Health inspection·November 21, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Record review of Resident #23's Care Plan, last updated on 8/22/2024, reflected a focus area of ADL self-care performance deficit with interventions of Bed Mobility-resident independent with bed mobility, no assistance required. There was no mention of bed rails/grab bars. Record review of Resident #36's Face Sheet reflected a [AGE] year-old female who initially admitted to the facility on [DATE]. Resident #36 had relevant diagnoses of mild dementia with mood disturbance in other diseases classified elsewhere (mild symptoms of dementia, or a decline in mental abilities that effect a person's daily life, in other diseases with mood disturbance such as depression or apathy), Parkinson's disease without dyskinesia and without mention of fluctuation (a chronic condition that can be managed with medications to help control symptoms such as tremors, slow movement, stiffness, and loss of balance), bilateral angular blepharoconjunctivitis (eye condition that causes redness, irritation, scaling, and fissuring in the inner or outer corner of the eyelid of both eyes), unspecified anxiety disorder, type 2 diabetes mellitus without complications (chronic condition where the body does not use insulin properly resulting in unusual blood sugar levels), unspecified schizoaffective disorder (mental illness that combines symptoms of schizophrenia (chronic mental disorder affecting thoughts, perceptions, emotions, and social interactions) and a mood disorder but does not meet the criteria for either alone), bipolar disorder (serious mental illness that causes mood swings, along with changes in energy, thinking, behavior, and sleep), metabolic encephalopathy (brain disorder that occurs when a chemical imbalance in the blood affects the brain), other reduced mobility, history of falling, unspecified polyneuropathy (disease that causes widespread nerve damage which can lead to impaired sensory and motor function), moderate stage primary open-angle glaucoma of right eye (moderate level of damage to the optic nerve in the right eye along with visual field loss of the peripheral vision but not yet significantly affecting the central vision), and essential tremor. Record review of Resident #36's Quarterly MDS, dated [DATE], reflected a BIMS score of 07, which indicated a severe cognitive impact. The Quarterly MDS also showed that Resident #36 had no functional limitations in range of motion by upper or lower body impairments, utilized a wheelchair for mobility; was dependent for lower body dressing, showering/bathing, putting on/taking off footwear; required moderate assistance with tub/shower/toiler transfers, sit to stand, sit to lying, lying to sitting on side of bed, and chair/bed-to-chair transfers. Observation on 11/19/2024 at 9:55AM of Resident #36 room area and bed revealed that the bed had a half-length bed rail raised on the left-hand side of the bed along the wall and a grab bar raised on the right-hand side. The resident was in the room sitting in a manual wheelchair and dressed for the day. The bed rail and grab bar were observed again on 11/20/2024 at 8:10 AM in same positions. Interview on 11/19/2024 at 9:55 AM with Resident #36 revealed is the resident felt she was well taken care of by staff, had no concerns for safety in the facility, and that she intended to be a long-term resident. Resident #36 did not remember if she had been evaluated for having bed rails or grab bars on her bed and did not mind them on the bed. Resident #36 did not remember if the grab bar or bed rail were used frequently or not. Resident #36 was unsure why or when the grab bar or bed rail was placed on the bed. Record review of Resident #36's Care Plan, last updated on 10/24/2024, reflected that Resident had ADL self-care performance deficits and required interventions of: a Hoyer lift with 2 staff for transferring, assistance with personal hygiene, assistance with bathing, assistance with bed mobility, and assistance with dressing. The Care Plan had no mention of bed rails or grab bars as an intervention or focus for Resident #36. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675891 If continuation sheet Page 2 of 9 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 11/21/2024 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Interview on 11/21/2024 at 2:15PM with the ADON revealed that the facility procedure for bed rails or grab bars was to care plan the reason for the items to be on the resident bed with the IDT, document what had been tried before, and give reason the bed rail/grab bar was needed or what it would provide for the resident in specifics. The ADON stated there was no exception to the bed rails/grab bars being included in the care plan and was the standard for the facility. The ADON stated that if a resident were found to have bed rails/grab bars on their bed staff should be verifying the devices were care planned, the resident was assessed for safety, a signed consent form is in place, and that the ADON over that part of the building was consulted to the missing part of the process. The ADON stated it was important for bed rails/grab bars to be care planned so that staff know why they were being used, to ensure residents were assessed safe to use them, and to be able to reference back in the event somethings happens to be able to verify why they were in place. The ADON was not familiar with reasons specific to Resident #23 or #36 having bed rails or grab bars on their beds as the ADON was assigned to a different area of the facility; the ADON who was assigned to these residents was involved in care plan meetings on this day. The ADON stated that the grab bars/bed rails were typically used to promote residence independence and ability to