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Bluebonnet Nursing & Rehabilitation: Transfer Safety Deficiency - TX
The inspection report describes a specific protocol that was not being followed....
Latest reports, citations, and penalties from CMS data
The inspection report describes a specific protocol that was not being followed....
One of those deficiencies cut to the center of what a nursing home is supposed to do....
That phrase, "potential for more than minimal harm," is the floor of what triggers a formal citation....
The two men, identified in inspection records as Resident #2 and Resident #4, shared a room at the facility....
When inspectors sat down with the Director of Nursing on the morning of August 23, she confirmed both....
The inspection, completed August 25, 2025, was triggered by a complaint....
Level D is not a paperwork problem....
Potential for more than minimal harm....
It also found the facility had not properly employed or obtained the services of a licensed pharmacist....
The August 23 complaint inspection produced an Immediate Jeopardy finding under F0689, the federal standard governing accident hazards and resident safety....
The group either lacked the required members, failed to meet at least quarterly, or both....
The incident happened on August 6....
The deficiency, cited under federal tag F0580, was one of three violations inspectors documented during the August 25 complaint inspection....
Inspectors classified the violation as an isolated incident, meaning it affected a limited number of residents rather than representing a widespread pattern....
That finding was one of 35 deficiencies cited at Antelope Valley Care Center during a complaint inspection conducted on August 29, 2025....
The inspection, completed on August 25, 2025, was triggered by a complaint, not a routine survey....
Savannah Heights did not provide it....
The citation, issued August 25, falls under the category of nursing and physician services deficiencies....
Residents who cannot independently bathe, dress, eat, groom, or move around depend entirely on staff to do those things for them....
The citation fell under the regulatory category covering freedom from abuse, neglect, and exploitation....