Inspection·February 26, 2024

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some report any abnormal levels. The Care Plan reflected Resident #1 had an altered endocrine system (a network of glands and organs in the body that use hormones to control and regulate many of the body's functions) status related to chronic kidney disease (date initiated and revised: [DATE]) and the interventions included: Fasting Blood Glucose as ordered by MD, Monitor/document/report to MD PRN any s/sx (signs and symptoms) of behavioral changes: nervousness, increased irritability, emotional lability (change or inconsistency), insomnia, extreme fatigue, confusion, disorientation, delirium, psychosis, stupor, coma. and Monitor/document/report to MD PRN for s/sx of hyperglycemia (elevated or high blood sugar): increased thirst and appetite, weight loss, fatigue, dry skin, poor healing, muscle cramps, abdominal pain, deep labored breathing (Kussmaul), acetone (fruity) breath, stupor, coma. Record review of Resident #1's Order Summary Report, order date range: [DATE] - [DATE], revealed Resident #1 had active blood glucose check orders which included: Glucose Check BID x 7 days then report to PCP on 02/22 two times a day (repeated direction to check blood sugars twice a day) related to type 2 diabetes mellitus with hyperglycemia, ordered and start date: [DATE], Monitor for signs or symptoms of hypoglycemia or hyperglycemia Q shift. Every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy (damage to the nerves that control arm and leg movement), ordered [DATE] and started [DATE], and Monitor resident for confusion, combativeness, and restlessness. If resident is experiencing any of these, check blood sugar, every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy, ordered [DATE] and started [DATE]. Active blood glucose check orders found to not include blood sugar parameters, directing staff when they were to notify the physician of blood sugars below or above the expected range. Resident #1 had active diabetes medication orders which included: Glucagon Emergency Injection Kit 1 MG .Inject 1 mg subcutaneously (between the skin and muscle) as needed for signs or symptoms of hypoglycemia related to type 2 diabetes mellitus with other diabetic neurological complication, ordered and started [DATE] and Trulicity Subcutaneous Solution Pen-injector 0.75 mg/0.5 mL .Inject 0.75 mg subcutaneously one time a day every 7 days(s) related to Type 2 diabetes mellitus with hyperglycemia, ordered [DATE] and started [DATE]. Active diabetes medication orders found to not include an active order for insulin. Record review of Resident #1's TAR, dated [DATE] - [DATE], revealed Resident #1's blood sugar checks BID which included: - a blood sugar of 577 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 432 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, - a blood sugar of 550 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 487 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 498 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 502 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 486 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 424 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 492 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 2 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0580 - a blood sugar of 498 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, and Level of Harm - Immediate jeopardy to resident health or safety - the blood sugar check coded as not taken due to hospitalization by LVN M. Residents Affected - Some Record review of Resident #1's progress notes, dated [DATE] at 07:00 p.m., revealed the following note by the ADON, [Resident #1's PCP] notified of resident with blood sugar 577. Asymptomatic (no symptoms). No new orders. Record review of Resident #1's progress notes, dated [DATE] at 10:00 a.m., revealed the following note by RN Z, [Resident #1's PCP] is aware of blood sugar this AM (morning) 432; no new orders at this time. Record review of Resident #1's progress notes, dated [DATE] at 12:55 p.m., revealed the following note by LVN 1, .[MD X] will no longer be PCP for [Resident #1]. She (Resident #1 RP) stated [MD W] will now be his primary care physician. I informed [MD X], and notified [MD W]'s nurse of change effective today. Record review of Resident #1's progress notes, dated from [DATE] at 10:01 a.m. to [DATE] at 03:53 p.m., revealed no progress notes mentioning blood sugar results or notification to physician. Record review of Resident #1's progress notes, dated [DATE] at 03:54 p.m., revealed the following note by RN Z, one week of blood sugar results sent to [Resident #1's PCP]. Pending response. Record review of Resident #1's progress notes, dated [DATE] at 04:00 p.m., revealed the following note by RN Z, called into room by CNAs. Res (resident) was lying in bed with eyes closed, respirations shallow, difficult to arouse. Unresponsive to tactile stimuli. Upon assessment .blood sugar too high to register on glucometer (machine used to test blood sugar). Immediately contacted [Resident #1's PCP]. New orders received to send to [local hospital] ER (emergency room) for further eval (evaluation) and tx (treatment) . Record review of Resident #1's progress notes, dated [DATE] at 04:09 p.m., revealed the following note by LVN N, [Resident #1] was transferred to a hospital on [DATE] 4:05 PM related to High blood sugar, unresponsive. Record review of Resident #1's progress notes, dated [DATE] at 11:40 a.m., revealed the following note by RN Z, Res (resident) is admitted to [hospital name and location]; ICU (intensive care unit) DX (diagnoses): Hyperglycemia, Altered Mental Status. Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 was admitted to the ER on [DATE] at 05:44 p.m. The records reflected Resident #1 was discharged from the ER on [DATE] to an alternate hospital. The ER notes dated [DATE] reflected Resident #1's chief complaint was hyperglycemia and an altered mental status. Resident #1 noted to had started seizing when on bed with no prior history of seizures. Resident #1 was intubated and placed on a mechanical ventilator, diagnosed with altered mental status, hyperglycemia (high blood glucose/sugar), hyperosmolar hyperglycemic state (HHS; a life-threatening complication of diabetes when the blood glucose or blood sugar levels are too high for a long period, leading to severe dehydration and confusion), seizure, respiratory failure, GI (gastrointestinal) bleed, sepsis (a condition in which the body's extreme response to an infection become life-threatening), urinary tract infection, and an electrolyte disorder. Glucose level measured at 798 mg/dL on [DATE] at 05:52 p.