Health inspection·October 30, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, the facility failed to keep the environment as free from accident hazards for 1 (Resident #1) of 4 residents reviewed for accidents. The facility failed to ensure Resident #1's environment was free from accidents and hazards when being pushed by another resident, with her permission, from a smoke break. While going up the ramps towards the entrance to the door, Resident#1's wheelchair got stuck on the ramp on 300 hall, as the ramp does not cover the length of the doorway, and she fell face first on 10/27/25. On 10/29/2025 at 5:22pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/29/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk of accidents, hazards and a decline in quality of care. Findings included:Record review of Resident #1's face sheet, dated 10/29/25, reflected a [AGE] year-old female, admitted [DATE] and readmitted [DATE], diagnosed with but not limited to: traumatic subdural hemorrhage without loss of consciousness (a condition where a collection of blood (hematoma) forms between the brain and its outer covering (dura mater) after a head injury, without the person experiencing a loss of consciousness) -onset 10/28/25, unspecified sequelae (a condition which is the consequence of a previous disease or injury)of cerebral infarction (long-term complications or after effects of a stroke (cerebral infarction) that cannot be specifically identified or classified), type 2 diabetes mellitus with mild nonproliferative diabetic retinopathy without macular edema (high blood sugar levels over time can damage the blood vessels in the retina. This damage can lead to the formation of small, leaky blood vessels.), bilateral, morbid (severe) obesity due to excess calories, anxiety disorder unspecified, depression unspecified, hemiplegia and hemiparesis (weakness on half of the body) following (body mass index (BMI) of 40 or higher, or a BMI of 35 or higher) cerebral infarction affecting right dominant side ((stroke) affecting the right dominant side of the brain would cause symptoms on the left side of the body, such as weakness or paralysis (left hemiparesis or hemiplegia), hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side (person has experienced weakness (hemiparesis) or paralysis (hemiplegia) on their left side due to damage to the right side of their brain),acquired absence of right and left leg below knee (double below-knee amputation). Record review of Resident #1's BIMS Evaluation, dated 10/28/25, reflected her BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #1's care plan, dated 10/28/25, reflected at risk for falls r/tdeconditioning, incontinence, psychoactive drug use, unaware of safety needs, Biliteral BKA, Bilateral Hemiplegia, Hx of CVA, dialysis, and was non-compliant with her POC. [Resident#1] goal reflected [Resident#1] will not sustain serious injury. [Resident#1] interventions reflected: [Resident #1] to be given frequent reminders to not lean forward or over the side while in wheelchair as she will fall r/t having bilateral lower Page 1 of 5 675891 675891 10/30/2025 Bridgeport Medical Lodge 2108 15th Street Bridgeport, TX 76426

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few amputations and is morbidly obese with poor balance. Record review of Resident #1's weight, dated 10/28/25, reflected 271 pounds. Record review of Resident #1's care plan, dated 07/15/25 reflected, an ADL self-care performance deficit r/t limited mobility and hemiplegia. Resident #1's goal was to maintain current level of function. Resident #1's intervention included bed mobility extensive with one person assist and transfer extensive with two-person assist. Record review of Resident #1's weight, dated 10/28/25, reflected 271 pounds. Record review of Resident #1's care plan, dated 07/15/25 reflected, an ADL self-care performance deficit r/t limited mobility and hemiplegia. Resident #1's goal was to maintain current level of function. Resident #1's intervention included bed mobility extensive with one person assist and transfer extensive with two-person assist. Record review of Resident #1's progress notes, dated 10/27/25 to 10/29/25, reflected: 10/27/25 [Resident#1] witnessed fall and hospital transfer written by LVN A. 10/27/25 LVN A contacted by local ER nurse. Nurse stated cranial bleed (Involve bleeding in or around the brain) confirmed, transferred to another hospital. Trauma care pending. ER nurse stated resident was requesting to leave AMA to return to facility. LVN A informed ER nurse per facility admin resident was unable to return d/t [sic] current diagnoses. ER nurse reports resident was no longer seeking AMA and would continue to receive treatment. LVN A will continue f/u with ER on resident's condition. 