turn in bed while the risks were that if not care planned staff would not know why they were in place, staff would not know the resident was safe to use them, and residents would be at risk with bed rails for potential injuries or entrapment. Interview on 11/21/2024 at 2:53 PM with the ADM revealed that care plans were expected for all residents to be updated as conditions changed, for staff to document concerns and issues that a family member or resident had and to document interventions. The ADM stated he expected staff to be truthful and to make sure to document more than less in care plans so resident needs and limitations were clear to anyone reading the care plan for the first time. The ADM stated that grab bars/bed rails were expected to be documented clearly. The ADM stated that Resident #23's care had been talked about last week during the IDT meeting and thought the care plan was updated at that time. The ADM stated that Resident #36 had utilized the grab bars/bed rail for some time and was unsure why they were not already on the care plan. Interview on 11/21/2024 at 3:20 PM with the DON revealed that care plans were to be updated based on the care plan meeting with the resident, family/responsible party, and IDT , and preferably in real time. The DON stated that grab bars/bed rails were to be updated within the care plan review period. The DON stated that risks to the resident for grab bars/bed rails not being on a bed when they should be could range from loss of independence or mobility; if not in the care plan could have had a result of CNA or other nursing staff not having awareness for what the resident was using the rails for. Bed rails/grab bars could be documented by anyone clinical who was in the IDT meeting where the bed rails/grab bars were discussed and approved. The DON stated that if a resident requested grab bars/bed rails then nursing staff will initiate the assessment and obtain consent from the resident or their responsible party, then the IDT will review for further assessment by therapy, for request to maintenance to add to the bed if not already, and the care plan to be updated. Record Review of the facility's Proper Use of Side Rails policy ©2001 MED-PASS, Inc. (Revised August 2024) pertinent sections state: Purpose: The purpose of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use of side rails as restraints unless necessary to treat a resident's medical symptoms. General Guidelines: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675891 If continuation sheet Page 3 of 9 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 11/21/2024 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 0656 5. The resident's care plan will reflect the use of side rails and updated as necessary. Level of Harm - Minimal harm or potential for actual harm Record Review of the facility's Care Plans, Comprehensive Person-Centered ©2001 MED-PASS, Inc. (Revised December 2016) pertinent sections state: Residents Affected - Few Policy Statement: A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident's physical, psychosocial and functional needs is developed and implemented for each resident. Policy Interpretation and Implementation: 2. Care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment. 8. The comprehensive, person-centered care plan will: g. Incorporate identified problem areas; h. Incorporate risk factors associated with identified problems; i. Build on the resident's strengths; m. Aid in preventing or reducing decline in the resident's functional status and/or functional levels; n. Enhance the optimal functioning of the resident by focusing on a rehabilitative program . 11. Care plan interventions are chosen only after careful data gathering, proper sequencing of events, careful consideration of the relationship between the resident's problem areas and their causes, and relevant clinical decision making. a. When possible, interventions address the underlying source(s) of the problem area(s), not just addressing only symptoms or triggers. b. Care planning individual symptoms in isolation may have little, if any, benefit for the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675891 If continuation sheet Page 4 of 9 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 11/21/2024 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 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 (Resident #39 and #29) reviewed for infection control. Residents Affected - Some 1.The facility failed to ensure LVN A wore gloves before opening capsule medication Depakote and administering it to Resident #39 via g-tube (a g-tube is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have difficulty swallowing). 2.The facility failed to ensure LVN B wore PPE for Enhanced Barrier Precautions while providing care for Resident #29 and failed to ensure LVN B did not use her finger to mix several medications in medication cups with water before administering medications to Resident #29 via g-tube. The failures could place residents that require assistance with personal care at risk for healthcare associated cross-contamination and infections. Findings included: 1. Review of Resident #39's face sheet dated 11/20/24, reflected a [AGE] year-old male admitted to the facility on [DATE]. Resident #39 had diagnoses which included Parkinson's disease with dyskinesia (a progressive nervous system disorder, which affects the ability to move muscles and inability to control involuntary jerks and shakiness), unspecified open wound to the left middle finger with damage to nail, unspecified fever, shortness of breath, gastrostomy status (this is a feeding tube that is placed through the abdominal cavity area into the stomach for nutritional purpose and medication for individual who have a difficulty swallowing), bipolar