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 3 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Record review of addendum to facility self-report to HHSC Complaint and Incident Intake, dated [DATE] at 03:53 p.m., revealed the following note by the ADMIN, He (Resident #1) passed away on [DATE] at 10:37 p.m. We (the facility) do not have a cause of death at this time. Interview with RN Z on [DATE] at 03:01 p.m. revealed she had reviewed Resident #1's weekend blood sugars when she came in to work on Monday, [DATE], seen that they were elevated, and sent the blood sugar results to Resident #1's physician. RN Z stated she had reported his high blood sugar that morning but Resident #1 was awake, alert, and up in the dining room for breakfast and lunch. RN Z stated Resident #1's change in condition started right before she had sent him out, after lunch. RN Z stated she did not hear back from Resident #1's physician when reporting the initial high blood sugar but called the physician again for the change of condition and transfer out to the hospital. RN Z did not state the time for the second call to Resident #1's physician. RN Z described Resident #1's change as condition as being slower to respond, not really answering staff, and just not himself. Interview with SNA AC on [DATE] at 03:17 p.m., revealed she had been taking care of Resident# 1 on Sunday, [DATE] and around 05:30 p.m. observed a concern about how Resident #1 was positioned in bed and that Resident #1 was not breathing as good as he normally did. SNA AC stated she had reported her observations to the nurse. SNA AC stated she had worked at the facility for less than a month and had not yet been trained on how to document in the facility's EMR. Interview with CNA A on [DATE] at 03:28 p.m., revealed she had been taking care of Resident #1 on Monday, [DATE] during the day. CNA A revealed she had observed Resident #1 to have been behaving normally, chatty and responsive that morning. CNA A stated after lunch, she had reported to Resident #1's nurse (RN Z) that when she and another CNA (CNA B) went into Resident #1's room to get him up from an after-lunch nap, he was not as responsive as normal. CNA A stated she had tried physical stimulus (rubbing Resident #1 wrist), which he did not respond to. CNA A stated she also observed an unknown purple substance around Resident #1's mouth, which she had cleaned off when the nurse came in to check Resident #1's vitals. CNA A did not state she documented her observations in the facility EMR or notify the nurse of the purple substance during the interview as part of her recollection of events. Interview with CNA B on [DATE] at 03:37 p.m., revealed she had observed Resident #1 during Monday, [DATE] and had noted that he was his normal responsiveness and able to have a conversation with her that morning. CNA B stated that after lunch Resident #1 started to be different, dazed. CNA B revealed she reported her observations to Resident #1's nurse (RN Z). Interview with the ADON on [DATE] at 04:08 p.m., revealed she had worked [DATE] for the 08:00 p.m. blood sugar check shift. The ADON stated that Resident #1 had looked fine, was acting his normal or not any different than he has been since his recent stroke. The ADON stated that for one of her shifts that week Resident #1 had a very high blood sugar and she had called Resident #1's physician who said he did not want to do anything if the resident was asymptomatic (without symptoms). The ADON stated she did not call Resident #1's physician again because when she had called on [DATE], the physician said that if Resident #1 was asymptomatic he was not going to do anything. Interview with MD W on [DATE] at 04:37 p.m., revealed he had been notified of changes in Resident #1's blood sugar medications, including the approval of diabetic medication Trulicity by Resident #1's insurance and that Resident #1's prior PCP had wanted to decrease Resident#1's insulin, but had not received any calls regarding Resident #1's high blood sugars until Monday morning, [DATE]. MD W revealed his expectation was for the facility to call him if a resident's blood sugar was below 60, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 4 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some over 400, or symptomatic (having symptoms). MD W stated he believed Resident #1's comorbidities (having more than one medical condition at the same time) were contributing to Resident #1's blood sugar problems. MD W revealed he was not sure that if the facility had contacted him sooner regarding Resident #1's elevated blood sugars, if it would have made a difference but it would have been ideal for the facility to have had contacted him sooner. Interview with LVN P on [DATE] at 05:37 p.m., revealed her observations for Resident #1 during her shifts on [DATE]- [DATE] were that he was fine when he had high blood sugars. His behaviors were fine and happy. He was back to his normal self. LVN P stated when Resident #1 had low blood sugars he would become confused and combative. LVN P stated she reported to Resident #1's physician when Resident #1 was experiencing lows but could not remember if she had called the physician for the high blood sugars. LVN P revealed Resident #1 did not have symptoms when his blood sugars were high. LVN P stated Resident #1's respirations were great, he was sleeping well, and he was his normal self. LVN P revealed she felt the physician would have known Resident #1 was having high blood sugars since the physician discontinued Resident #1's insulin. Interview with LVN R on [DATE] at 06:11 p.m., revealed her observations for Resident #1 during her shifts on [DATE] - [DATE] were that Resident #1 was good, just tired which was not abnormal for him recently. LVN R stated that she could recall that Resident #1 had an order during that time to monitor Resident #1's blood sugars and then to report it in 7 days, which she believed was either that following Monday ([DATE]) or Tuesday ([DATE]). LVN R stated she did not report Resident #1's high blood sugars during her shifts because of the monitoring order with instruction to report in 7 days and she had reviewed Resident #1's previous blood sugars and found them to be consistent with the blood sugars she had collected. LVN R stated Resident #1's blood sugars were all the same, all in the 400's and not fluctuating, such as from the 100's to the 400's. LVN R also revealed Resident #1 was not showing symptoms, which he did when experiencing a low blood sugar and that she did not have any concerns. Interview with MD X on [DATE] at 11:20 a.m., revealed Resident #1's blood sugars had been fluctuating quite a bit due to Resident #1's renal (kidney) failure, which was causing his blood sugars to become difficulty to control. MD X revealed that he did recall the facility's nursing staff contacting him regarding Resident #1's blood sugars but could not recall when without his notes. MD X stated the facility contacted him regarding Resident #1's change in physician on [DATE] and that was the last contact he received from the facility for Resident #1's care. MD X stated prior to the change in physician, he was trying to make chronic (long-term) changes and did not want to make acute (immediate) changes in regulating Resident #1's blood sugar. MD X revealed his expectation for the facility staff to notify him for blood sugars was for them to call if a resident's blood sugar was at 500. MD X revealed that if a resident was at 500 and symptomatic, he would order adjustments and send the resident out to the hospital, but if not symptomatic, he would just make adjustments to the insulin order. MD X revealed Resident #1's insulin orders had been discontinued due to Resident #1 having had bottomed out (experienced a low blood sugar episode) earlier that month (early February), Resident #1 was very brittle, and Resident #1's blood sugars had been going in the wrong direction (blood sugar dropped) with insulin. Interview with the RCN on [DATE] at 02:16 p.m., revealed the facility procedure for a blood sugar outside parameters (the expected range) was to follow the order, including to hold the medication, give an additional medication, re-check, and/or immediately contact the physician per the doctor's orders. She stated that staff are expected to contact the physician if there is a pattern in a resident's blood sugars being outside the blood sugar parameters or a pattern of refusals by the resident. