Bluebonnet Nursing & Rehabilitation

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Student Nurse Aide A was assisted by a second staff member while providing incontinence care to Resident #1 on the bed on 5/20/26. Resident #1 slid off the bed, fell to the floor and fractured her right leg. The noncompliance was identified as PNC on 5/20/26. The facility had corrected the noncompliance before the survey began on 5/28/26. This failure could place residents at risk of serious injury, harm, and/or death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health and safety of the resident or others for 1 of 4 residents (Resident #1) reviewed for call light placement. The facility failed to ensure the call light was within reach for Resident #1. This failure could place residents at risk of not receiving needed care and services in a timely manner

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 1 of 4 residents (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's physician's orders were updated to include the resident was treated with oxygen therapy. This deficient practice could place residents at risk of improper care due to inaccurate medical records.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 2 of 3 residents (Residents #2 and #3) reviewed for pressure ulcers.1. The facility failed to ensure Resident #2 receives necessary treatment and services when Resident #2's weekly skin assessments for the month of April reflected the resident did not have any pressure wounds.2. The facility failed to ensure Resident #3 received necessary treatment and services when Resident #3's skin assessments had not been completed since 3/24/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plans, and the residents' choices for 1 of 3 residents (Resident #1) reviewed for falls, in that: The facility failed to ensure Resident #1 received a STAT x-ray of her right elbow after a fall on the evening of 3/14/2026 until she was discharged to the hospital on 3/16/2026, creating a delay in care. This failure could place residents at risk for missed injuries and a delay in care and harm.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Residents #1) reviewed for care plans: The facility failed to ensure Resident #1 comprehensive care plan included a plan with interventions to address her recent fall 3/14/2026 and post-surgical right arm care. This failure could place residents at risk of receiving improper care and services.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for medical records accuracy, in that: The facility failed to ensure Resident #1's medical record was free of erroneous information when the DON documented assessments and progress notes when the resident was not in the facility and was hospitalized . This failure could place residents at risk for an inaccurate clinical picture and errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 4 of 4 medication carts (A hall/C hall left side medication cart (1), A hall/ C hall left side nurse cart (2), D hall/C hall right side nurse cart (3), and D hall/C hall right side medication cart (4)), reviewed for medications and pharmacy services, in that: 1. The facility failed to ensure the controlled drug count record was signed by oncoming staff for the medication cart 1. 2. The facility failed to ensure the controlled drug count record was signed by off-going staff for nurse cart 2. 3. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for care plans: 1. The facility failed to ensure Resident #1's comprehensive care plan included his pain related to gangrene (death of body tissue due to lack of blood flow or serious infection). 2. The facility failed to ensure Resident #1's comprehensive care plan included hospice services. This deficient practice could place residents at risk of receiving improper care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 3 residents (Residents #1) reviewed for medical records. The facility failed to ensure Resident #1's medication administration report did not contain blanks. The facility failed to ensure the paper MAR contained the required information to accurately capture if medications were administered, refused, held, or unavailable and which staff this information was documented by. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment option to choose the alternative option he or she preferred for 1 of 4 residents (Resident #7) reviewed for consent for antipsychotic medications. The facility failed to obtain consent by the responsible party for Resident #7 that her risperidone dosage was being reduced from 0.75 mg to 0.5 mg. This failure could place residents at risk for not being informed about care and treatments that may affect the resident's well-being.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 2 residents (Resident #44) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #44's dialysis port was correctly identified as a dialysis port rather than a central IV line. 2. The facility failed to develop an activity care plan for Resident #44. 3. The facility failed to identify that Resident #44's visual issue was not addressed in the resident's care plan. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, for 1 of 2 residents (Resident #35) reviewed for care plans. The facility failed to update the comprehensive care plan to reflect Resident #35 was receiving hospice services. This failure could have placed residents at risk of not having their needs identified and met.

Inspectors wroteBased on the observation, interview, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 2 of 3 residents (Resident #40 and #38) reviewed for accidents. The facility failed to ensure staff used the appropriate equipment for Resident #40 and Resident #38 during a transfer. This failure could place the resident at risk of falls and place them at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 2 residents (Resident #46) reviewed for incontinent care: The facility failed to ensure CNA E provided incontinent care to Resident #46 in the order of cleanest to dirtiest, and CNA E and Student Aide C performed hand hygiene between glove changes. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 2 of 3 Residents (Resident #40 and Resident #8) reviewed for respiratory care. The facility failed to ensure Resident #40 and Resident #8's oxygen tubing was not touching the floor. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications and/or infection.