disorder (this is a disorder associated with episodes of mood swings ranging from depressive lows to manic highs) and viral Hepatitis (this is a liver inflammation due to a viral infection). Review of Resident #39's quarterly MDS assessment dated [DATE], revealed the resident's BIMS score was 0, indicating he was unable to be assessed for cognitive status. The MDS Assessment reflected Resident #39 was usually unable to be understood by others. Further review revealed Resident #39 was dependent on staff for all ADL's and required a feeding tube to obtain 51 % or more nutrition. The MDS reflected Resident #39 was dependent on staff for all upper and lower bed mobility including turning and repositioning in bed. Review of Resident #39's care plan initiated 07/17/24, revealed Resident #39 required enteral feeding via G-tube, he relied on enteral feedings for all nutritional and hydration needs, and could not have anything to eat or drink by his mouth. The goal was Resident #39 would be free of preventable aspiration (choking) through the review date. The interventions included nursing to administer resident with tube feeding and water flushes, to discuss with the resident/family/caregivers any concerns about tube feeding, advantages, disadvantages, potential complications. To follow current enteral feeding orders per MD for nutritional/hydration support, to monitor/document/report PRN any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, self-extubating (process of removing a tube), tube dysfunction or malfunction, Abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, Nausea/vomiting, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675891 If continuation sheet Page 5 of 9 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 11/21/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some dehydration, to obtain and monitor lab/diagnostic work as ordered. Report results to MD and follow up as indicated, for RD to evaluate quarterly and PRN, to monitor caloric intake, estimate needs and make recommendations for changes to tube feeding as needed, ST evaluation and treatment as ordered, to always wear abdominal binder, may remove for showers, check skin under binder every shift. The Care plan further revealed Resident #39 had liver disease r/t Hepatitis C (viral infection that affects the liver and can cause acute or chronic illness). The goal was Resident #39 would be free from s/sx of liver complications, including Infection, abnormal or unexplained bleeding, malnutrition, anemia, cognitive decline, or mental status changes through review date. Interventions reflected to give anti-emetics (drug that treats nausea and vomiting) as ordered for any nausea and vomiting, to monitor/document side effects and effectiveness. The interventions were to give medications as ordered, to monitor/document effectiveness and side effects, and to monitor vital signs and notify MD of significant abnormalities. Review of Resident #39's active orders reflected Depakote Sprinkles Oral Capsule Delayed Release. Sprinkle 125 MG (Divalproex Sodium) Give 1 capsule via G-Tube three times a day related to bipolar disorder, unspecified. Review of Resident #39's November 2024 MAR dated 11/19/24 reflected Depakote Sprinkles Oral Capsule Delayed Release Sprinkle 125 MG (Divalproex Sodium). Give 1 capsule via G-Tube three times a day related to bipolar disorder was administered by LVN A. Observation on 11/19/24 at 1:59 PM revealed LVN A removed medication Depakote capsule from the medication bubble card and into a medication cup. LVN A then picked up the Depakote capsule with her bare hands, without sanitizing, and opened the capsule and sprinkled/emptied the medication into the medication cup to administer to Resident #39 via G tube. LVN A did not wear gloves to open the medication. In an interview with LVN A on 11/19/24 at 2:15 PM, she stated she thought it was ok to touch the capsule with her bare hands because the medication was inside. She stated she may have reacted without thinking because she was nervous being watched, that's why she forgot to wear gloves before opening the capsule medication with her bare hands. She stated the expectation was to wear gloves before touching any medication or applying medication or administering any medication that required touching skin. She stated the risk to the resident was contamination of the medication she touched with her bare hands, and she also risked exposing herself to the medication which was used for bipolar for Resident #39. 2. Review of Resident #29's face sheet dated 11/20/24 revealed a [AGE] year-old male who readmitted to the facility on [DATE], with an initial admission of 08/14/15. Resident #29 had diagnoses which included vascular dementia without other behaviors (this is brain damage that is caused by multiple strokes causes memory loss and cognitive decline), high blood pressure, dysphagia following stroke (difficulty swallowing), unspecified cough, depression, cognitive communication difficulty (difficulty communicating), chronic kidney diseases, hemiplegia and hemiparesis on left side following stroke (muscle weakness and paralysis on one side) and, gastrostomy status (g-tube) (surgical procedure that creates an opening into the stomach). Review of Resident #29's quarterly MDS assessment dated [DATE], reflected a BIMS of 99 indicating Resident #29 was cognitively impaired to complete the assessment. Resident #29 had impaired range of (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675891 If continuation sheet Page 6 of 9 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 11/21/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some motion on his left upper and left lower body and was completely dependent on staff to set up and clean up following activity. Resident #39 was always incontinent of bowel and bladder. The document reflected Resident #39 had a feeding tube and received 51% or more of his nutrition through the feeding tube. Review of Resident #29's Care Plan initiated 02/02/24 revealed Resident #29 was on Enhanced Barrier precautions related to feeding tube. The care plan did not reflect interventions. Care plan also revealed Resident #29 required tube feeding related to swallowing problems. The goal was for Resident #29 to maintain adequate nutritional and hydration status as evidenced by weight stable no signs and symptoms of malnutrition or dehydration the thorough the review date. The interventions were to keep head of bed elevated to 45 degrees during and thirty minutes after tube feeds, to follow current enteral feeding orders per MD for nutritional/hydration support, to monitor/document/report PRN any s/sx of: Aspiration- fever, SOB, Tube dislodged, Infection at tube site, Self-extubating, tube dysfunction or malfunction, Abnormal breath/lung sounds, abnormal lab values, abdominal pain, distension, tenderness, constipation or fecal impaction, diarrhea, Nausea/vomiting, dehydration, to obtain and monitor lab/diagnostic work as ordered. Review of Resident #29's active orders on 11/19/24 reflected: - Implement and maintain enhanced barrier precautions when performing high contact care activities. Every shift for g-tube. - Acetaminophen oral tablet 325 mg (acetaminophen). give 2 tablets via g-tube two times a day related to pain, unspecified. Give 2 tablets to equal 650 mg total; not to exceed 3gm of acetaminophen in 24hrs from all sources. - Enteral feed orders every shift enteral: crush or open capsules and dilute each medication with 5 to 10 ml of water if indicated. - Enteral feed orders every shift enteral: Flush feeding tube with 30 to 60 ml of water before and after each - Lisinopril oral tablet 10 mg (lisinopril) give 1 tablet via g-tube one time a day related to essential (primary) hypertension, hold if sbp<110, - Memantine HCL 10 mg tablet. Give 1 tablet via G-tube two times a day related to vascular dementia. - Provera oral tablet 5 mg (medroxyprogesterone acetate), give 1 tablet via g-tube one time a day related to abnormal level of hormones in specimens from other organs, systems and tissues. - Valproic acid oral solution 250 mg/5ml (valproate sodium). Give 5 ml via g-tube two times a day related to vascular dementia, unspecified severity, with other behavioral disturbance. - Zoloft oral tablet 50 mg (Sertraline hcl). Give 1 tablet via g-tube one time a day related to other recurrent depressive disorders. - Zyrtec allergy oral tablet 10 MG (Cetirizine HCL) Give 1 tablet via G-Tube one time a day related to cough. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675891 If continuation sheet Page 7 of 9 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 11/21/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Observation of medication administration via g-tube on 11/20/24 at 06:39 AM, revealed Resident #29's door signage reflected . STOP Enhanced Barrier Precautions. Everyone must clean their hands before entering the room and when leaving the room. Providers and staff must wear gloves and gown for the following: dressing, bathing/showering, transferring, changing linens, providing hygiene, changing briefs or assisting with toileting, device care or use such as; central lines, urinary catheter, feeding tube, tracheostomy (surgical procedure that creates an opening in the neck to provide an airway and remove secretions from the lungs). Wound care: any skin opening requiring dressing. LVN B did not wear her gown for Enhanced Barrier Precautions for Resident #29 with a g-tube during medication administration. LVN B left Resident #29's room to get more medication after it spilled, and reentered Resident #29's room to administer the medication and she did not put on PPE again for g-tube medication administration and for reconnecting Resident #29's feeding. LVN B placed each medication (Acetaminophen, lisinopril, Memantine, medroxyprogesterone, Zoloft, and Zyrtec) in separate medication bags, crushed them and placed them in individual medication cups. The Valproic acid solution was measured into an individual cup as well. LVN B put on gloves and went into Resident #29's room and placed the medication tray with the individual medication cups onto the prepared clean bed side table and went into the resident's bathroom with two cylinders and filled them with water. After listening to G-tube the resident's bed with the bed remote LVN B put some water in the individual crushed medication cups of Acetaminophen, lisinopril, Memantine, medroxyprogesterone, Zoloft, and Zyrtec. LVN B flushed Resident #29's g-tube with 30 ml of water, then she picked up one of the medication cups and swirled it to try and mix the crushed medication with water but failed to dissolve/mix, therefore LVN B used her right pointer finger to mix the medication and water before pouring the medication mixture into Resident #29's g-tube. She then administered 30 ml of water after medication administration. LVN B continued this process of mixing each individual medication with her finger before administering it via the tube of Resident #29. LVN B did not change her gloves before starting to administer Resident #29's medications via g-tube and she did not use a spoon, straw, or other acceptable device to dissolve the medications in with the water. LVN B's last medication to administer was 5ml of Valproic acid solution. LVN B stated she would get some more to finish the medication administration. In an interview on 11/20/24 at 06:55 AM, LVN B was asked if she saw the signage on Resident #29's doorway and what it meant, and she yelled ooh No! She stated she was upset with herself