Health inspection·October 22, 2022

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident #11's smoking safety evaluations dated 08/25/21, 11/29/21, 03/15/22, 06/7/22, and 09/13/22, listed him as demonstrating the ability to safely smoke without supervision. Review of Resident #15's undated face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Parkinson's Disease, Major Depressive Disorder, and anxiety disorder. Review of Resident #15's care plan last revised on 8/29/22 stated to keep all smoking materials in designated area at the nurses station and to monitor resident when smoking and ensure resident's safety. Review of Resident #15's MDS revealed a BIMS Score of 15 showing she was cognitively intact. Review of Resident #15's smoking safety evaluations dated 08/29/22 and 10/18/22 states, Resident is a safe smoker and can smoke without supervision. Review of Resident # 24's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of Major Depressive disorder, Recurrent, in partial remission, Anxiety disorder, Dependence on wheelchair, Panic Disorder, Other lack of coordination, Bipolar II Disorder, Primary insomnia, Muscle weakness (generalized), Unsteadiness on feet, Other abnormalities of gait and mobility and Nicotine dependence. Review of Resident #24's smoking safety evaluations dated 04/05/22, 07/12/22, and 09/20/22, revealed no concerns. Review of Resident #27's undated face sheet revealed a [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Dementia, anxiety, insomnia, muscle weakness, unsteadiness on feet, chronic a fib, and TIA. Review of Resident #27's care plan last revised 08/24/22 stated she is sometimes noncompliant with returning smoking materials to nurses desk and to keep all smoking materials in designated area at the nurses station and to monitor resident when smoking and ensure resident's safety. Review of Resident #27's MDS revealed a BIMS Score of 12 showing she was cognitively intact. Review of Resident #27's smoking safety evaluations dated 12/21/21, 03/29/22, 06/27/22, and 08/24/22, stated, Resident is a safe smoker. Review of Resident #34's undated face sheet revealed an [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of Dementia, Major Depressive Disorder, Unspecified Psychosis, Adjustment Disorder with Disturbance of Conduct, Other Psychoactive Substance use, unspecified with other Psychoactive Substance-Induced Disorders. Review of Resident #34's care plan last revised on 09/06/22 stated to keep all smoking materials in designated area at the nurses station and that supervision is needed while he is smoking and to ensure his safety. Review of Resident #34's MDS revealed a BIMS Score of 08 indicating he is moderately impaired. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 2 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Review of Resident #34's smoking safety evaluation dated 11/29/21, stated, Resident has smoked in non-designated areas. Recommend supervision and for staff to store his lighter and cigarettes. Review of his smoking safety evaluations on 06/27/22 and 09/06/22 states, Resident needs to be supervised during smoking. Review of Resident #36's undated face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of Dementia, Bipolar, Anxiety, Major Depressive Disorder, other impulsive disorders, and delusional disorders. Review of Resident #36's care plan last revised 08/30/2022 stated to keep all smoking materials in designated area at the nurses station and to monitor him when smoking and to ensure his safety. Review of Resident #36's MDS revealed a BIMS Score of 06 which indicated severely impaired cognition. Review of Resident #36's smoking safety evaluations dated 04/12/22, 07/19/22, and 10/18/22 stated, Resident is safe when smoking with staff assistance and supervision. Review of Resident #50's undated face sheet revealed a [AGE] year-old male was admitted to the facility on [DATE] with a diagnosis of Multiple Sclerosis, Cannabis abuse with Psychotic Disorder with Delusions, Lyme Disease, Unspecified, Major Depressive Disorder, Adjustment Disorder with Mixed Anxiety and Depressed Mood, and Attention-Deficit Disorder. Review of Resident #50's care plan last revised 09/14/2022 stated he is keeping a cigar cutter and scissors at bedside and has been found smoking inside his room and is noncompliant with keeping smoking products and materials at nurses desk. The interventions included to keep all smoking materials in designated are at the nurses station and to monitor him when smoking to ensure his safety. Review of Resident #50's MDS dated [DATE] revealed a BIMS Score of 15 showing he was cognitively intact. Review of Resident #50's smoking safety