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 5 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some She revealed that if a resident was experiencing a high blood sugar, the doctor was to tell them what they are to give to the resident and when to re-check the resident's blood sugar. The RCN stated that the nurse was responsible for entering the physician's order into the facility's EMR, documenting the order and interventions in a progress note, and reporting any changes to the resident's RP. She revealed that reporting high and low blood sugars is important for tracking the resident's blood sugar trends and that if a resident was running a high blood sugar all the time, their medications would need to be adjusted to limit the long-term effects it could have, which may be harmful if not treated. The RCN stated that facility staff should monitor blood sugars as ordered, notify the resident's physician immediately if outside parameters and follow the orders that the physician gives. Interview with the ADMIN on [DATE] at 02:34 p.m., revealed reporting any change of condition is important, to let the physician know and be aware of it. The ADMIN revealed his expectation was that staff call the resident's physician, report that they had contacted the physician, make the changes per the physician, and make notifications to the resident's family for any changes of condition. The ADMIN revealed that this was standard nursing practice and an order. Record review of facility policy, Notifying the Physician of Change in Status, dated revised [DATE], revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .11. Abnormal lab, x-ray and other diagnostic reports require physician notification. Record review of facility policy, Medication Administration Procedures, dated 2003, revealed 13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber. This failure resulted in an identification of an immediate jeopardy on [DATE] at 01:27 p.m. The Administrator was informed and provided the IJ template on [DATE] at 06:00 p.m. and a plan of removal (POR) was requested. The plan of removal reflected: [DATE] Plan of Removal- F580 Notify of Changes Interventions: - 100% blood sugar audit completed on [DATE] by Regional Compliance Nurse - Blood sugar checks were assessed on [DATE] to ensure that blood sugar parameters were in place, if not, parameters were requested by attending physician and added. - 100% of residents with blood sugar checks were audited on [DATE] and Physician(s) were notified of all blood sugars outside of parameters or were excessively high or low. Date completed [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 6 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some - The following in-services were initiated [DATE] by Regional Compliance Nurse. Inservice 100% of staff completion date: [DATE]. Inservice has been added to new-hire packets for all new hires and agency staff to ensure all staff is in-serviced prior to start of their first shift. - Perform blood sugar checks as ordered. - Ensure any resident who has blood sugar checks has a parameter to the physician or nurse practitioner (NP). This includes when to report new orders for current residents, new admissions, and readmissions. - To report to the MD or NP if a blood sugar check is outside the ordered parameters immediately and to initiate any new orders. - If resident(s) has an order for glucagon, follow the prescriber's orders. - Policy on Notifying the Physician of Change in Status - The following in-services were initiated on [DATE] for all NA/CNAs by nursing administration and/or Regional Compliance Nurse. Inservice 100% of NA/CNA completion date [DATE]. - Hyperglycemia - excessive thirst/dry mouth, excessive urine, increased fatigue/weakness, blurred vision - Hypoglycemia-sweating, dizzy, shaking, increased confusion, anxiety, drowsy, change in mental status, slurred speech, nausea, lightheaded, loss of coordination. - Notified Medical Director of IJ situation on [DATE] at 6:17 pm. Monitoring: - At least five (5) times per week, nursing administration will review the previous days orders using the order listing report in [the facility's EMR] to monitor for new orders for blood sugar checks and ensure that parameters are added. This will include new orders for current residents, new admissions, and readmissions. This was initiated on [DATE] continue x 4 weeks. - At least 5 times per week nursing administration will review the previous days TARS and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters. This was initiated on [DATE] and will continue x 4 weeks. - Nursing Administration will ask at least 10 nursing staff per week a situational question regarding if a resident presented with hyper or hypoglycemia and what they would do. This was initiated on [DATE] and will continue x 4 weeks. - DON/Designee will review 5-8 residents slide scale results for proper notification to MD if outside parameters weekly. This will be initiated on [DATE] and continue x 4 weeks. - DON/Designee will monitor all blood sugars outside parameters of slide scale for notification to MD weekly x 4 weeks. This was initiated [DATE] and will continue x 4 weeks. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 7 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0580 - Regional Compliance Nurse will monitor for compliance weekly x 4 weeks starting on [DATE]. Level of Harm - Immediate jeopardy to resident health or safety - The QA (Quality Assurance) Committee will review findings and Physician Notification Policy and will make changes as needed monthly. This will occur during the next QAPI (Quality Assurance and Performance Improvement) meeting on [DATE]. Residents Affected - Some Monitoring of the plan of removal included: Interviews were conducted on [DATE] from 02:50 p.m. to 07:47 p.m. with 2 RNs (RN Z and RN AA) of 2 and 9 LVNs (LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, and LVN S) of 9, who worked multiple shifts, revealed they had all been trained on the facility policy, Notifying the Physician of Change in Status. The nursing staff were knowledgeable on the requirement that all blood sugar monitoring orders must include blood sugar parameters, and on the protocols to follow including what to document and who to notify if a blood sugar was outside parameters or a resident was showing signs or symptoms of being hypo or hyperglycemic. The staff were able to identify when it would be appropriate to administer glucagon and how to report and document glucagon administration. Interviews were conducted on [DATE] from 03:13 p.m. to 08:37 p.m. with 6 CNAs (CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F) of 9, 3 HAs (HA H, HA I, and HA J) of 3, 2 MAs (MA T and MA U) of 3, and 6 SNAs (SNA AB, SNA AC, SNA AD, SNA AE, SNA AF, and SNA AG) of 8; and on [DATE] at 10:32 a.m. with 1 CNA (CNA G). Interviews revealed they worked multiple shifts, had all been trained and were able to identify signs and symptoms of hypo and hyperglycemia, and were knowledgeable on who they needed to report to. In an interview and record review with the RCN on [DATE] at 03:55 p.m., she revealed she had started and was conducting the staff in-services. The RCN confirmed the ADMIN, with her present, had notified the facility's medical director of the Immediate Jeopardy (IJ). The RCN revealed the plan for the facility administration to monitor every new blood sugar order, ensuring that every new order included parameters was to review the previous day's (or days' for new orders over the weekends and holidays) orders by printing out an Order Listing Report from the facility's EMR, which would show all of the previous days' orders. The RCN revealed she had completed the initial blood sugar monitoring audit on [DATE]. She revealed that she had discovered a few residents without parameters on their orders. The RCN revealed she called the residents' physicians to add the parameters, asked the physicians about glucagon orders if not currently included in the residents' active order list, and added the orders with parameters per the physician's order. