said she told Housekeeper E, I have to report that, and she went and reported it to the Administrator. The Admissions Coordinator said the Administrator took over.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 During an interview on 03/27/2025 at 9:42 AM, RN A said Resident #45 did hit her head on the wall every now and then. RN A said when this happened, she tried to stop Resident #45 and move her away from the Level of Harm - Immediate wall. RN A said at times she did get frustrated and said, don't do it. RN A said Resident #45 got irritated and jeopardy to resident health or she did her best to try to move her away from the wall, so she did not hurt herself. RN A said she did not tell safety Resident #45 where to hit her head on the wall or 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 said she did not laugh or make fun of Resident Residents Affected - Some #45 for banging her head on the wall. RN A said she could get frustrated that Resident #45 was banging her head on the wall and tell her can you just stop. RN A said the Administrator called her and told her an allegation was made against her by Housekeeper E. RN A said she was not suspended, and an in-service was done with her on doing teaching and that it could be frustrating when educating residents but she should try as much as she could to do it calmy when she was getting frustrated. RN A said she told the Administrator she did teaching with Resident #45 and told her you are going to fracture yourself. RN A said

the Administrator told her maybe it was the tone she had used, and Housekeeper E perceived it as she was telling Resident #45 to kill herself. RN A said when the incident occurred, she was giving report to RN D and

the DON was also there and a CNA and they were laughing about something different they were not laughing at Resident #45.

During an interview on 03/27/2025 at 9:54 AM, the DON said last week RN D, RN A, and herself were at the nurses' station. She said maybe it was the Friday before last, but she did not remember the day. The DON said she remembered it was during shift change and they were at the nurses' station. The DON said RN A did not tell Resident #45 to hit her head on the wall. The DON said they were not laughing at Resident #45.

The DON said she was at the nurses' station, and they were talking and laughing, and then Resident #45 pulled over and started banging her head. The DON said she told her to stop banging her head, if she kept banging her head, she was going to hurt herself. The DON said she did not witness RN A frustrated at Resident #45. The DON said the Administrator told her the Admissions Coordinator had taken Housekeeper E to him, and Housekeeper E said the DON was present and laughing at Resident #45. The DON said she told the Administrator to let Housekeeper E write the witness statement and send it to corporate. The DON said she told the Administrator whatever corrective actions needed to be taken to take them. The DON said

she did not laugh at Resident #45. The DON said the Administrator told her he had sent the witness statement to corporate, and they said it was not abuse because they did not laugh. The DON said she did not get suspended.

During an interview in 03/27/2025 at 10:04 AM, MA B stated RN A put her hand on the same spot Resident #45 was hitting her head to prevent injury. MA B stated she was not laughing at Resident #45. MA B stated

the Administrator spoke to her about the incident and brought Resident #45 to her. The Administrator asked Resident #45 if MA B had ever been mean to her. Resident #45 stated no. MA B stated she was in-serviced, but not suspended.

During an attempted interview on 03/27/2025 at 10:05 AM, RN D did not answer the phone.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 During an interview on 03/27/2025 at 10:09 AM, the Administrator said he was the abuse coordinator. The Administrator said depending on the severity of the abuse some are reported within 2 hours and others Level of Harm - Immediate within 24 hours. The Administrator said all allegations of abuse should be reported to HHSC. The jeopardy to resident health or Administrator said Housekeeper E had gone to him and reported some of the staff were laughing at Resident safety #45 at the nurses' station. The Administrator said he thought it was on March 21st, Thursday (3/20/2025) or Friday (03/21/2025). The Administrator said the Admissions Coordinator had taken him to Housekeeper E for Residents Affected - Some her to tell him what happened. The Administrator said he told her to write a statement and he talked to Resident #45, and Resident #45 told him they were not laughing at her. The Administrator said he did a customer service in-service with the staff. The Administrator said the nurses told him they were sitting at the nurses' station having a conversation. The Administrator said he had taken a staff member to Resident #45 and asked her if the staff member was mean to her. The Administrator said Resident #45 had identified the staff member and said she was not mean to her. The Administrator said he did an in-service on customer service with all of them (the DON, RN D, RN A, MA B, and MA C). The Administrator said what Housekeeper E told him was not an allegation of abuse. The Administrator said Housekeeper E said Resident #45 was hitting her head on the wall and the nurses were laughing at the nurses' station. The Administrator said he had spoken to all the staff, and they told him they were having a conversation before Resident #45 pulled up to them. The Administrator said when Housekeeper E reported the incident to him it was more of a grievance. The Administrator said before he suspended any staff, he notified his team and talked to all the staff. The Administrator said he talked to all the staff involved and they gave him the same story, therefore, it was a grievance. The Administrator said abuse was willful infliction of pain that it could be emotional, psychological, sexual, or financial. The Administrator said staff laughing at a resident could cause psychological issues and it was emotional abuse. The Administrator said the allegation should have been reported to the state immediately. The Administrator said he asked the staff if they were banging their heads