evaluations dated 08/23/21, 11/29/21, 02/15/22, 05/31/22, and 08/30/22 did not list any concerns for the resident. Review of Resident #53's undated face sheet revealed an [AGE] year-old female was admitted to the facility on [DATE] with a diagnosis of Dementia, Bipolar Disorder, Major Depressive Disorder, Lack of Coordination, Essential Tremor, and anxiety disorder. Review of Resident #53's care plan last revised 09/20/22 stated she is noncompliant with keeping smoking products at nurses desk. Her interventions included keep all smoking materials in designated area at the nurses station. Review of Resident #53's MDS dated [DATE] revealed a BIMS Score of 12 which indicated moderately impaired cognition. Review of Resident #53's smoking safety evaluations dated 08/23/21, 11/29/21, 03/01/22, 06/07/22, and 09/20/22, did not list any concerns for the resident. Review of Resident #55's undated face sheet revealed a [AGE] year-old male was admitted to the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 3 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety facility on [DATE] with a diagnosis of cognitive impairment, alcohol abuse, insomnia, anxiety disorder, hx of falls, muscle weakness, and CVA (cerebrovascular accident) (Stroke). Review of Resident #55's care plan last revised 09/20/22 stated he is periodically noncompliant with keeping smoking products at nurses desk. His interventions included to keep all smoking materials in designated area at the nurses station and to monitor while smoking to ensure resident's safety. Residents Affected - Some Review of Resident #55's MDS dated [DATE] revealed a BIMS Score of 11 which indicated moderately impaired cognition. Review of Resident #55's smoking safety evaluations dated 04/19/22, 07/19/22, 09/20/22, stated, Resident smokes safely and does not require staff supervision. Review of Resident #68's undated face sheet reflected a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of 2x12 Low Vision Right Eye Category 1, Low Vision Left Eye Category 2, Bilateral Unspecified Hearing loss, Alcohol Dependence, Unspecified Speech Disturbances and Personal history of Nicotine Dependence. Review of Resident #68's smoking safety evaluation dated 08/17/22, states, Resident is able to smoke without supervision. In an observation on 10/18/22 at 8:07 AM, 8:52 AM, and 9:14 AM, Resident #55 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/18/22 at 9:12 AM, 10:46 AM, and 11:12 AM, Resident #11 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/18/22 at 9:52 AM, 10:44 AM, and 11:46 AM, Resident #50 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/18/22 at 11:45 AM, 1:452 and PM, 3 PM, Resident #68 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 9:34 AM, 10:26 AM, and 11:19 AM, Resident #50 was seen smoking in the smoking courtyard area without staff supervision. In an observation on 10/19/22 at 11:05 AM, 1:05PM, 1:35PM, 2:02PM, 2:48PM, 3:42PM, and 4:12PM, Resident #55 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 11:25 AM, 1:32 PM, 2:42 PM, and 3:41 PM, Resident #11 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 10:30 AM, 1:20 PM and 2:30 PM Resident #24 was seen smoking in smoking courtyard area without staff supervision. In an observation on 10/19/22 at 11:20 AM, an overstock of smoking supplies was observed to be kept in an unsecured drawer at the nurses' station. Plastic trash cans and metal trash cans with cigarette butts mixed with trash was located in designated smoking areas outside of the 400 hall, the front of the building, and the therapy area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 4 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some In an observation and interview on 10/18/22 at 2:53 PM, Resident #53 was observed smoking and she said she keeps her cigarettes and lighter with her. She uses oxygen at night and her room has a board posted that says, Do not smoke, oxygen in use. In an observation and interview on 10/19/22 at 08:50 AM Resident #50 was observed to be asleep in his room. There was a strong smell of smoke. Investigator A asked CNA #1 to step into the room to identify the smell and she said, It smelled like it could be coming from his body, his clothes, and/or definitely smoking in the room. At 9:30 AM Investigator B visited Resident #50's room with ADM. ADM confirmed the smell of smoke and stated that Resident #50 had the history of smoking in his room and noncompliance to facility staff directives regarding safe smoking practices. In an observation and interview on 10/19/22 at 11:25 AM, Resident #11 was observed with visible tremors to his bilateral upper extremities. He said he had a difficult time holding onto