The incident occurred during the CNA's final rounds on October 23, when he found the resident had soiled herself with a large bowel movement. Federal inspectors found the nursing assistant violated basic safety protocols by abandoning the resident to retrieve additional supplies from his cart at the room door.
"He said he lowered the bed but she would raise it up," according to the inspection report. "He said his supply cart was at the room door so he went to get another trash bag and get more supplies. He said Resident #1 screamed and he saw her on the floor so he got the nurse."
The resident was hospitalized the next day after developing altered mental status and a urinary tract infection. Hospital imaging revealed the femur fracture near her knee, though the facility's director of nursing questioned whether the break occurred at the nursing home or hospital, noting the resident "possibly had a fall at the hospital."
The X-ray report showed the resident's bones were osteopenic, meaning they lacked sufficient minerals for strength, but did not indicate when the fracture occurred.
During his phone interview with inspectors, the nursing assistant acknowledged he knew the resident required two-person assistance for all care. He said he was unable to find other staff members to help because "they were in other rooms."
The violation represents a fundamental breach of care planning requirements. Federal regulations mandate that nursing homes develop comprehensive care plans addressing each resident's specific needs and ensure staff follow those protocols.
But inspectors discovered broader problems with care planning at Huntsville Health Care Center. Two other residents requiring substantial assistance with daily activities had care plans that completely omitted their documented needs for help with bathing, dressing, and toileting.
Resident #2, admitted with spinal compression fractures and dementia, required maximum assistance with toileting and dressing according to her assessment. Her care plan, initiated October 18, failed to address any of these assistance requirements.
Resident #3, diagnosed with dementia, falls, and muscle weakness, needed substantial to maximum help with lower body dressing and bathing, plus moderate assistance with upper body dressing. Her September 30 care plan also ignored these documented needs entirely.
When inspectors interviewed both women, each said staff helped them when needed and reported no unmet needs. But their care plans contained no guidance for staff about the specific types and levels of assistance required.
The director of nursing told inspectors he was responsible for care plans, describing them as "a collaboration of several people who met and developed the care plan according to the residents' needs." He said the plans were reviewed quarterly or when residents' conditions changed.
However, when inspectors requested the facility's comprehensive care plan policy, administrators could only provide a "Baseline Care Plan policy" instead.
The gaps in care planning create dangerous situations where staff may not understand residents' specific needs or safety requirements. In the case of the resident who fell, the nursing assistant knew she required two-person care but proceeded alone anyway when he couldn't locate another staff member.
The timing of the fall during final evening rounds suggests potential staffing challenges. The CNA described being unable to find assistance because other staff were occupied in different rooms, indicating possible understaffing during a critical care period.
Hospital records showed the resident's X-ray was taken at 6:34 p.m. on October 23 with a clinical history of "fall injury." The imaging revealed not only the femur fracture but also confirmed the resident's bones were in a weakened state that made fractures more likely.
The facility's director of nursing expressed uncertainty about when the fracture occurred, telling inspectors he was "trying to get a determinate of age of the fracture to know if it happened at the facility or at the hospital." This uncertainty emerged only after the resident had already been hospitalized for a day with altered mental status.
The resident was ultimately transferred from the hospital to another facility and was not available for interview during the inspection. Her current condition and recovery status remain unknown.
The violations underscore systemic problems with both immediate care delivery and long-term planning at the facility. While residents reported satisfaction with their care, the documented gaps between their assessed needs and written care plans suggest staff are working without proper guidance about safety requirements and assistance levels.
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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