San Rafael Nursing: Moved Injured Resident - TX
The incident at San Rafael Nursing and Rehabiliation involved an unwitnessed fall where Resident #1 was discovered on the floor of another resident's room. Despite obvious signs of serious injury, licensed vocational nurse LVN-I instructed nursing assistants to transport the resident rather than keeping her immobilized.
CNA-J heard a male resident announce "there was a woman on the floor in his room." When staff arrived, they found Resident #1 lying on the floor, moaning and groaning in pain while making facial expressions indicating severe distress.
LVN-I assessed the resident while she remained on the floor. During this assessment, the nurse observed that one of Resident #1's legs appeared longer than the other — a classic sign of hip fracture or other serious injury requiring immediate medical attention and careful handling.
Nobody questioned the male resident about what happened to Resident #1 or how she ended up on the floor.
Despite the resident's obvious pain and the visible leg length discrepancy, LVN-I asked the nursing assistants to move her. CNA-J and another aide transported Resident #1 from the floor to her wheelchair, then from the wheelchair to her bed.
The assistant director of nursing who investigated the incident later stated that LVN-I "should not have moved Resident #1 while in severe pain or after noting one leg was longer than the other because it could have meant there was a fracture or major injury, and movement could have caused further injury."
CNA-J told investigators that LVN-I never communicated the observation about the leg length difference to the nursing assistants. "The LVN-I never said anything about one leg being longer than the other, so both CNAs assumed it was okay to move Resident #1," she explained.
The nursing assistant acknowledged understanding the risks involved. "She realized moving a resident with an injury could make it worse," according to the inspection report.
This was Resident #1's only documented fall this year, making it her first major injury incident. The assistant director of nursing responsible for fall trending and tracking completed her investigation report based on notes written by the attending nurse.
According to facility documentation, the nurse called the director of nursing to report the fall. However, the investigation revealed critical gaps in immediate response protocols when residents show signs of serious injury.
The assistant director of nursing followed up with both the resident and the reporting nurse as part of the standard post-fall investigation process. During these interviews, she learned the details of how LVN-I handled the immediate aftermath of discovering Resident #1 on the floor.
Federal guidelines require nursing homes to properly assess and handle residents who fall, particularly when signs point to potential fractures or other serious injuries. Moving a resident with suspected hip fracture can cause additional damage to bones, blood vessels, and surrounding tissue.
The facility's administrator stated there was no specific internal policy on fall reporting procedures, but claimed staff followed CMS guidelines. However, the incident revealed a disconnect between federal requirements for proper injury assessment and the actual response when a resident displayed clear signs of serious trauma.
CNA-J's account highlighted how communication failures between licensed and unlicensed staff can compound medical emergencies. The nursing assistants, who physically moved the resident, were never informed about the critical observation that should have prevented any movement.
The investigation found that basic fall response protocols were not followed when a resident showed obvious signs of major injury requiring immediate medical evaluation and careful handling.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for San Rafael Nursing and Rehabiliation from 2025-08-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
San Rafael Nursing and Rehabiliation in Corpus Chrisit, TX was cited for violations during a health inspection on August 21, 2025.
The incident at San Rafael Nursing and Rehabiliation involved an unwitnessed fall where Resident #1 was discovered on the floor of another resident's room.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.