Health inspection·September 18, 2025

F 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few no padding at all noted and the collar was wrapped with 2-inch silk tape all the way around, rolled around the brace to adhere it to the neck. ER RN stated the tape was not on the skin, but the neck brace was wrapped so tightly around the neck that they had to use bandage scissors to remove the 10 -12 wrapped circles of tape around the brace and around her neck. ER RN stated, I understand she was probably pulling it off, but the tape was excessive and if it was an emergency they would not be able to get it off of the resident's neck. The ER RN stated in the ER they cut it off with bandage scissors and it took about 5 minutes to get off. The silk tape was soiled with food and fecal matter. The ER RN stated when they finally got it loose, there was bloody tissue where a skin adhesion to the collar had occurred. It was difficult to get the collar off the skin. The skin had a very strong smell the ER RN described as rotting flesh, putrid, or a bacteria smell. The smell was so strong the ER cultured the wounds on the left ear area of the neck, and chin for bacteria. The ER RN described the wounds as ulcers from the c-collar. In an interview on 09/16/2025, at 3:39 PM, the RP stated on 9/11/2025, she visited the facility to pick up Resident #1's cell phone for repair. The RP stated the facility had her sign a form acknowledging Resident #1 may fall and sustain injury due to her behaviors. The RP stated that during that visit, her loved one was wearing a brace that was covered with cotton gauze which had a foul odor and appeared dirty. She further stated that each time she visited, she requested that the facility clean Resident #1's room. She also reported observing fecal matter on the resident's bedsheets and fingers. Review of Resident #1's weekly skin assessment dated [DATE] performed by LVN C reflected no identified pressure ulcers.Review of Resident #1's weekly skin assessment dated [DATE] performed by the Treatment Nurse reflected no identified pressure ulcers.In an interview conducted on 09/16/2025 at 4:35 PM, the Treatment Nurse stated she had been in her position for a few months but was with the company for 6 years. The Treatment Nurse stated when she assessed Resident #1 on 09/13/2025 she stated she noticed some redness but that she did not remove the c-collar or loosen it to do a full assessment. She stated she did not notice any tape on the c-collar. The Treatment nurse stated on yesterday she sent Resident #1 to the ER, and she did not notice any tape on resident.In an interview conducted on 09/16/2025 at 5:17 PM, LVN D stated Resident #1 had tape on her C-Collar since she returned from the 9/10/2025 ER visit. LVN D stated he was off work two days and when he returned Resident #1 had tape on the collar. LVN D stated there were no instructions given on the tape.In an interview conducted on 09/16/2025 at 5:24 PM, LVN C stated Resident # 1 returned from the ER with tape at the bottom of her collar. The LVN stated this information was not documented but stated vanilla tape was at the bottom of the collar. LVN C volunteered this information without being prompted by the surveyor. LVN C stated she knew the tape was a concern. LVN C further explained that the nurses removed the C-collar at bath times and applied a different type of collar that could get wet. LVN C stated the C-collar was only removed when Resident #1 did not refuse shower. LVN C stated she was PRN and her last time at work was last Thursday, 9/11/2025. LVN C stated the Treatment Nurse checked the resident on that same day.In an interview conducted on 09/16/2025 at 6:00 PM, CNA A stated she worked at the facility since March of 2024. CNA A stated she worked with Resident #1. CNA A stated she did not shower Resident #1 the previous day. She stated the night shift normally provides the showers for Resident #1. She further explained that Resident #1 showers had recently been changed to daily. CNA A stated the last gave Resident #1 a shower on 9/5/2025. She also stated that LVN C removed the gray C-Collar and placed a tan collar on Resident #1 that could get wet.Review of Resident #1's ADL flow sheet for bathing reflected Resident #1 was documented as having a bath on 09/05/2025 and 09/13/2025.In an interview conducted on 09/17/2025 at 10:53 am, CNA B stated she worked with Resident #1 one day. She stated she provided Resident #1 with a bed bath on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 2 of 6 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 09/18/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 9/13/25 but did not remove the collar. CNA B stated she didn't touch that area during bath. CNA B stated only the nurses touch the collars and wounds; the aids do not.In an interview conducted on 09/17/2025 at 9:44 am, Resident #1's physician stated it was his expectation that staff check the resident's skin for pressure areas when a splint was in use. He explained the brace/ collar must be fitted correctly by medical staff. Resident #1's physician stated a collar should not necessarily be taped unless there was a malfunction with the splint. The physician stated there should be a follow up with orthopedic surgeon, based on orthopedic recommendation. Resident #1's physician stated the splint should not be altered unless it was cleared by the medical doctor.In an interview conducted on 09/17/2025 at 12:30 PM, the RCN stated Resident #1 should have had orders in place to remove the splints and conduct skin assessments every shift. The RCN further stated a thorough skin assessment should have been completed upon the resident's readmission from the hospital.Review of the facility's policy immobilization devices, splint/slings/collars/straps (not rated) reflected, Immobilization devices are splints, slings, cervical collars and clavicle straps that are applied to restrict movement, support and preserve the integrity of an injured arm, shoulder or neck. 3. Secure with Velcro, strips of cloth, pin, or tape the loose end. Secure the material with firmness but without compromising circulation. 