Inspection·August 12, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few transferred to a chair. He said he was sore for several days after he fell. He said he asked CNA A why there was not another person in there when she was transferring him from the bed to the chair because he said it took two people to transfer him. He said CNA A told him it did not take two people to transfer him. Interview on 08/08/25 at 1:40 pm with CNA A reflected she was going to transfer Resident #1 from his bed to a shower chair, but the chair went back, and she assisted Resident #1 to the floor. She stated Resident #1 did not hit his head. CNA A said Resident #1 was care planned for a mechanical lift, which required two people when transferring a resident, and she was in Resident #1's room alone transferring him not using the mechanical lift. CNA A said she was transferring him alone because she was just going to move him to the shower chair and she could transfer him to the shower chair not using a mechanical lift, which required two people. She said she had not previously transferred him alone, she always used the mechanical lift but because she was going to transfer him from the bed to shower chair, she felt like she could transfer him without using two people and a mechanical lift. CNA A said Resident #1 did not ask her why there were not two people transferring him or why she did not use a mechanical lift. She stated she was familiar with the Kardex (a documentation system that provides a concise summary of patient information, aiding nurses in organizing and referencing patient care details). She said the Kardex gave information about the residents' transfer status and included how to transfer Resident #1 when he was going to have a shower. She stated she was trained at the facility on how to use a mechanical lift and was told a mechanical lift always required two people. CNA A said she thought Resident #1 used a mechanical lift because he was obese, and he did not have a lot of control of his legs. She said she made the decision to transfer him alone because she was confident she was going to be able to do it and never expected the chair to go backwards. She said she was aware that he could have been hurt and she thought it was unsafe to transfer Resident #1 on her own. She said knowing the transfer status of the resident was the responsibility of everybody who worked with residents, and it was her responsibility to follow information in the Kardex and she had full access to the Kardex. CNA A stated she was aware prior to this transfer that Resident #1 needed a mechanical lift transfer that required two people. She said after Resident #1 went to the floor she asked Resident #1 if he was okay then found the nurse and together, CNA A and LVN B, put the mechanical lift sling under Resident #1 and picked him up by the mechanical lift. CNA A said she had not transferred any other facility residents who used mechanical lifts by herself. Interview on 08/08/25 at 1:40 pm with LVN B reflected that on 07/30/25 CNA A was the aide on charge nurse LVN B's assigned hall where Resident #1's room was located. LVN B said CNA A called her to Resident #1's room and Resident #1 was on the floor and there was a shower chair in the room. LVN B said she did not see a mechanical lift in Resident #1's room and no other person was assisting CNA A with transferring Resident #1. LVN B said Resident #1 told her he did not hit his head and initially denied he was in pain, but about 30 minutes later Resident #1 complained of right ankle pain and Resident #1 said he did not want to go to the hospital. STAT x-rays were ordered and reflected no fracturs. A day after the incident Resident #1 complained of the back of his right knee hurting and he was successfully treated with Tylenol and bio freeze. LVN B said he might have had some soreness from the fall on 07/30/25. LVN B said Resident #1 was care planned for a two-person transfer using a mechanical lift. She said there was enough staff at the time of the incident for Resident #1 to have received a two-person mechanical lift transfer. LVN B said she was not aware of CNA A not conducting a two-person mechanical lift transfer when a resident was care planned for a two-person mechanical lift transfer. LVN B said it was the responsibility of CNAs and the charge nurses to ensure residents were transferred appropriately according to their care plan. LVN B said there was no reason for CNA (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 2 of 4 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 08/12/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few A to be in Resident #1's room doing a transfer alone without a mechanical lift. The possible negative effects of not having two people when using a mechanical lift transfer was the resident could get hurt. LVN B said she did not believe Resident #1 sustained a severe physical injury; it was more mental because staff were constantly redirecting Resident #1 to let him know that he was okay. LVN B did not witness transfers of other residents in the facility who were care planned for mechanical lift transfers that always required two people who were transferred using a mechanical lift using one person. Interview on 08/08/25 at 5:16 pm with CNA C reflected Resident #1 was to always be transferred by 2 people using a mechanical lift. CNA C said all residents who required a transfer using a mechanical lift were a two-person transfer. She said it did not matter if they were going to transfer them to a wheelchair or a shower chair, a mechanical lift required two people for the transfer. She said it was very unsafe to not have two people when transferring a resident using a mechanical lift. She said the resident could be dropped on the floor. She said everyone was responsible for looking at the Kardex before transferring a resident to confirm the residents' transfer safety needs. Interview on 08/08/25 at 5:47 pm with LVN D reflected she was a charge nurse and if a resident used a mechanical lift transfer, they required two people for a transfer no exception. She said if staff were working with her, they better get two people to do a mechanical lift transfer. She said CNAs had access to the Kardex. She said it was everybody's responsibility to make sure the Kardex was followed for safe