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days orders using the order listing report in [EMR system name] to monitor for new orders for blood sugar checks and ensure that parameters were added., was the monitoring document the facility would use to track their completion of this monitor. The document revealed this monitor was to be tracked 5 times a week for 4 weeks and that the monitor had been completed on [DATE], [DATE], and [DATE] for week 1. The RCN revealed the plan for facility administration to monitor each resident's blood sugar, that had a blood sugar monitoring order, for being completed per order and to verify the resident's MD or NP was notified if the blood sugar was outside parameters was by printing out the previous day's (or days' if after a weekend and/or holiday) Weights and Vitals Summary report from the facility's EMR, which would show all the previous days' blood sugar results, identify any blood sugars outside parameters, and review the resident's progress notes for a note on notification to the physician and/or nurse practitioner for any blood sugar results outside parameters. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days TARs and the medical record to ensure that blood sugar checks were performed as (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 8 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some ordered and the MD or NP was notified if it was outside the ordered parameters., was the monitoring document the facility would use to track their completion of this monitoring. The document revealed this monitoring was to be tracked 5 times per week for 4 weeks and that the monitoring had been completed on [DATE], [DATE], and [DATE] for week 1. Weights and Vitals Summary reports for dates [DATE], [DATE], and [DATE] were provided and revealed initials on each page to indicate it had been reviewed and check marks next to each blood sugar out of parameters to indicate a corresponding progress note had been confirmed to indicate the MD or NP had been notified. The RCN revealed the ADON would be responsible for completing the review of the 5-8 residents with sliding scale insulin orders for proper notification of the MD if the blood sugar was outside parameters. The RCN stated that this monitor was the same process or intervention as the intervention for reviewing the TARs for residents with orders for blood sugar monitoring. The RCN revealed the plan for the facility administration to ask at least 10 nursing staff situational questions regarding if a resident had high or low blood sugars and what they would do was to utilize the monitoring document, labeled with Nursing administration will ask at least 10 nursing staff per week a situational question ., mark Yes or No if the staff member answered the question correctly or incorrectly, and if incorrect, document how they answered the question incorrectly and what the nursing administration's plan was for correcting the incorrect answer (ex. in-service training). The document revealed this monitoring was to be completed 10 times per week for 4 weeks, had a spot to put the date, indicate if the answer was correct or incorrect, the staff name of the person questioned, and the name of the interviewer. The document revealed two staff members had been questioned, both on [DATE], and both had answered correctly. The RCN revealed the plan for her to monitor that the facility administration and DON/designee were compliant with the other interventions/monitors for 4 weeks was for her to come to the facility at least one time per week, review the other monitoring forms to ensure they are up to date, review the related Weights and Vitals Summary reports and Order Listing Report that the facility will be maintaining in a specified binder, and to mark Yes or No on the monitoring document, labeled with Regional Compliance Nurse and/or ADO (ADON) compliance monitoring:. The document revealed this monitoring was to be completed for 4 weeks and did not have any weeks marked as completed at the time of the interview. In an interview with the ADON on [DATE] at 04:08 p.m., she revealed she had received training on the facility policy, Notifying the Physician of Change in Status, blood sugar checks procedure, administering glucagon per order, reporting blood sugars to the resident's physician or NP immediately if outside parameters or when symptomatic, documenting physician notifications and new orders, and verifying that all new blood sugar monitoring orders included parameters on [DATE]. The ADON revealed she was to print out the Weights and Vitals report and document for new orders daily. The ADON revealed she was to review the reports for new orders and to review the blood sugars to identify if any residents had blood sugars less than 60 or over 400. She revealed that she was to review the progress notes and the 24-hour or 72-hour report to confirm the nurse notified and documented that they notified the physician of a blood sugar outside parameters. The ADON revealed she was to ask CNAs from different shifts to determine if they could recognize signs and symptoms of a hyper or hypoglycemia and what they were supposed to do if they observed those signs or symptoms. The ADON revealed she planned to in-service the staff member if they answered incorrectly and document on the monitoring form FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 9 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals. Level of Harm - Immediate jeopardy to resident health or safety **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to ensure that based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 13 residents (Resident #1) reviewed for quality of care, in that: Residents Affected - Some The facility failed to ensure Resident #1's received timely treatment and care for the resident's Type II Diabetes when the resident went multiple days of blood sugar readings above 400 with no interventions, resulting in the resident being hospitalized on [DATE] and expired on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 01:27 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm and a scope of isolated due to the facility still monitoring the effectiveness of their Plan of Removal. This deficient practice could place residents at risks for a delay in medical treatment, which could lead to worsening of their condition, hospitalization, or death. Findings included: Record review of Resident #1's Administration Record, dated [DATE], revealed an [AGE] year-old male who originally admitted to the facility on [DATE] and last re-admitted on [DATE]. Resident #1 was noted to have discharged [DATE] to an acute care hospital. Resident #1 had diagnoses which included the following: diabetes mellitus (a condition that develops with the way the body regulates and uses sugar as fuel), chronic kidney disease (a condition where the kidneys lose their ability to filter blood and remove wastes), and heart failure. Record review of Resident #1's Quarterly MDS assessment, dated [DATE], revealed a BIMS score of 04, which indicated Resident #1's cognition was severely impaired. The MDS revealed Resident #1 was diabetic and received insulin injections. Further