on the wall, and they said they were doing it to demonstrate to the resident she could hurt herself. The Administrator said he talked to the resident immediately and to the staff involved and the resident said it did not happen and they said it did not happen. The Administrator said when he received an allegation of abuse

he should report it to the state first, and then investigate it. The State Surveyor asked the Administrator if Resident #45 with a BIMS of 4 was a reliable interviewee. The Administrator was silent and did not answer

the question.

During an interview on 03/27/2025 at 10:30 AM, MA C stated she was not laughing at Resident #45. MA C stated the Administrator called her to his office to discuss the incident. MA C stated the Administrator brought Resident #45 to her. The Administrator asked Resident #45 if she knew MA C and Resident #45 stated, yes.

The Administrator asked Resident #45 if MA C had ever laughed at her and Resident #45 stated no.

During an interview on 03/27/2025 at 10:34 AM, the Regional Nurse stated she learned of the incident today (03/27/2025), and she considered the incident to be abuse. The Regional Nurse stated the incident should have been reported within 2 hours to the state, and the staff involved should have been suspended pending investigation and all statements necessary should have been gathered. The Regional Nurse said the incident not being reported placed the residents at risk for abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 During an interview on 03/27/2025 at 10:44 AM, the Regional Director of Operations stated she was not aware of the incident until today (03/27/2025). The Regional Director of Operations stated the Administrator Level of Harm - Immediate should have made her aware of the incident. After reading the statement that was provided by the jeopardy to resident health or Administrator, she stated Housekeeper E's statement was an allegation of abuse. The Regional Director of safety Operations said the allegation of abuse should have been reported within 2 hours and staff suspended pending investigation. The Regional Director of Operations stated the victim of an abuse allegation should Residents Affected - Some never be taken to the perpetrator. The Regional Director of Operations said these failures placed the residents at risk for abuse.

During an interview on 03/27/2025 at 12:13 PM, Housekeeper E confirmed the incident occurred on 03/19/2025 around 2-2:30 PM. Housekeeper E said she did not see if Resident #45 did what the nurses demonstrated to her to do, but Resident #45 continued banging her head against the wall throughout the day.

During an interview on 03/27/2025 at 12:16 PM, the Executive Director stated the Administrator contacted him and told him about the incident with staff laughing at a resident. The Executive Director stated the Administrator told him he spoke with the staff, and they told him they were not laughing at the resident. The Administrator told the Executive Director he spoke with the resident, and she did not have any complaints.

The Executive Director stated he redirected the Administrator to contact corporate. The Executive Director stated the incident was an allegation of abuse, and it should have been reported within 2 hours to the state.

The Executive Director said the staff involved should have been suspended pending investigation. The Executive Director stated taking the resident to the perpetrator exposed her to harm, and stated you never take the victim to the alleged perpetrator.

During an interview on 03/27/2025 at 12:30 PM, Resident #45 said staff had laughed at her. Resident #45 was unable to provide details. When questioned further she said she did not know.

During an attempted phone interview on 03/29/2025 at 8:43 AM, RN D did not answer the phone.

Record review of an in-service record with topic, Professionalism/Customer Service, conducted by the Administrator, dated 03/21/2025, indicated it was signed by MA C, the DON, MA B, RN A, and RN D.

This was determined to be an Immediate Jeopardy (IJ) on 03/27/2025 at 12:30 PM. The Regional Director of Operations was notified. The Regional Director of Operations was provided with the IJ template on 03/27/2025 at 2:06 PM and a Plan of Removal was requested.

The facility's plan of removal was accepted on 03/28/2025 at 10:17 AM and included the following:

March 27,2025

POR

F-Tag F607

Harm Level: Immediate on 3/27/2025.