things at times. In an observation and interview on 10/19/22 at 10:05 AM in her room, Resident #15 said she kept her cigarettes and lighter in her walker and displayed the items. She was informed that there was a Smoking Policy about where you were allowed to smoke. In an interview on 10/19/22 at 10:25 AM Resident #36 said the nurse rolled him out to smoke and she stayed most of the time. In an interview on 10/19/22 at 10:42 AM Resident #50 said his cigarettes and lighter fluid for his cigars were kept at the nursing station. He kept his cigars in his room in the brown box above his safe. He kept his cigarette lighter in his jacket. He stated the nurses, the ADMIN, and the DON were aware that he kept the cigars in his room. In an interview on 10/19/22 at 10:50 AM Resident #55 said he smoked on his own and displayed his cigarettes and lighter. He said the facility did not keep any of his supplies. He stated he did not have to adhere to smoking times and he smoked whenever he wanted. He did not have issues with burns on him, or his clothing. In an interview on 10/18/22 at 11:15 AM Resident #68 said she kept her cigarettes and lighter with her and displayed the cigarette packet and lighter that was with her in her room. In an interview on 10/19/22 at 1:00 PM Resident #24 said she secured the cigarettes and lighter in her room. She said she never smoked in her room as it was not safe. In an interview on 10/19/22 at 11:20 AM, the ADON stated that 8 residents kept their cigarettes and lighters on them or in their room (Resident #11, Resident #15, Resident #24, Resident #27, Resident #50, Resident #53, Resident #55, and Resident #68) and one of these residents were not allowed to keep smoking supplies because of previously smoking in his room. Staff were aware he kept his own supplies. Two additional residents required supervision (Resident #36 and Resident #34, but they had not smoked for several months). If an aide or nurse were available, they would take these two residents outside to smoke or leave them with other residents to supervise them while they smoked. In an interview on 10/20/22 at 3:30 PM with the RNA, she said without a proper Smoking Assessment, placed residents in jeopardy of harm. They have to monitor their residents. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 5 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety In an interview on 10/20/22 at 3:40 PM the ADMIN stated noncompliance to smoking policies and procedures lead to the risk of fire hazards that could cause serious harm to the residents. He said they have changed their policy to include supervision for all residents and checking their rooms daily. He said they cannot search personal items but would search around to avoid injuries and unnecessary fires inside of trash bins. Residents Affected - Some Record Review on 10/19/22 of policy titled [facility name] Smoking Policy (undated) stated: All smoking materials (lighters, matches, cigarettes, cigars, pipes, electronic cigarettes) are to be kept at the nurses' station in a secure container. Staff will be required to supervise/assist those residents identified as having risk factors that require supervision/assistance during smoking. Smoking assessments are to be done on admission, quarterly, annually, and as needed for changes Record Review of policy titled Smoking Policy - Residents [facility name] (dated: Revised July 2017) stated: 11. Any resident with restricted smoking restrictions requiring monitoring shall have the direct supervision of a staff member, family member, visitor or volunteer worker at all times while smoking. 12. No resident is allowed to keep smoking materials, to include lighters in their possession at any time. 13. Residents will be provided their smoking materials at designated smoking times by the staff member supervising the smoke time. The ADM was notified on 10/19/22 at 04:30 PM an IJ situation was identified due to the above failures. The facility's Plan of Removal was accepted on 10/22/2022 at 5:10 PM and included: Revisions were made to the policy to include safe smoking assessments that will be done monthly and on an as need basis started on 10/19/22. These assessments will be completed by the social worker. In-services on the revised smoking policy were started on 10/19/22 at 5:45 PM and completed the following morning on 10/20/22 at 9:00 AM by the ADON for all facility staff, including direct nursing staff, charge nurses, dietary staff, SW, MDS nurses, maintenance, and the receptionist. No employee will be allowed to work until they have been in-serviced on the revised smoking policy. This will be monitored for compliance daily by the ADM and the ADON