Navasota Nursing & Rehabilitation
Navasota Nursing & Rehabilitation in Navasota, TX — inspection on September 18, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
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.
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