Terra Bella Health and Wellness Suites: Fall Ignored - TX
The resident, identified in inspection records only as Resident 1, fell during a transfer on the afternoon of May 11, 2026. The nurse on duty, LVN A, described it as a controlled lowering to the ground and reported no injuries. That assessment went up the chain. The nurse practitioner on call was notified and told the resident was fine. It was not even really a fall, the NP later recalled being told.
What the NP was not told was that the resident was in pain.
Her roommate knew. Resident 2, who shared the room, would later tell staff that Resident 1 had been in pain all day on May 12. Room camera footage reviewed by the resident's responsible party showed Resident 1 screaming in pain at 4:30 p.m. on May 11, the same day as the fall. The responsible party sent that video to a state surveyor on May 22, the day after inspectors arrived.
Nobody at the facility had flagged it.
LVN B came on for the night shift on May 11 and said the handoff from LVN A included no mention of pain, no report that the resident had needed PRN pain medication, nothing to suggest anything was wrong. LVN B said she did rounds that night with CNAs and neither she nor anyone else observed Resident 1 in distress. She came back the next night, May 12, and again received a handoff saying the resident was fine through the day shift.
That night, during the first round of care, CNA C was attempting perineal care on Resident 1 when the resident yelled out. LVN B was in the same room tending to Resident 2. She heard it. She said Resident 1 did not typically yell during care, so she came to look. CNA C barely moved the resident's right leg and she yelled out again.
Resident 2 spoke up then. Resident 1 had been in pain all day, the roommate said.
LVN B medicated the resident with PRN Tylenol, notified the nurse practitioner and the responsible party, and got orders for a knee x-ray. Early on the morning of May 13, more than 36 hours after the fall, the results came back. There was a fracture. LVN B called the NP, who ordered Resident 1 transferred to the emergency room. Before the transfer, the resident cried out in pain again and had to be medicated a second time. LVN B told the CNA not to move or change the resident until they had orders from the NP.
The hospital's own scans initially showed no fracture and sent her back. The facility's inspection record reflects that conflicting result without resolution.
The nurse practitioner, interviewed by surveyors, said she had only been told about pain once, on the night of May 12 when LVN B called her. She said she was never informed of any pain complaints before that call. When the surveyor told her that Resident 1 had been complaining of knee pain before that night, the NP said she only recalled the one notification. She added that if a resident complains of acute pain after a fall, staff should let her know, because depending on the pain it could be a sign of an injury.
The Director of Nursing told surveyors on May 22 that she had not heard about Resident 1 being in pain on May 11 and said she would have to check into it. She said a new onset of acute pain after a fall could be considered a change in condition, but that it would depend on the assessment.
The facility is disputing the citation. Inspectors rated the violation as immediate jeopardy.
What the room camera captured on May 11 at 4:30 p.m., and what the responsible party found when she went back through the footage, was a resident in serious pain, alone in her room, hours after a fall that staff had already closed the book on. The screaming is on video. No one at the facility had watched it.
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: August 15, 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 resident, identified in inspection records only as Resident 1, fell during a transfer on the afternoon of May 11, 2026.
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.