Health inspection·June 5, 2025

F 0577 Level of Harm - Potential for minimal harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete updated the survey book with the last three survey reports. The ADM stated she found the surveys in different binders in the office, but she combined them into one book . An interview was conducted with the ADM on June 5, 2025, at 2:18 PM, the ADM stated she could not find a written policy and that no policy had been provided to her. She further stated, I assume one does not exist. Event ID: Facility ID: 675399 If continuation sheet Page 2 of 19 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 06/05/2025 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)

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based on observation, interview, and record review the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for five of six residents (confidential residents) reviewed for grievances. The facility failed to post the grievance procedure in a prominent and accessible locations throughout the facility; provide residents with access to grievance forms, and instruction on how to file an anonymous grievance. This failure could place residents at risk by limiting their access to the grievance process, which may result on unresolved concerns that impact their well-being and overall quality of care. Findings include: Observation on June 4, 2025, at 10:38 AM, revealed the facility's grievance procedure posted in the first hallway near the front entrance. The notice was affixed approximately nine feet above the floor, which made it difficult to read. The height rendered it inaccessible to residents who use wheelchairs or those who were shorter in height, and it was not positioned in a way that supported easy viewing by all residents, resident's representatives, staff, or visitors. A walkthrough of other hallways and common areas revealed one additional posting located at the station 2 nurse's station. The posting was positioned on the wall behind the nurse's station desk, in a small area not accessible to residents. Due to the confined space and placement behind staff work areas, residents would not be able to view or access the information independently. During a confidential resident interview five of six residents stated they had not received information regarding the process for filing grievances or concerns within the facility. The residents reported they were unaware of their right to formally voice concerns or complaints and did not know who to contact or where to find grievance forms or related resources. An interview was conducted with the ADM on June 4, 2025 at 3:43 PM, the ADM stated residents were provided information regarding the grievance process and how to file grievances by the facility conducting daily Champion Rounds, during which department managers were assigned to check in with different residents to ask how they were doing and if they had any concerns. She also stated grievance information was included in the admission packet and added, Hopefully it's posted on the open board. The ADM was then led to the open board in the front entry hallway. She experienced some difficulty locating the grievance posting. The state surveyor pointed it out and asked if she believed the posting was accessible to residents or family members, considering its high placement on the wall. The ADM responded the posting needs to be brought down to be more accessible. The ADM was also shown the second grievance posting located behind Nurse's Station #2. When asked if this posting was accessible to residents, she stated, That is mostly for the nurses to have the information to provide if a family member asks how to file. She would work on making the grievance signs more available to residents and families. Record review of the facility's Grievance Policy dated November 2, 2016, reflected, The resident has the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal .The facility will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 3 of 19 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 06/05/2025 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)

F 0585 notify residents on how to file a grievance orally, in writing, or anonymously with postings in prominent locations. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 4 of 19 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 06/05/2025 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)

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 3 of 11 residents (Residents # 11, #17, and #32) reviewed for ADLS . Residents Affected - Some 1. The facility failed to ensure Resident #11's fingernails were cleaned, trimmed and filed. 2. The facility failed to ensure Resident #17 received baths per her care plan and her request and failed to ensure her nails were trimmed. 