Huntsville Health Care Center

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

presented to patient's room during rounds, patient observed to be lethargic and responsive to painful stimuli only. Vitals were checks - BP: 145/84 HR:125 O2:88MD [name] contacted, verbal orders for ER send out for evaluation and treatment received along with 2L O2 via nasal canula.[Name] EMS contacted 1110[Name] EMS arrival 1120RP - [Name] notified 1118Report called in to ER nurse 1121Patient left facility via stretcher at 1128. 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Huntsville Health Care Center

2628 Milam Huntsville, TX 77340

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

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. 2. Record review of a face sheet dated 10/29/25 indicated Resident #2 was a admitted on [DATE REDACTED] with a diagnoses of wedge compression fracture (the front part of a spinal bone collapses slightly, making the bone look like a wedge) of the of T9-T10 thoracic vertebrae (the twelve spine bones located in the middle section of the spine), dementia (loss of cognitive functioning), and anxiety (persistent and excessive worry that interferes with daily activities). Record review of the admission MDS dated [DATE REDACTED] indicated Resident #2 was dependent on staff for personal hygiene and bathing and required maximum assistance with toileting and dressing.

Record review of the care plan initiated 10/18/25 did not address Resident #2's ADL assistance requirements. 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 REDACTED]. Her diagnoses included dementia (loss of cognitive functioning), falls, and muscle weakness. Record review of the admission MDS dated [DATE REDACTED] 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.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Huntsville Health Care Center

2628 Milam Huntsville, TX 77340

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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.

Event ID:

Facility ID:

If continuation sheet

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.