Terra Bella Health: Fractured Knee Ignored for Days - TX
The inspection, completed May 23, 2026, was triggered by a complaint. What investigators found earned the facility an immediate jeopardy citation, the most serious level CMS assigns, reserved for situations where a facility's failures put residents at risk of serious harm or death. Terra Bella is disputing the citation.
The resident, identified in inspection records only as Resident 1, fell during a transfer on May 11, 2026. A nursing assistant lowered her to the ground. The nurse on duty, LVN A, reported afterward that there were no injuries and the resident was fine.
She was not fine.
Video from a camera inside Resident 1's room, later reviewed by the state surveyor, showed the resident lying in bed at 4:30 that same afternoon, yelling "owe, owe, owe" while a nursing assistant stood at her bedside preparing to provide care. Nobody reported what the camera recorded. Nobody called the nurse practitioner. Nobody documented that Resident 1 was in pain.
That night, LVN B came on for the night shift. She said LVN A reported no concerns from the day, no pain complaints, no PRN pain medication given. LVN B did her rounds and said she observed nothing alarming. Resident 1, she said, was fine.
The next day passed the same way. A day shift came and went. According to LVN B, when she returned for her night shift on May 12, she again received a handoff indicating the resident was fine.
It was during the first set of rounds on the night of May 12 that things finally broke open. LVN B was in the room tending to Resident 1's roommate when a nursing assistant, CNA C, was attempting perineal care on Resident 1. LVN B heard the resident yell. CNA C asked her to come look because, she said, Resident 1 did not typically yell during care. At that moment, Resident 1's roommate spoke up and told LVN B that Resident 1 had been in pain all day.
LVN B asked CNA C what movement had caused the yelling. CNA C barely touched Resident 1's right leg and the resident screamed.
LVN B medicated her with PRN Tylenol, notified the nurse practitioner and the responsible party, and got orders for a knee x-ray. Early the next morning, May 13, the results came back showing a fracture. The nurse practitioner ordered Resident 1 transferred to the emergency room. Before the transfer, Resident 1 complained of pain again and had to be medicated a second time. LVN B told the nursing assistant not to move or change the resident until they had orders.
The nurse practitioner told the surveyor she had only been informed of Resident 1's pain once, the night of May 12. She said if a resident complains of acute pain after a fall, staff should notify her, because depending on the severity it could indicate an injury. When the surveyor told her that Resident 1 had been complaining of pain before that night, the NP said she had no knowledge of it.
The hospital initially read the x-ray as showing a fracture, then sent Resident 1 back after their own scans showed none. The NP said she ordered the hospital transfer based on the initial fracture finding.
The Director of Nursing told the surveyor she had not heard about Resident 1 being in pain on May 11 and said she would have to look into it. She acknowledged that a new onset of acute pain after a fall could constitute a change in condition requiring assessment and provider notification, though she added it would depend on the assessment.
The responsible party, who had access to the room camera footage, sent the surveyor a text message on May 22 noting she had reviewed additional recordings. She forwarded the video from May 11 at 4:30 p.m., the one showing Resident 1 screaming, and a second clip from May 12 at 9:30 p.m., around the time LVN B finally made the call. The surveyor received copies of both.
For more than 24 hours, a woman lay in a bed in pain serious enough to make her scream, in a room with a camera recording it, surrounded by staff who either did not see it, did not ask, or did not say anything to anyone who could have ordered an x-ray sooner. Her roommate knew. The camera knew. The nurse practitioner did not find out until the second night.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Terra Bella Health and Wellness Suites from 2026-05-23 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 8, 2026 · Our methodology
Terra Bella Health and Wellness Suites in Houston, TX was cited for violations during a health inspection on May 23, 2026.
The inspection, completed May 23, 2026, was triggered by a complaint.
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.