Bluebonnet Point Wellness

Inspectors wroteBased on observation, interviews and record reviews, 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 5 of 6 medication carts (hallway 200 MA's cart, hallway 200 Nurse's cart, hallway 300 MA's cart, hallway 400 MA's cart, and hallway 400 Nurse's cart) reviewed for pharmacy services. 1. The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and documented change of shift narcotic counts on hallway 200 MA's cart, hallway 200 Nurse's cart, hallway 300 MA's cart, hallway 400 MA's cart, and hallway 400 Nurse's cart. 2. MA-C signed the Controlled Drugs-Audit Record count sheets for the end of their shift at the beginning of their shift on MA's cart station 200 on 07/08/2026. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity and respect in full recognition of his or her individuality for 1 of 3 residents reviewed for dignity. (Resident #2) The facility failed to ensure Resident #2 was treated with dignity and respect when LVN A told him he was acting like a 2-year-old. This failure placed residents at risk for diminished quality of life, loss of dignity and decrease in comfort.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly for 1 of 2 residents (Resident #1) reviewed for enteral nutrition. The facility failed to notify Resident #1's attending physician when her tube feeding was stopped early due to her diarrhea. The facility failed to notify Resident #1's attending physician when her tube feeding was held due to diarrhea. These failures could place residents at risk for delayed treatment, not receiving necessary treatments and medications, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services, including the accurate acquiring, administering, and receipt of all drugs and biologicals, to meet the needs of 1 of 2 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure that Resident #1's Atorvastin (for reducing cholesterol), Cetrizine (for allergies), Melatonin (for sleep), Ropinirole (for discomfort of restless legs), Venlafaxine (for depression-mood disorder causing persistent sadness and loss of interest affecting thoughts feelings and daily activities), Depakene (to prevent migraine headaches), Gabapentin (for neuropathy-numbness, tingling, and burning of feet and hands), and Biotin (for moisture in the mouth) were administered per physician's orders. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS assessment was electronically transmitted to the CMS System within 14 days after completion for 1 of 6 residents (Resident #74) reviewed for encoding/transmitting assessments. The facility failed on 08/04/2025 to transmit a quarterly assessment to CMS for Resident #74 within 14 days of completion when the assessment was completed on 07/21/2025 by the Corporate RN Assessment Coordinator and the facility submitted the quarterly assessment for Resident #74 to CMS 9 days pass due on 08/13/2025. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 2 of 12 residents (Resident's #4 and #8) reviewed for MDS assessment accuracy. The facility failed to ensure a comprehensive MDS assessment dated [DATE] for Resident #4 captured oxygen use, suctioning, and tracheostomy care. The facility failed to ensure a quarterly MDS assessment dated [DATE] for Resident #8 was not inaccurately coded for tracheostomy, dialysis, and hospice care. These failures could place residents at risk of not receiving adequate care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews 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 infections for 1 of 6 residents (Resident #36) and 1 of 6 staff (CNA E) reviewed for infection control. The facility failed to ensure CNA E changed gloves when going from dirty to clean and washed or sanitized her hands between glove changes when providing care to Resident #36 on 8/12/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately consult with the resident's physician and notify the resident representative of a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 10 residents reviewed for notification of changes. The facility failed to notify Resident #1's physician when they did not administer his valproic acid, topiramate, levetiracetam, and lacosamide on 07/22/25-07/25/25 as ordered. The facility failed to notify Resident #1's physician after he had a seizure on 07/25/25. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/22/2025 and ended on 07/26/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident #1) of 10 residents reviewed for pharmacy services. The facility failed to order Resident #1's valproic acid, topiramate, levetiracetam, and lacosamide after he re-admitted on [DATE]. Resident #1 had a seizure on 07/25/25. The noncompliance was identified as PNC. The Immediate Jeopardy (IJ) began on 07/22/2025 and ended on 07/26/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure a resident environment remained as free of accident hazards as is possible for 1 of 3 residents reviewed for accidents (Resident #1) Resident #1 asked for hot water, MA A heated the water in the microware and did not place a lid on the cup. Resident #1 spilled the water and received a burn on her leg. The facility failed to have measures in place to prevent residents from burns. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 9/1/24 and ended on 9/10/24. The facility had corrected the noncompliance before the survey began. This failure could place resident at risk of suffering, injuries, and hospitalization.