and was in compliance on 10/20/22. All new employees will be in serviced; on the smoking policy before they begin their employment. The SW and the ADON completed new smoking assessments on the 8 residents that choose to smoke, and no resident required supervision except for one resident due to noncompliance with the smoking policy. Revisions were made to the policy to include safe smoking assessments that will be done monthly by the social worker. This will be monitored for initial and continued compliance by the ADM and /ADON. All 8 residents were observed by the social worker when the smoking assessment were completed. There are 4 additional residents that have not smoked for the past 2 to 3 months that had the resident status portion of the smoking assessment completed with documentation that the resident no longer (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 6 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 smokes. This was completed by the SW on 10/19/22. Level of Harm - Immediate jeopardy to resident health or safety The SW observed each of the 8 smokers while they were smoking for a new baseline assessment on 10/19/22. All new residents will also be given smoking assessments on arrival, and as needed. Residents Affected - Some The ADM met with each resident that smoke on 10/19/22 to review the smoking policy which include supervision of smoking for any residents requiring supervision per their care plan. If they are unable to appropriately answer smoking safety evaluation questions, and or exhibit unsafe physical ques that could lead to possible harm and require supervision to be noted in their care plan. Each resident verbalized understanding of the smoking policy as explained by the ADM. All residents that smoke signed the revised smoking policy on 10/19/22. This will be monitored for initial and continued compliance by the ADM and ADON for six weeks or until achieved compliance. After review of the new smoking assessments, all residents were cleared to smoke with exception of one resident. To achieve safety compliance, and ensure all fire and accidental hazards are removed, a tackle box with a lock was purchased on 10/19/22 and all smoking materials for one non-compliant resident were placed inside. This resident is non-compliant due to ordering and using lighters and potential hazardous materials via mail and using these items in an unsafe environment. This resident also has past and recent history of smoking in his room, which could lead to fire hazards. No smoking materials were visually observed in this resident's room on 10/19/22 at 7:00 PM, or on 10/20/22 at 7:00 AM. The ADM confirmed that this resident's lighters or any combustible items were collected on 10/20/22 at 7:00 AM. These items were placed in the lock box at that time on 10/20/22 at 7:00 AM and will remain until resident demonstrates compliancy. Nurses will keep a key to the lock box and provide access per the resident's request. All nursing staff were in-serviced on the items that are to be kept in the locked box belonging to this resident. This will be monitored for compliance by the ADM and ADON. Rounding on one will be done to ensure the resident remains compliant, and not in possession of lighters or any combustible items two times per day by the SW, ADM or ADON starting on 10/19/22 on an as need basis for six weeks or until achieved compliance. The resident agreed for the ADM to remove smoking materials from his room on 10/20/22. This resident has been put on 1 on 1 observation due to a history of non-compliance due to ordering and using lighters and potential hazardous materials via mail and using these items in an unsafe environment. Resident #50 has past and recent history of smoking in his room, which could lead to fire hazards. Resident #50 will continue 1 on 1 supervision until safety concerns are met (related to non-compliance due to purchasing and maintaining lighters via mail). A hospitality aide will provide 1 on 1 supervision to this one resident. Only one resident has been placed on one-on-one supervision and his care plan has been updated by the MDS nurse on 10/20/22. This will be monitored for compliance by the ADM and ADON until safety concerns are met via IDT meetings. The ADM and MDIR rounded all smoking areas on 10/19/22 at 7:00 PM and replaced all regular trash cans and replaced them with metal trash bins that are covered and non-flammable. All facility staff were in-serviced on the proper disposal of cigarette butts. In-service was completed on 10/19/22 and 10/20/22 by the ADON and the ADM 10/20/22. All new employees will be in-serviced on cigarette butts not being emptied into trash cans at orientation