3. The facility failed to ensure Resident #32 had clean clothing, failed to ensure she received baths three times a week and failed to ensure her nails were trimmed and filed. These failures could place residents at risk for a decline in health, skin breakdown, loss of self-esteem, a diminished quality of life and health-related issues from lack of hygiene . Findings include: 1. Record review of Resident #11's, undated, face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #11 had diagnoses which included Alzheimer's Disease (progressive disease that destroys memory and other important mental functions) late onset and Cerebral Infarction (brain stroke). He was on hospice care. Record review of Resident #11's Quarterly MDS, dated [DATE], reflected he was unable to complete a BIMS interview. Section GG - Functional Abilities reflected he required supervision or touching assistance for personal hygiene. Record review of Resident #11's Care Plan, dated 02/01/2021 and revised 05/09/2025, reflected he had an ADL self-care performance deficit related to impaired cognition, decreased mobility and end stage disease process. Interventions: The resident requires skin inspection weekly and as needed. CNA: observe for redness, open areas, scratches cuts, bruises and report changes to the nurse. Observation on 6/03/2025 at 10:27 AM revealed Resident #11's nails on both hands were jagged. Two of his nails were ¾ inch long from the fingertip and all nails had brown debris underneath. Resident #11 was not interviewable. In an interview on 06/05/2025 at 9:02 AM, RN A stated Resident #11 was a hospice patient. She stated she was not aware the facility was responsible for his ADL care . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 5 of 19 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 06/05/2025 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 2. Record review of Resident #17's, undated, face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE]. Resident #17 had diagnoses which included Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy) and morbid obesity. Record review of Resident #17's Quarterly MDS, dated [DATE], reflected she had a BIMS score of 15, which indicated intact cognitive status. Section GG - Functional Abilities reflected she was dependent for personal hygiene. Record review of Resident #17's Care Plan, dated 12/12/2024 and revised on 03/14/2025, reflected she had an ADL self-care deficit related to CVA , hemiplegia and impaired mobility. Interventions: Personal hygiene she requires extensive assistance by 2 staff with personal hygiene. Record review of a bathing task sheet for Resident #17 for Monday, Wednesday and Fridays reflected she received baths on Wednesday 5/7/2025, Friday 5/9/2025, Monday 5/12/2025, Friday 5/16/2025, Monday 5/19/2025, Friday 5/23/2025 and Wednesday 5/28/2025. 5 baths were not documented as given for the month of May 2025. In an interview on 06/03/2025 at 1:55 PM, Resident #17 stated she did not always get her baths as she would like , and she would like her nails trimmed by the nurse. In an interview on 06/05/2025 at 8:57 AM, RN A stated if Resident #17's baths were not documented, they could not prove they were given. She stated nurses should trim her nails, but she was not aware they needed to be trimmed. 3. Record review of Resident #32's, undated, face sheet reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #32 had a diagnosis which included unspecified Dementia with psychotic disturbance (loss of memory and thinking skills along with hallucinations and delusions). Record review of Resident 32's Quarterly MDS, dated [DATE], reflected she had a BIMS score of 11, which indicated moderate cognitive status. Section GG - Functional Abilities reflected she was dependent for personal hygiene. Record review of Resident #32's Care Plan reflected she had an ADL self-care performance deficit . Record review of the bathing task sheet for Resident #32 reflected she was to receive baths on Mondays, Wednesdays and Fridays. She had documented baths on Wednesday 05/07/2025, Friday 05/09/2025, Monday 05/12/2025 and Monday 05/26/2025. 8 baths were not documented as given for the month of May 2025. Record review of the bathing task sheet for Resident #32 reflected she was to receive baths on Mondays, Wednesdays and Fridays. She had documented baths on Wednesday 05/07/2025, Friday 05/09/2025, Monday 05/12/2025 and Monday 05/26/2025. 8 baths were not documented as given for the month of May 2025. Observation and interview on 06/03/2025 at 9:27 AM revealed Resident #32's nails on both hands were ¾ to 1-inch -long, jagged with brown debris underneath. She was wearing a long-sleeved stained sweatshirt with a holiday theme. She stated she would like her fingernails trimmed . (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 6 of 19 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 06/05/2025 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)

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation on 06/04/2025 at 8:00 AM revealed Resident #32 was wearing the same holiday themed stained sweatshirt as the day before. Her fingernails on both hands were long jagged with brown debris underneath. Observation on 06/05/2025 at 8:43 AM revealed Resident #32 was wearing the same holiday themed, stained top as the previous two days. Her fingernails on both hands were long and jagged with brown debris underneath. In an interview on 06/05/2025 at 8:59 AM, RN A stated it absolutely was not acceptable for Resident #32 to be wearing the same top for three days in a row. She stated her nails should not have been long, dirty or jagged. She stated she could get bacteria in her mouth from unclean nails, and she could scratch herself and get an infection. She stated she had a habit of picking at her face . In an interview on 06/05/2025 at 9:05 AM, CNA C stated she worked at the facility for two weeks and was also a van driver . She stated if a resident refused to be changed or bathed , she would report it to the nurse. She stated she would chart a refusal of care. She stated by not getting bathed and having their nails trimmed there was a potential risk of infection. She stated a resident could scratch themselves and get a skin tear. She stated sometimes it was helpful to call a family member to talk to the resident. In an interview on 06/05/2025 at 9:02 AM, RN A stated she had