Health inspection·October 30, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to report an allegation of neglect to HHSC for 1 of 5 residents reviewed for neglect. The facility did not report when CNA A did not have another staff member to provided care to Resident #1, left Resident #1 to obtain more supplies for care, and the resident rolled off of the bed. Resident #1 sustained a fracture of the left thigh bone near the knee.This failure could place residents at risk of harm due to delays in reporting neglect. Findings included:Record review of a face sheet dated 10/29/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage)/hemiparesis (one-sided muscle weakness) due to cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting left side, pain, peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), and hypertension (condition in which the force of the blood against the artery walls is too high).Record review of the state optional MDS dated [DATE] indicated Resident #1 required extensive assistance of 2 persons for bed mobility. Record review of a Fall Risk Screener dated 09/05/25 indicated Resident #1 was low risk for falls with a score of 9 out of 31 (0-9-low risk; 10-31-high risk).Record review of the quarterly MDS dated [DATE] indicated Resident #1 was dependent for toileting hygiene and required substantial-maximum assistance for roll left-to-right. Record review of an incident report dated 10/22/25 indicated Resident #1 while receiving peri-care from CNA A at 03:20 a.m., resident was rolled onto her side to provide care after an incontinent episode. While the resident was on her side, she suddenly had a large bowel movement in the middle of care. CNA A turned to get some more supplies from the cart he had in the doorway. During that time, the resident attempted to reach for something on her bedside table and rolled off the bed. Nurse was notified and upon arrival, performed a head to toe assessment. No injuries nor bruising noted on assessment. Vitals are normal, respiration was even and unlabored. Resident was assisted back to bed with the help of 2 staff. Resident #1 indicated she hurt all over and PRN pain medication was given as previously ordered by the physician. Record review of Progress Notes indicated a nurse note entry dated 10/22/25 at 03:44 a.m. resident slipped and fell as aid was performing peri care. No injuries nor bruising noted on assessment. Vitals are normal, resp is even and unlabored. Resident is assisted back to bed, pain medication given. Resident is stable condition.Record review of a Post Fall Review dated 10/23/25 at 08:00 a.m. indicated Resident #1 was awake, alert, and oriented to person, place, and time. Her vital signs and neuro checks were normal for the resident with no abnormal findings. Record review of neuro check monitoring documentation from 10/22/25 at 04:00 a.m. through 10/23/25 at 11:00 a.m. indicated no abnormal findings. Record review of Progress Notes with a nurse note entry dated 10/23/25 at 11:18 a.m. indicated Note Text : This nurse Page 1 of 6 675691 675691 10/30/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 675691 Page 2 of 6 675691 10/30/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 10 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans.The facility failed to ensure that Resident #1's, #2's and #3's care plans were initiated and included appropriate interventions for ADL Care.This failure could place residents who required assistance with care at risk of serious harm and injury. Findings included:1. Record review of a face sheet dated 10/29/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage)/hemiparesis (one-sided muscle weakness) due to cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting left side, pain, peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), and hypertension (condition in which the force of the blood against the artery walls is too high). Record review of the care plan initiated on 05/21/25 for Resident #1 did not address her ADL assistance requirements. Record review of the state optional MDS dated [DATE] indicated Resident #1 required extensive assistance of 2 persons for bed mobility. Record review of the quarterly MDS dated [DATE] indicated Resident #1 was dependent for toileting hygiene and required substantial-maximum assistance for roll left-to-right. Record review of an incident report dated 10/22/25 indicated Resident #1 while receiving peri-care from CNA A at 03:20 a.m., resident was rolled onto her side to provide care after an incontinent episode. While the resident was on her side, she suddenly had a large bowel movement in the middle of care. CNA A turned to get some more supplies from the cart he had in the doorway. During that time, the resident attempted to reach for something on her bedside table and rolled off the bed. Nurse was notified and upon arrival, performed a head to toe assessment. No injuries nor bruising noted on assessment. Vitals are normal, respiration was even and unlabored. Resident was assisted back to bed with the help of 2 staff. Resident #1 indicated she hurt all