Inspection visit
Health inspection
1 citation recorded
Inspector’s narrative
What the inspector wrote
This survey cited 1 deficiency. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Ensure each resident receives and the facility provides food that accommodates resident allergies,
intolerances, and preferences, as well as appealing options.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observations, interviews, and record review, the facility failed to accommodate residents' food preferences
and allergies for 2 of 6 (Residents #1 and Resident#2) residents reviewed for food preferences and
allergies.
1. The facility failed to provide Resident #1 with a strawberry (preference) or vanilla house shake, when she
had listed that she disliked the chocolate house shake.
2. The facility failed to ensure Resident #2 did not receive a chocolate house shake, which was listed as a
food allergy in her medical record.
These failures could cause an allergic reaction, a decrease in resident choices, a diminished interest in
meals, placing them at risk for contributing to poor intake and/or weight loss.
Findings included:
Record review of Resident #1's admission record revealed she was a [AGE] year-old female admitted to the
facility on [DATE]. Resident #1 was diagnosed with unspecified protein-calorie malnutrition (imbalance
between the nutrients your body needs and the nutrients it gets), deficiency of other vitamins (lacking any
of the 13 essential vitamins that your body needs in small amounts to work optimally), and
gastro-esophageal reflux disease without esophagitis (common digestive disorder- reflux of stomach acid
into the esophagus).
Record review of Resident #1's quarterly MDS dated [DATE] revealed Resident#1 had a BIMS score of 12
which indicated a moderate cognitive impairment .
Record review of Resident #1's care plan dated 02/28/24 revealed Resident#1 had GERD (a condition in
which stomach acid repeatedly flows back up into the tube connecting the mouth and stomach). Resident#1
Goal was for Resident#1 to remain free from discomfort, complications related to GERD Resident#1
interventions revealed avoid food or beverages that tend to irritate esophageal lining .alcohol, chocolate,
caffeine .
Record review of Resident #1's order dated 05/17/24 revealed the following: house shake 40 oz two times a
day for weight loss.
Interview on 07/18/24 at 9:42 AM with the Ombudsmen revealed Resident #1 had not received her
preference flavor of the house shake. The ombudsmen revealed resident #1 would throw up the chocolate
house shake. The Ombudsmen revealed Resident #1 could deal with the vanilla shakes but preferred
(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 3
Event ID:
675891
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
675891
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bridgeport Medical Lodge
2108 15th Street
Bridgeport, TX 76426
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 0806
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
strawberry house shakes. The Ombudsmen revealed she was in the building on 07/14/24 and the facility
only had chocolate house shakes for the residents.
Interview on 07/18/24 at 11:25 AM with Resident #1 revealed she had not had a house shake since
Monday because the kitchen only had chocolate. Resident #1 revealed she had informed the dietary staff
(unknown) that she could not drink the chocolate house shakes. Resident #1 revealed that she cannot have
the chocolate ones because they made her stomach hurt. Resident #1 stated that it irritated and upset her
that she was not able to get the strawberry house shake but she would drink the vanilla.
Observation and interview on 07/18/24 at 12:50 PM with Resident #1 revealed she did not have a house
shake on her lunch tray. Observation of the lunch tray ticket revealed a notation that read chocolate shake
only. Interview with Resident #1 revealed she did not have a house shake for lunch.
Interview on 07/18/24 at 12:56 PM with the Dietary Manager revealed the facility met the Residents need
for nutrition. The Dietary Manager revealed she ordered twice a week and enough house shakes are
ordered. The Dietary Manager revealed she was aware that Resident #1 preferred the strawberry house
shakes over the vanilla and chocolate. The Dietary Manager revealed the dietary staff put aside certain
flavors for each resident that want certain flavors. The Dietary Manager revealed the Dietary Aide was
responsible for putting the house shakes on trays and to follow the instructions on the ticket tray. The
Dietary Manager met with residents and documented their preferences. The Dietary Manager revealed
residents had the right to refuse the house shakes . Dietary Manager revealed Resident#1 could have an
upset stomach.
Observation and interview on 07/22/24 at 8:20 AM revealed Resident #1 did not have a house shake on her
breakfast tray. Observation of Resident #1's tray ticket revealed a written notation that read chocolate shake
only. Interview with Resident #1 revealed she did not have her house shakes because the facility only had
chocolate house shakes available.
Observation on 07/22/24 at 8:57 AM of the facility kitchen revealed chocolate house shakes in the reach in
refrigerator. Observation of the walk-in refrigerator revealed an open box of chocolate house shakes.