never received any training and had never worked in that kind of environment (nursing home). She stated if residents did not have their clothing changed, have baths and get their nails trimmed it could affect their dignity. She stated it could make them feel like no one cared about them. In an interview on 06/05/2025 at 11:52 AM, the Traveling DON stated residents should receive or at least be offered baths and their nails should be trimmed and cleaned. She stated they could scratch themselves and potentially get an infection. She stated by not getting the care they needed it could affect their self-esteem. In an interview on 06/05/2025 at 11:57 AM, the RCN stated she worked for the company for 8 months. She stated residents should be receiving physical care and if they refused, it should be reported to the nurse, MD, and RP. She stated it should be care planned . She stated the facility had just started training on dementia care so the staff would know how to approach the resident. She stated Resident #32 allowed her to change her clothing and trim her nails. She stated the potential risk to Resident #32 was she could contaminate her facial lesion. She stated residents could cause skin tears if their nails were not trimmed. She stated residents had a right to be clean and it was a dignity issue. She stated Resident #11 allowed her to trim his nails. She further stated it was a nurse's responsibility to seek out training if she did not know how to care for the residents . In an interview on 06/05/2025 at 1:55 PM, the ADM stated her expectation was for the facility to take care of all resident ADLS which included showers, shaving, nail care and changing clothes. She stated their responsibility was to take care of the residents. as it was important for their overall physical and mental health. She stated hands were the dirtiest places on the body. She stated long jagged nails could cause skin tears. She stated not attending to ADLS could be a dignity issue. Record review of the facility's Bath/Tub/shower policy and procedure, dated 2003, reflected Bathing by tub bath or shower is done to remove soil, dead epithelial cells, microorganisms from the skin and body odor to promote comfort, cleanliness, circulation and relation. The frequency and type of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 7 of 19 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 06/05/2025 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)

F 0677 bathing depends on resident preference, skin condition, tolerance and energy level. The aging skin can be maintained by bathing every two days and with partial bathing as needed. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 8 of 19 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 06/05/2025 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)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of six residents (Resident #39) reviewed for quality of care. Residents Affected - Some The facility failed to take vital signs daily for 58 of the last 68 days per the QAPI initiated physician orders for Resident #39. This failure could place residents at risk of not receiving necessary medical care and lead to an unacknowledged change in condition and possible hospitalization. Findings include : Record review of Resident #39's face sheet reflected a [AGE] year-old, female who was admitted to the facility on [DATE]. Resident #39 had diagnoses which included, Dementia, severe with agitation (damage or loss of nerve cells in the brain resulting in behavior changes), Essential Hypertension (high blood pressure), and Generalized Anxiety Disorder (excessive worry about various aspects of life). Record review of Resident #39's Optional State Assessment MDS, dated [DATE], reflected a BIMS score of 3, which indicated (severe cognitive impairment). Record review of Resident #39's Care Plan reflected a Focus Area initiated 04/13/2025, for, [Resident #39] has potential for abnormal blood pressure readings related to cardiac disease with an intervention of the same initial date for Obtain blood pressure readings as ordered or as needed. Record review of Resident #39's Physician Orders reflected an order for, Facility Initiated QAPI PIP Data Collection for Rehospitalization Prevention. May obtain vital signs every day shift for Prevention of Hospitalization with a start date of 03/30/2025. Medication orders reflected Resident #39 received Carvedilol 12.5 mg by mouth twice a day for heart and Lisinopril oral tablet 20 mg by mouth one time a day related to hypertension . Both the Lisinopril and the Carvedilol orders were started on 03/29/2025. Record review of Resident #39's blood pressure readings reflected there were no blood pressure readings recorded on 03/31/2025, 04/01/2025, 04/04/2025, 04/05/2025, 04/06/2025, 04/09/2025, 04/10/2025, 04/11/2025, 04/12/2025, 04/13/2025, 04/14/2025, 04/15/2025, 04/17/2025, 04/18/2025, 04/19/2025, 04/20/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/26/2025, 04/28/2025, 04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/05/2025, 05/06/2025, 05/07/2025, 05/08/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/15/2025, 05/16/2025, 05/17/2025, 05/18/2025, 05/19/2025, 05/20/2025, 05/21/2025, 05/22/2025, 05/24/2025, 05/25/2025, 05/26/2025, 05/27/2025, 05/28/2025, 05/29/2025, 05/31/2025, 06/01/2025, 06/02/2025, 06/03/2025, or 06/04/2025. Record review of Resident #39's pulse readings reflected there were no pulse readings recorded on 03/31/2025, 04/01/2025, 04/04/2025, 04/05/2025, 04/06/2025, 04/09/2025, 04/10/2025, 04/11/2025, 04/12/2025, 04/13/2025, 04/14/2025, 04/15/2025, 