by human resources. Safety concerns will be monitored for compliance by the administrator and the ADON daily until compliance is attained or as needed to ensure all residents and resident environment is free from fire hazards and potential harm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 7 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record Review on 10/21/22 at 5:20 PM of the new Smoking Safety Evaluations revealed assessments had been completed for all smokers. Record Review on 10/21/22 at 5:45 PM revealed in-services on the Smoking Policy had been completed for all staff. In an interview on 10/21/22 at 6:30 PM, Resident 11 stated his cigarettes and lighter were at the nurse's station. He stated he follows the smoke schedule and is supervised while smoking. He did not need help while smoking and his hands only shook when they were cold. He demonstrated with his hands on how he smoked a cigarette, and observation revealed his hands were not shaking. In an interview on 10/21/22 at 7:13 PM, OT #1 stated she had been in-serviced on the Smoking Policy and made aware of the supervised smoking times and that all smoking supplies were to remain at the nurse's station. In an interview on 10/21/22 at 7:24 PM, LVN #2 stated she had been in-serviced on the Smoking Policy and made aware there were now posted smoke times and a staff member must be present to observe the residents at all times. She understood it must be done for safety purposes. In an interview on 10/22/22 at 1:05 PM, CNA #2 stated she had been in-serviced on the Smoking Policy by the ADM. She understood the residents were to be taken outside every 2 hours to smoke and they must be monitored at all times. In an interview on 10/22/22 at 2:15 PM with Resident #15, she stated they were monitored, and her cigarettes and lighters were left at the nurse's station at all times. In an interview on 10/22/22 at 2:30 PM with Resident #50, he stated he was not allowed to keep smoking materials in his room. He stated he was supervised and was only allowed to smoke during the designated times. During an observation on 10/22/22 at 3:11 PM revealed CNA #2 outside with the smokers and monitoring them while they were smoking. On 10/22/22 at 5:10 PM the ADM was notified the IJ was removed. However, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy with a scope of widespread due to the facility's need to complete in-service training and evaluate their corrective actions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 8 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. Food and beverage items were not properly labeled with product and expiration date. Food items were not properly sealed when not in use. Food and beverage items were past expiration or use by date. Food items were stored in improper location. Frozen fish was defrosted in unsafe method and temperature. Expired food was to be served to 12 residents. This failure could place residents who ate meals prepared in the kitchen at risk for food borne illness. Findings included: In an observation in the kitchen at facility on 10/18/2022 at 7:13AM pre poured cups of juice and milk were on trays in the refrigerator that was not labeled with product type or dated. A plastic container containing a white substance that was not labeled with product type or dated. A glass container containing a yellow substance that was not labeled with product type or dated. There were 2 brown paper sacks with chips and sandwich inside that was not labeled with product type or dated. There were 3 plates with a slice of cake that was not labeled with product type or dated. There were brown patties inside an open bag that was not labeled with product type or dated. There was half of a cut cantaloupe located inside refrigerator dated 10/7/22. There were 2 packages of bread that was not labeled with product type or dated. There were 6 plastic containers of cereal located on a shelf outside of dishwashing area that was not labeled with product type or expiration date. There was 4 gallons of whole milk with expiration date of 10/16/22 located with other milk inside refrigerator. There was a box of medium white eggs located in the refrigerator with an expiration date of 10/03/22. There was a container of Ranch dressing located in refrigerator with best if used by date 02/Feb/22. There was 2 cartons of Carrot and Raisin Salad located in refrigerator with use by date of 10/11/22. There was a container of chicken noodle soup dated 10/6/22. There was a plastic bag of breaded patties inside refrigerator with a use by date of 10/13/22 and no product label. Inside of the freezer was 6 plastic bags of frozen food that were all