Health inspection·August 6, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete dryness and could get stuck on facial hair. Interview on 8/6/2025 at 2:53 PM the MDS Nurse stated she has worked at the facility since 2021 and used to be a certified nurse aide. The MDS Nurse stated she was not aware Resident #3 did not like to have his facial hair shaven by aides. The MDS did not have any further response. Interview on 8/6/2025 at 6:08 PM with CNA E stated she did take Resident #3 to shower yesterday, and he did not want her to shave his face. CNA E stated she tried to quickly shave the side of his face with a disposable single razor. Interview on 8/6/2025 at 3:59 PM with the Administrator and the DON revealed they had no response and stated they were not aware Resident #2 preferred to be clean shaven with no mustache or goatee, and preferred to be shaved with an electric razor instead of with a disposable razor like the staff always used because it hurt his face. Record review of policy, Resident Rights, dated 11/28/2016 was documented, The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this policy. Respect and Dignity-3. the right to reside and receive services in a facility with reasonable accommodation of resident needs and preferences . 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 08/06/2025 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 2 of 3 residents (Residents #1 and #2) reviewed for tube feeding management, in that: 1.The facility failed to follow physician's orders for Resident #1 to cleanse g-tube (gastrostomy tube, a small flexible tube surgically inserted through the abdomen to deliver nutrition, fluids and medication directly to the stomach) site with normal saline and apply split sponge every shift. 2.The facility failed to follow physician's orders for Resident #2 to cleanse g-tube site every day shift. These failures could place resident at risk for not receiving appropriate care and treatment and/or a decline in their health. Findings included: 1.Record review of Resident #1's admission Record dated 8/5/25 revealed an [AGE] year-old female admitted to the facility on [DATE] and re-admitted [DATE]. Diagnoses listing revealed dementia (a group of conditions categorized by impairment of brain function), atherosclerosis (hardening of the arteries), Vitamin B12 Deficiency, anxiety, cerebral infarction (a condition where brain tissues dies due to lac of blood supply) with right sided hemi-paresis, atrial fibrillation (irregular heartbeat), congestive heart failure (chronic condition in which the heart does not pump blood as well as it should), peripheral vascular disease (circulatory condition in which narrowed blood vessels reduce blood flow to the limbs), osteoarthritis (arthritis that occurs when flexible tissue at the ends of bones wears down), schizoaffective disorder (a mental health condition / mood disorder). Record review of Resident #1's BIMS assessment revealed a score of 9 indicating moderate cognitive impairment. Record review of Resident #1's MDS dated [DATE] revealed Resident #1 presented with functional limitations to upper and lower extremities, was dependent in eating, toileting, bathing, dressing, transfers and mobility. Record review of Resident #1's physicians orders revealed an order dated 5/29/24 to Cleanse g-tube site with NS (normal saline), pat dry and apply split sponge Q (every) shift. Record review of Resident #1's Medication Administration Record dated August 2025 revealed nursing staff were signing off on day shift and night shift from 8/1/25-8/4/25 that they provided stoma site care per physician's order. Observation of Resident #1 on 8/5/25 at 10:05 a.m. revealed multiple (6) brown colored dried substances around stoma (surgically created opening) site. No split drain sponge was observed. 2. Record review of Resident #2's admission record dated 8/5/25 revealed a [AGE] year-old female admitted [DATE]. Diagnoses listing revealed [NAME]-[NAME] syndrome (a disorder of the skin and mucous membranes), hypertension (high blood pressure), diabetes type II, hypothyroidism (a condition in which the thyroid gland does not produce enough thyroid hormone), hyperlipidemia (high cholesterol), and intracerebral hemorrhage (bleeding in the brain) with left sided hemiplegia (paralysis) and dysphagia (difficulty swallowing). Record review of Resident #2's MDS dated [DATE] revealed a BIMS score of 15 indicating intact cognition. Further record review of MDS dated [DATE] revealed Resident #2 had limited range of motion to upper and lower extremity, required set-up assistance with eating; maximum assistance in bathing and upper body dressing; and required total assistance in toileting, bed mobility, lower body dressing, transfers and mobility. Record review of Resident #2's physicians orders revealed an order dated 5/15/25 to cleanse g-tube site very day shift. Record review of Resident #2's care plan revealed intervention for tube feeding included clean insertion site daily as ordered. Observation of Resident #2's stoma site revealed multiple (5) brown colored dried substance around the stoma site. (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 08/06/2025 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete During an interview on 8/5/25 at 10:05 am with LVN A regarding stoma site care for Resident #1, LVN A stated that she would normally utilize a drainage sponge, but up until about a week ago, this resident's tube was sewn in and secured to her skin. LVN A stated that resident's order does indicate to clean stoma site daily and apply drain split sponge. LVN A acknowledged that dried substance surrounding stoma site. During an interview on 8/5/25 at 10:05 am with LVN A regarding stoma site care for Resident #2, LVN A stated that we clean her stoma site every shift. LVN A stated she had not provided stoma care yet for this resident today. LVN A acknowledged dried substance surrounding stoma site. During an interview on 8/5/25 at 1:00 pm with LVN C regarding stoma site care for Resident # 1 and Resident #2, LVN C stated she only works 1 day a week, but when she does work, she clean[s] both sites with normal saline and replaces split drain gauze. During an interview on 8/5/25 with Resident #2, Resident #2 stated, they clean it (stoma site) at night. During an interview on 8/6/25 with the DON, the DON stated that she expects nursing staff to follow physicians' orders for stoma site care and monitor stoma site care each shift. The DON stated that failure to provide proper stoma care could result in infection and complications with the feeding tube. Review of facility policy titled, Nursing Policy & Procedure Manual, Gastrostomy Tube Care (undated), revealed Procedure 9. Perform site or stoma care: b. cleanse the skin area around the catheter or stoma with wound cleanser or normal saline in a circular motion from the center outward and d. If ordered, place gauze dressing on the stoma and tape. Event ID: Facility ID: 675306 If continuation sheet Page 4 of 4