04/17/2025, 04/18/2025, 04/19/2025, 04/20/2025, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 9 of 19 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 06/05/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/26/2025, 04/28/2025, 04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/05/2025, 05/06/2025, 05/07/2025, 05/08/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/15/2025, 05/16/2025, 05/17/2025, 05/18/2025, 05/19/2025, 05/20/2025, 05/21/2025, 05/22/2025, 05/24/2025, 05/25/2025, 05/26/2025, 05/27/2025, 05/28/2025, 05/29/2025, 05/31/2025, 06/01/2025, 06/02/2025, 06/03/2025, or 06/04/2025. Record review of Resident #39's temperature readings reflected there were no temperature readings recorded on 03/31/2025, 04/01/2025, 04/04/2025, 04/05/2025, 04/06/2025, 04/09/2025, 04/10/2025, 04/11/2025, 04/12/2025, 04/13/2025, 04/14/2025, 04/15/2025, 04/17/2025, 04/18/2025, 04/19/2025, 04/20/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/26/2025, 04/28/2025, 04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/05/2025, 05/06/2025, 05/07/2025, 05/08/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/15/2025, 05/16/2025, 05/17/2025, 05/18/2025, 05/19/2025, 05/20/2025, 05/21/2025, 05/22/2025, 05/24/2025, 05/25/2025, 05/26/2025, 05/27/2025, 05/28/2025, 05/29/2025, 05/31/2025, 06/01/2025, 06/02/2025, 06/03/2025, or 06/04/2025. Record review of Resident #39's respiration counts reflected there were no respiration count readings recorded on 03/31/2025, 04/01/2025, 04/04/2025, 04/05/2025, 04/06/2025, 04/09/2025, 04/10/2025, 04/11/2025, 04/12/2025, 04/13/2025, 04/14/2025, 04/15/2025, 04/17/2025, 04/18/2025, 04/19/2025, 04/20/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/26/2025, 04/28/2025, 04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/05/2025, 05/06/2025, 05/07/2025, 05/08/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/15/2025, 05/16/2025, 05/17/2025, 05/18/2025, 05/19/2025, 05/20/2025, 05/21/2025, 05/22/2025, 05/24/2025, 05/25/2025, 05/26/2025, 05/27/2025,05/28/2025, 05/29/2025, 05/31/2025, 06/01/2025, 06/02/2025, 06/03/2025, or 06/04/2025. Record review of Resident #39's oxygen saturation level readings reflected there were no oxygen saturation level readings recorded on 03/31/2025, 04/01/2025, 04/04/2025, 04/05/2025, 04/06/2025, 04/09/2025, 04/10/2025, 04/11/2025, 04/12/2025, 04/13/2025, 04/14/2025, 04/15/2025, 04/17/2025, 04/18/2025, 04/19/2025, 04/20/2025, 04/21/2025, 04/22/2025, 04/23/2025, 04/24/2025, 04/25/2025, 04/26/2025, 04/28/2025, 04/29/2025, 04/30/2025, 05/01/2025, 05/02/2025, 05/03/2025, 05/04/2025, 05/05/2025, 05/06/2025, 05/07/2025, 05/08/2025, 05/09/2025, 05/10/2025, 05/11/2025, 05/12/2025, 05/13/2025, 05/14/2025, 05/15/2025, 05/16/2025, 05/17/2025, 05/18/2025, 05/19/2025, 05/20/2025, 05/21/2025, 05/22/2025, 05/23/2025, 05/24/2025, 05/25/2025, 05/26/2025, 05/27/2025, 05/28/2025, 05/29/2025, 05/30/2025, 05/31/2025, 06/01/2025, 06/02/2025, 06/03/2025, or 06/04/2025. Observation of medication administration for Resident #39 with MA on 06/04/2025 at 07:17 AM revealed MA A did not take the blood pressure or pulse prior to the morning medication administration, which included the blood pressure medication Carvedilol . In an interview with the RNC on 6/4/25 at 04:30 PM, she stated the orders were part of a QAPI intervention to prevent rehospitalizations. She stated the order was a valid physician order and her expectation was the vital signs be taken daily for residents with the order. In an interview with RN A on 06/4/2025 at 04:43 PM, she stated the medication aide usually took the vital signs with medication pass. She stated it was the nurses responsibility to take vital signs ordered for residents without medication parameters. She stated she was told the order, was not valid anymore. She stated the order, was removed from a bunch of them [resident charts]. She stated she (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 10 of 19 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 06/05/2025 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)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some had not done vital signs for Resident #39. She stated her understanding was everyone usually got weekly vital signs unless they had blood pressure medications or other concerns. In an interview on 06/04/2025 at 04:48 PM, MA A stated it was the nurse's responsibility to obtain vital signs that were not related to medication parameters for administration. She stated she did not take vital signs for Resident #39 . In an interview with CNA B on 06/05/2025 at 01:50 PM, she stated she did not do ordered vital signs for patients. She stated the nurses do the vital signs. In a follow up interview on 06/05/2025 at 02:02 PM, RN A stated she could not recall the name, but it was one of the ADONs who told her to disregard the daily vital signs orders from QAPI. She stated, it just shows up as a programmed order. She stated she would question the ADON or nursing management regarding questions regarding facility generated orders. She stated she did not do daily vital signs for Resident #39. She stated if nursing did not monitor vitals signs per the orders the resident could potentially have really high or low blood pressure and/or could have a change in condition that might not be acknowledged . In an interview with the ADON on 06/05/2025 at 02:07 PM, she stated her expectation was vital signs be done daily for the residents with the QAPI order to monitor vital signs daily. She denied informing any staff to disregard the QAPI related orders. She stated it was the responsibility of the