review revealed Resident #1 was dependent with mobility in rolling left to right, sit to lying, lying to sitting on side of bed, and sit to stand. Resident #1 required substantial to maximal assistance with chair to bed transfer, toilet transfer, and tub or shower transfer. Resident #1 was noted to have had an indwelling catheter (a tube that drains urine from the bladder into a bag outside the body) and always bowel incontinent. Record review of Resident #1's Care Plan, dated as last reviewed [DATE], reflected Resident #1 had diagnosed diabetes mellitus with other neurological complications (date initiated: [DATE] and date revised: [DATE]) and the interventions included: Diabetes medication as ordered by doctor. Monitor/document for side effects and effectiveness. and Fasting Serum Blood Sugar as ordered by doctor, report any abnormal levels. The Care Plan reflected Resident #1 had an altered endocrine system (a network of glands and organs in the body that use hormones to control and regulate many of the body's functions) status related to chronic kidney disease (date initiated and revised: [DATE]) and the interventions included: Fasting Blood Glucose as ordered by MD, Monitor/document/report to MD PRN any s/sx (signs and symptoms) of behavioral changes: nervousness, increased irritability, emotional lability (change or inconsistency), insomnia, extreme fatigue, confusion, disorientation, delirium, psychosis, stupor, coma. and Monitor/document/report to MD PRN for s/sx of hyperglycemia (elevated or high blood sugar): increased thirst and appetite, weight loss, fatigue, dry skin, poor healing, muscle (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 10 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0684 cramps, abdominal pain, deep labored breathing (Kussmaul), acetone (fruity) breath, stupor, coma. Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's Order Summary Report, order date range: [DATE] - [DATE], revealed Resident #1 had active blood glucose check orders which included: Glucose Check BID x 7 days then report to PCP on 02/22 two times a day (repeated direction to check blood sugars twice a day) related to type 2 diabetes mellitus with hyperglycemia, ordered and start date: [DATE], Monitor for signs or symptoms of hypoglycemia or hyperglycemia Q shift. Every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy (damage to the nerves that control arm and leg movement), ordered [DATE] and started [DATE], and Monitor resident for confusion, combativeness, and restlessness. If resident is experiencing any of these, check blood sugar, every day and night shift related to type 2 diabetes mellitus with diabetic polyneuropathy, ordered [DATE] and started [DATE]. Active blood glucose check orders found to not include blood sugar parameters, directing staff when they were to notify the physician of blood sugars below or above the expected range. Resident #1 had active diabetes medication orders which included: Glucagon Emergency Injection Kit 1 MG .Inject 1 mg subcutaneously (between the skin and muscle) as needed for signs or symptoms of hypoglycemia related to type 2 diabetes mellitus with other diabetic neurological complication, ordered and started [DATE] and Trulicity Subcutaneous Solution Pen-injector 0.75 mg/0.5 mL .Inject 0.75 mg subcutaneously one time a day every 7 days(s) related to Type 2 diabetes mellitus with hyperglycemia, ordered [DATE] and started [DATE]. Active diabetes medication orders found to not include an active order for insulin. Residents Affected - Some Record review of Resident #1's TAR, dated [DATE] - [DATE], revealed Resident #1's blood sugar checks BID which included: - a blood sugar of 577 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 432 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, - a blood sugar of 550 mg/dL (high) on [DATE] at 08:00 p.m. by the ADON, - a blood sugar of 487 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 498 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 502 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 486 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 424 mg/dL (high) on [DATE] at 07:00 a.m. by LVN R, - a blood sugar of 492 mg/dL (high) on [DATE] at 08:00 p.m. by LVN P, - a blood sugar of 498 mg/dL (high) on [DATE] at 07:00 a.m. by RN Z, and - the blood sugar check coded as not taken due to hospitalization by LVN M. Record review of Resident #1's progress notes, dated [DATE] at 07:00 p.m., revealed the following note by the ADON, [Resident #1's PCP] notified of resident with blood sugar 577. Asymptomatic (no symptoms). No new orders. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 11 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Record review of Resident #1's progress notes, dated [DATE] at 10:00 a.m., revealed the following note by RN Z, [Resident #1's PCP] is aware of blood sugar this AM (morning) 432; no new orders at this time. Record review of Resident #1's progress notes, dated [DATE] at 12:55 p.m., revealed the following note by LVN 1, .[MD X] will no longer be PCP for [Resident #1]. She (Resident #1 RP) stated [MD W] will now be his primary care physician. I informed [MD X], and notified [MD W]'s nurse of change effective today. Residents Affected - Some Record review of Resident #1's progress notes, dated from [DATE] at 10:01 a.m. to [DATE] at 03:53 p.m., revealed no progress notes mentioning blood sugar results or notification to physician. Record review of Resident #1's progress notes, dated [DATE] at 03:54 p.m., revealed the following note by RN Z, one week of blood sugar results sent to [Resident #1's PCP]. Pending response. Record review of Resident #1's progress notes, dated [DATE] at 04:00 p.m., revealed the following note by RN Z, called into room by CNAs. Res (resident) was lying in bed with eyes closed, respirations shallow, difficult to arouse. Unresponsive to tactile stimuli. Upon assessment .blood sugar too high to register on glucometer (machine used to test blood sugar). Immediately contacted [Resident #1's PCP]. New orders received to send to [local hospital] ER (emergency room) for further eval (evaluation) and tx (treatment) . Record review of Resident #1's progress notes, dated [DATE] at 04:09 p.m., revealed the following note by LVN N, [Resident #1] was transferred to a hospital on [DATE] 4:05 PM related to High blood sugar, unresponsive. Record review of Resident #1's progress notes, dated [DATE] at 11:40 a.m., revealed the following note by RN Z, Res (resident) is admitted to [hospital name and location]; ICU (intensive care unit) DX (diagnoses): Hyperglycemia, Altered Mental Status. Record review of Resident #1's hospital records, dated [DATE], reflected Resident #1 was admitted to the ER on [DATE] at 05:44 p.m. The records reflected Resident #1 was discharged from the ER on [DATE] to an alternate hospital. The ER notes dated [DATE] reflected Resident #1's chief complaint was hyperglycemia and an altered mental status. Resident #1 noted to had started seizing when on bed with no prior history of seizures. Resident #1 was intubated and placed on a mechanical ventilator, diagnosed with altered mental status, hyperglycemia (high blood glucose/sugar), hyperosmolar hyperglycemic state (HHS; a life-threatening complication of diabetes when the blood glucose or blood sugar levels are too high for a long period, leading to severe dehydration and confusion), seizure, respiratory failure, GI (gastrointestinal) bleed, sepsis (a condition in which the body's extreme response to an infection become life-threatening), urinary tract infection, and an electrolyte