Inspection·April 9, 2024

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few support for mobility beyond the manual type of transfer) for transfers x 2 staff. Date initiated: 11/05/2021. Further review reflected Focus, alteration in musculoskeletal status r/t fracture of the C2-4, C collar splint (a cervical collar, also known as a neck brace, is a medical device used to support and immobilize a person's neck) as recommended, when out of bed. Date initiated: 01/19/2024. Record review of Resident #1's progress note written by LVN B dated 01/17/2024 at 08:41 AM reflected Transfer Notification,] Resident #1] was transferred to a hospital on [DATE] 08:46 AM related to resident fell onto floor, causing a 2 cm laceration to top of head. Hematoma (a pool of mostly clotted blood that forms in tissue) to right forehead, 4x2 with abrasion. Record review of Resident #1's hospital CT (computed tomography scan is a medical imaging technique used to obtain detailed internal images of the body) dated 01/17/2024 at 09:54 AM reflected Reason for exam, laceration to head, trauma/injury, Findings, nondisplaced transversely oriented fracture ((still broken bones, but the pieces weren't moved far enough to be out of alignment during the break) involving the right C4 inferior articular facet (smooth, anterolaterally(the position of a structure as being away from the middle line, in front of the body) facing articular (referring to the joint or joints) processes of a lumbar vertebra) and right C5 superior articular facet (the superior articular processes project vertically upward from the articular pillars (the columnar arrangement of the articular portions of the cervical vertebrae) between the pedicles (connect the vertebral body to the transverse processes) and the [NAME] (connect the transverse and spinous processes) (a series of levers both muscles of posture and for muscles of active movement). Record review of NA A's written statement dated and signed 01/17/24 (untimed) reflected he was looking for someone to help, but no one was around and they were understaffed, so he attempted to place Resident #1 in the bed by himself. During the process, the sling on the mechanical lift on one side came undone and Resident #1 slipped out and he helped to guide her to the floor as safe as possible but she did hit the top of her head, and he immediately called for the nurse. Record review of the Administrator's follow-up note (undated) reflected he interviewed NA A on 01/17/2024 and was told NA A did not see anyone in his hall so he did not ask for assistance with the mechanical lift transfer for Resident #1. He stated his investigation of staffing revealed the census at the time was 58 and there were 2 nurses, one medication aide and 4 aides assigned to the units, and administrative staff was available. Record review of the Administrator's PIR dated 01/17/2024 at 10:39 AM reflected: Aide was suspended pending investigation. He was subsequently terminated. All staff were given abuse and neglect in-service and were trained on Hoyer policy requiring 2 people. Instructions given for intervening and reporting if witnessing improper Hoyer transfer. 100% of aides were required to perform return demonstration of proper Hoyer lift use. Family, physician, and Medical Director were informed of the incident. All Hoyer lift residents received a heat to toe assessment for any evidence of injury. Monitoring was implemented for incidents involving Hoyer residents. Five return demonstrations to be performed a week for 4 weeks and upon new hire. Training on recognizing sling condition was done with staff. Administrative staff examined all slings to ensure they were in good condition. Hoyer lifts were inspected. They were inspected in November 2023 by an outside company per policy. Aide verbalized to administrator that he knew a Hoyer transfer should be performed by 2 people. He verbalized that he had been trained to use the Hoyer. The NA chose not to wait for assistance as he did not see anyone in his hall. Hoyer was performed properly for getting Resident #1 out of bed. All equipment functioned properly and was in good condition during transfer. Poor decision making on part of the NA led to the incident .QA team had an Ad Hoc meeting to discuss and correct the situation. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Record review of NA A's CNA Proficiency Audit dated 04/04/2023 reflected he was signed off as an S for Transfers Hoyer lift- 2 person assist. Observation on 04/04/2024 at 08:00 AM of Resident #1 revealed she was sitting in the dining room in a Geri-chair and had a C-collar around her neck. Interview on 04/05/2024 at 1:00 PM with the Administrator, he stated after Resident #1 was sent out to the hospital for evaluation he reported the incident to HHSC immediately. He stated that later in the day a nurse from the hospital informed a nurse at the facility of Resident #1's fracture. He immediately identified that 100% in-services for the nursing assistants needed to be done and a competency of their performance for mechanical lift transfers. He stated that was completed on 01/18/2024. He stated 100% of the staff, nursing and non-nursing staff were in-serviced on abuse and neglect and on having 2 people for a mechanical lift transfer and to report any variances of that immediately. He stated that was completed on 01/18/2024. He stated he checked the staffing for 1/17/2024 at 08:15 AM when the incident happened, and sufficient staff were available in the building and that NA A chose not to wait. Attempted interview on 04/09/2024 with NA A at 10:00 AM revealed the phone number listed for him at the facility was disconnected. Observation on 04/05/2024 at 09:10 AM of Resident #1 being transferred from her Geri chair to the bed by CNA D and NA E revealed no concerns. Observation on 04/08/2024 at 12:30 PM of Resident #2 being transferred from her Geri chair to the bed by CAN D and CNA F revealed no concerns. Interview on 04/09/2024 at 2:50 PM with LVN B revealed she assessed Resident #1 when the incident happened, made notifications to include the Administrator and had Resident #1 transferred to the hospital. Interview on 04/09/2024 at 09:00 a.m. with the DON at the time, RN C, she stated Resident #1 was transferred with a mechanical lift by NA A, who did not ask for help. She stated that he was trained on how to use the mechanical lift and everyone was retrained after the incident. Record reviews of the other two residents who required Hoyer lift transfers, Resident #2 and Resident #3 reflected both had 2-person transfers care planned and identified in their MDS assessments. Record review of the facility policy and procedure titled Hydraulic Lift (undated) reflected The hydraulic lift is a mechanical device used to transfer a resident from and to the bed and chair It is reserved for those who are paralyzed, obese or too weak to transfer without complete assistance. The number of staff to provide assistance with the transfer should be determined by manufacturer recommendations The resident will receive safe transfer to bed or chair via a mechanical lift device. Record review of the owners guide for the MEDLINE Hydraulic lift MODEL: MDS450EL (undated) reflected Transfer From Bed and From Chair To Bed .with the assistance of another caregiver. The facility course of action prior to surveyor entrance included: Record review of the Administrator's PIR dated 01/17/2024 revealed: All required notifications were (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 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 675306 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/09/2024 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few made which included the Medical Director, Responsible Party, Physician, Nurse Practitioner, QA Ad Hoc Committee and HHSC. Record review of NA A's personnel folder reflected he was immediately suspended pending investigation on 01/17/2024 and subsequently terminated. Record review dated 01/17/2024- 54 staff, all staff, were in-serviced on using a staff roster were checked off and signed for in-services titled: Abuse/Neglect, Mechanical Lift. Record review of staff competencies dated from 01/17/2024 to 1/18/2024 reflected 100 return demonstrations were completed with the Hoyer transfers and 5 additional observations were done weekly and marked off by nurse managers for an additional 4 weeks. The staff who completed this training for the mechanical lift was all CNA's, MAs, and NAs, 12 CNAs, 6 MAs and 6 Student Nurse Aides to total 24 Record review of slings examined dated 01/17/2024 to 04/09/2024 reflected the slings were examined weekly for condition and wear. STAFF INTERVIEWS ON TRAINING: 04/05/2024 from 2:00 PM to 3:30 PM revealed staff were scheduled for 12-hour shifts, many worked both day, evening, and night shifts. On 04/05/2024 at total of 3 LVN's, 5 CNA's and 2 NAs were interviewed on the mechanical lift transfers, 2 people requirement, intervening, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. On 04/09/2024 between 02:00 PM and 5:00 PM, 2 RN's and 2 CNAs were interviewed on the mechanical lift, 2 people requirement, reporting, abuse, and neglect. They were trained on asking for assistance, reporting if they witnessed someone trying to transfer a resident with a mechanical lift with one person, and to let the charge nurse know if they could not find someone to help them with a transfer. They were trained to check the straps for wear and condition and placement on the lift to ensure they were secure. The noncompliance was identified as past noncompliance IJ. The noncompliance began on 01/17/2024 and ended on 01/18/2024 when all staff had been in-serviced on abuse/neglect, mechanical lift transfers (2 people required) and reporting it immediately if observed with only one person using the lift. The NA was suspended and then terminated before the surveyor entrance. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675306 If continuation sheet Page 4 of 4