nurses to take ordered vital signs readings. She stated she and the nursing administration team monitored to ensure vital signs were being taken as ordered. She stated the potential impact to the resident of not having their vital signs taken per the orders would be the resident could be hospitalized or re-hospitalized . She stated she did not know of a way the nurses could bypass the treatment order to record the vital signs for a resident. In an interview with RNC on 06/05/2025 at 02:12 PM, she stated there were not daily vital signs recorded for Resident #39. She stated the RN who initiated the order did not select the individual fields that were required for the order. She stated it was her responsibility to ensure that staff were checking vital signs. She stated when she reviewed the vital signs for the facility, the lack of vital signs for Resident #39 was not triggering the audit that vital signs were not recorded or that the fields were missing because the order was not set up correctly. She stated the RN who set up the order no longer worked at the facility. She stated she added the fields to Resident #39's treatments to record the vital signs in such a way the nurses could not bypass the task. She stated she added parameters to the Carvedilol order for Resident #39 per their facility guidelines to ensure the blood pressure and pulse were also taken and recorded prior to medication administration. Requested a policy for vital signs from RNC . In an interview with the ADM on 06/05/2025 at 03:05 PM, she stated it was her expectation nursing followed all orders for residents. She stated if vital signs were not monitored per the physician orders residents could have an adverse reaction and the staff would not know. She stated early prevention could contribute to quality of life for the residents. Record review of an email correspondence with RCN on 06/09/2025 at 01:42 PM, RNC stated, We do not have a specific policy for vital signs, we just follow physician orders . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 11 of 19 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 06/05/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one of two medication carts (RN medication cart) reviewed for medication safety. The facility failed to ensure that a loose Tramadol pill (controlled medication) in RN Medication Cart was secured, administered, and/or disposed of based on facility policy. The failure puts residents at risk for not receiving their prescribed medication and risk of possible drug diversion. Findings include: Observation of the RN Medication Cart for Station II and III on 6/4/2025 at 03:10 PM with RN A revealed one loose pill on the bottom of the drawer within the locked drawers of the medication cart. It was a small, white circular pill AN 627. Medication identified by RN A as Tramadol 50 mg. The medication was put into a cup and taken to the RCN and DON. The RCN and Traveling DON were notified of the loose medication in the cart. The RCN and Traveling DON stated that they would audit the narcotic count and interview residents receiving Tramadol and dispose of the medication per their facility's policy. The RCN stated she would start an in-service on Narcotic storage. In an interview on 6/4/25 at 03:10 PM, RN A stated that if the residents didn't get their medication, they could have unrelieved pain. She also stated that someone could have diverted the medication since it was loose. She stated it was the responsibility of the staff, providing medications, to check their carts before administering medications. She stated that all medication counts were correct that morning. She denied any previous discrepancies with the narcotics count of any medication; including Tramadol. She stated that she would complete an incident report regarding the medication. In a group interview with the RCN, ADON, and Traveling DON on 06/04/2025 at 04:00 PM, the RCN stated that the impact to the resident of having loose medications in the medication cart was that a resident likely did not get their pain medications, and the medication could have been diverted from the cart by staff. RCN stated that an audit was performed for the two residents in the facility prescribed that medication and the count for both residents was correct. The RCN stated that the medication could have fallen out of a medication cup during the preparation process, which would not make the count off for the records. The RCN stated that there had been no narcotic discrepancies for the facility. The Traveling DON agreed with the impact to the resident and the potential for diversion stated by the RCN. Both the RCN and DON stated that it was the nurse taking the cart over that was responsible for ensuring the count was correct, and the cart was clean. The Traveling DON stated that it was the responsibility of the ADON, Traveling DON, and RCN to audit medication carts periodically, during mock surveys, and when the RCN visits. The RCN stated that pharmacy came every other month for audits of carts and medication storage. ADON agreed it was her responsibility to audit the carts. ADON stated that she agreed with the resident outcomes stated by RCN. Traveling DON, the RCN, and ADON denied any reports from the staff stating that the narcotic count was off. Traveling DON stated that she would expect staff to bring any loose medications found in the medication carts to the Nursing administration to perform a follow up investigation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 12 of 19 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 06/05/2025 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)

