Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Terrell Healthcare Center during CMS and state inspections, most recent first.
Surveyors observed a medication aide leaving a card of gabapentin 300 mg capsules on top of a 200-hall med cart while entering a resident's room, leaving the medication unattended and out of view in a hallway with residents present. In a separate instance, an LVN left a 200-hall nurse med cart unlocked and unattended with a vial of insulin lispro on top while inside a resident's room, with staff and residents nearby. Both staff acknowledged that medications should not be left unattended or on top of carts and that carts should be locked, while the DON and Administrator confirmed expectations and a facility policy requiring all drugs and biologicals to be stored in locked compartments and prohibiting unattended unlocked med carts.
Surveyors found that a resident with anxiety and heart failure did not consistently receive a prescribed TID antianxiety medication, despite the MAR showing it as given and multiple partially used medication cards remaining on the cart, and that another resident with depression and bipolar disorder had both an active sertraline 50 mg dose and a discontinued sertraline 100 mg dose still present on the medication cart. Staff interviews revealed that a medication aide denied missing doses, the DON had only verbally addressed the concern after the resident reported missed noon doses, and nursing staff gave conflicting accounts about communication and responsibility for removing discontinued medications, contrary to facility policies on medication administration and storage.
A resident with pneumonia and chronic respiratory failure was placed on droplet precautions per physician orders, with signage and PPE supplies outside the room, but the care plan did not address droplet precautions. A CNA entered the room without PPE and later removed PPE in the hallway instead of before exiting the room. A medication aide twice failed to use a face shield as required for droplet precautions and removed or retained PPE inappropriately while moving between the room and hallway and preparing medications. The DON and Administrator stated staff were expected to don mask, face shield, gown, and gloves before entry and remove PPE before exit, while the written IPCP lacked specific PPE guidance for droplet precautions and no droplet-specific policy was provided.
A resident with quadriplegia, mental illness, and TBI was identified as needing a specialized pressure-reducing mattress per PASRR recommendations, but the facility failed to submit the required NFSS form and did not provide the DME within the mandated timeframe. Staff interviews revealed gaps in PASRR training and the absence of a facility policy for PASRR coordination.
A staff member did not complete the required annual training on resident rights and facility responsibilities, as identified through record review and confirmed by the Administrator. Facility policy requires all staff to participate in annual in-service training on these topics.
The facility did not ensure that all staff completed required annual training on the Quality Assurance and Performance Improvement (QAPI) program, as three employees—a RN, a CNA, and a LVN—were found to have missed this mandatory training, contrary to facility policy.
A registered nurse did not complete the required annual compliance and ethics training, as identified through record review and staff interviews. Facility policy mandates annual in-service training on compliance and ethics for all staff, but this requirement was not met for one employee.
Unattended and Unsecured Medications on 200 Hall Medication Carts
Penalty
Summary
The deficiency involves failures to properly secure and store medications on two medication carts on the 200 hall. During an observation, a medication aide (MA A) was seen administering medications and left a medication card containing gabapentin 300 mg capsules on top of the 200-hall medication aide cart in a hallway where residents were present. MA A then entered a resident's room to administer medications, leaving the gabapentin card out of her view and unattended. MA A acknowledged that medications should not be left on top of the cart unattended, stated she should have returned the gabapentin to the inside of the cart before going into the room, and recognized that unattended medications could be picked up by residents or staff. In a separate observation, an LVN (LVN B) left an unlocked and unattended nurse medication cart on the 200 hall with a vial of insulin lispro 100 units/mL on top of the cart in front of a resident's room, while staff and residents were present in the area. LVN B exited the resident's room and confirmed it was her cart, stating she had forgotten to put the insulin back inside the cart and lock it before entering the room. She acknowledged that people could pick up medications left on top of the cart and could take medications from inside the cart when it was left unlocked and unattended. The DON stated that medications should not be left on top of medication carts, that carts should be locked whenever staff walk away or turn their backs, and that unattended medications and unlocked carts could result in residents or employees taking medications or residents ingesting them with adverse effects. The Administrator stated he expected medication carts to be locked when not under staff supervision and medications not to be left on top of carts, and that the DON was responsible for monitoring staff compliance. Facility policy on Storage of Medications required all drugs and biologicals to be stored in locked compartments and specified that unlocked medication carts are not to be left unattended.