Residents Affected: serviced. Staff will not be able to work until completed.

F-F607

On 3/25/2025, resident #45 was placed on 1:1 supervision to ensure resident safety.

On 3/27/2025, RN A, RN D, DON, MA C, MA B and Administrator were suspended pending the outcome of

the investigation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 On 3/27/2025, Corporate Clinical Specialist in-serviced ADON and MDS nurse regarding Abuse and Neglect policies and procedures, to include ensuring implementation. Competency was verified by quiz. Completed Level of Harm - Immediate on 3/27/2025. jeopardy to resident health or safety On 3/27/2025, ADON and MDS nurse in-serviced all staff regarding Abuse and Neglect policies and procedures, to include ensuring implementation. Competency was verified by quiz. Started on 3/27/2025 and Residents Affected - Some ongoing until all staff are in-serviced. Staff will not be able to work until completed.

The above training will continue to be implemented in new hire orientation.

On 3/27/2025 the Social Worker will make life safety rounds to all residents that can be interviewed to ensure free from abuse and neglect. Any abuse or neglect identified will be immediately reported to abuse coordinator and then HHSC. Completed 3/27/2025

To monitor compliance, the Social Worker, or designee, will conduct life safety rounds 1x weekly for 4 weeks and monthly thereafter x3 months.

The QA committee will meet weekly for the next eight weeks to review compliance with the plan of action. If no further concerns are noted, the facility will continue to monitor as per routine facility QA committee.

Regional Director of Operations will be the interim Abuse Coordinator. She has received the education on abuse and neglect reporting and policies and procedures with competency quiz. All staff were notified through voice friend messaging and Core staffing system of this change in addition to cell phone contact 3/27/2025. This change, with contact posted for staff, residents and visitors. Completed on 3/28/2025

On 03/28/2025 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the Immediate Jeopardy (IJ) by:

During an observation on 03/28/25 at 11:15 AM, it was verified the posting for the abuse coordinators information was updated to reflect the interim abuse coordinator's information.

During an interview on 03/28/2025 at 11:23 AM, the MDS Coordinator said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz.

During an interview on 03/28/2025 at 11:37 AM, the ADON said she was in-serviced on the abuse and neglect policies and procedures and completed the competency quiz.

During an interview on 03/28/2025 at 12:54 PM, the Social Worker said she would be completing life safety rounds weekly for four weeks and monthly thereafter for 3 months.

During an interview on 03/28/2025 at 1:45 PM, the Corporate Clinical Specialist said she had in-serviced staff on abuse and neglect policies and procedures.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 During an interview on 03/28/2025 at 1:45 PM, the Regional Director of Operations said she received education on abuse and neglect and reporting and policies and procedures and completed the competency Level of Harm - Immediate quiz. The Regional Director of Operations said the staff were notified via a digital system that she was the jeopardy to resident health or interim abuse coordinator along with her contact information. safety

During interviews conducted on 03/28/2025 beginning at 11:17 AM and ending at 2:12 PM: (Day) the Human Residents Affected - Some Resources, CNA G, CNA H, CNA K, the Maintenance Director, the Dietary Manager, [NAME] N, the Business Office Manager, MA C, RN R, the Transportation Driver, Dietary Aide X, the Social Worker, the Activities Director, Housekeeper Z, Housekeeper AA, the Housekeeper/Laundry Supervisor, Speech Therapist BB, COTA CC, the Director of Rehab, and CNA DD, Housekeeper E, LVN F, (Evening) CNA M, CNA O, MA P, LVN S, CNA V, CNA Y, (Nights) LVN T, LVN U, [NAME] W, (Weekend) LVN L, MA Q, were able to properly verbalize the abuse and neglect policies and procedures, and that the Regional Director of Operations was the interim abuse coordinator.

Record review completed of Resident #45's 1:1 supervision dated 03/25/2025-03/26/2025.

Record review completed of the life safety rounds completed on 3/27/2025 by the Social Worker.

Record review completed of the Personnel Action Forms dated 03/27/2025 for RN A, RN D, the DON, MA C, MA B and the Administrator's suspension.