F 0755 Level of Harm - Minimal harm or potential for actual harm In an interview with the ADM on 06/05/2025 at 03:09 PM, the ADM stated that her expectation regarding medication administration for nurses would be that the medication, goes in the cup. She stated that that her expectation was that the controlled medications were kept in the lock box. She stated that because the loose medication was still in a locked drawer the risk to the resident were that the resident did not receive their ordered medication. Residents Affected - Few Review of the facility's Policy for Controlled Medication- Ordering and Receipt (No Date) reflected, Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances, and medications classified as controlled substances by state law are subject to special ordering, receipt, and recording requirements in the facility, in accordance with federal and state laws and regulations. Procedure 1. The Director of Nursing and the Consultant Pharmacist maintain the facility's compliance with federal and state laws regulations in handling of controlled medications. Only authorized licensed nursing and pharmacy personnel have access to controlled medications. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 13 of 19 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 06/05/2025 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)

F 0790 Provide routine and 24-hour emergency dental care for each resident. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide or obtain from an outside source dental service to meet the needs of 1 of 4 residents (Resident #33) reviewed for dental services. Residents Affected - Few The facility did not assist Resident #33, who had missing teeth and pain when she ate , with a dental service consult. This failure could place residents at risk of oral complications, pain, difficulty eating, and diminished quality of life. Findings included: Record review of Resident #33's face sheet showed a 69 -year-old woman, who was admitted on [DATE]. Diagnoses included: Parkinson's disease (neurodegenerative disorder that affects movement), Protein calorie malnutrition (inadequate intake of food (as a source of protein, calories, and other essential nutrients). Rhabdomyolysis (muscle tissue break down ). Record Review of Resident #33 's quarterly MDS assessment dated [DATE] , reflected a BIMS score of 10 which indicted moderately impaired cogntition. MDS section L- Oral / dental status reflected no mouth or facial pain, or discomfort or difficulty chewing. Record review of Resident #33's Care plan revised on 05/02/2025 reflected [Resident #33] has potential for oral health problems related to having no natural teeth. GOAL: Resident #33 will be free of infection, pain or bleeding in the oral cavity by/through review date 07/18/2025. INTERVENTION:Administer medications as ordered. Monitor for side effects and effectiveness and document as needed. Coordinate arrangements for dental care, transportation as needed/as ordered. Monitor/document/report to MD PRN s/sx of oral/dental problems needing attention: Pain (gums, toothache, palate), Abscess, Debris in mouth, Lips cracked or bleeding, Teeth missing, loose, broken, eroded, decayed, Tongue (black, coated, inflamed, white, smooth), Ulcers in mouth, Lesions. Review of Resident #33 's care plan conference dated 01/14/2025 reflected there was no dental consult. Record review of Resident #33's Physician order dated 12/30/2024 reflected a regular textured diet and dental consult as needed. Review of Resident #33's progress notes from 12/31/2024 to 06/04/2025 reflected no notes regarding dental exam. Interview and observation on 06/03/2025 at 12:45 p.m. with Resident #33 revealed her sitting up in her hospital bed and attempting to eat steak with gravy, baked potato, and broccoli. She stated the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 14 of 19 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 06/05/2025 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)

F 0790 Level of Harm - Minimal harm or potential for actual harm bake potato was easier for her to chew because it was soft. She stated she like steak was delicious , but it was difficult for her to eat because she was missing teeth, and she did not want to choke. She stated some food that are hard in texture, cause her teeth to hurt when she chews. She stated she did not want to complain and try to do the best she can when eating. She stated she had not seen a dentist in 3 years and since her stay at the facility she had not seen a dentist. Residents Affected - Few Interview on 06/04/2025 at 04:32 p.m. with the Social Service Worker revealed she reviewed her dental referral records and did not know why Resident # 33 was not seen by a Dentist since her admission on [DATE]. She stated they used a mobile dentist for routine dental care, and they called their mobile dentistry unless the resident or family request to see an outside dentist and they would provide transportation. She stated she was not sure why Resident # 33 had not had a dental consult, but she would ensure she was seen . She stated the mobile dental service come to the facility every 3-6 months or during emergency visits .She stated when there was a new admission, she , the business office manager, or nursing will add the resident to a list to see the dentist. She stated dental care was usually care planned and the CNAs would review the care plan to ensure dental care was provided, and if there was a concern, they would report it to floor nurse. In an interview on 06/05/2025 at 11:46 a.m. with CNA