disorder. Glucose level measured at 798 mg/dL on [DATE] at 05:52 p.m. Record review of addendum to facility self-report to HHSC Complaint and Incident Intake, dated [DATE] at 03:53 p.m., revealed the following note by the ADMIN, He (Resident #1) passed away on [DATE] at 10:37 p.m. We (the facility) do not have a cause of death at this time. Interview with RN Z on [DATE] at 03:01 p.m. revealed she had reviewed Resident #1's weekend blood sugars when she came in to work on Monday, [DATE], seen that they were elevated, and sent the blood sugar results to Resident #1's physician. RN Z stated she had reported his high blood sugar that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 12 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0684 Level of Harm - Immediate jeopardy to resident health or safety morning but Resident #1 was awake, alert, and up in the dining room for breakfast and lunch. RN Z stated Resident #1's change in condition started right before she had sent him out, after lunch. RN Z stated she did not hear back from Resident #1's physician when reporting the initial high blood sugar but called the physician again for the change of condition and transfer out to the hospital. RN Z did not state the time for the second call to Resident #1's physician. RN Z described Resident #1's change as condition as being slower to respond, not really answering staff, and just not himself. Residents Affected - Some Interview with SNA AC on [DATE] at 03:17 p.m., revealed she had been taking care of Resident# 1 on Sunday, [DATE] and around 05:30 p.m. observed a concern about how Resident #1 was positioned in bed and that Resident #1 was not breathing as good as he normally did. SNA AC stated she had reported her observations to the nurse. SNA AC stated she had worked at the facility for less than a month and had not yet been trained on how to document in the facility's EMR. Interview with CNA A on [DATE] at 03:28 p.m., revealed she had been taking care of Resident #1 on Monday, [DATE] during the day. CNA A revealed she had observed Resident #1 to have been behaving normally, chatty and responsive that morning. CNA A stated after lunch, she had reported to Resident #1's nurse (RN Z) that when she and another CNA (CNA B) went into Resident #1's room to get him up from an after-lunch nap, he was not as responsive as normal. CNA A stated she had tried physical stimulus (rubbing Resident #1 wrist), which he did not respond to. CNA A stated she also observed an unknown purple substance around Resident #1's mouth, which she had cleaned off when the nurse came in to check Resident #1's vitals. CNA A did not state she documented her observations in the facility EMR or notify the nurse of the purple substance during the interview as part of her recollection of events. Interview with CNA B on [DATE] at 03:37 p.m., revealed she had observed Resident #1 during Monday, [DATE] and had noted that he was his normal responsiveness and able to have a conversation with her that morning. CNA B stated that after lunch Resident #1 started to be different, dazed. CNA B revealed she reported her observations to Resident #1's nurse (RN Z). Interview with the ADON on [DATE] at 04:08 p.m., revealed she had worked [DATE] for the 08:00 p.m. blood sugar check shift. The ADON stated that Resident #1 had looked fine, was acting his normal or not any different than he has been since his recent stroke. The ADON stated that for one of her shifts that week Resident #1 had a very high blood sugar and she had called Resident #1's physician who said he did not want to do anything if the resident was asymptomatic (without symptoms). The ADON stated she did not call Resident #1's physician again because when she had called on [DATE], the physician said that if Resident #1 was asymptomatic he was not going to do anything. Interview with MD W on [DATE] at 04:37 p.m., revealed he had been notified of changes in Resident #1's blood sugar medications, including the approval of diabetic medication Trulicity by Resident #1's insurance and that Resident #1's prior PCP had wanted to decrease Resident#1's insulin, but had not received any calls regarding Resident #1's high blood sugars until Monday morning, [DATE]. MD W revealed his expectation was for the facility to call him if a resident's blood sugar was below 60, over 400, or symptomatic (having symptoms). MD W stated he believed Resident #1's comorbidities (having more than one medical condition at the same time) were contributing to Resident #1's blood sugar problems. MD W revealed he was not sure that if the facility had contacted him sooner regarding Resident #1's elevated blood sugars, if it would have made a difference but it would have been ideal for the facility to have had contacted him sooner. Interview with LVN P on [DATE] at 05:37 p.m., revealed her observations for Resident #1 during her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 13 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some shifts on [DATE]- [DATE] were that he was fine when he had high blood sugars. His behaviors were fine and happy. He was back to his normal self. LVN P stated when Resident #1 had low blood sugars he would become confused and combative. LVN P stated she reported to Resident #1's physician when Resident #1 was experiencing lows but could not remember if she had called the physician for the high blood sugars. LVN P revealed Resident #1 did not have symptoms when his blood sugars were high. LVN P stated Resident #1's respirations were great, he was sleeping well, and he was his normal self. LVN P revealed she felt the physician would have known Resident #1 was having high blood sugars since the physician discontinued Resident #1's insulin. Interview with LVN R on [DATE] at 06:11 p.m., revealed her observations for Resident #1 during her shifts on [DATE] - [DATE] were that Resident #1 was good, just tired which was not abnormal for him recently. LVN R stated that she could recall that Resident #1 had an order during that time to monitor Resident #1's blood sugars and then to report it in 7 days, which she believed was either that following Monday ([DATE]) or Tuesday ([DATE]). LVN R stated she did not report Resident #1's high blood sugars during her shifts because of the monitoring order with instruction to report in 7 days and she had reviewed Resident #1's previous blood sugars and found them to be consistent with the blood sugars she had collected. LVN R stated Resident #1's blood sugars were all the same, all in the 400's and not fluctuating, such as from the 100's to the 400's. LVN R also revealed Resident #1 was not showing symptoms, which he did when experiencing a low blood sugar and that she did not have any concerns. Interview with MD X on [DATE] at 11:20 a.m., revealed Resident #1's blood sugars had been fluctuating quite a bit due to Resident #1's renal (kidney) failure, which was causing his blood sugars to become difficulty to control. MD X revealed that he did recall the facility's nursing staff contacting him regarding Resident #1's blood sugars but could not recall when without his notes. MD X stated the facility contacted him regarding Resident #1's change in physician on [DATE] and that was the last contact he received from the facility for Resident #1's care. MD X stated prior to the change in physician, he was trying to make chronic (long-term) changes and did not want to make acute (immediate) changes in regulating Resident #1's blood sugar. MD X revealed his expectation for the facility staff to notify him for blood sugars was for them to call if a resident's blood sugar was at 500. MD X