Huntsville Health Care Center
HUNTSVILLE HEALTH CARE CENTER in HUNTSVILLE, TX — inspection on October 30, 2025.
Found 4 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
During an interview on 10/29/25 at 10:25 a.m. the DON said 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 said the next day she started showing altered mental status, so they sent her to the hospital, and she had a UTI. He said nothing was said about her having a fracture until several days after she was admitted to the hospital. He said the x-ray report he received did not indicate the age of the fracture but did indicate she was osteopenic. He said 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.
Record review of a hospital Imaging Report dated 10/23/25 provided by the DON via email on 10/29/25 at 12:37 p.m. indicated Resident #1 had a 2 view x-ray of the left femur at 06:34 p.m. with clinical history of fall injury.
Findings were the femur was osteopenic (condition where the bone lacks enough minerals to be strong) and there was a fracture of the femoral (thigh bone) shift near the knee.During a phone interview on 10/29/25 at 01:33 p.m. CNA A said he was making his last 2 hour round on his residents. He said he knew Resident#1 required 2 staff for care. 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. He said he went to clean her up and she had a large bowel movement which he needed more supplies to clean her. He said he lowered the bed but she would raise it up. 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. Resident #1 was not observed or interviewed as she was transferred to another facility from the hospital.
During an interview on 10/30/25 at 05:08 p.m. the Administrator said any violation of neglect of a resident should be reported to HHSC. 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. He said he had been told several different stories about Resident #1 since then regarding what happened during her care. He said the resident's RP said she had two fractured legs a few days later.
The Administrator said he did not know if they happened at the facility or at the hospital.
Record review of an undated Abuse, Neglect, and Exploitation policy indicated: .VII.
Reporting/ResponseA.
The facility will have written procedures that include:1.
Reporting of all alleged violations to the Administrator, state agency, adult protective services and to all other required agencies (e.g., law enforcement when applicable) within specified timeframes:a.
Immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, orb.
Not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/30/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Huntsville Health Care Center
2628 Milam Huntsville, TX 77340
SUMMARY STATEMENT OF DEFICIENCIES
During an observation and interview on 10/29/25 at 11:55 a.m. Resident #2 was up in her wheelchair in the dining room for lunch.
She said she was doing fine and everyone was nice.
She said staff assisted her when needed. 3.
Record review of a face sheet dated 10/29/25 indicated Resident #3 was a [AGE] year-old female admitted on [DATE].
Her diagnoses included dementia (loss of cognitive functioning), falls, and muscle weakness.
Record review of the admission MDS dated [DATE] indicated Resident #3 required substantial to maximum assistance with lower body dressing and bathing, moderate assistance with upper body dressing and footwear, and touch assistance with toileting and eating.
Record review of the care plan initiated on 09/30/25 did not address Resident #3's ADL assistance requirements.
During an observation and interview on 10/29/25 at 11:58 a.m. Resident #3 was sitting in her wheelchair in the dining room.
She said she was doing okay and had no unmet needs.
She said staff would help her when needed.
During an interview on 10/30/25 at 05:56 p.m. the DON said he was responsible for care plans and they were a collaboration of several people who met and developed the care plan according to the residents' needs and reviewed them at least quarterly or when there was a change in the resident or their needs. A policy for comprehensive care plans was requested but a Baseline Care Plan policy was provided by the Administrator.
Facility ID:
IDENTIFICATION NUMBER:
A.
Building
COMPLETED
10/30/2025
STREET ADDRESS, CITY, STATE, ZIP CODE
Huntsville Health Care Center
2628 Milam Huntsville, TX 77340
SUMMARY STATEMENT OF DEFICIENCIES
she was assisted back into bed with no complaints of pain or discomfort. He said the next day she started showing altered mental status, so they sent her to the hospital, and she had a UTI. He said nothing was said about her having a fracture until several days after she was admitted to the hospital. He said the x-ray report he received did not indicate the age of the fracture but did indicate she was osteopenic. He said 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.
Record review of a hospital Imaging Report dated 10/23/25 provided by the DON via email on 10/29/25 at 12:37 p.m. indicated Resident #1 had a 2 view x-ray of the left femur at 06:34 p.m. with clinical history of fall injury.
Findings were the femur was osteopenic (condition where the bone lacks enough minerals to be strong) and there was a fracture of the femoral (thigh bone) shift near the knee.During a phone interview on 10/29/25 at 01:33 p.m. CNA A said he was making his last 2 hour round on his residents. He said he knew Resident#1 required 2 staff for care. 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. He said he went to clean her up and she had a large bowel movement which he needed more supplies to clean her. He said he lowered the bed but she would raise it up. 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. Resident #1 was not observed or interviewed as she was transferred to another facility from the hospital.
Facility ID:
Federal health inspectors cited HUNTSVILLE HEALTH CARE CENTER in HUNTSVILLE, TX for a deficiency under regulatory tag F-F0880 during a complaint investigation conducted on 2025-10-30.
Category: Infection Control Deficiencies
The facility was found deficient in the following area: Provide and implement an infection prevention and control program.
Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.
While no actual harm was documented, there was potential for more than minimal harm to residents.
This was one of 4 deficiencies cited during this inspection of HUNTSVILLE HEALTH CARE CENTER.
Correction Status: Deficient, Provider has no plan of correction.