Health inspection·July 29, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and she did not respond to questions. Resident #1 appeared to be clean and was dressed appropriate for the weather. Resident #1 showed no signs of pain or distress and only mumbled a few unintelligible words. In an interview on 07/29/2025 at 8:11 AM, the FM stated Resident #1 was left suspended in the air in the sling of the mechanical lift by the CNA for 31-32 seconds and there was no injury during the transfer. She stated resident had had some bumps, cuts, and bruises with some of the other transfers. She stated she was not aware of any other transfers being done with only one staff member present. In an interview on 07/29/25 at 10:57 AM, CNA A stated he had worked in the facility for about a year, and he usually worked the 8-5 shift, but he also filled in on other shifts when they needed him. He stated he had been in-serviced on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. He stated when he transferred a resident with the mechanical lift, there must be 2 staff members present the entire time from start to finish. He stated if there were not 2 staff member present during the mechanical lift transfer, it could have caused a resident to fall or get hurt. He stated the lift could have tilted or anything could have happened. He stated he was not aware of any falls from the mechanical lift. He stated he knew he should not ever leave a resident hanging suspended in air in the sling of the mechanical lift while he went to go look for help or to do anything else. He stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could have caused the resident to fall, or the lift could have tilted. In an interview on 07/29/25 at 11:10 AM Interview with staff CNA B, she stated she had worked in the facility for about 5 years, and she worked the 2-10 shift and extra shifts at times. She stated she had been in-serviced regularly on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. She stated when she transferred a resident with the mechanical lift, there must be 2 staff members present the entire time from start to finish. She stated if there were not 2 staff member present during the mechanical lift transfer, it could have caused a resident to fall, or anything could have happened and that is why there needed to be 2 people in there during the entire process. She stated she was not aware of any falls from the mechanical lift. She stated she would never leave a resident hanging suspended in air in the sling of the mechanical lift while she went to look for help or to do anything else. She stated she should have never had to look for help because there should have always been 2 staff members present when using the lift. She stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could have caused a resident to fall. In an interview on 07/29/25 at 11:31 AM, LVN C stated she had worked in the facility for about 5 years, and she worked the 6-2 shift. She stated she had been in-serviced on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. She stated when transferring a resident with the mechanical lift, there should have always been 2 staff members present the entire time from start to finish. She stated if there were not 2 staff members present during the mechanical lift transfer, it could have caused a resident to get an injury and it could have kept the resident from being safe. She stated she was not aware of any falls from the mechanical lift. She stated she would have never left a resident hanging suspended in air in the sling of the mechanical lift while she went to look for help or to do anything else. She stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could have caused the resident to fall out of the lift or get injured and it could have been very bad. In an interview on 07/29/25 at 11:43 AM, the DON stated staff were in-serviced regularly on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. She stated it was her expectation that when transferring a resident with the mechanical lift, there was 2 staff members present the entire time from start to finish. She stated if there were not 2 staff members present during (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 2 of 4 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 07/29/2025 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 - Minimal harm or potential for actual harm Residents Affected - Few the mechanical lift transfer, it could have caused resident injury or death. She stated it was a resident safety and an employee safety issue. She stated she was not aware of any falls from the mechanical lift. She stated it was her expectation that staff never leave a resident hanging suspended in air in the sling of the mechanical lift for any reason. She stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could have causes resident injury or death. In an interview on 07/29/25 at 12:02 PM, the ADM stated staff were in-serviced regularly on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. He stated it was his expectation that when transferring a resident with the mechanical lift, there was 2 staff members present the entire time from start to finish. He stated if there were not 2 staff members present during the mechanical lift transfer, it could have caused harm to the resident and could have led to a fall. He stated he was not aware of any falls from the mechanical lift. He stated it was his expectation that staff never left a resident hanging suspended in air in the sling of the mechanical lift for any reason. He stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could have caused physical or emotional harm or distress. In an interview on 07/29/25 at 12:11, LVN D stated she had worked in the facility for about 8 months, and she worked the 6-2 shift. She stated she was in-serviced regularly on abuse and neglect, transfers/mechanical lift transfers, and falls/fall prevention. She stated when transferring a resident with the mechanical lift, there must be 2 staff members present the entire time from start to finish. She stated if there were not 2 staff members present during the mechanical lift transfer, it could have caused a fall or injury to a resident, or a staff member could have been hurt as well. She stated she was not aware of any falls from the mechanical lift. She stated she would have never left a resident hanging suspended in air in the sling of the mechanical lift while she went to look for help or to do anything else. She stated if a resident were left suspended in the air in the sling of the mechanical lift and staff walked away, it could cause harm to the resident. In an interview on 07/29/25 at 1:08 PM, the ADM identified CNA A in the picture provided by FM and stated CNA A had been trained on mechanical lift transfers and knew he should not have left Resident #1 suspended in the air for any amount of time. In an interview on 07/29/2025 at 1:17 PM, CNA A stated it was right around dinner time, and he went to get resident up. He stated he put Resident #1 in the mechanical lift sling and lifted resident up and realized he could not do it by himself and went to the door opening and looked out a yelled for the nurse to come help him. He stated the nurse was at the end of the hall, and he went straight back to the resident. He stated Resident #1 was alone for maybe 10 seconds and the nurse came in to assist him and they completed the transfer. He stated there were no issues while resident was suspended in the air and no injuries occurred from the transfer. He stated he knew he should not have tried to transfer the resident by himself, and it was a onetime thing, He stated he was in a hurry, and it was a mistake. He stated he had been trained on mechanical lift transfers and it was just a mistake and a spur of the moment thing, and he would never do it again. During an attempted phone interview on 07/29/25 at 2:30 PM, 2:32 PM, 2:41 PM, with LVN F, there was no answer, and the call went directly to voicemail. A voice message was left after the 3rd call stating the purpose of call and requesting a return call. During a phone interview on 07/30/25 at 12:59 PM, LVN F stated she worked the evening shift on 07/10/25 but she could not remember if CNA A had asked her for help with a transfer for Resident #1. Record review of the facility list of residents that required transfer by the mechanical reflected Resident #1 was to be transferred by the mechanical lift. Record review of undated facility form titled Transferring a resident using a mechanical lift reflected: Two staff members are required to assist when using a mechanical lift, three staff members (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 3 of 4 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 07/29/2025 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 - Minimal harm or potential for actual harm for larger residents if care plan requires. Reverse the procedure to return the resident to bed. When raising the resident from the chair, ensure that one person guides the feet and legs to ensure the resident does not lean forward and one person to protect the head. Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675150 If continuation sheet Page 4 of 4