Medication Administration and Discontinued Drug Storage Failures
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensured accurate acquiring, receiving, dispensing, and administering of medications for multiple residents. For a male resident with chronic systolic congestive heart failure and generalized anxiety disorder, the physician had ordered buspirone 5 mg to be given three times daily starting in mid-January 2025. His MDS showed intact cognition (BIMS 15) and documented use of antianxiety and antidepressant medications, and his care plan directed that buspirone be administered as ordered. The MAR from October 2025 through March 2026 showed the buspirone as administered three times daily, except for one documented absence from the facility. However, during a medication pass observation, the buspirone card in use had 42 tablets remaining from a card dispensed in late November 2025, and the medication aide stated there was no overstock for this resident on the cart or in storage. On the following day, surveyors observed that the same medication aide’s cart actually contained three additional overstock cards of buspirone 5 mg for this resident, dispensed in July 2025, October 2025, and January 2026, with substantial tablet counts remaining. In an interview, the resident reported that he sometimes received his midday dose of buspirone and sometimes did not, and that he had reported this to the DON, although he could not recall when. He stated that when he remembered, he would go ask for the medication and that the medication aide in question was the only one not administering his buspirone. The DON acknowledged that the resident had reported not receiving his noon dose from this aide, that she had questioned the aide and reviewed the medication cards, and that she had provided verbal education, but there was no documentation of this. A second deficiency involved a female resident with chronic respiratory failure with hypoxia, bipolar disorder, and depression, whose MDS also showed intact cognition (BIMS 15) and receipt of antidepressant medications. Her care plan addressed depression with administration of medications as ordered. Physician orders showed an active order for sertraline 50 mg once daily and a discontinued order for sertraline 100 mg in the morning, which had been stopped in late January 2026. Despite this discontinuation, surveyors observed both sertraline 100 mg and 50 mg on the medication cart. The medication aide stated she did not know why the discontinued 100 mg dose remained on the cart and acknowledged that discontinued medications should be removed. The DON reported that she relied on weekly cart checks and had not noticed the discontinued sertraline remaining on the cart, while an LVN and another medication aide gave conflicting accounts about whether the discontinuation had been communicated, demonstrating a breakdown in the process for removing discontinued medications from active stock.
Failure to Enforce Droplet Precautions and Proper PPE Use
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program for a resident on droplet precautions. The resident was an adult female with chronic respiratory failure with hypoxia, bipolar disorder, and tracheostomy status, and had a care plan initiated for pneumonia. Physician orders dated 03/05/2026 directed that the resident be placed on droplet isolation precautions related to flu/pneumonia starting 03/04/2026. A droplet precaution sign was posted beside the resident’s doorframe, and a cart with face shields, face masks, gowns, gloves, and shoe covers was placed outside the room. However, the resident’s care plan did not address the use of droplet precautions. On 03/04/2026 at 10:31 AM, a CNA was observed inside the resident’s room without any PPE, despite the posted droplet precaution sign and available PPE cart. After noticing the surveyor, the CNA exited the room, donned a face mask, face shield, and gown, and re-entered the room. When leaving the room, the CNA removed PPE in the hallway instead of before exiting the resident’s room. In a subsequent interview, the CNA stated she was not aware the resident required droplet precautions, said she had been in a rush and did not pay attention to the sign, and acknowledged that PPE should be removed before leaving residents’ rooms and that proper PPE use was important for infection control. On 03/04/2026 at 11:13 AM, a medication aide donned a face mask, gown, and gloves, but not a face shield, before entering the resident’s room to administer medications, and then removed PPE in the hallway. The medication aide stated she did not need a face shield because she was not in the room for a long time and believed removing PPE in the hallway was appropriate. On 03/05/2026 at 8:21 AM, the same medication aide again wore a face mask, gown, and gloves to enter the room, exited into the hallway still wearing the gown and mask, removed only her gloves, performed hand hygiene, donned new gloves, prepared medications in the hallway, and administered them to the resident without removing the gown and mask before exiting the room. The DON stated that droplet precautions for this resident required staff to don a face mask, face shield, gown, and gloves prior to entering the room and to remove PPE before exiting, and the Administrator stated he expected staff to follow facility protocol. The facility’s written Infection Prevention and Control Program referenced educating staff and ensuring adherence to proper techniques but did not specifically address PPE requirements for droplet precautions, and a droplet-specific policy was requested but not provided.