Record review completed of the in-service sign in sheet for Abuse and Neglect regarding all allegations of abuse and neglect are to be reported to your abuse coordinator immediately-abuse is the willful infliction of injury, withholding or misappropriating property or money confinement intimidation or punishment with resulting physical harm, pain or mental anguish. Verbal abuse is defined as the use of oral, written or gestured language that willfully includes disparaging or derogatory terms to residents or their families or within their hearing distance regardless of their age ability to comprehend or disability dated 03/27/2025 indicated 32 staff signatures.

Record review completed of the in-service sign in sheet for Abuse and Neglect regarding review of policy-all allegations of abuse are to be reported immediately-free from abuse-resident safety facility has two hours to report to state office perpetrators must be suspended immediately pending investigation-facility is required to investigate/protect resident at all times dated 03/27/2025 indicated 44 signatures.

Record review completed of all the staffs' posttests Post Abuse Training Quiz and Verbal Abuse Competency Quiz dated 03/27/2025 and 03/28/2025.

The Regional Director of Operations was notified the Immediate Jeopardy was removed on 03/28/2025 at 4:14 PM, the facility remained out of compliance at a potential for more than minimal harm with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Immediate jeopardy to resident health or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46892 safety Based on observation, interview, and record review, the facility failed to ensure that all alleged violations Residents Affected - Few involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 1 of 23 residents (Resident #45) reviewed for abuse and neglect reporting.

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 identify and report an allegation of abuse to HHSC within 2 hours 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 how she should hit her head on the wall to injure herself, and 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.

An Immediate Jeopardy (IJ) was identified on 03/27/2025 at 12:30 PM. The IJ template was provided to the facility on [DATE REDACTED] at 2:06 PM. While the IJ was removed on 03/28/2025, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Findings included:

1. Record review of a face sheet dated 03/29/2025 indicated Resident #45 was a [AGE] year-old female admitted to the facility on [DATE REDACTED] with diagnoses which included bipolar disorder current episode manic severe with psychotic features (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), schizoaffective disorder bipolar type (a mix of symptoms such as hallucinations, delusions, depression and mania), and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (partial or complete paralysis of the right side of the body due to a stroke that damaged

the left side of the brain).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Record review of Resident #45's Comprehensive MDS assessment dated [DATE REDACTED] indicated she was usually understood by others, and she was usually able to understand others. Resident #45's BIMS score was a 4, Level of Harm - Immediate which indicated her cognition was severely impaired. The MDS assessment indicated Resident #45 required jeopardy to resident health or partial/moderate assistance with showering/bathing self, setup or clean-up assistance with oral, toileting, and safety personal hygiene and dressing. The MDS assessment indicated Resident #45 exhibited verbal behavioral symptoms towards others (e.g., threatening others, screaming at others, cursing at others) and other Residents Affected - Few behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds). The MDS assessment indicated Resident #45's behavioral symptoms placed her at significant risk for physical illness or injury.

Record review of Resident #45's Order Summary Report dated 03/29/2025 indicated:

Seroquel (medication used to treat mood and behaviors) 200 mg give 1 tablet by mouth three times a day with a start date of 02/13/2025.

Zoloft (medication for depression) 100 mg give 1 tablet by mouth one time a day with a start date of 03/07/2025.

Clonazepam (medication for anxiety) 1 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025.

Oxcarbazepine (used to treat bipolar disorder) 300 mg give 1 tablet by mouth three times a day with a start date of 03/25/2025.

Record review of Resident #45's care plan with a date initiated 01/15/2025 indicated she had a behavior problem and banged her head against the wall when she got frustrated, called 911 multiple times a shift, and when they arrived, she banged her head on the walls or furniture and demanded to be taken to a psychiatric hospital and 911 refused to take her. The interventions for Resident #45 included administer medications as ordered, anticipate, and meet the resident's needs, caregivers to provided opportunity for positive interaction and attention, stop and talk with her as passing by, explain all procedures to the resident before starting and allow the resident a few minutes to adjust to changes, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention remove from situation and take to alternate location as needed, and monitor behavior episodes and attempt to determine underlying cause consider location, time of day, persons involved, and situations document behavior and potential causes.