Observation of the walk-in freezer revealed an unopened box of vanilla house shakes on the bottom shelf in
the back of the walk-in freezer.
Interview with Dietary Manager07/22/24 at 9:00 AM revealed the vanilla house shakes could have been
taken out and thawed out. The Dietary Manager revealed the Dietary Aides knew the house shake was in
the freezer and it would have taken fifteen minutes to thaw the shakes.
Interview with Dietary Aide on 07/22/24 at 10:00 AM revealed the chocolate house shakes were the only
ones in the refrigerator and she wrote on the tray ticket chocolate shake only to let Resident#1 know that
was the only flavor available. Dietary aide revealed the Dietary aides are responsible for the tray set up.
Record review of Resident #2's admission Record revealed, she was a [AGE] year-old female admitted to
the facility initially on 04/10/22 and readmitted on [DATE]. Resident#2 was diagnosed with vomiting,
unspecified, unspecified diarrhea, diverticulosis of large intestine without perforation (small pockets on the
inside of the colon) or abscess without bleeding, and gastro-esophageal reflux disease without esophageal
reflux disease without esophagitis (common digestive disorder- reflux of stomach acid into the esophagus).
Record review of Resident#2's admission Record revealed Resident#2 had an allergy to chocolate.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675891
If continuation sheet
Page 2 of 3
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
675891
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/22/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Bridgeport Medical Lodge
2108 15th Street
Bridgeport, TX 76426
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 0806
Level of Harm - Minimal harm
or potential for actual harm
Record review of Resident #2 quarterly MDS dated [DATE] revealed her BIMS score was 15 which
indicated she was cognitively intact.
Record review of Resident# 2's orders dated 09/25/23 revealed the following: House supplement 2.0 three
times a day 90 CC .Please open .
Residents Affected - Few
Record review of Resident #2's miscellaneous note created by the Dietary Manager and dated 08/31/22
revealed Resident #2 had an allergy to chocolate, severity unknown and reaction noted on admission.
Observation of Resident #2 on 07/22/24 at 8:00 AM revealed her to be eating breakfast in the dining hall.
Interview with Resident #2 revealed she was allergic to chocolate, and she gave her house shake to her
neighbor. Observation of Resident#2 tray ticket revealed she was allergic to chocolate.
Interview on 07/22/24 with the Dietary Manager at 9:00 AM revealed Resident #1 should not have gotten a
chocolate house shake and the dietary aide would be written up. The Dietary Manager revealed she would
need to check with nursing to see if she has an allergy to chocolate or if it was a dislike of chocolate.
Resident could end up with an upset stomach if this was a true allergy.
Interview with the ADON on 07/22/24 at 9:12 AM revealed if the residents did not receive their house
shakes, they could experience weight loss. Resident #2 has an intolerance to chocolate and would have an
upset stomach and possibly diarrhea.
Interview over the phone at 07/22/24 at 9:38 AM with the Registered Dietitian revealed the nursing staff and
the Dietary Manager went over the recommendations for residents with weight loss. The Registered
Dietitian revealed the Dietary Manager met with the residents upon admission and throughout their stay to
document residents' preferences . Registered Dietitian revealed Resident could experience weight loss.
Interview with Dietary Aide on 07/22/24 at 10:00 AM revealed the aides were responsible for setting up the
resident's tray. The Dietary Aide revealed she was rushed to get breakfast out and put the chocolate shake
on Resident#2 tray. The Dietary Aide revealed the chocolate house shakes were the only ones in the
refrigerator.
Interview on 07/22/24 at1:35 PM with Administrator revealed Resident #2 has asked for chocolate cake in
the past and may be at risk for an upset stomach .
Record review of the facility policy, Food Preference , dated 07/2017, reflected, Individual food preferences
will be assessed upon admission and communicated to the interdisciplinary team .10. The food service
department will offer a variety of foods at each scheduled meal .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675891
If continuation sheet
Page 3 of 3
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Back to topCitations
1 citation recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F806 - Food and drink
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
FAQ · About this visit
Common questions about this visit
What happened during the July 22, 2024 survey of Bridgeport Medical Lodge?
This was a inspection survey of Bridgeport Medical Lodge on July 22, 2024. The surveyor cited 1 deficiency, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Bridgeport Medical Lodge on July 22, 2024?
Yes, 1 deficiency was cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and pre..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.