The resident, who required two staff members for all care, was being cleaned by a single nursing assistant when she fell from her bed on October 21st. The CNA had stepped away to get supplies from a cart at the door when he heard her scream and saw her on the floor.
During a phone interview, CNA A told inspectors he was making his final two-hour rounds when he went to clean the resident. "He said he knew Resident #1 required 2 staff for care," the inspection report states. "He said when he went to clean Resident #1 he was not able to find any other staff to assist because they were in other rooms."
The resident had a large bowel movement that required additional supplies. The nursing assistant lowered the bed, but she kept raising it back up. His supply cart was positioned at the room door.
"He said he went to get another trash bag and get more supplies," according to the inspection. "He said Resident #1 screamed and he saw her on the floor so he got the nurse."
Two days later, on October 23rd, the resident showed signs of altered mental status. Staff found her lethargic and responsive only to painful stimuli. Her vital signs were concerning: blood pressure 145/84, heart rate 125, oxygen saturation 88 percent.
The facility's medical director ordered an emergency room evaluation and oxygen therapy. EMS arrived at 11:20 a.m. and transported her to the hospital by stretcher eight minutes later.
Hospital imaging revealed the extent of her injuries. A two-view x-ray of her left femur showed she was osteopenic, a condition where bones lack sufficient minerals for strength. The x-ray also revealed a fracture of the femoral shaft near her knee.
The facility's Director of Nursing initially denied the resident had fallen. During an interview on October 29th, he told inspectors "Resident #1 did not have a fall. He said she was part way out of the bed. He said she was assisted back into bed with no complaints of pain or discomfort."
He claimed the altered mental status the following day was due to a urinary tract infection. "He said nothing was said about her having a fracture until several days after she was admitted to the hospital," the inspection states.
The DON said the x-ray report didn't indicate the age of the fracture but noted her osteopenic condition. He was "trying to get a determinate of age of the fracture to know if it happened at the facility or at the hospital since he was told she possibly had a fall at the hospital."
The Administrator provided a different account when interviewed the following day. He acknowledged receiving multiple conflicting stories about what happened during the resident's care.
"He said he was originally told Resident #1 did not have a fall because only her legs were hanging off the bed when CNA A provided care," inspectors documented. "He said he had been told several different stories about Resident #1 since then regarding what happened during her care."
The resident's representative later reported she had fractured both legs. The Administrator admitted uncertainty about where the injuries occurred: "The Administrator said he did not know if they happened at the facility or at the hospital."
Federal regulations require nursing homes to report allegations of neglect immediately. The facility's own policy mandates reporting "all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies" within specific timeframes.
For incidents involving serious bodily injury, facilities must report "immediately, but not later than 2 hours after the allegation is made." Other incidents must be reported within 24 hours.
The Administrator acknowledged this requirement during his interview. "He said any violation of neglect of a resident should be reported to HHSC," the inspection report states.
Yet no report was filed about the October 21st incident until days later, after the resident's fracture was discovered at the hospital. The facility's failure to investigate and report the fall violated federal requirements designed to protect nursing home residents from harm.
The inspection classified this as a violation with "minimal harm or potential for actual harm" affecting "few" residents. However, the resident required hospitalization and sustained a fractured femur while in the facility's care.
The case illustrates how nursing homes can fail vulnerable residents through inadequate staffing and poor incident reporting. The resident, who needed two staff members for safe care, was left alone during a procedure that required the nursing assistant to leave her bedside.
When she fell, facility leadership initially denied it happened, then claimed uncertainty about when and where her injuries occurred. Meanwhile, the resident was transferred from the hospital to another facility, unable to return to her room at Huntsville Health Care Center.
The facility's written policies promised immediate reporting of potential neglect cases. In practice, administrators spent days trying to determine whether the fracture happened under their watch, while the injured resident received care elsewhere.
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
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