Health inspection·December 12, 2024

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the representative when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure Resident #1's MD was notified after she experienced swelling in her left arm. Resident #1 complained of pain 11/16/2024, the Medical Doctor was not informed. On 11/20/2024 the Medical Doctor assessed the resident and ordered an X-ray which showed no significant findings on 11/21/2024 of which the MD was not notified. On 11/26/2024 the resident requested to go to the emergency room where she was diagnosed with a ruptured left bicep tendon with instructions to keep arm elevated and free of compression. This failure could place residents at risk of illness, injury, uncontrolled pain, and a decreased quality of life. Findings included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including cerebral infarction (stroke), type II diabetes , muscle weakness, and unspecified lack of coordination. Review of Resident #1's quarterly MDS assessment, dated 09/11/24, reflected a BIMS score of 15, indicating she had no cognitive impairment. Review of Resident #1's quarterly care plan, dated 11/19/24, reflected she had a potential for uncontrolled pain with an intervention of notifying the physician if interventions were unsuccessful or if current complaint was a significant change from past experience of pain. Review of Resident #1's progress note, dated 11/16/24 and documented by LVN A, reflected the following: [Resident #1] c/o pain on the left arm, stated 10/10 on pain scale. Left arm swollen and muscle contracte. PRN Tylentol 625mg given and applied Voltaren Gel on the pain site. Cold compress applied to the left arm and [Resident #1] expresses relief and comfort. Will continue to monitor [Resident #1]. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675399 Printed: 05/15/2026 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 675399 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/12/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Navasota Nursing & Rehabilitation 1405 E Washington Navasota, TX 77868 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)