4. Remove the splint periodically to assess skin and maintain cleanliness and dryness under the splint. 8. All immobilization devices, except clavicle straps, should be removed periodically. All devices will be monitored on every two-hour schedule. Monitoring will be documented in the clinical record or flow sheet.Review of the facility's policy pressure injury: prevention, assessment and treatment (not rated) 1. Nursing personnel will continually aim to maintain the skin integrity, tone, turgor and circulation to prevent breakdown, injury and infection. 9. Assess early signs of skin breakdown and report any abnormal findings. Early signs of pressure sores include redness, tenderness and swelling of the skin. Notify Treatment Nurse/designee of any potential problems by completing Skin Concern Notification Worksheet.This was determined to be an Immediate Jeopardy (IJ) on 09/17/2025, the Administration was notified. The Administrator was provided with the IJ template on 09/17/25 at 1:01 PM and a plan of removal was requested. The following POR was accepted on 09/18/2025 at 8:30 AM. Plan of removalProblem: F686 Failure to prevent pressure injury On 09/16/2025 an abbreviated survey was initiated at the facility. On 09/16/2025 the surveyor provided an Immediate Jeopardy (IJ)Template notification that the Regulatory Services has determined that the condition at the facility constitutes an immediate threat to residents' health and safety. The facility failed to ensure Resident #1 had interventions in place to prevent unstageable pressure ulcers from forming under her C-Collar neck brace. The facility failed to perform through skin checks under her C-Collar to ensure pressure ulcers were not forming. The facility failed to ensure the C-Collar was applied properly and maintained when it was noted to be taped to prevent removal with fecal matter smeared on tape.There are 3 residents with braces and splints ordered that could potentially be affected by the deficient practice. 1. Resident #1 remains in the hospital as of 09/15/2025. No other residents in the facility have cervical collars. 2. Action: o 100% resident head to toe skin assessments initiated 09/17/2025 by DON, ADON, and treatment nurse. No further residents were noted with any skin integrity issues. o Head-toe assessment skin assessments were completed for the two residents with orders for a leg brace and bilateral hand splints. No further skin integrity issues were noted. No tape was noted. Start Date: 09/17/2025 Completion Date: 09/17/2025Responsible: These assessments were completed by DON, ADON, and treatment nurse with oversight from Regional Compliance Nurse. 3. Action: o The two residents identified with a brace and a splint were verified to have physician orders to remove for skin assessment and showers. o The two residents identified with a brace and a splint were verified (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 3 of 6 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 09/18/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few to have the orders to remove for skin assessments and showers were also care planned. Start Date: 09/17/2025 Completion Date: 09/17/2025Responsible: The orders were care planned by Regional Compliance Nurse, DON, and treatment nurse. 4. Inservice Action (Leadership): The Administrator and DON were in serviced 1:1 and for the following policies:o Pressure ulcer prevention and treatment: Turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. In-service also includes to ensure braces and splints are removed as ordered to prevent skin integrity issues. o Braces/Splints: Braces and splints must be removed every shift, during showers and bed baths, and weekly skin assessments to check skin integrity.o Initial Skin Assessment: A thorough initial skin assessment is to be completed within 4 hours of admission or readmission.o Weekly Skin Assessment: Skin assessments must be done weekly and as needed for any skin issues for every resident in the facility. Report changes in a resident's skin condition to wound care and DON immediately.o Abuse and Neglect: Residents have the right to be free from abuse and neglect. Not following MD orders to remove braces and assess skin could be considered neglect. Any Allegation of abuse, neglect, or exploitation/misappropriation of funds should be immediately reported to the abuse preventionist.o New Process: The Weekly Skin Assessment UDA in PCC has been revised to include assessment questions related to braces, immobilizers, and other devices. An alert will trigger the clinical PCC dashboard if a device is present.Employee Retention Checks: Administrator and DON were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained by regional compliance nurse for Administrator and DON understanding.Start Date: 09/17/2025Completion Date: 09/17/2025Responsible: This Inservice was completed