Inspection·June 7, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure Resident #1's bath or shower was documented as given or as refused 9 times in May and June 2025. These failures could place residents at risk for improper care due to inaccurate records. Findings included: Record review of Resident #1's admission Record (face sheet) dated 06/07/2025 revealed she was admitted to the facility on [DATE] with diagnoses which included Schizoaffective disorder (is a mental health condition that is marked by hallucinations and delusions),anxiety disorder (disorder involving feelings of nervousness, panic and fear) and hypertension (condition in which the force of the blood against the artery walls is too high) . Record review of Resident #1's MDS, a Quarterly assessment dated [DATE], revealed a BIMS score of 15 out of 15, indication her cognitive skills for daily decision making were intact; and the resident was dependent on staff to be showered or bath Record review of Resident #1's Care Plan for Self-Care performance deficit, initiated on 01/05/2021 and revised on 03/07/2022, revealed under interventions assist with personal hygiene . Record review of Resident #1's undated Kardex revealed the resident preferred to be bathed 2-3 times a week. Record review of Resident #1's nurses' notes from 05/01/2025 to 06/01/2025 revealed no notation of Resident #1 had refused to be bathed. Record review of the undated Shower Schedule revealed Resident #1 was to be bathed on Monday, Wednesday, and Friday on the 6 am - 2 pm shift. Record review of Resident #1's electronic clinical record for the Bathing Task from 05/01/2025 to 06/03/2025 revealed Resident #1 had only been bathed 6 times on: 05/02/2025, 05/05/2025, 05/05/2025, 05/07/2025,05/09/2025, and 05/12/2025; there was no documentation the resident had refused to be (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675306 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 06/07/2025 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)