revealed that if a resident was at 500 and symptomatic, he would order adjustments and send the resident out to the hospital, but if not symptomatic, he would just make adjustments to the insulin order. MD X revealed Resident #1's insulin orders had been discontinued due to Resident #1 having had bottomed out (experienced a low blood sugar episode) earlier that month (early February), Resident #1 was very brittle, and Resident #1's blood sugars had been going in the wrong direction (blood sugar dropped) with insulin. Interview with the RCN on [DATE] at 02:16 p.m., revealed the facility procedure for a blood sugar outside parameters (the expected range) was to follow the order, including to hold the medication, give an additional medication, re-check, and/or immediately contact the physician per the doctor's orders. She stated that staff are expected to contact the physician if there is a pattern in a resident's blood sugars being outside the blood sugar parameters or a pattern of refusals by the resident. She revealed that if a resident was experiencing a high blood sugar, the doctor was to tell them what they are to give to the resident and when to re-check the resident's blood sugar. The RCN stated that the nurse was responsible for entering the physician's order into the facility's EMR, documenting the order and interventions in a progress note, and reporting any changes to the resident's RP. She revealed that reporting high and low blood sugars is important for tracking the resident's blood sugar trends and that if a resident was running a high blood sugar all the time, their medications would need to be adjusted to limit the long-term effects it could have, which may be harmful if not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 14 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some treated. The RCN stated that facility staff should monitor blood sugars as ordered, notify the resident's physician immediately if outside parameters and follow the orders that the physician gives. Interview with the ADMIN on [DATE] at 02:34 p.m., revealed reporting any change of condition is important, to let the physician know and be aware of it. The ADMIN revealed his expectation was that staff call the resident's physician, report that they had contacted the physician, make the changes per the physician, and make notifications to the resident's family for any changes of condition. The ADMIN revealed that this was standard nursing practice and an order. Record review of facility policy, Notifying the Physician of Change in Status, dated revised [DATE], revealed The nurse should not hesitate to contact the physician at any time when an assessment and their professional judgement deem it necessary for immediate medical attention .1. The nurse will notify the physician immediately with significant change in status. The nurse will document signs and symptoms of significant change, time/date of call to physician, and interventions that were implemented in the resident's clinical record .11. Abnormal lab, x-ray and other diagnostic reports require physician notification. Record review of facility policy, Medication Administration Procedures, dated 2003, revealed 13. When ordered or indicated, include specific item(s) to monitor (e.g., blood pressure, pulse, blood sugar, weight), frequency (e.g., weekly, daily), timing (e.g., before or after administering the medication), and parameters for notifying the prescriber. This failure resulted in an identification of an immediate jeopardy on [DATE] at 01:27 p.m. The administrator was informed and provided the IJ template on [DATE] at 06:00 p.m. and a plan of removal (POR) was requested. The plan of removal reflected: [DATE] Plan of Removal- [Citation Number] Notify of Changes Interventions: - 100% blood sugar audit completed on [DATE] by Regional Compliance Nurse - Blood sugar checks were assessed on [DATE] to ensure that blood sugar parameters were in place, if not, parameters were requested by attending physician and added. - 100% of residents with blood sugar checks were audited on [DATE] and Physician(s) were notified of all blood sugars outside of parameters or were excessively high or low. Date completed [DATE]. - The following in-services were initiated [DATE] by Regional Compliance Nurse. Inservice 100% of staff completion date: [DATE]. Inservice has been added to new-hire packets for all new hires and agency staff to ensure all staff is in-serviced prior to start of their first shift. - Perform blood sugar checks as ordered. - Ensure any resident who has blood sugar checks has a parameter to the physician or nurse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 15 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0684 practitioner (NP). This includes when to report new orders for current residents, new admissions, and readmissions. Level of Harm - Immediate jeopardy to resident health or safety - To report to the MD or NP if a blood sugar check is outside the ordered parameters immediately and to initiate any new orders. Residents Affected - Some - If resident(s) has an order for glucagon, follow the prescriber's orders. - Policy on Notifying the Physician of Change in Status - The following in-services were initiated on [DATE] for all NA/CNAs by nursing administration and/or Regional Compliance Nurse. Inservice 100% of NA/CNA completion date [DATE]. - Hyperglycemia - excessive thirst/dry mouth, excessive urine, increased fatigue/weakness, blurred vision - Hypoglycemia-sweating, dizzy, shaking, increased confusion, anxiety, drowsy, change in mental status, slurred speech, nausea, lightheaded, loss of coordination. - Notified Medical Director of IJ situation on [DATE] at 6:17 pm. Monitoring: - At least five (5) times per week, nursing administration will review the previous days orders using the order listing report in [the facility's EMR] to monitor for new orders for blood sugar checks and ensure that parameters are added. This will include new orders for current residents, new admissions, and readmissions. This was initiated on [DATE] continue x 4 weeks. - At least 5 times per week nursing administration will review the previous days TARS and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters. This was initiated on [DATE] and will continue x 4 weeks. - Nursing Administration will ask at least 10 nursing staff per week a situational question regarding if a resident presented with hyper or hypoglycemia and what they would do. This was initiated on [DATE] and will continue x 4 weeks. - DON/Designee will review 5-8 residents slide scale results for proper notification to MD if outside parameters weekly. This will be initiated on [DATE] and continue x 4 weeks. - DON/Designee will monitor all blood sugars outside parameters of slide scale for notification to MD weekly x 4 weeks. This was initiated [DATE] and will continue x 4 weeks. - Regional Compliance Nurse will monitor for compliance weekly x 4 weeks starting on [DATE]. - The QA (Quality Assurance) Committee will review findings and Physician Notification Policy and will make changes as needed monthly. This will occur during the next QAPI (Quality Assurance and Performance Improvement) meeting on [DATE]. Monitoring of the plan of removal included: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 16 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Interviews were conducted on [DATE] from 02:50 p.m. to 07:47 p.m. with 2 RNs (RN Z and RN AA) of 2 and 9 LVNs (LVN K, LVN L, LVN M, LVN N, LVN O, LVN P, LVN Q, LVN R, and LVN S) of 9, who worked multiple shifts, revealed they had all been trained on the