Health inspection·January 4, 2024

F 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #68's face sheet, dated 1/04/24, reflected the resident was an [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of Adult Failure to Thrive, Unspecified Dementia (loss of cognitive Functioning that affects reasoning and thinking), Hypertension (elevated blood pressure), and Depression. Review of Resident #68's Quarterly MDS Assessment, dated 12/20/23, reflected he had a BIMS score of 10 indicating moderate cognitive impairment. Further review reflected Resident #68 was dependent for transfers, locomotion on and off unit, toilet use, and personal hygiene. Record review of Resident #68's care plan dated 11/20/23 reflected Resident #68 had a communication. problem related to expressive aphasia (difficulty speaking) and hard of hearing. Resident #68's care plan also reflected he had a self-care performance deficit and required assistance of two staff members for toilet use, and transfers. Interventions listed on the care plan included to encourage Resident #68 to use bell to call for assistance. In an observation and interview on 01/02/24 at 9:20 AM Resident #68's call light was observed on the floor out of reach of the Resident. Resident #68 reported he uses his call light to call for help but must wait sometimes an hour or more for someone to come in the room. In an observation on 01/03/24 at 09:27 AM Resident #68's call light was attached to his roommate's bed. C) Review of Resident #39's face sheet, dated 1/04/24, reflected the resident was a [AGE] year-old male who admitted to the facility on [DATE] with diagnosis of Type 2 Diabetes (elevated blood sugar), Major Depressive Disorder, Essential Hypertension (elevated blood pressure), Left Leg Below Knee Amputation. Review of Resident #39's Quarterly MDS Assessment, dated 12/05/23, reflected he had a BIMS score of 14 indicating he was cognitively intact. Record review of Resident #39's care plan dated 07/30/23 and revised 12/18/23 reflected Resident #39 has had an actual fall and had poor safety awareness. Resident #39s goal was to resume his usual activities without further incidents of falls. Resident #39's care plan also reflected he had a self-care performance deficit, was totally dependent on staff for toilet use and staff were to encourage him to use his call bell to call for assistance. In an observation on 01/02/24 at 9:29 AM Resident #39s call light was on the floor out of the residents reach. Resident #39 was in his bed resting. In an observation and interview on 01/02/24 at 01:33 PM - Resident #39's call light was on the floor. Resident #39 reported if he needs help, he can just yell for staff. In an interview with CNA C on 01/03/24 at 09:30 AM CNA C reported call lights should always be attached to the bed or in reach of residents. She reported the staff were educated with in-services to ensure call lights were within reach. CNA C reported the risk for Residents not having their call (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 2 of 10 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 01/04/2024 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 0558 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some light within reach was the residents would not be able to get assistance when needed which could lead to residents falling. She reported the CNA should have made sure the call light was in reach all the time. In an Interview with LVN B on 01/03/24 at 09:37 AM she stated it was her expectation that call lights would be in residents' reach while the resident was in the room. She reported the risk for the resident was falls with injury, related to unsafe transfers. LVN B reported all staff were trained regularly on making sure the call lights are within reach and all staff were responsible for monitoring. In an interview with DON on 01/04/24 at 12:09 PM she reported it was the facility policy that call lights should have always been within reach of the resident. The DON reported the risk to residents for not having their call light within reach would have been lack of needs met and risk for falls. She reported staff were educated in In-Services on having call lights within reach of residents. The DON reported she is responsible for staff education, but all staff should have been looking and monitoring to ensure call lights were in place. Review of the facility's Answering the Call Light policy, dated October 2010, reflected: .5. When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 3 of 10 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 01/04/2024 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 0641 Ensure each resident receives an accurate assessment. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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: Residents Affected - Few 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. Findings included: A record review of Resident #30's face sheet reflected Resident #30 was a [AGE] year-old male who was admitted to the facility on [DATE] with a diagnosis of chronic obstructive pulmonary disease (a disease that causes airflow blockage and breathing-related problems) end-stage renal disease (the last stage of long-term kidney disease), shortness of breath (unable to breathe normally or feeling suffocated), other sleep apnea (common condition in which your breathing stops and restarts many times while you sleep), and unspecified asthma (difficulty in breathing with wheezing, a feeling of tightness in the chest, and coughing). Record review of Resident #30's annual MDS dated [DATE] reflected the resident had a BIMS score of 15 indicating cognitive intactness. The MDS did not reflect Resident #30 had shortness of breath or used tobacco. Record Review of Resident #30's care plan dated 12/11/23 reflected Resident #30 was care planned for COPD (a disease that causes airflow blockage and breathing-related problems), asthma (difficulty in breathing with wheezing, a feeling of tightness in the chest, and coughing), shortness of breath (unable to breathe normally or feeling suffocated), respiratory failure (condition that makes it difficult to breathe on your own), sleep apnea (common condition in which your breathing stops and restarts many times while you sleep), hypoxia (low oxygen level in body tissue), and nicotine dependence/tobacco use (difficult to stop using tobacco). Record Review of Resident #30's physician orders dated 01/02/24 reflected Resident #30 had physician orders for the following: Resident to have Bi-Pap on QHS setting 15/5 rate 14 fl.oz 2-30%, O2 @ 2 liter PRN if O2 saturation below 90%; check O2 Qshift related to shortness of breath, and oxygen filter change every Sunday on 10-6 shift when in use. Interview with Resident #30 on 01/03/24 at 8:55 am, Resident #30 stated that he used snuff tobacco. Resident #30 stated he had used snuff for a long time but could not remember how long but stated it was before he was admitted to the facility. Resident #30 stated that he used a C-PAP machine, an inhaler, and oxygen due to him having shortness of breath. Record review of RES #55's AR, dated 1-3-2024, indicated RES #55 was a [AGE] year-old female who (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 4 of 10 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 01/04/2024 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 0641 Level of Harm - Minimal harm or potential for actual harm was admitted to the facility on [DATE]. She was diagnosed with Sepsis (which was a serious condition with the way her body responded improperly to an infection) due to Streptococcus pneumoniae and Type 2 Diabetes (which was a disease that disrupted the way her body used sugar for fuel. co. Residents Affected - Few Record review of RES #55's Quarterly MDS, dated [DATE], reflected Section H0300., Urinary Continence, coded as a 9 (nine.) A code of 9 indicated RES #55 was not rated for Urinary Continence because RES # 55 had a catheter (indwelling, condom), urinary ostomy, or no urine output for the entire 7 days. The MDS indicated the look back period was 7 days unless another time frame was indicated. Observations and interview on 1/2/2024 at 10:51 AM reflected RES #55 in her room in her wheelchair, fully dressed, and well-groomed. RES #55 did not have a catheter bag attached to her person. Interview with RES #55 revealed she felt fine and did not have any issues or concerns with her care. She stated she no longer had a catheter, [they removed it a while ago.] Record review of RES #55's CP, updated on 12/22/2023, reflected RES #55 CP Focus, initiated on 8/28/2023, indicated RES #55 had a foley catheter. The Goal, revised on 12/22/2023 as [RESOLVED,] indicated RES #55 would remain free from catheter related trauma through the target date of 2/27/2024. Record review of RES #55's Order Summary Report reflected RES #55's Foley Catheter, one time only for healing, was discontinued on 9/28/2023. Record review of RES #55 PN, dated 9/28/2023 at 1:08 PM entered by LVN/LVN M, reflected RES #55's Foley Catheter was discontinued on 9/28/2023; and PN, dated 9/28/2023 at 4:10 PM entered by LVN/LVN M, reflected RES #55's Foley Catheter was removed. Interview with ADON on 01/04/24 at 11:15 am, ADON stated that Resident #30 used a C-PAP machine, an inhaler, and Oxygen due to him having shortness of breath. ADON stated that resident #30 used snuff tobacco but did not smoke due to his asthma. Interview with MDS coordinator on 01/04/24 at 1135 am, MDS coordinator stated that she and LVN A were responsible for completing the MDS assessments. MDS coordinator stated the information for the MDS assessment was gathered from all departments for the complete assessment. MDS coordinator stated that if the MDS assessment was inaccurate then it could cause a resident to not receive proper care. Interview with DON on 01/04/24 at 12:50 pm, DON stated the MDS coordinator and LVN A were responsible for completing