A , he stated if a resident had dental problems, he would let their nurse know. CNA A denied Resident # 33 complaining to him about dental pain or concerns. In an interview on 06/05/2025 at 12:52 PM, LVN A stated that if she received a report of concerns with mouth or teeth, she would have assessed the resident, report to the MD, let the social worker know, and ask the social worker to make an appointment. LVN A stated it was important to have dental concerns addressed because a resident may not have brushed their teeth well or could have an infection, and they may have needed to be evaluated for concerns with their teeth. In an interview on 06/05/2025 at 1:00 p.m. with the ADON, she said Social Services should have referred Resident #33 or any resident to dentistry by the nurse. She stated each department was responsible or completing assessment upon admission and the nurse was responsible for dental .She stated the nurse would send the referral to Social Services and they would ensure the resident was scheduled to see the Dentist. She stated Social Services was responsible for reaching out to the family and Resident, and make them aware of their dentist appointment or find if they would prefer to see Dentist of their choice. She stated possible consequences of a Resident not receiving dental care could lead to decrease in quality of life, and they would not be able to enjoy food. She stated there could be nutritional concerns related to weight lost and food preparation could be provided incorrectly. In an interview with the DON on 06/05/2025 at 2:05 p.m., she said Social Services was responsible for scheduling dentist consults after the nurse completed their assessment for the IDT care plan meeting . She stated the nurses should always communicate the need for dental services to Social Services. She stated, in most cases, dental consults are standing orders, and if there was a dental issue or emergency, they would call their mobile dentist to come in and review Resident, or the Resident and family could choose to see an outside dentist of their choice. She stated social services sends the resident's face sheet and physician orders with residents. and the facility would provide transportation . She stated she would expect the Resident's needs to be met. She stated if dental was not provided to a Resident, they could develop an infection and have a need for dentures to increase their quality of life. An interview on 06/05/2025 at 2:15 p.m. , the ADM stated social services was responsible for dental (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 15 of 19 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 06/05/2025 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)

F 0790 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few appointments. The ADM stated they have a mobile dental contract, and if a resident needed emergency services, an appointment was scheduled as well as routine dental care. The ADM stated the resident can choose to see the provider who came to the facility or in the community. The ADM stated if it was routine, a referral would be sent to the provider and the provider would provide the facility a date of when they would be at the facility next. She stated the consequences of not receiving routine dental care could lead to weight loss and malnutrition from not eating. Record review of the facility's Dental Services policy unknown month and day , 2003 reflected , Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Policy Interpretation and Implementation: 1. Oral health services are available to meet the resident's needs. 2.Routine and emergency dental services are provided to our residents through: A contract agreement with a local dentist; Referral to the resident's personal dentist; Referral to community dentists; or Referral to other health care organizations that provide dental services. 3.The Director of Nursing Services, or his/her designee, was responsible for notifying Social Services of a resident's need for dental services. 4.Social Services personnel will be responsible for assisting the resident/family in making dental appointments and transportation arrangements as necessary. 5.For Medicare and private pay residents, the facility was responsible for having the services available, but may bill an additional charge for the services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 16 of 19 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 06/05/2025 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)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure a hair net was worn by Dietary Aide . These failures could place residents who ate food served by the kitchen at risk of food-borne illness. Findings included: An observation on 06/04/2025 at 10:49 AM, a Dietary Aide was observed in the kitchen prepping dessert and washing dishes without a hair restraint on. In an interview on 06/05/2025 at 9:08AM with Dietary Aide , she stated she had worked in the kitchen for 1 year and she knew a hair net should be always on. She stated she found a hair net on the floor in the kitchen but did not realize her hair net had fallen off. She stated she was trained by a previous Dietary Manager to always wear a hair net and she also had her food handler certificate . She stated some consequences for not wearing a hair net could be food getting into the food and causing contamination . In an interview on 06/05/2025 at 9:15AM , with the Dietary Manager, she stated she could not remember if she had a hand restraint in-service recently, but it was expected for her staff to have their hair restraints on