open and without product label or date. There was a can of [NAME] leaf turnip greens on the floor in front of the door to dry storage. There was a cardboard box of potato chips on the floor in dry storage. There was an open container of Rich and Creamy Cream Cheese Frosting located on a shelf in the dry storage with no open date and with product instructions stating Cover and refrigerate leftover frosting up to 30 days. In 3 bay sink was a container filled with fish sitting in water under a faucet that was not running, and a hose connected to disinfectant cleanser was hanging 2 inches above container. In an observation and interview on 10/18/22 at 7:31AM [NAME] A was seen with eggs sitting out on a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 9 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many prep table. She said she was going to use those eggs to make fried eggs for 12 residents for breakfast. She pointed to the carton she retrieved these eggs from. She checked expiration date and confirmed she was fixing to serve residents fried eggs that were expired 10/03/22. She said she did not think to check the expiration date because her responsibility is making sure the freezer is cleaned out. In an interview 10/18/22 at 7:42AM DMGR said the expired eggs were going to be used for breakfast. She acknowledged the food products in refrigerator that were not labeled correctly and were expired after a surveyor voiced concern. She acknowledged the items in the freezer that were not labeled, left open, and with freezer burn present. She acknowledged the food items in the dry storage that were on the floor and the frosting that was inappropriately stored and not labeled after a surveyor voiced concern. She acknowledged the 6 plastic containers of cereal that were not labeled outside of the dishwashing area. She acknowledged the fish should not be thawed in stagnant water after a surveyor voiced concern. She said the proper way to defrost fish would be for the water to be running and the food should not be placed under the hose of the disinfectant chemical after a surveyor voiced concern. She acknowledged the thermometer showed the temperature of the fish defrosting was 75.2F after a surveyor voiced concern. She informed [NAME] the fish would need to be thrown out. The temperature for the dishwasher was checked at 118F with chemical sanitation during wash cycle instead of regulation 120F after a surveyor voiced concern. She said she was new to the position, had recently completed her training, and was still learning the new position. In an interview on 10/20/22 at 3:35PM with RNA said defrosting frozen fish incorrectly could lead to residents becoming ill. She said serving eggs that were expired could lead to residents being ill. She said serving milk that were expired could lead to residents becoming ill. She said not labeling food/beverages with expiration date could lead to residents being ill. In an interview on 10/20/22 at 3:45 PM ADMIN said DMGR was new to manager position and was still learning the requirements. He said defrosting frozen fish incorrectly could lead to residents becoming ill. He said serving eggs that were expired could lead to residents being ill. He said serving milk that were expired could lead to residents becoming ill. He said not labeling food/beverages with expiration date could lead to residents being ill. Record review on 10/20/22 of Food Preparation and Service Policy (revised April 2019) revealed, Food Preparation Area: 4. Appropriate measures are used to prevent cross contamination. These include d. cleaning and sanitizing work surfaces and food-contact equipment between uses, following food code guidelines. Thawing Frozen Food: b. completely submerging the item in cold running water (70F or below) that is running fast enough to agitate and remove loose ice particles Food Preparation, Cooking and Holding Time/Temperatures: 1 The danger zone for food temperatures is between 41F and 135F. This temperature range promotes the rapid growth of pathogenic microorganisms that cause foodborne illness. 2. Potentially hazardous foods include meats, poultry, seafood, cut melon, eggs, milk, yogurt and cottage cheese. Record review on 10/20/22 of Food Receiving and Storage stated, 6. Food in designated dry storage areas shall be kept off the floor (at least 18 inches) and clear of sprinkler heads, sewage/waste disposal pipes and vents. 7. Dry foods that are stored in bins will be removed from original packaging, labeled and dated (use by date). Such foods will be rotated using a first in-first out system. 8. All foods stored in the refrigerator or freezer will be covered, labeled and dated (use by date). Foods can be kept for up to 3 days. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 10 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure accurate weight measurement for 4 of 4 residents reviewed for the accuracy of weight measurements completed (Resident #45, Resident #23, Resident # 24, and Resident #58). This failure could place residents at risk for not receiving care and services to meet their needs. Findings included: Review of Resident # 45's undated face sheet reflected an [AGE] year-old female admitted on [DATE]. Diagnoses included Gastrointestinal Hemorrhage (bleeding in the intestine), Unspecified Dementia, Psychotic disturbance, Mood disturbance, Anxiety, Urgency of urination, Lack of coordination, Anemia, Protein-calorie malnutrition, Abnormal weight loss and muscle weakness. Record review of Resident # 45 care plan dated 9/20/22 indicated that she had nutritional problem of Malnutrition. Goals indicated, Mrs. Resident#45 will not develop further complications related to malnutrition, including skin breakdown . Interventions included: Monitor/record/report to MD PRN s/s of malnutrition: Emaciation (Cachexia), muscle wasting, significant weight loss: 3lbs in 1 week, >5% in 1 month, >7.5% in 3 months, >10% in 6 months Record review of the weight and vital summary of Resident # 45 completed on 9/26/22 revealed inaccurate weights compared to previous measurements . On 9/26/22 the weight measured was 173lbs. On 9/12/2022 it was 130lbs; an increase of 43lbs. in 14 days (33% increase). The weight measured were on 8/11/22-126lbs., , 7/26/22-125.9lbs., ,6/13/22-126.4lbs., and 9/28/22-174lbs., The resident was weighed 2 times on 10/18/22. The result at 9.36am was 148.2 lbs. and at 9.37am it was 144.6 lbs. (2.4 % variation). Weighing Resident #45 on 10/20/22 at 9.45am by CNA1 and CNA2 was observed. The result was 118.6 lbs.; 29.6lbs (19.9%) lesser than the weight that was 2 days ago. The weighing machine's accuracy was confirmed by weighing known weights. No errors were observed in the weighing procedure on 10/20/22 at 9.45am. Review of Resident # 23's undated face sheet reflected a [AGE] year-old female initially admitted on [DATE] and readmitted on [DATE]. Diagnoses included Unspecified Atrial Fibrillation (irregular rapid heart rhythm), Chronic Obstructive Pulmonary Disease(COPD) ( Obstructed airflow from the lungs),Hypertension, Unsteadiness on feet, Insomnia, Muscle wasting, Parkinson's disease, Major depressive disorder, Protein-calorie Malnutrition, and History of falling Record review of Resident # 23 care plan dated 04/12/2022 indicated that she had nutritional problem related to Dysphagia (swallowing difficulties) and Protein Calorie Malnutrition. Goals indicated, Resident #23 will maintain adequate nutritional status as evidenced by maintaining weight, no s/s of malnutrition, and consuming at least 50% of at least 2 meals daily through review date. Record review of the weight and vital summary of Resident # 23 on 9/26/22 showed inaccurate weights compared to previous measurements. On 9/26/22 the weight measured was 114.8 lbs. On 9/12/2022 it was 133.9lbs.; a variation of 19.1 lbs. in 14 days (14.2%). The weight recorded were on (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 11 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 8/11/22-133lbs., ,6/21/22-134lbs and 6/13/21-126lbs. Level of Harm - Minimal harm or potential for actual harm Weighing Resident #23 on 10/20/22 at 10:16am by CNA1 and CNA 2 was observed. The result was 117.2 lbs. The weighing machine's accuracy was confirmed by weighing known weights. No errors were observed in the weighing procedure. Residents Affected - Some Review of Resident # 24's undated face sheet medical record reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included Enterocolitis (inflammation in the digestive tract) due to clostridium difficile, Major Depressive disorder, Anxiety Disorder, Panic Disorder, Other lack of coordination, Bipolar II Disorder, Primary Insomnia, Muscle weakness (generalized), unsteadiness on feet, and Nicotine Dependence. Record review of the weight and vital summary of Resident # 24 revealed the weights were on 9/15/22278.4 lbs, 8/11/22- 266.3lbs, 7/26/22-274.1lbs and 6/13/22-273lbs. On 9/26/22 and 9/28/22 the weight was 176 lbs.; a weight loss of 102.4 lbs. (36.7 %) in 13days. The measurement taken on 10/18/2022 was 268.2lbs. Weighing Resident #24 on 10/20/22 at 2.30 pm by LVN1 was observed. The result was 279 lbs. The weighing machine's accuracy was confirmed by weighing known weights . No errors were observed in the weighing procedure. Review of Resident # 58's undated face sheet reflected a [AGE] year-old