facility policy, Notifying the Physician of Change in Status. The nursing staff were knowledgeable on the requirement that all blood sugar monitoring orders must include blood sugar parameters, and on the protocols to follow including what to document and who to notify if a blood sugar was outside parameters or a resident was showing signs or symptoms of being hypo or hyperglycemic. The staff were able to identify when it would be appropriate to administer glucagon and how to report and document glucagon administration. Interviews were conducted on [DATE] from 03:13 p.m. to 08:37 p.m. with 6 CNAs (CNA A, CNA B, CNA C, CNA D, CNA E, and CNA F) of 9, 3 HAs (HA H, HA I, and HA J) of 3, 2 MAs (MA T and MA U) of 3, and 6 SNAs (SNA AB, SNA AC, SNA AD, SNA AE, SNA AF, and SNA AG) of 8; and on [DATE] at 10:32 a.m. with 1 CNA (CNA G). Interviews revealed they worked multiple shifts, had all been trained and were able to identify signs and symptoms of hypo and hyperglycemia, and were knowledgeable on who they needed to report to. In an interview and record review with the RCN on [DATE] at 03:55 p.m., she revealed she had started and was conducting the staff in-services. The RCN confirmed the ADMIN, with her present, had notified the facility's medical director of the Immediate Jeopardy (IJ). The RCN revealed the plan for the facility administration to monitor every new blood sugar order, ensuring that every new order included parameters was to review the previous day's (or days' for new orders over the weekends and holidays) orders by printing out an Order Listing Report from the facility's EMR, which would show all of the previous days' orders. The RCN revealed she had completed the initial blood sugar monitoring audit on [DATE]. She revealed that she had discovered a few residents without parameters on their orders. The RCN revealed she called the residents' physicians to add the parameters, asked the physicians about glucagon orders if not currently included in the residents' active order list, and added the orders with parameters per the physician's order. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days orders using the order listing report in [EMR system name] to monitor for new orders for blood sugar checks and ensure that parameters were added., was the monitoring document the facility would use to track their completion of this monitor. The document revealed this monitor was to be tracked 5 times a week for 4 weeks and that the monitor had been completed on [DATE], [DATE], and [DATE] for week 1. The RCN revealed the plan for facility administration to monitor each resident's blood sugar, that had a blood sugar monitoring order, for being completed per order and to verify the resident's MD or NP was notified if the blood sugar was outside parameters was by printing out the previous day's (or days' if after a weekend and/or holiday) Weights and Vitals Summary report from the facility's EMR, which would show all the previous days' blood sugar results, identify any blood sugars outside parameters, and review the resident's progress notes for a note on notification to the physician and/or nurse practitioner for any blood sugar results outside parameters. The RCN indicated the facility's monitoring document, labeled with At least 5 times per week nursing administration will review the previous days TARs and the medical record to ensure that blood sugar checks were performed as ordered and the MD or NP was notified if it was outside the ordered parameters., was the monitoring document the facility would use to track their completion of this monitoring. The document revealed this monitoring was to be tracked 5 times per week for 4 weeks and that the monitoring had been completed on [DATE], [DATE], and [DATE] for week 1. Weights and Vitals Summary reports for dates [DATE], [DATE], and [DATE] were provided and revealed initials on each page to indicate it had been reviewed and check marks next to each blood sugar out of parameters to indicate a corresponding progress note (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 17 of 18 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/26/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Bluebonnet Nursing and Rehabilitation 696 Fm 99 Karnes City, TX 78118 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 0684 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some had been confirmed to indicate the MD or NP had been notified. The RCN revealed the ADON would be responsible for completing the review of the 5-8 residents with sliding scale insulin orders for proper notification of the MD if the blood sugar was outside parameters. The RCN stated that this monitor was the same process or intervention as the intervention for reviewing the TARs for residents with orders for blood sugar monitoring. The RCN revealed the plan for the facility administration to ask at least 10 nursing staff situational questions regarding if a resident had high or low blood sugars and what they would do was to utilize the monitoring document, labeled with Nursing administration will ask at least 10 nursing staff per week a situational question ., mark Yes or No if the staff member answered the question correctly or incorrectly, and if incorrect, document how they answered the question incorrectly and what the nursing administration's plan was for correcting the incorrect answer (ex. in-service training). The document revealed this monitoring was to be completed 10 times per week for 4 weeks, had a spot to put the date, indicate if the answer was correct or incorrect, the staff name of the person questioned, and the name of the interviewer. The document revealed two staff members had been questioned, both on [DATE], and both had answered correctly. The RCN revealed the plan for her to monitor that the facility administration and DON/designee were compliant with the other interventions/monitors for 4 weeks was for her to come to the facility at least one time per week, review the other monitoring forms to ensure they are up to date, review the related Weights and Vitals Summary reports and Order Listing Report that the facility will be maintaining in a specified binder, and to mark Yes or No on the monitoring document, labeled with Regional Compliance Nurse and/or ADO (ADON) compliance monitoring:. The document revealed this monitoring was to be completed for 4 weeks and did not have any weeks marked as completed at the time of the interview. In an interview with the ADON on [DATE] at 04:08 p.m., she revealed she had received training on the facility policy, Notifying the Physician of Change in Status, blood sugar checks procedure, administering glucagon per order, reporting blood sugars to the resident's physician or NP immediately if outside parameters or when symptomatic, documenting physician notifications and new orders, and verifying that all new blood sugar monitoring orders included parameters on [DATE]. The ADON revealed she was to print out the Weights and Vitals report and document for new orders daily. The ADON revealed she was to review the reports for new orders and to review the blood sugars to identify if any residents had blood sugars less than 60 or over 400. She revealed that she was to review the progress notes and the 24-hour or 72-hour report to confirm the nurse notified and documented that they notified the physician of a blood sugar outside parameters. The ADON revealed she was to ask CNAs from different shifts to determine if they could recognize signs and symptoms of a hyper or hypoglycem[TRUNCATED] FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 18 of 18