the MDS assessment. DON stated if a resident had shortness of breath, used tobacco, or had any other areas of care it should have been indicated accurately on the MDS. DON stated if a resident's MDS was not accurate then the resident may not be receiving adequate care. Interview with the Administrator on 01/04/24 at 12:50 pm, the Administrator stated that MDS coordinator was responsible for completing the MDS assessment. The administrator stated a resident's needs of care should have been indicated accurately on the MDS. The administrator stated if a resident's MDS were not accurate then the resident may not be receiving proper care. Record review of the facility's Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy not dated, reflected The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 5 of 10 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 01/04/2024 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 0641 physical, mental, and psychosocial well-being. Level of Harm - Minimal harm or potential for actual harm According to CMS's RAI Version 3.0 Manual; the MDS is a core set of screening, clinical, and functional status elements, including common definitions and coding categories, which forms the foundation of a comprehensive assessment for all residents of nursing homes certified to participate in Medicare or Medicaid. The items in the MDS standardize communication about resident problems and conditions within nursing homes, between nursing homes, and outside agencies. Residents Affected - Few Federal regulations at 42 CFR 483.20 (b)(1)(xvill), (g), and (h) require that: 1. The assessment accurately reflects the resident's status 2. A registered nurse conducts or coordinates each assessment with the appropriate participation of health professionals. 3. The assessment process includes direct observation, as well as communication with the resident and direct care staff on all shifts. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 6 of 10 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 01/04/2024 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 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. Finding included: Observation and interview on 1/2/2024 at 9:10 AM reflected [NAME] A removing items from the exiting side of the facility's dishwasher and drying them with a towel before placing them in their respective locations. [NAME] A stated that she learned to wipe items, that came out of the dishwasher, from other people in the kitchen. She stated that having dried the equipment, there was less water spilled on the floor, so people would not slip and fall. Observations on 1/2/2024 at 9:15 AM reflected the facility's beverage dispensing system, which consisted of two beverage dispensers at the end of two separate hoses, had an accumulation of dirt and grime on the sides and on top of the machine. One of the beverage dispensers was placed on top of the beverage dispensing machine and had an accumulation of a dark sticky substance leaking from the beverage dispenser itself. The beverage dispensing machine had a small section of metal fins, as part of the cooling mechanism, which were covered by a small plastic grate. The metal fins and the small plastic grate had an accumulation of dust and debris. Observation on 1/2/2024 at 9:35 AM of the kitchen's only industrial can opener reflected a dark sticky substance on the sharp metal mechanism used to pierce metal cans. The internal working parts of the industrial can opener reflected the same dark stick substance. Observations on 1/2/2024 at 9:40 AM reflected the inside of the facility's only ice machine had internal mechanical parts that were not clean. Inside the machine, there was a white 20-degree angle shelf affixed to the sides of the machine with two metal bolts. The 20-degree angled white shelf channeled the ice from the top of the machine to the lower accumulation bin. The metal bolts were discolored with a dark brown substance that left a discolored stain that led downwards into the ice. Observations on 1/2/2024 at 9:45 AM reflected two metal electric fans on separate sides of the facility's only kitchen. Each fan had an accumulation of dust and dirt between the circular metal safety bars as well as coating each of the three internal fan blades. Interview on 1/2/2024 at 9:50 AM with [NAME] B revealed that the kitchen did not have a posted cleaning schedule. [NAME] B stated the DM told them, the kitchen staff, what needed to be cleaned. