Bluebonnet Nursing & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Bluebonnet Nursing & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF580Feb 26, 2024

  Based on interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of thirteen residents reviewed for notification of changes. The facility failed to notify the physician for an acute change in a resident's condition related to type 2 diabetes, resulting in the resident was hospitalized on [DATE] and expired on [DATE]. An immediate jeopardy (IJ) was identified on [DATE] at 01:27 p.m. […]

• Immediate jeopardy, patternF684Feb 26, 2024

  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: 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. […]

• Immediate jeopardy, isolatedF689Jun 1, 2024

  Based on observation, interview, and record review, the facility failed to ensure the environment was free of accident hazards and supervision of staff for 1 of 7 residents (Resident #1) reviewed for accidents and hazards, in that: The facility failed to ensure Resident #1 had a low bed (bed positioned near the floor) as ordered on 04/16/2024 and instead had a regular bed in the lowest position. Resident #1 fell from the bed in the higher position and onto the mat beside her bed and she sustained a C2 vertebral fracture. An IJ was identified on 05/31/2024. The IJ template was provided to the facility on [DATE] at 4:00 PM. […]

• Immediate jeopardy, isolatedF689Apr 9, 2024

  Based on observations, interviews, and record reviews the facility failed to ensure the environment was free of accident hazards and supervision of staff for one resident (#1) of 3 residents who required mechanical lift transfers. NA A transferred Resident #1 alone on 01/17/2024 at 08:15 AM with a mechanical lift which required 2 people for safety. One of the straps holding the sling came loose and Resident #1 slipped toward the floor and hit her head on the mechanical lift which caused a head laceration and fractures to C4 (provides sensation for parts of the neck, shoulders and upper arms) and C5 (controls the deltoid muscles of shoulders and biceps, provides sensation to the upper arm down to the elbow). The noncompliance was identified as PNC. […]

• Actual harm, isolatedF689Jun 3, 2026

  Based on interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Student Nurse Aide A was assisted by a second staff member while providing incontinence care to Resident #1 on the bed on 5/20/26. Resident #1 slid off the bed, fell to the floor and fractured her right leg. The noncompliance was identified as PNC on 5/20/26. The facility had corrected the noncompliance before the survey began on 5/28/26. This failure could place residents at risk of serious injury, harm, and/or death. […]