before they always entered the kitchen door. She stated the Dietary aide had a small head and the brown hair nets provided often fell off her head. She stated she did not want to make any excuses, but would look into a different type of hair net for the Dietary aide. She stated she had a sign on the kitchen entrance door do not enter without hair net. She stated if a staff member was not wearing a hair restraint, there was a potential risk for a resident to consume hair in their food, and germs/bacteria and a resident could get sick . In an interview on 06/05/2025 at 09:20 AM with the ADM, she stated her expectations were for all Dietary staff to follow the rule and wear a hair net when they are in the kitchen. She said a consequence of not wearing hair nets could lead to food in a resident's food and could lead to possible infections. Record review of the facility's infection control policy dated 04/09/2025 reflected We will ensure that all employees practice infection control in the Food and Nutrition Services Department and maintain sanitary food preparation. Procedure: We will ensure that all employees practice infection control in the Food and Nutrition Services Department and maintain sanitary food preparation. 1.Personal cleanliness is required in sanitary food preparation. Employees should follow general sanitation guidelines from the Center of Disease Control (CDC) and the state food code when working in the Food and Nutrition Department. . b.Clean hair is required. It is to be covered with an effective hair restraint. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 17 of 19 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 06/05/2025 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for one of six residents reviewed for infection control practices. (Resident #52). Residents Affected - Few The facility failed to ensure that LVN B used gloves to open a capsule prior to medication administration on 6/4/2025. This failure could place the resident at risk for cross contamination. Findings include: Review of Resident #52's Face sheet reflected a [AGE] year-old, female admitted on [DATE]. Diagnoses included Dementia, severe with other behavioral disturbance, Essential Hypertension (high blood pressure), and Cognitive Communication Deficit (problem with communication caused by cognition rather than a language or speech deficit). Review of the MDS assessment for Resident #52 dated 05/02/2025 reflected a BIMS score of 7 (severe cognitive impairment). Section G- Functional Status, subsection I indicated she required supervision with eating/drinking. Review of the Care Plan for Resident #52 reflected a Focus Area dated 04/18/2025, stating Resident #52 has a potential nutritional problem related to impaired cognition, impaired dentition and wandering with interventions for, Administer medications as ordered and Monitor/document/report to MD PRN for s/sx of dysphagia: Review of the Physician Orders for Resident #52 reflected an order for Depakote Sprinkles or Capsule Delayed Release Sprinkle 125 mg, Give 4 capsules by mouth twice a day. Observation of medication administration for Resident #52 on 6/4/2025 at 07:08 AM, revealed LVN B did not wear gloves when she opened 4 capsules of Depakote Sprinkles Oral Capsules Delayed Release 125mg. In an interview with MA A on 06/05/2025 at 10:19AM, she stated that the proper way to open a capsule for administration was to wear gloves. She stated that gloves should always be worn; even with clean hands. She stated the risk to the resident was potential cross contamination. In an interview with LVN B on 06/05/2025 at 10:29AM, she stated that when opening capsules to administer to a resident with crushed medication orders, the proper way to do it was with gloves on. She stated that she did not wear gloves when administering medication to Resident # 52 during medication administration observation. She stated that the potential impact to the resident would be cross contamination. In an interview on 06/05/2025 at 10:03AM, the RCN stated that the proper way to open a medication capsule was to do so with gloves on. She stated that the impact to the resident was that they could cross contaminate and spread germs to the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 18 of 19 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 06/05/2025 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 06/05/2025 at 10:05AM, the DON stated that capsule medications should be opened with gloves on. She stated that the potential impact to the resident would be cross contamination. In an interview on 06/05/2025 at 3:08 PM, the ADM stated that it was her expectation that staff washed their hands and followed the facility infection control guidelines. She stated that the resident would have an increased risk of infection if staff did not follow the infection control guidelines for the facility. Review of the facility's policy for Infection Control (No Date) reflected, Gloves are to be worn for three important reasons 2. To reduce the likelihood that microorganisms present on the hands of personnel will be transmitted to the residents during invasive or other resident-care procedures that involve touching a resident's mucous membranes or nonintact skin. 3. To reduce the likelihood that hands of personnel contaminated with microorganisms from a resident or a fomite (a contaminated object) can transmit, these microorganisms to another resident; in this situation, gloves must be changed between resident contacts, and hand washed after gloves are removed. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 19 of 19