Terrell Healthcare Center

Findings included:

Record review of Resident #9's face sheet dated 4/3/26, reflected Resident #9 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which major depressive disorder (a serious mood disorder involving one or more episodes of intense psychological depression or loss of interest or pleasure that lasts two or more weeks), and hallucinations (sensory experiences-seeing, hearing, smelling, tasting, or feeling things-that appear real but are created by the mind in the absence of external stimuli).

Record review of Resident #9's admission MDS assessment dated [DATE], reflected Resident #9 made himself understood and understood others. Resident #9's BIMS score was 15 which indicated the resident's cognition was fully intact.

The MDS assessment reflected Resident #9 was taking an antipsychotic and there was an indication noted for medication in this drug class.

Record review of the order summary report dated 4/3/26 , reflected Resident #9 was ordered one Olanzapine oral tablet 5 mg by mouth two times a day for hallucinations on 1/25/26.

Record review of the Medication Administration Review dated 4/3/26 indicated Resident #9 was administered Olanzapine tablet 5mg by mouth two times a day at the 8:00 am medication pass and at the 8:00 pm medication pass daily since 1/25/26.

Record review of Resident #'s EMR accessed on 4/2/26 at 3:30pm revealed no consent form signed by the resident.

Record review of the Pharmaceutical Review dated 1/31/26 indicated the recommendation to please ensure signed consent form is scanned into PCC for the following medication: Olanzapine (on Texas form 3713).

Point Click Care (PCC) is an electronic medical record platform.

Record review of Resident #9's EMR accessed 4/3/26 at 5:00 pm revealed Texas Health and Human Services Form 3713 titled Consent for Antipsychotic or Neuroleptic Medication Treatment signed by Resident #9 and the medical director and dated 4/3/26 for the medication Olanzapine. In an interview on 4/2/26 at 5:42 pm, the Executive Director stated all consents should be in the EMR.

The Executive Director stated the ADON and the DON were responsible for ensuring consents for all medications that needed consent to be completed and uploaded into the chart prior to administration.

The Executive Director stated it was important for residents to be informed of the side effects of the medications, and have the right to chose to take it. In an interview on 4/3/26 at 4:30 pm, the DON stated the nurses were responsible for getting the proper consents prior to administering the medication.

The DON stated she is responsible for monitoring the charts to ensure all the necessary consents were present.

The DON stated it was important to obtain the informed consent so residents were informed of risks versus benefits. In an interview on 4/3/26 at 5:25 pm, the Administrator stated that he expected all consents to be obtained prior to the administration of medications that require one.

The Administrator stated that it was the ADON and the DON's responsibility to ensure consents are obtained.

The Administrator stated it was important to obtain consent prior to administration because a resident should know about the side effects and be able to make the choice to take it or not.

Record review of the facility's policy titled, Psychotropic/ Psychoactive Medication Policy last reviewed 6/24/25, indicates all residents have full rights to participate or refuse treatment.

Before initiating or increasing psychotropic medication the resident and or responsible party must be notified of and have the right to participate in their treatment, including the right to accept or decline the medication.

The risk and benefits should be clearly explained.

Consent needs to be completed and signed by the Resident or Responsible party.

Explain the medication, why it is administered, what are side effects, and black box warning.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

During an observation and interview on 04/01/26 at 4:25 p.m., LVN K said she was the charge nurse for Resident #64.

She looked and said Resident #64 does have a call light but because the pull cord was not long enough for the resident, she would not be able to reach it. LVN K said Resident #64 could move her right and left hand a little related to her contractures but could benefit from the push pad call light.

She said the risk of not having a call light could be Resident #64 would not get the help she needed in a timely manner.

She said she would get a push pad call light system for Resident #64.During an observation on 04/02/26 at 11:00 a.m., Resident #64 was in bed with a push pad call light system in reach.

During an interview on 04/03/26 at 3:39 p.m., the DON said all staff should be checking on the residents and ensuring they had a call light within reach.

She said she was not aware Resident #64 did not have a call light she could use.

She said she expected call lights to always be within reach of residents.

The DON said failure to have or keep call lights within reach could cause a resident to fall, receive a bump, bruise, or even a fracture.

During an interview on 04/03/26 at 5:32 p.m., the Administrator said he expected call lights to work, have a string long enough for the residents to use and if they needed a special call light then they should have it. He said 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. He said all staff were responsible for ensuring residents had call lights.