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 7 of 10 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 01/04/2024 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 Interview on 1/2/2024 at 9:52 AM with [NAME] C revealed the kitchen did not have a posted cleaning schedule. She stated that the kitchen staff worked as a team to make sure the kitchen was clean. Interview, observation, and record review on 1/4/2024 at 9:00 AM with CNA M revealed snacks for residents, along with food brought to residents from friends and family, were stored in the snack refrigerator in the storeroom in the 200 hallway (refrigerator A.) CNA M stated the nursing staff was responsible for Refrigerator A, and its contents. The Refrigerator A had a sheet of paper affixed to its outside, which indicated the refrigerator was monitored for temperature daily. The log sheet indicated [designated staff and volunteers will record the time, air temperature, and their initials. Refrigerators should be between 36 Degrees F and 41 Degrees F.] The Refrigerator A was checked on 1/1/2024 at 12:00 midnight, with a logged temperature of 32 degrees F; 1/2/2024 at 1:00 AM, with a logged temperature of 30 degrees F; 1/3/2024 at 12:00 AM, with a logged temperature of 30 degrees F; and 1/4/2024 at 12:00 AM, with a logged temperature of 30 Degrees F. At the time of the observation, a state issued temperature and humidity monitor, Smart Pro SC42, was utilized to obtain the internal temperature, which reflected 46 Degrees F. The Refrigerator A had a thermometer inside, which registered the same temperature as the Smart Pro SC42, which was 46 Degrees F. Interview and observation 1/4/2024 at 9:15 AM with the DON at Refrigerator A revealed that the Smart Pro SC42, which read 46 Degrees F, and the internal thermometer of Refrigerator A, which read 46 Degrees F, were the same. The DON reached in the refrigerator and turned the cooling mechanism dial in the direction to make Refrigerator A colder. There were 18 pudding cups, a personal lunch box for a staff member, and two unopened bottles of juice in the refrigerator. The pudding cups, and the two unopened bottles of juice, were not marked with labels to signify the product name, the date they were placed in the refrigerator, or the date they would expire. Interview on 1/4/2024 at 9:20 AM with MW revealed that he has not been asked by nursing staff to check the Refrigerator A for any issues or concerns with it having not cooled to a proper temperature. Interview on 1/4/2024 at 9:25 AM with HK A revealed that housekeeping staff was supposed to be checking the refrigerators in each resident's room for proper temperature; however, HK A stated she had not been checking the refrigerators, and logging the temperatures, since December, because she did not have any temperature log sheets. Interview on 1/4/2024 at 9:22 AM with HK B revealed she had been checking temperature daily but had not been recording any for January because she did not have any log sheets. Interview and observation on 1/4/2024 at 9:27 AM with HK C revealed she was the housekeeping supervisor. HK C confirmed that housekeeping staff was responsible to check the refrigerator temperatures in the rooms and to log the temperature on a log sheet, but she did not have any log sheets to give to her staff. The Refrigerator A, which was in a nearby room, had log sheets in a plastic sleeve taped to the Refrigerator A. HK C was observed getting a blank copy of the log sheet so she could make copies. Observations on 1/4/2024 at 9:45 AM in room [ROOM NUMBER] reflected the internal temperature of the refrigerator was 49 Degrees F. The foods inside of the refrigerator did not possess any labels or dates to signify the item name or the date the product would expire. Observations on 1/4/2024 at 9:55 AM in room [ROOM NUMBER] reflected the internal temperature of the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 8 of 10 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 01/04/2024 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 refrigerator was 50 Degrees F. The foods inside of the refrigerator did not possess any labels or dates to signify the item name or the date the product would expire. Observations on 1/4/2024 at 10:04 AM in room [ROOM NUMBER] reflected the internal temperature of the refrigerator was 72 Degrees F. There was no food in the refrigerator, only bottles of water. Residents Affected - Many Observations on 1/4/2024 at 10:10 AM in room [ROOM NUMBER] reflected the internal temperature of the refrigerator was 53 Degrees F. The foods inside of the refrigerator did not possess any labels or dates to signify the item name or the date the product would expire. Interview on 1/4/2024 at 10:15 AM with HK D revealed housekeeping staff was supposed to check the refrigerators in each resident's room and write down the temperatures, but she did not have any log sheets to write the temperature down. Interview on 1/4/2024 at 1:15 PM with the ADON M stated the nursing staff was responsible for the temperature logs and the foods in the 200-hallway snack refrigerator, Refrigerator A. If the Refrigerator A was not keeping the correct temperatures, she stated that staff was supposed to notify a supervisor or maintenance about the issue. The ADON M stated that food was supposed to be stored at the correct temperatures in Refrigerator A because food could go bad, and residents could get sick if eaten. The ADON M stated