over and PRN pain medication was given as previously ordered by the physician. Record review of Progress Notes indicated a nurse note entry dated 10/22/25 at 03:44 a.m. resident slipped and fell as aid was performing peri care. No injuries nor bruising noted on assessment. Vitals are normal, resp is even and unlabored. Resident is assisted back to bed, pain medication given. Resident is stable condition.Record review of a Post Fall Review dated 10/23/25 at 08:00 a.m. indicated Resident #1 was awake, alert, and oriented to person, place, and time. Her vital signs and neuro checks were normal for the resident with no abnormal findings. Record review of neuro check monitoring documentation from 10/22/25 at 04:00 a.m. through 10/23/25 at 11:00 a.m. indicated no abnormal findings. Record review of Progress Notes with a nurse note entry dated 10/23/25 at 11:18 a.m. indicated Note Text : This nurse 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 675691 Page 3 of 6 675691 10/30/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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] 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] 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]. 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. 675691 Page 4 of 6 675691 10/30/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for 1 of 5 residents reviewed for accidents and supervision. (Resident #1)The facility failed to provide adequate supervision for Resident #1 who was assessed for 2 staff members for care. CNA A did not have another staff member to provided care to Resident #1, left Resident #1 to obtain more supplies for care, and the resident rolled off of the bed. Resident #1 sustained a fracture of the left thigh bone near the knee. This failure could place residents at risk of not receiving the amount of supervision or assistance required to prevent serious injury and/or actual harm. Findings included:Record review of a face sheet dated 10/29/25 indicated Resident #1 was a [AGE] year-old female admitted on [DATE]. Her diagnoses included hemiplegia (severe or complete loss of strength leading to paralysis on one side of the body and is usually the result of brain damage)/hemiparesis (one-sided muscle weakness) due to cerebral infarction (lack of adequate blood supply to brain cells deprives them of oxygen and vital nutrients which can cause parts of the brain to die off) affecting left side, pain, peripheral vascular disease (a blood circulation disorder that causes the blood vessels outside of the heart and brain to narrow, block, or spasm), and hypertension (condition in which the force of the blood against the artery walls is too high).Record review of the state optional MDS dated [DATE] indicated Resident #1 required extensive assistance of 2 persons for bed mobility. Record review of a Fall Risk Screener dated 09/05/25 indicated Resident #1 was low risk for falls with a score of 9 out of 31 (0-9-low risk; 10-31-high risk).Record review of the quarterly MDS dated [DATE] indicated Resident #1 was dependent for toileting hygiene and required substantial-maximum assistance for roll left-to-right. Record review of an incident report dated 10/22/25 indicated Resident #1 while receiving peri-care from CNA A at 03:20 a.m., resident was rolled onto her side to provide care after an incontinent episode. While the resident was on her side, she suddenly had a large bowel movement in the middle of care. CNA A turned to get some more supplies from the cart he had in the doorway. During that time, the resident attempted to reach for something on her bedside table and rolled off the bed. Nurse was notified and upon arrival, performed a head to toe assessment. No injuries nor bruising noted on assessment. Vitals are normal, respiration was even and unlabored. Resident was assisted back to bed with the help of 2 staff. Resident #1 indicated she hurt all over and PRN pain medication was given as previously ordered by the physician. Record review of Progress Notes indicated a nurse note entry dated 10/22/25 at 03:44 a.m. resident slipped and fell as aid was performing peri care. No injuries nor bruising noted on assessment. Vitals are normal, resp is even and unlabored. Resident is assisted back to bed, pain medication given. Resident is stable condition.Record review of a Post Fall Review dated 10/23/25 at 08:00 a.m. indicated Resident #1 was awake, alert, and oriented to person, place, and time. Her vital signs and neuro checks were normal for the resident with no abnormal findings. Record review of neuro check monitoring documentation from 10/22/25 at 04:00 a.m. through 10/23/25 at 11:00 a.m. indicated no abnormal findings. Record review of Progress Notes with a nurse note entry dated 10/23/25 at 11:18 a.m. indicated Note Text : This nurse 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 675691 Page 5 of 6 675691 10/30/2025 Huntsville Health Care Center 2628 Milam Huntsville, TX 77340

F 0689 Level of Harm - Actual harm Residents Affected - Few 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. 675691 Page 6 of 6