by Regional Compliance Nurse.5. Inservice Action (All Staff): All staff were inserviced on the following topics. Any staff member not present or inserviced as of 9/17/2025 will not be allowed to assume their duties until in-serviced. All new hires will be in-serviced during orientation. All PRN, agency staff, or staff on leave will inserviced prior to assuming their next assignment.o Pressure ulcer prevention and treatment: Turning and repositioning at least every 2 hours, elevating heels/feet on pillows, using cushions as needed or directed. In-service also includes to ensure braces and splints are removed as ordered to prevent skin integrity issues. o Braces/Splints: Braces and splints must be removed every shift, during showers and bed baths, and weekly skin assessments to check skin integrity.o Initial Skin Assessment: A thorough initial skin assessment is to be completed within 4 hours of admission or readmission.o Weekly Skin Assessment: Skin assessments must be done weekly and as needed for any skin issues for every resident in the facility. Report changes in a resident's skin condition to wound care and DON immediately.o Abuse and Neglect: Residents have the right to be free from abuse and neglect. Not following MD orders to remove braces and assess skin could be considered neglect. Any Allegation of abuse, neglect, or exploitation/misappropriation of funds should be immediately reported to the abuse preventionist.o New Process: The Weekly Skin Assessment UDA in PCC has been revised to include assessment questions related to braces, immobilizers, and other devices. An alert will trigger the clinical PCC dashboard if a device is present.Employee Retention Checks: All staff were provided with written in-service cheat sheets to place in name badge for quick reference, signature and verbal acknowledgements were obtained by Administrator of all staff understanding.Start Date: 09/17/2025Completion Date: 09/17/2025Responsible: These in services were completed by Administrator and DON.6. Monitoring: Monitoring steps will be documented on the individual monitoring tools.o The DON/designee will monitor all new residents with braces to ensure orders are in place for removal of brace per physician orders, treatments have been ordered, ensure assessments done daily, 7 days a week X's 6 weeks, to ensure compliance using the monitoring tool. o The DON / designee will (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 4 of 6 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 09/18/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few view each pressure ulcer weekly X's 6 weeks using available monitoring tool.o The DON / designee will audit all skin assessments weekly to ensure all assessments match the resident's current condition for 6 weeks using current monitoring tool.o DON/designee will audit charting daily for accuracy of weekly skin assessments x's 6 weeks.o DON/designee will monitor all treatments being done for accuracy per orders using monitoring tools, x's 6 weeks o The QA committee will review findings at the monthly QA meeting and makes changes as needed. o Monitoring will be initiated 9/17/25 and will continue indefinitely. 7. ADHOC QAPI: This meeting was completed by the interdisciplinary team to include the Medical Director and wound care doctor on 09/17/2025.8. Involvement of the Medical Director: The medical director as notified of the immediate jeopardy on 09/17/2025 by the Administrator.Monitored the POR on 9/18/2025 as followed:In an interview on 9/18/2025 at 9:25 AM, the RA stated all in services were completed and provided surveyor with the plan of removal binder.In an interview on 9/18/2025 at 11:07 AM, the RCN stated she in serviced the facility leadership 1on 1 which includes, the ADM, Interim DON, ADON, and the Treatment nurse on proper precautions that need to be in place for residents with collars, braces, and splints. RNC stated the topics were pressure ulcer prevention and treatment, braces/splints, initial skin assessments, weekly skin assessments, abuse and neglect, and new process on weekly skin assessments. RNC stated she completed a 1 on 1 with Treatment Nurse on skin assessments and stated she also trained the ADM on nursing items as she can follow-up in morning meetings.RNC stated she also in- serviced CNAs, medication aids, the Activity Director, therapy staff housekeeping, dietary, and administration staff. She stated all staff were in serviced, some in person, some by phone and some were notified through their electronic message system, COVR. RNC stated everyone that worked on yesterday reviewed and signed off on their trainings, and the staff who were trained via phone and their electronic system will have to sign in-service sheet prior to working their shift. RNC stated monitoring will be ongoing by Interim DON and herself.In an interview on 9/18/2025 at 12:25 PM, the physical therapist assistant stated she was in serviced on 9/17/2025 by the RA and the ADM on abuse and neglect and resident rights. The physical therapist assistant stated she also trained on refusal of care, the process to notify when there is refusal of care, pressure ulcers, showers, braces/splints, and notification of changes. The physical therapist assistant stated they were given a cheat sheet to keep with their name badge for reference.In an interview on 9/18/2025 at 12:47 PM, the ADM stated the RNC in serviced her on pressure ulcer prevention and treatment, braces/splints, initial skin assessments, weekly skin