transfers.Interview on 08/08/25 at 5:47 pm with the Administer reflected it was the responsibility of everyone, CNAs and nurses, who provided care to residents, to know the required transfer needs of all residents. She said CNAs could find resident transfer requirements on the Kardex. The Administer stated that when the resident status stated mechanical lift was required, two people were required for the transfer using a mechanical lift with no exceptions to that rule for the safety of the residents. The negative outcome of not following the resident's care planned required transfer status was there could be either major or minor injuries to the resident. The Administer stated that CNA A had returned to work but as of 08/12/25, she had not worked in the capacity of a CNA after the incident. Interview on 08/08/25 at 6:45 pm with the CN reflected it was the responsibility of the person who transferred the resident to know the safe transfer needs of the resident. She stated CNAs could locate resident transfer information on the Kardex and they could ask the charge nurse. She said it took two people for a safe mechanical lift transfer and there were no exceptions to that requirement. She said if a resident was care planned and required a mechanical lift transfer it was for the safety of the resident. She said if a resident was care planned and required a mechanical lift transfer it was because they were not able to stand. She said all CNAs were trained by the facility to use a mechanical lift when they were hired by the facility. Interview on 08/12/25 at 7:00 pm with the Administrator revealed she reviewed facility policies on Mechanical Lift Transfers, Abuse and Neglect, Trauma Informed Assessment, and how to use the Kardex and trained the MDS Coordinator and former DON on these policies and procedures prior to the MDS Coordinator and former DON administering the in-services, skills training, and mechanical lift demonstration to the facility staff. Interview on 08/12/25 at 4:25 pm with the MDS Coordinator reflected she administered 50 - 75 percent of the in-services given to the staff on 07/30/25. The remainder of the staff were in-serviced by the former DON. The MDS Coordinator said she and the former DON immediately began in-services to the staff after the morning meeting on 07/30/25. The MDS Coordinator said she received her instructions for all in-servicing from the former DON and the Administrator. She said staff was in-serviced at a 100 percent completion rate on 07/30/25.Observation on 08/12/25 at 3:40 pm of CNA A and RN E who conducted a transfer of Resident #2 from her wheelchair to her bed reflected a safe transfer.Interview on 08/12/25 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 3 of 4 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 08/12/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete at 3:04 pm with Resident #5 reflected the staff treated her respectfully. She said two people always assisted when she was transferred by a mechanical lift. Interview on 08/12/25 at 3:08 pm with Resident #3 reflected the staff treated her respectfully, she felt safe at the facility, and the staff used two people when they used a mechanical lift to transfer her. Interview on 08/12/25 at 3:17 pm with Resident #4 reflected she was transferred by a mechanical lift and felt safe when staff used a mechanical lift and staff always used two people when they transferred her using the mechanical lift. Interview on 08/12/25 at 2:54 pm with Resident #6 revealed the staff treated her respectfully and she felt safe at the facility. She said staff used a mechanical lift to transfer her, and they always had two people when they used the mechanical lift. She did not have any concerns about her care or treatment at the facility. During interviews on 08/12/25 from 4:25 pm - 6:23 pm, two RNs, two LVNs, and six CNAs from different shifts all stated they were in-serviced on 07/30/25 on Mechanical Lift Transfers, Abuse and Neglect, Trauma Informed Assessment, and how to use the Kardex. All staff interviewed stated that if a person was care planned for a mechanical lift transfer, always use a mechanical lift to transfer the resident and always have two people to transfer the resident to ensure resident safety. All staff interviewed stated they knew where to locate the resident transfer information in the Kardex. Review of the facility's self-report to HHSC, dated 07/30/25 reflected the Administrator reported the incident with CNA A not using a mechanical lift to transfer Resident#1 as care planned the same day it occurred. Record review of CNA A's Employee Disciplinary Report dated 07/30/25 reflected CNA A was placed on investigatory suspension pending an investigation into allegations of not following a resident's care plan. CNA A would remain on investigatory suspension until the investigation was completed. Record review of in-service dated 07/30/25 given by the MDS Coordinator to the nursing and CNA staff on Mechanical Lift Transfer Skills Check and demonstration on using a mechanical lift was administered to 100 percent of facility nurses and CNAs included training for CNA A.Record review of in-services dated 07/30/25 on Abuse and Neglect administered to all facility staff at 100 percent staff completion rate included training for CNA A.Record review of in-service dated 07/30/25 on Trauma Informed Assessment administered to all facility staff at 100 percent completion rate. Record review of in-service dated 07/30/25 on how to use the Kardex located in the eMAR was administered to all nurses and CNAs at 100 percent completion including CNA A. Review of facility undated Hydraulic Lift Policy reflected the hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair. It is reserved for those who are paralyzed, obese, or too weak to transfer without complete assistance. Goals:a. The resident will achieve safe transfer to bed or chair via a mechanical lift device.b. The caregiver will demonstrate safe and correct transfer of the resident to the bed or chair via the hydraulic lift.The facility has a program to promote and assure safe patient handling for both the resident and the employee. The policy includes identification, assessment, and interventions to provide a comfortable, safe transfer. Event ID: Facility ID: 675399 If continuation sheet Page 4 of 4