Inspectors wroteBased on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 2 of 4 residents (Resident #33 and #35) reviewed for pharmacy services. The facility failed to ensure Medication Aide G documented she dispensed Resident #33's Xanax prescribed for major depressive disorder and Resident #35's Tramadol in the narcotic log for August 2025. This deficient practice could put residents at risk of misappropriation and drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 2 of 4 medication carts (C/D Hall cart and A/C Hall cart) reviewed for labeling and storage of drugs. 1. The facility failed to ensure the C/D Hall medication cart was not left unlocked and unattended.2. The facility failed to provide a change of direction label for Resident #6's Seroquel medication bottle from 50 mg at bedtime to 50 mg two times a day prescribed to treat depression on the A/D medication cart. These deficient practices could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 4 residents (Resident #9, #51 and #46) reviewed for infection control: 1. The facility failed to ensure the nurse sanitized the blood pressure cuff between residents #9 and #51.2. Facility staff failed to wear PPE while doing pericare for Resident #46 and did not wash or sanitize their hands between glove changes.3. The treatment nurse and a CNA did not wear PPE during wound care treatment for Resident #46 and did not wash or sanitize hands between glove changes. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure that each resident is treated with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 6 (Resident #3) residents in that: Resident #3 did not get his preference of being cleaned shaven. Resident #3 had a full/thick mustache and thin haired goatee. This failure could place residents at risk of not being provided grooming as needed.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 2 of 3 residents (Residents #1 and #2) reviewed for tube feeding management, in that: 1. The facility failed to follow physician's orders for Resident #1 to cleanse g-tube (gastrostomy tube, a small flexible tube surgically inserted through the abdomen to deliver nutrition, fluids and medication directly to the stomach) site with normal saline and apply split sponge every shift. 2. The facility failed to follow physician's orders for Resident #2 to cleanse g-tube site every day shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure Resident #1's bath or shower was documented as given or as refused 9 times in May and June 2025. These failures could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes or maintains their quality of life for 3 of 3 residents (Resident #2, Resident #4, and Resident #5) reviewed for dignity. 1. The facility failed to ensure Resident #2's was provided privacy during incontinent care. 2. The facility failed to ensure Resident #4's was provided privacy during incontinent care. 3. The facility failed to ensure Resident #5's was provided privacy during incontinent care. These failures could affect residents by contributing to poor self-esteem, and decreased self-worth and quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #4 and Resident #5) and 2 of 2 linen carts reviewed for infection control. 1. The facility failed to use proper infection control practices during perineal care for Resident #2. 2. The facility failed to use proper infection control practices during perineal care for Resident #4. 3. The facility failed to use proper infection control practices during perineal care for Resident #5. 4. The facility failed to ensure clean linen was stored properly on the A hall. 5. The facility failed to ensure clean linen was stored properly on the D hall on (2) occasions. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infection for 1 of 3 residents (Residents #2) reviewed for incontinent care. While providing incontinent care for Resident #2, CNA B wiped Resident #2 from the anal area to the vaginal area on (5) occasions. This deficient practice could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (Treatment Cart #1) reviewed for medication storage. The facility failed to ensure the treatment cart on D hall was locked while unattended. This failure could place residents at risk of medication misuse and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was safe, clean, comfortable, and homelike for 2 of 3 shower rooms reviewed for environment, in that: The A and D hall shower rooms contained barrels with soiled linen and trash including soiled briefs. This deficient practice could place residents at risk of living in an unsanitary environment, and psychosocial harm due to diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 3 of 8 residents (Residents #21, #30 and, #40) reviewed for infection control, in that: 1. Medication Aide A did not sanitize the blood pressure cuff between Residents #30 and #21. 2. While providing incontinent care for Resident #40, CNA B and CNA C did not change their gloves or wash her hands after touching the privacy curtain and bed remote. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment was safe, functional, sanitary, and comfortable for residents, staff, and visitors for 1 of 3 halls reviewed for environment, in that: The facility beauty shop on D Hall was unlocked and contained potentially dangerous materials. This deficient practice could result in accidents and/or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote and protect the resident's right to a dignified existence for 1 (Resident #13) of 40 residents reviewed for dignity, in that: Resident #13 was dependent upon staff to perform all activities of daily living and was observed with hair on her chin. This deficient practice could lead to diminished quality of life and psychosocial harm due to feelings of shame or embarrassment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards and supervision of staff for 1 of 7 residents (Resident #1) reviewed for accidents and hazards, in that: The facility failed to ensure Resident #1 had a low bed (bed positioned near the floor) as ordered on 04/16/2024 and instead had a regular bed in the lowest position. Resident #1 fell from the bed in the higher position and onto the mat beside her bed and she sustained a C2 vertebral fracture. An IJ was identified on 05/31/2024. The IJ template was provided to the facility on [DATE] at 4:00 PM. While the IJ was removed on 06/01/2024 the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm because all staff had not been trained on low bed orders and compliance. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the environment was free of accident hazards and supervision of staff for one resident (#1) of 3 residents who required mechanical lift transfers. NA A transferred Resident #1 alone on 01/17/2024 at 08:15 AM with a mechanical lift which required 2 people for safety. One of the straps holding the sling came loose and Resident #1 slipped toward the floor and hit her head on the mechanical lift which caused a head laceration and fractures to C4 (provides sensation for parts of the neck, shoulders and upper arms) and C5 (controls the deltoid muscles of shoulders and biceps, provides sensation to the upper arm down to the elbow). The noncompliance was identified as PNC. The IJ began on 01/17/2024 and ended on 01/18/2024. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of thirteen residents reviewed for notification of changes. The facility failed to notify the physician for an acute change in a resident's condition related to type 2 diabetes, resulting in the resident was hospitalized on [DATE] and expired on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 01:27 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 13 residents (Resident #1) reviewed for quality of care, in that: The facility failed to ensure Resident #1's received timely treatment and care for the resident's Type II Diabetes when the resident went multiple days of blood sugar readings above 400 with no interventions, resulting in the resident being hospitalized on [DATE] and expired on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 01:27 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes for 2 of 5 residents (R#1 and #3), reviewed for care plans, in that: R#1 and R#3 care plans did not document potassium services that would attain or maintain the resident's highest practical physical well-being. This deficiency could result in residents not receiving the care and treatments and could lead to a diminished quality of life, not attaining medical, nursing, and mental and psychosocial needs.