for forgetting to put on her gown for PPE. LVN B stated she had been in-serviced on EBP which was to prevent infection of MDRO's for residents that had internal tubing. LVN B stated that not following the proper way of g-tube care and not wearing PPE for EBP could cause residents to be at risk for infection. She stated it was her responsibility as a nurse to follow infection precautions. LVN B stated she was upset with herself for forgetting to get something to use to dissolve and mix the medication, something like a spoon or steerer. She stated she used her finger to improvise for not having a spoon. LVN B stated that was unacceptable procedure and she should have stopped and went and gotten a spoon or straw on her medication cart. She stated she was knowledgeable of g-tubes but was nervous being watched and forgot to follow the proper way of dissolving and mixing the medication before administration via g-tube. LVN B stated that not following the proper way of g-tube care could cause residents to be at risk for contamination of the medication and at risk for infection. In an interview with the ADON on 11/21/24 at 01:58 PM she stated she had taken over as the infection control preventionist three weeks ago. She stated she had not done any in-service on enhance barrier precautions yet. She stated the expectation was for nursing staff to use PPE for g-tube medication administration. The ADON stated It was an extra layer of protection between the staff and the patient, and for anyone (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675891 If continuation sheet Page 8 of 9 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 11/21/2024 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some who had any type of opening. She stated staff had to gown up to make beds, to touch the patient, and any direct care with the resident, on Enhanced Barrier Precaution to prevent MDRO infections. The ADON stated it was ultimately her responsibility to monitor and follow up that staff were following infection control, but each staff was responsible to prevent spread of infection. In an interview with the DON on 11/21/24 at 02:31 pm, she stated she had been at the facility for three months as the DON. The DON stated the nurses should follow the proper way of administering medication through the g-tube which meant also wearing PPE for EBP. The DON stated nurses were responsible for making sure that they followed the policy for g-tube and preventing spread of infection and the ADON monitored infection control, and she was overall responsible for all nursing staff. She stated both LVN A and LVN B were really upset with not following proper aseptic technique (this is a set of practice and procedure that healthcare providers use to prevent spread of infection causing germs) for g-tube and she had completed 1:1 check off and in-service with them. She stated the nurses should follow the proper way of administering medication through the g-tube and LVN A should have worn gloves before touching the capsule to open it and LVN B should have used something else like a spoon or the wooden steer to mix the medication with the water and not use her finger. The DON stated nurses were responsible for making sure that they follow the g-tube policy to prevent adverse effects and infections. In an interview with the Administrator on 11/21/24 at 3:31 PM, he stated he expected staff to follow all infection control, enhanced barrier precautions, and for the department heads to do monthly in services and audits to draw attention to problem areas of staff not following the signage outside the doors and not following the facility policies. The Administrator stated he had a new DON now and they are working together to get training and 1:1 with different staff members so everyone can be on the same page. The Administrator stated it was not an excuse, but people tend to mess up when they are being watched and he was like that himself, but as a team, they are working on that so that they do it the correct way all the time and not mess up even if someone was watching them. He stated the expectation was that they learned from their mistake. Review of the facility's Implementation of Standard and Transmission-Based Precautions policy, dated 03/24, revealed, .EBP are indicated for residents with any of the following: 1. Infection or colonization with a CDC-targeted MDRO .Wounds and/or indwelling medical devices even if a resident is not known to be infected or colonized with a MDRO .post signage .high-contact resident care activities requiring gown and glove use . Review of facility policy titled Administering Medication through an Enteral Tube revision date 07/05/19, reflected . the purpose of this procedure is to provide guidelines for the safe administration of medication through an enteral tube Assemble the equipment and supplies as needed .personal protective equipment (e.g., gown, gloves, mask, etc., as needed) .dilute the crushed or split medication with 5-15 ml water (or as prescribed), administer the medication by gravity flow . Review of undated policy Enteral Nutrition for Closed System Nasogastric, Naso intestinal, Gastric and Jejunal feeding tubes reflected Enteral nutrition therapy will be performed in a safe manner by qualified licensed nurses according to standard practice guidelines . Review of the facility's policy dated August 2016, and titled Standard Precautions revealed .Standard precautions are used in the care of all residents regardless of their diagnoses, or suspected or confirmed infection status .hand hygiene is performed with soap (anti-microbial or non-antimicrobial) or alcohol-based hand rub before and after contact with the resident . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675891 If continuation sheet Page 9 of 9