Record review of a witness statement signed by Housekeeper E dated 03/20/2025 indicated, To whom it may concern: I [Housekeeper E] 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. [MA C] the med ade [sic] was laughing and [MA B] was laughing. I witnessed them making fun of her. As if it was funny but it was (is) wrong for them to behave in that manner. 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. And deserve the best of care. I believe in telling the truth. It is unprofessional to behave the way that they did. Thank you! [Housekeeper E] (housekeeper).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 During an interview on 03/27/2025 at 8:48 AM, Housekeeper E said on March the 20th or 21st, towards the end of her shift, she witnessed the DON, RN D, and RN A making fun of Resident #45. Housekeeper E Level of Harm - Immediate became teary-eyed and started crying. Housekeeper E said the DON, RN D and RN A were at the nurses' jeopardy to resident health or station, and Resident #45 was upset and had wheeled up and was banging her head on the wall. safety Housekeeper E said the DON, RN D, and RN A were telling Resident #45 where to bang her head on the wall to hurt herself. Each one of them were taking turns telling Resident #45 where she should hit her head Residents Affected - Few on the wall. 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. Housekeeper E said MA B and MA C were watching and laughing. Housekeeper E said Resident #45 often banged her head on the wall and RN A would get irritated with her. Housekeeper E said Resident #45 always talks about killing herself. Housekeeper E said she did not feel comfortable telling the Administrator because of how he had handled other situations in the past and she feared retaliation. Housekeeper E said she did not know who she could trust, and she was scared nobody would believe her. Housekeeper E said she wished she would have recorded the incident because she did not have any witnesses. Housekeeper E said the next morning she reported the incident to her boss, the Housekeeping/Laundry Supervisor, and she had taken her to the Admissions Coordinator. Housekeeper E said the Admissions Coordinator listened to her and took her to the ADON's office where she reported the incident to the ADON and Administrator.

During an interview on 03/27/2025 at 9:17 AM, the Housekeeping/Laundry Manager said Housekeeper E had come to her the day after she witnessed an incident maybe a couple days ago or last week. The Housekeeping/Laundry Manager said Housekeeper E told her the staff was laughing and making fun of Resident #45. She said Housekeeper E said they were gathered around Resident #45 and were telling her just hit your head on the corner if you really want to hit your head and hurt yourself hit your head on the corner. The Housekeeping/Laundry Manager said she reported it to the Admissions Coordinator because

she was the department head available. The Housekeeping/Laundry Manager said she did not think she could write a grievance because she was contracted. The Housekeeping/Laundry Manager said she could not remember the staff members names, but she knew it was a nurse, the DON, and some CNAs. The Housekeeping/Laundry Manager said the incident reported to her by Housekeeper E could be considered abuse.

During an interview on 03/27/2025 at 9:33 AM, the Admissions Coordinator said last week some day she did not remember the day, the Housekeeping/Laundry Manager told her that Housekeeper E had a concern about what happened the day before. Then, Housekeeper E went to her office and told her there were a couple of the nurses that were laughing at Resident #45 because she was hitting her head on the wall and said something to her. The Admissions Coordinator said Housekeeper E told her the nurses were gathered around Resident #45 laughing at her while she was hitting her head. The Admissions Coordinator said she told Housekeeper E, I have to report that, and she went and reported it to the Administrator. The Admissions Coordinator said the Administrator took over.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 99 675879 Department of Health & Human Services Printed: 08/31/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 675879 B. Wing 03/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Terrell Healthcare Center 204 W Nash Terrell, TX 75160

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 During an interview on 03/27/2025 at 9:42 AM, RN A said Resident #45 did hit her head on the wall every now and then. RN A said when this happened, she tried to stop Resident #45 and move her away from the Level of Harm - Immediate wall. RN A said at times she did get frustrated and said, don't do it. RN A said Resident #45 got irritated and jeopardy to resident health or she did her best to try to move her away from the wall, so she did not hurt herself. RN A said she did not tell safety Resident #45 where to hit her head on the wall or 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 said she did not laugh or make fun of Resident Residents Affected - Few #45 for banging her head on the wall. RN A said she could get frustrated that Resident #45 was banging her head on the wall and tell her can you just stop. RN A said the Administrator called her and told her an allegation was made against her by Housekeeper E. RN A said she was not suspended, and an in-service was done with her on doing teaching and that it could be frustrating when educating residents but she should try as much as she could to do it calmy when she was getting frustrated. RN A said she told the Administrator she did teaching with Resident #45 and told her you are going to fracture yourself. RN A said