that negative outcomes of residents eating spoiled food could be nausea, vomiting, diarrhea, and abdominal pain. She stated that there have not been any singular, or multiple, events of residents having had complained about gastrointestinal problems. Interview on 1/4/2024 at 1:23 PM with the DON revealed housekeeping staff was provided with a log sheet and were supposed to check temperatures of the refrigerators in the resident's rooms daily; as well, housekeeping staff were to make sure all food products in the resident's rooms were labeled with product names and a date when they would be expected to expire. The DON stated that foods not stored in proper containers, or at the proper temperature, could grow food borne pathogens and make residents sick. The DON stated the failure for missing temperature logs, and foods not being labeled properly, in the resident's rooms was that the housekeeping supervisor was not following up and checking on the staff's work. surfaces in the kitchen needed to be kept clean to prevent both food borne pathogens and the spread of germs. She stated the failure on the kitchen's part to keep surfaces clean and sanitized was the DM and the lack of staff training. She described negative outcomes of ingesting bacteria and food borne pathogens could lead to nausea, diarrhea, abdominal pain, weight loss, and dehydration. The DON stated there have been no singular, or multiple, events of residents complaining of gastrointestinal issues. Interview on 1/4/2024 at 2:17 PM with the DM revealed it was important to clean and sanitize kitchen surfaces to prevent bacteria, food borne pathogens, and cross contamination. If a resident ingested bacteria or food borne pathogens, they could get sick and experience stomach pain, diarrhea, and vomiting. The DM stated the failure to keep kitchen equipment and surfacers sanitized was a result of staff not doing what they were supposed to do. Interview on 1/4/2024 at 2:55 PM with the ADM revealed he expected his kitchen staff to be cleaning the kitchen both before and after meals. He stated the facility was feeding residents, who might already have compromised immune systems, and the consumption of bacteria and food borne pathogens could make the residents' sick. The ADM stated the failure to keep kitchen surfaces clean and sanitized, regulate refrigerator temperatures, and store food correctly was that staff simply failed to perform their job duties as instructed. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 9 of 10 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 01/04/2024 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 Record review of the facility's [Food Preparation and Service Policy], dated July 2014, indicated foods stored between 41 Degrees F and 135 Degrees F promotes the rapid growth of pathogenic microorganisms that cause foodborne illnesses; residents should be discouraged from saving anything from their meals for later consumption; and residents are strongly discouraged from keeping potentially hazardous foods in their rooms. Residents Affected - Many Record review of the facility's [Foods Brought by Family/Visitors], dated February 2014, indicated perishable food must be stored in sealable containers with tightly fitting lids in the refrigerator. Containers will be labeled with the resident's name, the item, and the [use by] date; the nursing staff was responsible for discarding perishable foods on or before the [use by] date; and potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than two hours will be discarded. Record review of the facility's [Sanitization Policy], dated October 2008, indicated all utensils, counters, shelves, and equipment shall be kept clean, maintained in good repair and shall be free from (2) breaks, corrosion, open seams, cracks, and chipped areas that may affect their use or proper cleaning. Seals, hinges, and fasteners will be in good repair; (3) all equipment, food contact surfaces, and utensils shall be washed to remove or completely loosen soils by using the manual or mechanical means necessary and sanitized using hot water or chemical sanitizing solution; (10) food preparation equipment and utensils that are manually washed will be allowed to air dry whenever practical; (12) ice machines and ice storage containers will be drained, cleaned, and sanitized per manufacturer's instructions and facility policy; (16) kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and frequently enough to prevent accumulation of grime; and (17) the food service manager will be responsible for scheduling staff for regular cleaning of kitchen and dining areas. Food service staff will be trained to maintain cleanliness throughout their work areas during all tasks, and to clean after each task before proceeding to the next assignment. Record review of the kitchen's cleaning schedule, undated, indicated to clean the can opener after every use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 10 of 10