Inspectors wroteBased on interview, and record review the facility failed to ensure residents were free from significant medication errors for 1 of 3 residents reviewed for medications (Resident #2). The facility failed to follow their policy on medication administration resulting in a significant medication error. *Resident #2 was readmitted [DATE] and had an order on 12/22/24 for Eliquis to be held until 12/27/24- the order did not have a restart date. *Resident #2 had an order on 12/23/24 to hold Eliquis for 4 days and restart the medication on 12/27/24. *The facility did not resume Resident #2's Eliquis medication and he was sent to the hospital on 1/26/25 with DVT and pulmonary embolism. The noncompliance was identified as Immediate Jeopardy PNC (past non-compliance). The IJ (Immediate Jeopardy) began on 1/26/25 and ended on 2/28/25. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident was oriented with a planned, safe and orderly discharge for 1 of 5 residents reviewed for discharge (Resident #3). Resident # 3 was discharged to the hospital, the facility refused to take him back due to nonpayment. Resident # 3 resided at the hospital for over 30 days until the hospital was able to find placement. This Failure could place residents at risk of not permitting a safe and orderly dischargeFindings included: During an interview on 6/30/25 at 11:42 a.m. the Administrator said there were no records for Resident #3 in their computer system, because he was discharged out of the system prior to their change of ownership on 7/1/24. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent new pressure injuries from developing was provided for 1 of 4 residents reviewed for pressure injuries (Resident #3). The facility failed to ensure Resident #3 did not develop a stage II pressure injury to the right heel on 3/25/25 and a stage III pressure injury to the right buttock on 4/8/25 that were not present on her admission to the facility. The facility did not ensure Resident #3 was repositioned to effectively alleviate pressure to right buttock on 4/4/25 and 4/5/25. The facility did not ensure Resident #3 was repositioned to effectively alleviate pressure to the right heel on 4/4/25 and 4/5/25. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical needs for 1 of 6 residents (Resident #2) reviewed for comprehensive resident centered care plan. The facility failed to ensure Resident #2 was not care planned for a secured unit when the facility did not have a secured unit. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings Included: 1. Record review of the face sheet dated 4/5/25 indicated Resident #2 admitted to the facility on [DATE] with diagnoses including second cervical vertebrae (the second vertebrae in the spinal column, located in the neck region) with routine healing, surgical aftercare, seizures, hypertension (elevate blood pressure), and shortness of breath. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 7 (Resident #1) residents reviewed for ADLs. The facility failed to ensure Resident #1 received incontinent care for an episode of urine incontinence on 4/5/25. These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings Included: 1. Record review of the face sheet dated 4/7/25 indicated Resident #1 was admitted to the facility on [DATE] with diagnoses including overactive bladder, urinary incontinence, muscle weakness, unsteadiness on feet, and difficulty walking. Record review of the quarterly MDS dated [DATE] indicated Resident #1 understood others and was understood by others. [...]

Inspectors wroteBased on observations, interviews, and record review, in accordance with State and Federal laws, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys on 3 of 7 medication carts reviewed for labeling and storage of medication. The facility did not ensure the medication cart on hall 200 and 2 medication carts on hall 300 were secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk for not receiving drugs and biologicals as needed or a drug diversion.

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 1 of 4 staff (CNA C) observed for infection control. The facility failed to ensure CNA C changed gloves and performed hand hygiene while performing incontinent care on Resident #1. This failure could place residents and staff at risk for cross-contamination, spread of infection, and could potentially affect all others in the building.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 7 (Resident #1) residents reviewed for quality of care. The facility failed to perform neurological assessments following an incident report dated 1/9/25 indicating Resident #1 had a fall and hit her head resulting in her being hospitalized with a subdural hematoma. The facility failed to recognize a change in Resident #1's level of consciousness resulting in the family requesting for Resident #1 to be sent to the hospital and Resident #1 being admitted to the hospital with a diagnosis of a subdural hematoma. The failures resulted in an identification of an Immediate Jeopardy (IJ) at 11:00 a.m. on 1/23/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 2 of 7 (Resident #1 and Resident #4) residents reviewed for ADL's. The facility did not ensure Resident #4 was cleaned up after having a liquid yellow substance covering his mouth, gown, sheets, and blanket. The facility did not provide scheduled showers for Resident #1 and Resident #4. These failures could place residents at risk of not receiving services/care, embarrassment, and decreased quality of life. Findings Include: 1. Record review of the face sheet dated 1/22/25 indicated Resident #4 was aa [AGE] year-old male, re-admitted to the facility on [DATE] with diagnosis including age-related cognitive decline, dementia. [...]

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 diseases and infections for 2 of 4 staff (CNA M and CNA X) observed for infection control. The facility failed to ensure CNA M performed hand hygiene between glove changes. The facility failed to ensure CNA M changed her gloves and performed hand hygiene after picking barrier cream up off the floor and continuing incontinent care. The facility failed to ensure CNA M did not touch Resident #2's face or swab her mouth after performing incontinent care, not changing gloves, and picking up the trash bag containing the dirty brief and wipes. [...]

