Bluebonnet Rehab at Ennis

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive care plan that described the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to revise Resident #1's care plan to reflect an unwitnessed fall and intervention on 05-15-2026. This deficient practice placed residents at risk of not having their individualized needs met and communicated to providers that could result in a decline in physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices (cleaning the ice machine, cleaning the juice machine dispenser, cleaning the inside of the microwave, storing the ice scoop in an ice scoop receptacle that was free from food debris buildup, cleaning the refrigerator unit shelving to ensure they are free of mold). 2. The facility failed to ensure cleaning logs were being completed. 3. The facility failed to ensure all items were covered and stored properly. 4. The facility failed to label and date all food items in the kitchen. These failures could place residents at risk of foodborne illness. [...]

Inspectors wroteBased on interviews and records review, the facility failed to ensure that medical records maintained on each resident were accurately documented for three (3) of seven (7) residents, (Resident #8, Resident #19, and Resident #62) reviewed for accurate clinical records, in that: The facility failed to ensure Resident #8, Resident #19, and Resident #62's EMRs contained orders upon admission to the secured unit that included corresponding clinical criteria for admission to the secured unit. This deficient practice could result in errors in care and treatment and violate resident rights. Resident #8 Review of Resident #8's face sheet dated 4/22/2026, reflected an [AGE] year-old male admitted to the facility on [DATE], with diagnoses that included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident 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 residents (Resident #86) reviewed for dignity with meal assistance. The facility failed to ensure MA D did not stand while she assisted Resident #86 with eating. This failure could place residents at risk of loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service for 1 (Resident #74) of 6 residents reviewed for personal privacy. The facility did not deliver unopened mail for Resident #74. This failure could affect residents' personal privacy and could result in decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accident hazards and the residents received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents. The facility failed to provide Resident #1 with adequate supervision and assistance on 07/10/25 when CNA A began to transfer Resident #1 when using a mechanical lift (specialized device designed to safely transfer individuals with limited mobility). CNA A was conducting a mechanical lift transfer without the required two (2) staff members and stopped the transfer to call for assistance from another staff member while CNA A left Resident #1 suspended in the air in the mechanical lift sling. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 1 facility reviewed for a clean and homelike environment. The facility failed to ensure hall 100 and hall 200 floors were swept and maintained. These failures could place residents at risk of living in an uncomfortable and unsafe environment, decreased feelings of self-worth, and a diminished quality of life.

Inspectors wroteBased on observation, interviews 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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for two(Resident #2 Resident #3) of 5 residents reviewed for care plans. The facility failed to revise Resident #2's care plan to reflect Resident #2 no longer required monitoring when smoking cigarettes. The facility failed to revise Resident #3's care plan to reflect Resident #3 no longer had to return cigarettes to the nursing station. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs. Findings Included: [...]

Inspectors wroteBased on observation, interviews, 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 one (Resident #1) of 5 residents reviewed for medications and pharmacy services The facility failed to ensure Resident #1's physician ordered medication Neurontin was administered on 03/05/2025 at 2:00 PM. The facility failed to monitor Resident # 1 for pain every shift according to physician orders. This failure could place residents at risk of not receiving necessary medical care and hospitalization. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication or care to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff and residents for 1 of 1 facility reviewed for medication storage. The facility failed to secure one over-the-counter Tylenol 500 MG tablet that was observed on 03/21/2025 at 10:15 AM in the shower room on the 500 hall. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medication or care to maintain their highest practicable physical, mental, and psychosocial well-being.

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 infections for 1 of 1 facility reviewed for infection control practices. The facility failed to ensure the ice scoopers on hall 100 and hall 600 were not exposed and not covered. This failure placed residents at risk of cross contamination.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for dietary services. 1. The facility failed to ensure that the dry storage items were free from expired foods. 2. The facility failed to ensure kitchen staff followed proper hand hygiene during meal preparations. 3. The facility failed to ensure that the puree blender was cleaned between menu items. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow their own established smoking policy for 5 (Residents #4, #27, #35, #48, and #50) of 8 residents reviewed for smoking. 1. The facility failed to ensure that Residents #4, #48, and #50 did not keep their personal cigarette lighters in their rooms per facility policy. 2. The facility failed to ensure that Resident #35 only used his e-cigarettes inside the designated smoking areas. 3. The facility failed to address where e-cigarettes should be stored, how to handle the devices, batteries, and refill cartridges. This failure could place residents at risk of an unsafe smoking environment and injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change of condition for 1 of 6 (Resident #3) residents reviewed for comprehensive assessments. The facility did not complete a significant change MDS for Resident #3 after she was admitted to hospice services. This failure could place residents at risk of not having their individual needs met when a significant change in condition occurs.

Inspectors wroteBased on interviews and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 (Resident #31) of 6 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #31's significant change MDS accurately reflected his hospice status. This failure could place residents at risk of not having their individual needs met when a significant change in condition occurs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, which was observed for dietary services. The facility failed to: 1. Clean and sanitize kitchen surfaces and kitchen equipment to reduce food-borne pathogens. 2. Ensure snack refrigerators and individual resident refrigerators maintained adequate temperature to reduce food borne pathogens. This failure placed residents at risk for ingesting food-borne pathogens.

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 for 3 of 6 residents (Resident #59, Resident #68, and Resident #39) who were reviewed for accommodation of needs. The facility failed to ensure Resident #59's, Resident #68's, and Resident #39's call lights were placed within their reach. This failure could place dependent residents at risk of injuries and unmet needs.

Inspectors wroteBased on interviews, observations, and record review the facility failed to complete an assessment that accurately reflected the resident's status for 2 of 8 residents (Residents #'s 30 and 55) whose records were reviewed for MDS accuracy, in that: The facility failed to ensure that Resident #30's Annual MDS Assessment reflected shortness of breath and tobacco use. The facility failed to accurately assess RES #55 on her Quarterly MDS Assessment, for Section H0300., Urinary Continence, which created an MDS discrepancy. These failures by the facility placed residents at risk of not receiving the care and services to meet their needs.