Record review of the facility's policy titled, Call System, Residents, dated 09/22, indicated, Policy Statement: Residents are provided with a means to call staff for assistance through a communication system that directly calls a staff member or a centralized workstation.

Policy Interpretation and Implementation: Each resident is provided with a means to call staff directly for assistance from his/her bed, from toileting/bathing facilities and from the floor.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

During a telephone interview on 04/01/26 at 6:08 p.m., Dietary Aide E stated she had a key to the mailbox that was left in the Dietary Manager office for her to check the mail.

Dietary Aide E stated the Business Office Manager told her to check the mail on Saturdays and place it under her door.

Dietary Aide E stated she was never told to pass out mail to residents on Saturdays.

Dietary Aide E stated it was important for the residents to get their mail because it was their right.

During an interview on 04/02/26 at 2:39 p.m., Dietary Aide D stated she checked the mail on Saturdays and if there was personal mail such as a letter or a package, she gave it to the residents and the other mail she put at the nursing station to be stored until Monday for the Business Office Manager.

Dietary Aide D stated it was discussed in an all-staff meeting that she could not recall the date the dietary staff should check the mail on Saturdays and give it to the residents.

Dietary Aide D stated it was important for the residents to get their mail because it was their right.

During an interview on 04/03/26 at 3:30 p.m., the Business Office Manager stated the locked mailbox was located outside.

The Business Office Manager stated the weekend dietary staff were responsible for checking the mailbox and distributing mail on the weekends.

The Business Office Manager stated she did obtain mail from Saturdays and give the Activity Director the residents' mail to distribute.

The Business Office Manager stated she was aware of the requirements for the residents to have access to their mail on Saturdays.

The Business Office Manager stated it was important for residents to receive their mail because it was their right.

During an interview on 04/03/26 at 4:04 p.m., the DON stated she expected mail to be delivered on Saturdays.

The DON stated she was unsure who was supposed to monitor and oversee residents getting their mail on Saturdays.

The DON stated this failure was a resident rights issue.

During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he expected mail to be delivered on Saturdays.

The Administrator stated dietary staff were responsible for distributing mail to residents on Saturdays.

The Administrator stated there was not a system in place to ensure residents receive their mail on Saturdays.

The Administrator stated this failure could affect their rights.

Record review of the facility's policy titled Statement of Resident Rights (Texas), undated, indicated, the resident, do not give up any rights when you enter a nursing facility.

The facility must encourage and assist you to fully exercise your rights.

Any violation of these rights is against the law. It is against the law for any nursing facility employee to threaten, coerce, intimidate, or retaliate against you for exercising your rights. #6. privacy, including privacy during visits and telephone calls.#8. have facility information about you maintained as confidential. #17 receive unopened mail.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

and their needs.

Record review of the undated facility's policy titled MDS Coding, reflected. the

review of the Resident Assessment Instrument 3.0 Manual, dated 10/2025, reflected .1.

Ask the

respond a family member, significant other, and/or guardian/legally authorized representative should be asked.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

initial admission assessment.

The Social Worker stated she was responsible for that assessment.

stress disorder have trauma informed care so that the resident can get needs met and be most

Record review of the facility's undated policy titled PASRR Rationale, indicated, All individuals who are admitted to a Medicaid certified nursing facility must have a Level I PASRR completed to screen for possible mental illness (MI), intellectual disability (ID), (mental retardation (MR) in federal regulation)/developmental disability (DD), or related conditions regardless of the resident's method of payment (please contact your local State Medicaid Agency for details regarding PASRR requirements and exemptions).

Individuals who have or are suspected to have MI or ID/DD or related conditions may not be admitted to a Medicaid-certified nursing facility unless approved through Level II PASRR determination.

Those residents covered by Level II PASRR process may require certain care and services provided by the nursing home, and/or specialized services provided by the State.

Planning for Care: The Level II PASRR determination and the evaluation report specify services to be provided by the nursing home and/or specialized services defined by the State.

The State is responsible for providing specialized services to individuals with MI or ID/DD. In some States specialized services are provided to residents in Medicaid-certified facilities (in other States specialized services are only provided in other facility types such as a psychiatric hospital).

The nursing home is required to provide all other care and services appropriate to the resident's condition.

The services to be provided by the nursing home and/or specialized services provided by the State that are specified in the Level II PASRR determination, and the evaluation report should be addressed in the plan of care.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

PM the Administrator said anything that is a medication should be given by a nurse or someone

the DON was responsible for ensuring the CNAs knew what their scope of practice was.

