Inspection·July 8, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few hospital on [DATE]. Review of the HHSC database on [DATE] reflected a facility-reported incident called in on [DATE] in which Resident #1 presented with a scalp laceration of unknown origin on [DATE] and received one staple. There was no facility reported incident for the scalp laceration of unknown origin discovered on [DATE] which required four staples. During an interview on [DATE] at 12:30 PM, a FM for Resident #1 stated she had received a call from the facility notifying her that Resident #1 had been found in another resident's (empty) bed with a laceration to his head and had been taken to the ER, where he had received staples to his head laceration. An attempt was made to interview RN A on [DATE] at 1:00 PM. A voicemail was left but no return call had occurred as of [DATE]. During an interview on [DATE] at 1:05 PM, CNA B stated she had worked a double that day and had been in rounds all afternoon. She stated she had just done a round and seen Resident #1 in his room less than an hour before, and then she did some documentation at the nurse's station and then came back down to do another round and found Resident #1 in another resident's empty bed with a big cut on his head. She stated she reported to the nurse on duty and Resident #1 went to the hospital. She stated she was off work by the time Resident #1 came back, but she found out he did get staples. She stated he was hard to predict, and they had to put eyes on him once per hour. She stated he might sit still in his room for a couple hours and then suddenly, he would be ready to walk. CNA B stated he refused to be accompanied or to use any mobility equipment, and they tried everything to keep him from walking unassisted, but he would curse and sometimes even physically assault the aides when they tried to assist him. During an interview on [DATE] at 2:44 PM, the ADM who stated she was the abuse coordinator and was responsible for implementing the abuse prevention system in the facility. She stated she remembered the surveyor was present on [DATE] and investigated a facility self-reported incident about Resident #1 presenting with a head laceration of unknown origin. She stated she was not aware that another injury had occurred the night after the investigation exit. She stated a head laceration with four staples would definitely prompt her to report the incident to HHSC. She stated the family, and physician had been notified according to the incident report and there was evidence of neurological assessments and after-fall monitoring in the progress notes as well as a nurse practitioner visit on [DATE]. She stated the process that should occur was for the ADONs to pull the incident list the Monday after a weekend, which would have been [DATE]. They would then discuss it at the morning meeting and determine what other steps, including reporting to HHSC, would be required. She stated she did not see how not reporting to HHSC could have affected the resident, as the facility followed their own protocol otherwise. During an interview on [DATE] 3:10 PM, the DON who stated she was brand new to the facility and had no knowledge of the events of [DATE] regarding Resident #1. During an interview on [DATE] at 3:27 PM, the ADON who stated she had responsibility for two halls of residents in the facility, and Resident #1's hall was not one of them. She stated when Resident #1 presented with the head laceration on [DATE], the previous assistant director of nursing was still in that position. The ADON who stated she was not aware of that event and would not have pulled a report the Monday after the injury due to not being responsible for Resident #1's hall. During an interview on [DATE] at 3:09 PM, the ADM who stated it was possible the incident did not get reviewed during morning meeting because the nurse who completed it had not documented an injury beyond the progress note narrative that was included. Review of facility policy dated [DATE] and titled Abuse Prohibition Policy reflected the following: The facility will report all allegations and substantiated occurrences of abuse, neglect or misappropriation of resident property to the state agency and to all other agencies as required by law and will take all necessary, corrective actions, depending on the results of the investigation. The abuse coordinator will report all allegations of abuse, neglect with serious, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 2 of 3 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 676097 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/08/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Golden Creek Healthcare and Rehabilitation Center 2100 Dover Crossing Lane 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 0609 Level of Harm - Minimal harm or potential for actual harm bodily injury, and injuries of unknown source with serious bodily injury immediately or within two hours of the allegation. Coordinator will report all other allegations on neglect, mistreatment, exploitation, injuries of unknown source and misappropriation within 24 hours of the allegation. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676097 If continuation sheet Page 3 of 3