female admitted on [DATE]. Diagnoses included Urinary Tract Infection, Gastroenteritis (Inflammation in the stomach) and colitis (Inflammation in the colon), Major Depressive Disorder, Type 2 Diabetes Mellitus, Diarrhea, and Adjustment disorder with anxiety. Record review of the weight measurement of Resident # 58 on 8/10/22 showed inaccurate increase in weight compared to previous measurement. On 8/10/22 the weight measured was 130.09lbs. On 08/02/22 it was 145 lbs.; a variation of 14.5 lbs. in 8 days (10% decrease). The weight measured on 8/17/22-131lbs, 8/24/22-130lbs., 8/31/22-129lbs, 9/19/22-134lbs, 9/26/22- 134.4 lbs and 9/28/22-134.4lbs. Record review of Resident # 58's care plan dated 08/03/2022 indicated that she had dehydration or potential fluid deficit. Goals indicated, Resident#58 will be free of symptoms of dehydration and maintain moist mucous membranes, good skin turgor. One of the interventions was to monitor/document/report to MD s/s of dehydration: decreased or no urine output, concentrated urine, strong odor, tenting skin, cracked lips, furrowed tongue, new onset confusion, dizziness on sitting/standing, increased pulse, headache, fatigue/weakness, dizziness, fever, thirst, recent/sudden weight loss, dry/sunken eyes. During an interview on 10/20/22 at 3.30pm with RNA, she stated inaccurate information about residents' weights leads to wrong misinterpretation and interventions. This would affect residents with skin issues and pressure ulcers secondary to compromised nutritional management. Inaccurate weight measurement provides wrong information to the physicians which in turn affect their lab work and medication. She said henceforth she wanted an LVN overseeing entering the weights and a specialized, well-trained CNA do the weights for all the residents, all the time in order to maintain consistency. She said she was investigating the exact cause of these errors. During an interview on 10/20/22 at 4:40pm ADMIN stated medication and treatments could be off based on incorrect weights. Residents' diet could be changed unnecessarily. He said if one person does (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 12 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some the weights, the inaccuracy in weights could be prevented. Measured like making sure no additional items are on the person, check off list on how to complete the weigh-ins, weighing scales calibration and use of the same protocol could prevent errors in weighing. weighing He said he was investigating the exact cause of these errors to find a permanent solution Record review on 10/20/22 of facility policy weight Assessment and intervention dated September 2008 stated: The multidisciplinary team will strive to prevent, monitor and intervene for undesirable weight loss for our residents. Weight Assessment 1 · The nursing staff will measure resident weights on admission, the next day, and weekly for two weeks thereafter. If no weight concerns are noted at this point, weights will be measured monthly thereafter. 2· Weights will be recorded in each unit's weight record chart or notebook and in the individual's medical record. J. Any weight change of 5% or more since the last weight assessment will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing. Verbal notification must be confirmed in writing. 4. The dietitian will respond within 24 hours of receipt of written notification. 5. The dietitian will review the unit weight record by the 15th of the month to follow individual weight trends over time. Negative trends will be evaluated by the treatment team whether or not the criteria for significant weight change has been met. 6. The threshold for significant unplanned and undesired weight loss will be based on the following criteria [where percentage of body weight loss = (usual weight- actual weight) I (usual weight) x 100): a. I month - 5% weight loss is significant; greater than 5% is severe. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 13 of 14 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675150 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/22/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Rehab at Ennis 2300 South Oak Grove Rd Ennis, TX 75119 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 b. 3 months - 7.5% weight loss is significant; greater than 7.5% is severe. Level of Harm - Minimal harm or potential for actual harm c. 6 months - I 0% weight loss is significant; greater than I 0% is severe. 7. If the weight change is desirable, this will be documented and no change in the care plan will be Residents Affected - Some necessary. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 14 of 14