Navasota Nursing & Rehab: Lift Transfer Failure - TX
The inspection, conducted August 12, 2025, stemmed from a complaint. Inspectors determined the violation placed residents in immediate risk of serious harm or death.
The resident at the center of the incident, identified in inspection records only as Resident 1, had a care plan with explicit instructions: always use a mechanical lift for transfers, and always have two staff members present. The care plan wasn't buried in a file somewhere. Staff told inspectors they knew exactly where to find transfer instructions, in the Kardex, a standardized care reference that nursing home staff consult during daily work. Everyone knew. The lift wasn't used anyway.
The nursing assistant, identified in inspection records as CNA A, performed the transfer alone, without the lift, on July 30, 2025.
What makes a mechanical lift requirement more than paperwork is what it represents about a resident's physical condition. A facility's own hydraulic lift policy, reviewed by inspectors, described the device as reserved for residents who are paralyzed, obese, or too weak to transfer without complete assistance. Resident 1 fell into that category. A two-person manual transfer for someone in that condition creates real risk of a fall, a fracture, or a soft tissue injury, for the resident and potentially for the staff member attempting it alone.
The facility's administrator reported the incident to the Texas Health and Human Services Commission the same day it happened, July 30. That same day, CNA A was placed on investigatory suspension, pending the outcome of a formal investigation into the allegation of not following the resident's care plan. The suspension was to remain in place until the investigation concluded.
Also on July 30, the facility's MDS Coordinator gathered nursing staff and CNAs for hands-on training: a mechanical lift skills check and a live demonstration of proper lift technique. According to inspection records, 100 percent of facility nurses and CNAs completed it. CNA A was included.
Three additional in-services were administered that same day, all at 100 percent staff completion. One covered abuse and neglect. One covered trauma-informed assessment. One covered how to use the Kardex, the very reference tool where transfer instructions are stored, the one all staff had already said they knew how to find.
Four separate training sessions on a single day, all tied to one incident involving one nursing assistant.
The inspection record does not describe what happened to Resident 1 during or after the transfer. There is no documented injury in the materials reviewed. What the record does describe is a care plan that existed, that staff knew about, and that was not followed.
The facility's hydraulic lift policy, which inspectors noted was undated, laid out the purpose clearly: the resident will achieve safe transfer to bed or chair via a mechanical lift device, and the caregiver will demonstrate safe and correct transfer via the hydraulic lift. The policy described a broader program to promote and assure safe patient handling for both the resident and the employee, including identification, assessment, and interventions to provide a comfortable, safe transfer.
An undated policy. A known care plan. A Kardex that every staff member said they could locate. And a transfer that happened without the lift and without the second person.
The Immediate Jeopardy designation reflects inspectors' conclusion that the failure wasn't just a paperwork problem. It was a situation where the gap between what the care plan required and what CNA A actually did created conditions for serious harm. Immediate Jeopardy findings require a facility to submit an acceptable plan of correction before the designation can be lifted. They also carry the possibility of significant financial penalties and, in cases where the jeopardy is not removed, the termination of Medicare and Medicaid participation.
The inspection report does not indicate whether the Immediate Jeopardy was lifted before or after the August 12 inspection date, or what the status of CNA A's investigatory suspension was at the time inspectors arrived.
What the report does reflect is a facility that moved quickly on paper. Same-day reporting to the state. Same-day suspension of the employee. Same-day retraining of every nurse and CNA on the floor, four separate subjects, 100 percent completion across all of them. The response was comprehensive and documented.
It also reflects a facility where a resident with documented physical limitations requiring a mechanical lift and two-person assist was transferred by one person, without a lift, and where the staff member who did it had access to the care plan and knew where to find it.
The inspection covered few residents, according to the report's own designation of scope. This was not a pattern identified across dozens of cases. It was one resident, one transfer, one nursing assistant who didn't follow the plan.
That specificity matters. Immediate Jeopardy findings tied to a single incident, rather than a systemic pattern, sometimes reflect a facility where one employee's decision created a crisis that the organization then scrambled to address. They also sometimes reflect a facility where the training and the policies and the Kardex were all in place, and none of it was enough to stop what happened on July 30.
Resident 1's care plan required two people and a lift. On July 30, there was one person and no lift. The inspection report does not say what Resident 1 experienced during that transfer, or what they understood about what was happening, or whether anyone spoke to them about it afterward.
The record ends there.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Navasota Nursing & Rehabilitation from 2025-08-12 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 3, 2026 · Our methodology
Navasota Nursing & Rehabilitation in Navasota, TX was cited for violations during a health inspection on August 12, 2025.
The inspection, conducted August 12, 2025, stemmed from a complaint.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.