675879
07/17/2025
Terrell Healthcare Center
204 W Nash Terrell, TX 75160
F 0942
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Ensure that staff members are educated on resident rights and facility responsibilities to properly care for its residents.
Based on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility training was completed for 1 of 11 employees (LVN C) reviewed for training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by LVN C annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training. Findings include: Record review of the undated Mandatory Trainings list from July 2024 through July 2025 indicated the following staff had not received annual training on resident rights: LVN C, hire date 11/23/21 During an interview on 7/17/25 at 2:45 p.m. the Administrator said she expected staff to complete all mandatory training annually as required. The Administrator said the importance of staff completing mandatory training was to ensure they stayed up to date on any changes and got refreshed on the mandatory topics. Record review of the facility's In-Service Training, All Staff policy revised on September 2022 indicated, All staff must participate in initial orientation and annual in-service training. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. Required training topics include the following: .b. Resident rights and responsibilities; .
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675879
675879
07/17/2025
Terrell Healthcare Center
204 W Nash Terrell, TX 75160
F 0944
Level of Harm - Minimal harm or potential for actual harm
Residents Affected - Few
Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.
Based on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 3 of 11 employees (RN A, CNA B, and LVN C) reviewed for training. The facility did not ensure QAPI annual training was completed by RN A, CNA B, and LVN C. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings included: Record review of the undated Mandatory Trainings list from July 2024 through July 2025 indicated the following staff had not received annual training on QAPI: RN A, hire date 7/12/21 CNA B, hire date 7/9/10 LVN C, hire date 11/23/21 During an interview on 7/17/25 at 2:45 p.m. the Administrator said she expected staff to complete all mandatory training annually as required. The Administrator said the importance of staff completing mandatory training was to ensure they stayed up to date on any changes and got refreshed on the mandatory topics. Record review of the facility's In-Service Training, All Staff policy revised on September 2022 indicated, All staff must participate in initial orientation and annual in-service training. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. Required training topics include the following: .d. Elements and goals of the facility QAPI program; .
675879
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675879
07/17/2025
Terrell Healthcare Center
204 W Nash Terrell, TX 75160
F 0946
Provide training in compliance and ethics.
Level of Harm - Minimal harm or potential for actual harm
Based on interview and record review, the facility failed to ensure Compliance and Ethics training through an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program was completed for 1 of 11 employees (RN A) reviewed for training. The facility did not ensure annual Compliance and Ethics training was completed by RN A. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring. Findings included: Record review of the undated Mandatory Trainings list from July 2024 through July 2025 indicated the following staff had not received annual training on compliance and ethics: RN A, Hire Date 7/12/21 During an interview on 7/16/25 at 1:45 p.m. the Regional Nurse said the managing company had 29 buildings in Texas. During an interview on 7/17/25 at 2:45 p.m. the Administrator said she expected staff to complete all mandatory training annually as required. The Administrator said the importance of staff completing mandatory training was to ensure they stayed up to date on any changes and got refreshed on the mandatory topics. Record review of the facility's In-Service Training, All Staff policy revised on September 2022 indicated, All staff must participate in initial orientation and annual in-service training. The primary objective of the in-service training is to ensure that staff are able to interact in a manner that enhances the resident's quality of life and quality of care and can demonstrate competency in the topic areas of the training. Required training topics include the following: . g. The compliance and ethics program standards, policies and procedures. (Compliance and ethics training is conducted annually when this organization is operating five or more facilities.) .
Residents Affected - Few
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