Record

ensure medications are prepared, administered, and documented safely, accurately, and in accordance with prescriber orders and accepted nursing standards of practice.

General Standards: 1.

Only individuals licensed or legally authorized in this state may prepare, administer, and document medications. 2.

The Director of Nursing or designee supervises and oversees all personnel involved in medication administration.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

support for those in need of assistance with communication, whether it is for language services or

questions be accurately communicated to the staff.

Oral interpretation services include interpretation

meaningful access to services provided by this facility, translation and/or interpretation must be provided in a way that is culturally relevant and appropriate to the individual.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

During an interview on 04/03/26 at 4:04 p.m.,

they noticed it was not in there.

The DON stated she was responsible for monitoring contracture prevention/management by daily random rounds.

The DON stated during her random rounds she had noticed in the past the wrist roll was not applied.

The DON stated she immediately in serviced staff on replacing the roll.

The DON stated it was important for the wrist roll to be applied in the left hand to prevent further contractures and skin integrity.

During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he knew Resident #14 had contractures but did not know he was supposed to have a left wrist roll in his daily.

The Administrator stated the person that implemented the interventions was the charge nurse.

The Administrator stated the DON was responsible for oversight of the contracture prevention/management.

The Administrator stated it was important to ensure the left wrist roll was applied to prevent contractures and skin digging in his hand.

Record review of the facility's policy titled, Contracture Management Program, revised 03/04/26, reflected. To have a program within the facility geared towards the prevention of new contractures and maintenance or improvement of range of motion. 5) Interventions care planned by MDS or designee to ensure they are carried out.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

Preparation: 1.

Review the resident's care plan to assess for any special needs of the resident.

and movement at the insertion site. (Note: Catheter tubing should be strapped to the resident's inner thigh).

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

this procedure.

Review the physician's orders or facility protocol for oxygen administration. 2.

Review

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

Resident #9 did trigger for trauma informed care, but Resident #9 did not have issues.

The Social

review of the facility policy titled Trauma-Informed and Culturally competent Care, dated 10/22 and

screening to identify the need for further assessment and care.

The facility will perform an assessment involving an in-depth process of evaluating the presence of symptoms, their relationship to trauma, as well as the identification of triggers.

The facility will utilize licensed and trained clinicians who have been designated by the facility to conduct trauma assessments.

The facility will develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate.

The facility will identify and decrease exposure to triggers that may re-traumatize the resident.

The facility will recognize the relationship between past trauma and current health concerns.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

said if they were not counting medication, it could cause missing medication or have a drug diversion.

Administrator said the nurses should be counting narcotics every shift. He said if the nurses were not

said the DON was responsible for monitoring and overseeing nurses by rounding.

Record review of the undated facility policy, Controlled Substances, indicated, Policy Statement The facility complies with all laws, regulations, and other requirements related to handling, storage, disposal, and documentation of controlled medications (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention and Control Act of 1976).

Dispensing and Reconciling Controlled Substances 1.

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.7.

Waste and/or disposal of controlled medication are done in the presence of the nurse and a witness who also signs the disposition sheet.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

Procedure (Insulin Injections via Syringe) 2.

Check blood glucose per physician order or facility

recommendations for expiration after opening) .

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

During an interview on 04/03/26 at 4:49 p.m., the Administrator stated he expected labs to be drawn per physician order.

The Administrator stated the nursing department heads were responsible for monitoring and overseeing.

The Administrator stated it was important to ensure labs were drawn as scheduled for their overall health.

Record review of the facility's policy titled Laboratory Services reviewed 03/03/26 reflected. It is the policy of this facility to ensure that laboratory services meet the needs of residents and that the results are reported promptly to the ordering provider to address potential concerns and for disease prevention, provide for resident assessment, diagnosis, treatment, and that the facility has established policies and procedures. 1.

The facility will provide or obtain laboratory services to meet the needs of its residents and will be responsible for the quality and timeliness of the services.3.

The facility will provide or obtain laboratory services only when ordered by a physician, physician assistance or nurse practioner.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

The facility failed to provide

4/1/26.

These failures could place residents at risk of decreased food intake, hunger, and unintended weight loss.Findings Included:In a Resident Council Meeting on 4/1/2026 at 10:00 am, 8 of 8 residents said the food was bland and served warm.

