San Rafael Nursing: Resident Moved After Major Fall - TX
The woman was Resident #1, found lying on the floor in severe pain after an unwitnessed fall at San Rafael Nursing and Rehabilitation. Despite her moaning, groaning, and obvious distress, staff moved her from the floor to a wheelchair and then to her bed without proper assessment.
The licensed vocational nurse who responded to the scene, LVN-I, noticed that one of the resident's legs appeared longer than the other — a classic sign of a hip fracture. Yet the nurse still directed certified nursing assistants to move the resident.
"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," the assistant director of nursing told federal inspectors in July.
CNA-J, one of the assistants who helped move the resident, said she realized moving someone with an injury could make it worse. But the nurse never mentioned the leg length discrepancy to the CNAs, so they assumed it was safe to proceed.
The resident kept "moaning and groaning in pain as well as making faces like she was in severe pain" while lying on the floor, CNA-J recalled. Still, no one questioned the male resident who had witnessed whatever happened.
The facility's own fall policy, revised in March 2018, states that when a resident is found on the floor, a fall is considered to have occurred unless evidence suggests otherwise. Staff must immediately report falls to the charge nurse, who should assess both the resident and situation to determine if it's safe to move or transfer the person.
An all-staff training session from April 30, 2025, reinforced these protocols. The training defined a fall as "any break in plane regardless of where the patient lands" and emphasized that charge nurses must assess residents before any movement occurs.
But those protocols weren't followed. The assistant director of nursing who handles fall trending and tracking said this was Resident #1's only fall of the year — an unwitnessed fall with major injury that should have triggered immediate reporting requirements.
The administrator later told inspectors he wished the incident had been investigated further. If he had realized it was an unwitnessed fall with major injury, he said, he would have reported it within two hours as required.
Instead, the administrator completed his report based solely on a nurse's note stating that the nurse had called the director of nursing to report the fall. The assistant director of nursing said she followed up with both the resident and nurse after the incident, but by then the damage was done.
The male resident who witnessed the incident was never interviewed about what he saw. His simple statement that there was a woman on the floor became the extent of the investigation into how Resident #1 ended up there.
Federal inspectors found the facility failed to ensure residents received proper care and services to prevent accidents and maintain the highest practicable physical well-being. The violation caused actual harm to few residents.
The case highlights a breakdown in basic safety protocols that nursing homes are required to follow. When residents fall, especially with suspected fractures, immediate proper assessment can mean the difference between a manageable injury and permanent disability.
For Resident #1, lying on the floor in obvious distress with a leg that appeared different from the other, those critical first moments after her fall were handled in a way that could have worsened whatever injury she sustained. The facility's own policies existed to prevent exactly this scenario, but staff either didn't know them or chose not to follow them.
The administrator's admission that he would have handled things differently suggests the facility recognized the seriousness of the lapses. But for the resident who endured unnecessary movement while potentially suffering a major fracture, that recognition came too late.
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 woman was Resident #1, found lying on the floor in severe pain after an unwitnessed fall at San Rafael Nursing and Rehabilitation.
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.