Inspectors wroteBased on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, (mental, or psychosocial status in either life-threatening conditions or clinical complications) 1 of 7 (Resident #1) residents reviewed for notification of change. The facility did not notify the physician of Resident #1's fall on 1/9/25 when she hit her head. This failure could place residents at risk for physician intervention which could result in not receiving care and services to meet resident needs.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 7 (Resident #1) residents reviewed for abuse and neglect. The facility did not report to the state agency Resident #1's subdural hematoma (brain bleed) that was discovered during hospitalization admission date 1/12/25. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident and/or representative had the right to participate in the development and implementation of his or her person-centered plan of care, for 1 of 4 residents (Resident #1) reviewed for the right to participate in planning care. The facility failed to ensure Resident #1, or the resident's representative were invited to participate in the residents' care plan meeting. This failure could place residents at risk for not receiving adequate or individualized care.

Inspectors wroteBased on observation interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 4 residents reviewed for grievances. (Resident #1) The facility did not investigate or take prompt action to resolve grievances voiced by Resident #1's family member on behalf of Resident #1 These failures could place residents at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission and provide the resident and the resident representative with a summary of the baseline care plan for 2 of 4 residents reviewed for the base line care plans. (Resident #s 1 and 2). The facility did not provide a written summary of the baseline care plan to Residents #1 and #2 or their responsible party. The facility did not complete a baseline care plan within 48 hours of admission for Resident #2. This failure could place newly admitted residents at risk for services not being provided as needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were stored in locked compartments and permit only authorized personnel to have access to the keys on 1 of 2 medication carts reviewed for drug labeling and storage,. (Hall 100 Medication Aide Cart) -Medication Aide Cart for Hall 100 was left unlocked, unsecured, and unattended on Hall 100. This failure placed residents at risk of drug diversion and access to and ingestion of medications not prescribed for them.

Inspectors wroteBased on interview and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices for 1 of 6 residents reviewed for accuracy and completeness. (Resident # 1) The facility failed to accurately complete Resident # 1's comprehensive care plan. This failure could place the residents at risk for incomplete and inaccurate clinical records which could lead to miscommunication, a delay in services or a potential decline in resident's health.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessments were electronically completed and transmitted to the CMS System within 14 days after completion for 2 of 5 residents (Residents #'s 59 and 81) reviewed for discharge MDS assessments. The facility failed to complete and transmit a discharge MDS assessment for Residents #59. The facility failed to complete and transmit a discharge MDS assessment for Residents #81. These failures could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 of 4 residents (Residents #41) reviewed for care plans. The facility failed to ensure Resident #41's use of continuous oxygen was documented in her comprehensive care plan. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide residents treatment and care in accordance with professional standards of practice for 1 of 3 residents reviewed for quality of care. (Resident #258) The facility failed to provide dressing change to Resident #258's Peripherally Inserted Central Catheter (PICC) line per facility policy. This failure could place residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 4 residents (Residents #41) residents reviewed for oxygen orders. The facility failed to administer oxygen for Residents #41 as ordered by the physician. This failure could place residents at risk of receiving incorrect or inadequate oxygen support, resulting in a decline in health.

Inspectors wroteBased on observations and interviews, the facility failed to store all drugs and biologicals in locked compartments on 1 of 8 medication carts (400 Hall medication cart) reviewed for labeling and storage of medication. The facility did not ensure the 400 Hall medication cart was secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk for not receiving drugs and biologicals as needed or a drug diversion.

Inspectors wroteBased on interviews, observations and record review, the facility failed to provide suitable, nourishing alternative snacks to residents who want to eat at non-traditional times or outside of scheduled meal service times, consistent with physician orders for 2 of 8 residents (# 43 and 81), reviewed for bedtime snacks. The facility did not have bedtime snacks available for residents. The facility's failure to offer nightly bedtime snacks to residents could cause them to experience hunger at bedtime hours, cause hypoglycemia (low blood sugar), have avoidable weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for food service. Pitchers of liquids in the reach-in cooler were not labeled and dated. Food items were not properly dated, labeled, re-sealed and discarded as necessary. Opened food packaging in the pantry and walk-in cooler were not closed after opening. Packages of food items were stored on the floor in the freezer and pantry. The male dietary manager did not cover his facial hair. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents are free of significant medication errors for 1 of 1 residents reviewed for insulin administration. Physician orders for Resident #1 reflected Resident was to receive insulin 3 times a day with meals. RN gave insulin at 11:45 a.m., and food was not provided until around 2 p.m. Resident #1 blood glucose level was at a 54 mg/dl at 2 p.m. and RN provided Resident #1 a nutritional supplement at 2 p.m. This failure could result in hypoglycemia (low blood sugar) requiring emergency interventions or hospitalization.