Inspectors wroteBased on interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 5 residents (R #1) reviewed for documentation. 1. R #1's transfer ER file on [DATE] was alleged by the ER as containing the wrong lab result for the resident's potassium level. 2. R #1's electronic medical record did not contain complete and accurate documentation that the resident received bathing and oral hygiene on a consistent basis in the month of [DATE]. The non-compliance was identified as past non-compliance. The non-compliance began on [DATE] and ended on [DATE]. The facility had corrected the non-compliance before the survey began. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #7) reviewed for advanced directives, in that: The facility failed to ensure Resident #7's Out-of-Hospital Do Not Resuscitate (OOHDNR) was completed with the correct date. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents (Resident #6) reviewed for infection control, in that: NA J was not wearing the appropriate PPE while in Resident #6's room, who was in isolation. This deficient practice could place residents at risk of infection for transmission of communicable diseases and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an Infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 3 of 8 residents (Residents #8, #48 and, #50) reviewed for infection control, in that: 1. CNA C and NA D failed to wash or sanitize their hands after touching the privacy curtain and before starting incontinent care. CNA C failed to wash her hands after providing care and before leaving the resident's room. 2. CNA B failed to wash her hands after providing care and before leaving the resident's room. CNA B failed to wash her hands before providing care. 3. LVN E failed to wear gloves before handling medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete an assessment which accurately reflected the resident's status for 1 of 15 (Resident #1) residents reviewed, in that: Resident #1's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not included in the resident's comprehensive and quarterly MDS assessments. This failure could result in inadequate care due to an incomplete assessment of her psychological condition.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 1 of 15 (Resident #1) residents reviewed, in that: Resident #1's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not included in the resident's care plan. This deficient practice could place residents at risk of improper care due to inaccurate care plans.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 15 (Resident #1) residents reviewed, in that: Resident #1's diagnoses of Major Depressive Disorder and Generalized Anxiety Disorder were not listed on her face sheet. This failure could result in inadequate care due to incomplete and inaccurate medical records.