Huntsville Health Care Center: Fall Fracture Violation - TX
The resident, identified in inspection records only as Resident 1, required two staff members for any care. That night, CNA A was making his final two-hour rounds and went to clean her after she had a large bowel movement. He told inspectors he couldn't find another staff member to help because everyone else was occupied in other rooms. He decided to proceed alone.
He lowered the bed. She kept raising it back up. His supply cart was sitting at the door to her room, so he stepped away to grab a trash bag and more supplies.
She screamed. He turned around and she was on the floor.
He got the nurse.
Staff assisted Resident 1 back into bed. She showed no obvious signs of pain or discomfort, according to the facility's director of nursing. The next day, she began showing altered mental status, and the facility sent her to the hospital. Staff and family were told she had a urinary tract infection.
Nobody mentioned a fracture for several more days.
The hospital imaging report, dated October 23, 2025, and provided to inspectors by the director of nursing via email, told a different story. A two-view x-ray of the left femur, taken at 6:34 in the evening with a clinical history of fall injury, showed a fracture of the femoral shaft near the knee. The bone was also osteopenic, meaning it lacked enough mineral density to be strong, making it more vulnerable to breaking under stress.
The director of nursing told inspectors he was still trying to determine when the fracture occurred. He said he received an x-ray report that did not indicate the age of the fracture, and he had been told the resident possibly fell at the hospital as well. He said he was working to get a determination of the fracture's age to establish whether it happened at the facility or after she was admitted.
That question remained unresolved at the time of the inspection.
Resident 1 was not available to speak with inspectors. She had been transferred from the hospital to another facility.
CMS cited the violation under F0689, which covers the duty to protect residents from accidents the facility could reasonably prevent. The citation was tagged at actual harm, meaning inspectors determined a resident suffered real injury, not a theoretical risk. Few residents were listed as affected.
What the record shows is a gap that opened in the time it took to walk from a bedside to a doorway. A resident who needed two people to be safely cared for was left alone, even briefly, because the one staff member present couldn't find help and made a judgment call. The supply cart was right there. It would only take a second.
She was on the floor before he got back.
The fracture near her knee went unidentified for days while she was treated for a UTI, her family left to piece together what had happened from a hospital imaging report that offered no clear answer about when the bone broke or how.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Huntsville Health Care Center from 2025-10-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 9, 2026 · Our methodology
HUNTSVILLE HEALTH CARE CENTER in HUNTSVILLE, TX was cited for violations during a health inspection on October 30, 2025.
The resident, identified in inspection records only as Resident 1, required two staff members for any care.
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.