Failure to Coordinate PASRR Assessments and Timely Provision of Specialized Services
Penalty
Summary
The facility failed to coordinate assessments with the Pre-Admission Screening and Resident Review (PASRR) program and did not incorporate the recommendations from the PASRR evaluation report into the care planning for a resident. Specifically, the care plan identified that the resident, who had diagnoses including muscle weakness, quadriplegia, muscle spasm, and abnormal posture, required specialized services due to mental illness and traumatic brain injury (TBI). The interdisciplinary team (IDT) agreed that the resident needed a specialized or treated pressure-reducing support surface mattress as durable medical equipment (DME), but the facility did not provide or arrange for this service within the required timeframe set by PASRR. Record review and staff interviews revealed that the necessary Nursing Facility Specialized Services (NFSS) form for the DME was not submitted within the 20 business days required after the IDT meeting. The Clinical Reimbursement Coordinator and Corporate Nurse confirmed that the NFSS for the specialized mattress was not submitted until several months after the recommendation, and the facility remained out of compliance. Additionally, the MDS Coordinator reported not having been trained on PASRR, and the facility lacked a policy regarding PASRR coordination at the time of the deficiency.
Failure to Complete Annual Resident Rights Training for Staff
Penalty
Summary
The facility failed to ensure that all staff members completed annual training on resident rights and facility responsibilities, as required by facility policy. Specifically, one LVN, hired in November 2021, had not received the mandatory annual training on resident rights for the period reviewed. This was identified through a review of the facility's mandatory training records and confirmed during an interview with the Administrator, who acknowledged the expectation for all staff to complete required annual training. The facility's policy, revised in September 2022, mandates that all staff participate in both initial orientation and annual in-service training, including training on resident rights and responsibilities.
Failure to Complete Mandatory QAPI Training for All Staff
Penalty
Summary
The facility failed to ensure that all staff completed mandatory annual training on the Quality Assurance and Performance Improvement (QAPI) program, as required by facility policy. Record review showed that three employees—a registered nurse, a certified nursing assistant, and a licensed vocational nurse—had not received the required annual QAPI training for the period reviewed. The facility's policy, revised in September 2022, mandates that all staff participate in both initial orientation and annual in-service training, including training on the elements and goals of the QAPI program. During an interview, the Administrator confirmed the expectation that all staff complete mandatory annual training to stay updated and refreshed on required topics.
Failure to Ensure Annual Compliance and Ethics Training for Staff
Penalty
Summary
The facility failed to ensure that annual Compliance and Ethics training was completed for one of eleven employees reviewed, specifically a registered nurse hired in July 2021. Record review showed that this staff member had not received the required annual training on compliance and ethics for the period from July 2024 through July 2025. Interviews with facility leadership confirmed that all staff were expected to complete mandatory training annually, as outlined in the facility's policy, which requires participation in both initial orientation and annual in-service training, including compliance and ethics program standards. The deficiency was identified through both record review and staff interviews.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Terrell
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Countryview Nursing & Rehabilitation | 1.5 mi | — | 0 | 0 |
| Windsor Rehabilitation And Healthcare | 2.4 mi | — | 21 | 0 |
| Ridgecrest Healthcare And Rehabilitation Center | 9.7 mi | — | 1 | 0 |
| Sunflower Park Health Care | 10.4 mi | — | 19 | 0 |
| Avir At Kaufman | 11.5 mi | — | 19 | 0 |
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