assessments, showers, abuse and neglect. ADM stated they will review skin reports in morning meetings. ADM showed surveyor the cheat sheet for in services they all have in their name badge.In an interview on 9/18/2025 at 1:46 PM, the Interim DON stated she was in serviced by the RNC. The Interim DON stated she was trained on pressure ulcer prevention and treatment, braces/splints, initial skin assessments, weekly skin assessments, abuse and neglect. She stated the trainings included procedures to take for notification in skin changes, refusals, showers, and maintaining integrity of the skin. Interim DON stated training included removal of braces every shift per physician orders. In an interview on 9/18/2025 at 1:55PM, the ADON stated she was in serviced by the RNC. ADON stated she was trained on abuse an neglect, pressure ulcer and treatment, she provided examples of turning residents every two hours, elevating elbows, and making sure body parts are offloading. ADON described the process for braces/splints, initial skin assessments, weekly skin assessments, and refusals indicating she received all in servicing.In an interview on 9/18/2025 at 2:04 PM, the TN stated she was in serviced by the RNC on weekly skin assessments, pressure ulcer prevention and treatment, braces/splints, initial skin assessments, and abuse and neglect. TN stated she will be completing initial skin assessments with in the first 4 hours of arriving to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675399 If continuation sheet Page 5 of 6 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 09/18/2025 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 0686 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the facility and at readmission. TN stated if she is not available the assessments will be completed by the charge nurse. TN provided examples of braces/splint checks and pressure ulcer prevention treatment.Interviews conducted on 9/18/2025 with nurses on shift between 2:11 PM -2:35PM [LVN E, MDS Nurse, LVN C] indicated they participated in the mandatory in service training about Pressure ulcer and treatment, Braces/Splints, Initial Skin Assessments, Weekly Skin Assessments, Abuse and Neglect, and new process in Point Click Care weekly skin assessments will include assessment questions related to braces and other devices. The nurses summarized the topics of discussion in their own words of procedures to follow. Nurses stated they would notify the treatment nurse, DON, and physician immediately of resident change in condition.Interviews conducted on 9/18/2025 with CNAs on shift between 2:43 PM-3:04 PM [CNA G, CNA H] indicated they participated in an in-service training about reporting refusal of care, abuse and neglect, resident rights, pressure ulcer prevention, braces/splints, showers, and notification of change in condition. The CNAs summarized the topic of discussion - stating understanding regarding concerns about resident skin, identifying, reporting altered skin integrity, and change in condition. Each CNA stated in their own words the protocol was to notify the charge nurse about refusals, a resident change in condition or discovered skin issues.Interviews conducted on 9/18/2025 with night nurses and night CNAs scheduled for night shift between 3:19 PM-4:35 PM [RN K, LVN J, LVN L, LVN M, CNA B, CNA F] indicated they participated in the mandatory in-services. The LVN nurses indicated they received training via phone with RNC about Pressure ulcer and treatment, Braces/Splints, Initial Skin Assessments, Weekly Skin Assessments, Abuse and Neglect, and new process in Point Click Care weekly skin assessments will include assessment questions related to braces and other devices. RN K stated she received her training through the facility's electronic notification system, she summarized the topic of discussions and stated she will sign off before working her next shift. The CNAs stated they received their in-service training prior to starting their shift on 9/17/2025. The night CNAs both summarized the topic of discussion - stating understanding regarding concerns about resident skin, identifying, reporting altered skin integrity, and change in condition. Each CNA stated in their own words the protocol was to notify the charge nurse about refusals, a resident change in condition or discovered skin issues.Interviews attempted via outbound calls to LVN D, RN N, and RN P, the calls were unanswered and forwarded to an automated service that prompted to leave a voicemail. A return call was not received prior to exit on 9/18/2025.Record Review on 9/18/2025 of the In-Service Training Sheets reflected all facility staff had been in-serviced on all training topics listed on the plan of removal. About 5 percent of signatures were still needed as those employees had not worked a shift, those employees will reconfirm understanding of the training and sign off prior to working their shift. Record Review on 9/18/2025 of skin assessments completed, reflected all 56 residents in the facility had been completed.Record Review of care plans on 9/18/2025 for Resident #2 and Resident #3 reflected they were updated to include removal of braces/splints for skin assessments and showers.The Administrator was informed the Immediate Jeopardy was removed on 09/18/25 at 5:50 PM. The facility remained out of compliance at a severity level of potential for more than minimal harm that is not immediate jeopardy and scope of isolated. Event ID: Facility ID: 675399 If continuation sheet Page 6 of 6