During an observation on 4/1/26 at 12:48 pm the last food temperature was checked on the warming table, trays prepared, and service began at 12:52 pm.

The test tray was prepared at 12:59pm.

During an observation on 4/1/26 at 1:08pm the tray cart with the test tray left the kitchen preparation area, was checked by the nurses and went to hall 300.

The test tray arrived to the conference room at 1:14pm.

During a test tray interview with Dietary Manager by State Surveyors on 4/1/26 at 1:15 pm, the Dietary Manager stated the fried pork chops with white gravy could be warmer. It was not over seasoned or under seasoned.

The dietary manager stated the candied yams were ok, but he would add more butter and sugar because they were kind of bland.

The dietary manager stated the cauliflower with cheese sauce was nice and warm and had an ok flavor.

The Dietary Manager stated the lemon pudding could be cooler.

The Dietary Manager stated that overall, the flavor was ok, but it could be warmer.

Observation of the plate of food revealed the food was unattractive.

During an interview on 4/2/26 at 2:02 pm, the Dietary Manager stated he was responsible for ensuring the food was palatable and was hot when the resident received his or her meal tray.

The Dietary Manager stated he has had complaints about the food in the last three months.

The Dietary Manager stated it was important for the food to be presented in an appealing manner, be palatable, and the proper temperatures for residents to get the needed nutrition and prevent weight loss.

During an interview on 4/2/26 at 5:55 pm, the Administrator stated he expected the food to appear appetizing, taste good, and be delivered hot.

The Administrator stated the dietary manager was responsible for the residential dining experience.

The Administrator said the food should look appetizing because a person eats with his or her eyes first.

The Administrator stated it was important to serve palatable meals so the residents avoid weight loss and have adequate nutrition.

Record review of the food temperature log, dated 4/1/26, indicated the regular meat's temperature at the time of serving was 183 degrees Fahrenheit, the white gravy was 170 degrees, the candied yams were 183 degrees, the cauliflower with cheese sauce was 145 degrees, the cornbread was 114 degrees, and the lemon pudding was 60 degrees.

Record review of Food and Nutrition Services policy dated 10/2022 and revised 6/23/25, revealed each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident.

The policy also stated the food will appear palatable and attractive, and it is served at a safe and appetizing temperature.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

resident right.

Record review of the facility's policy titled Food and Nutrition Service Menus revised

each resident. 7.

Food and nutrition services staff will inspect food trays to ensure that the correct

nursing staff will report it to the Food Service Manager so that a new food tray can be issued.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

needs, taking into consideration the preferences of each resident. 7.

Food and nutrition services staff

Manager so that a new food tray can be issued.

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single-use articles.

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the care they needed at the end of life.

Record review of the facility's policy titled Coordination of

psychosocial well-being.

The policy stated the facility maintains written agreements with hospice

home communication of necessary information regarding the resident's care.

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160

infections.

The policy did not address how to discard linen during wound care.

Record review of the

During an interview on 04/03/26 at 4:26 PM the DON said the MDS nurse had her certification for infection preventionist.

The DON said the ADON was over logging the infections and tracking and trending and all that has to do with infection control.

The DON said the ADON was not certified but she should have been certified as an infection preventionist.

The DON said the failure placed a risk for something to be missed as far infection control.

During an interview on 04/03/26 at 4:53 PM the Administrator said he knew the ADON should have had her certification completed to be the infection preventionist.

The Administrator said the failure placed a risk for the ADON not following the infection control protocols correctly.

Review of the ADON's personnel file reflected the ADON was hired on 02/01/26.

Record review of the facility policy, reviewed 03/03/26, Infection Prevention and Control Program indicated 5.

Coordination and Oversighta.

The infection prevention and control program is coordinated and overseen by an infection prevention specialist (infection preventionist).Refer to Appendix PP.The regulatory requirements for the IP with tips on how to ensure compliance are listed below.

See CMS's State Operating Manual Appendix PP updated 2-03-23 for F-F882 Infection Preventionist pages 801-806.

Infection preventionist.

The facility must designate one or more individual(s) as the infection preventionist(s) (IPs) who are responsible for the facility's IPCP.

The IP must:(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field; (2) Be qualified by education, training, experience or certification; (4) Have completed specialized training in infection prevention and control.

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.

For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE

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Terrell Healthcare Center 204 W Nash Terrell, TX 75160