10/28/25 [Resident#1] returned back to facility.Educated on staff only pushing wheelchair. Record review of Resident #1's hospital record, dated 10/28/25, reflected: diagnosed with Traumatic subdural hemorrhage without loss of consciousness, initial encounter. Record review of Resident #2's face sheet, dated 10/30/25, reflected a [AGE] year-old male, admitted [DATE], diagnosed with but not limited to: lack of coordination, pain in right shoulder, pain in right hip, adjustment disorder and history of falling. Record review of Resident #2's MDS, dated [DATE], reflected her BIMS score of 12, which indicated moderate cognitive impairment. Record review of Resident #2's care plan, undated, reflected at risk for behavior problem. Resident#2 goal reflected no evidence of behavior problems. Resident#2's interventions included Intervene as necessary to protect the rights and safety of other residents During an interview on 10/29/25 at 10:00 am, the DON stated Resident #2 pushed Resident #1 around the facility and out for smoke breaks. The DON stated Residents #1 wanted Resident #2 to push her and it was her right to allow him to do so. The DON stated since the incident Resident #1, Resident #2 and staff were educated to only allow staff to push Resident#2 The DON stated the facility rehab looked for Resident #1 a self-propelling wheelchair because she was a double amputee. During an interview on 10/29/25 at 10:20 a.m., Resident #2 stated he was the Resident Council President, and he tried to help everyone. Resident #2 stated he always pushed Resident #1 around the facility with her permission. Resident #2 stated he was pushing Resident #1 in from smoke break and she fell out of the wheelchair in the entry way. Resident#2 stated since the incident he does not push the residents anymore.During an interview on 10/29/25 at 10:35 a.m., Resident #1 stated Resident #2 was pushing her back into the building with her permission from smoke break and her wheelchair got stuck in the doorway on the ramp. Resident#1 stated she took a nosedive and fell face first and was bleeding. Resident #1 stated that she was educated not to let other residents push her after the accident. Resident #1 stated, because both her legs were gone, it was easier for her to fall out of her wheelchair. During an observation and interview at on 10/29/2511:05 a.m., laundry Aide C showed surveyor where in the doorway Resident#1 fell. Surveyor observed a small, sliver metal ramp and a door with scratches. Laundry Aide C stated she witnessed Resident#1 fall out her wheelchair. Laundry Aide C stated Resident #1 was hard to push because she was a heavier lady. Laundry aide C stated Resident #2 always pushed her. Laundry Aide C stated Resident #2 pushed Resident #1 and could not get her over the ramp hump. Laundry Aide C stated it looked like Resident #2 675891 Page 2 of 5 675891 10/30/2025 Bridgeport Medical Lodge 2108 15th Street Bridgeport, TX 76426

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few lost his balance and Resident #1 fell out of the wheelchair. During an interview at 11:45 am on 10/29/25, the Maintenance Director stated the ramp was added because the residents asked for another ramp during resident council meeting. The Maintenance Director stated residents prefer not to use the ramp on 200 hall because of the slope. The Maintenance Director was told by the Regional Maintenance Director that it was ok to add the ramp. The Maintence Director he added the ramp to 300 hall. The Maintenance Director stated there was a 2-inch drop and the ramp made for a smooth transition from inside to outside.During an interview on 10/29/25 at 1:20 p.m., the Admin stated the Regional Maintenance Director was no longer with the company. The Admin stated the Regional Maintenance Director got the okay from life safety to install the ramp. During an interview on 10/29/25 at 1:30 p.m., the Surveyor requested the Regional Maintenance Director's telephone number from the Admin. The telephone number was not provided before exit. During an observation on 10/29/25 at 2:00 p.m., the surveyor observed residents out on smoke break with two staff supervising them (Laundry aide C and wound care nurse). Staff were observed assisting residents back into the building using the ramp on 300 hall which included Resident1 and Resident#2. Record review on 10/29/25 of the Life Safety Director's email to surveyor reflected, the ramp does not cover the width of the door; therefore, it is wrong. It does not look like it needed a ramp in the first place. (Life Safety Director) would say they added something they should not have added and created a hazard. Record review on 10/29/25, Admin email reflected, the ramp was put up on 08/19/2025 by the Maintenance Director. During an interview on 10/29/25 laundry aide D stated two staff go out with residents to smoke. Laundry aide D stated it was hard to push Resident #1 to smoke break. Laundry aide D stated since the incident Resident #2 had not pushed her and only staff can. This was determined to be an Immediate Jeopardy (IJ) on 10/29/25 at 5:22pm. The Administrator were notified. The Administrator was provide with the IJ template on 10/30/25 at 4:07 pm.The following Plan of Removal submitted by the facility was accepted on 10/30/24 at 4:07 pm: Plan of Removal - F689Tag: F689 - Free of Accident Hazards/Supervision/DevicesFacility: Resident Involved: Resident #1Date of Incident: 10/27/25Date of Return to Facility: 10/28/25Immediate Jeopardy Template Submitted: 10/29/25 Corrective Action Taken for Resident #1Upon return from the hospital, Resident #1 was immediately assessed by nursing staff for injury and pain.A new care plan was developed and implemented addressing supervision and transport needs.Resident #1 was educated on safety awareness, including not allowing other residents to push her wheelchair.The resident's responsible party and physician were notified of the incident and updated on the new interventions.Resident #1's wheelchair was inspected for mechanical safety and replaced with a facility-provided wheelchair with safety locks and anti-tippers.Environmental Services completed a review of ramps and thresholds to ensure proper coverage and safe transition between surfaces.Environmental Correction: Maintenance has removed the ramp on 10/29/25.o On 10/30/25 The previous exit door on 300 hall was temporarily closed, two exit strategies still available at the end of hall 300 all/both are 150 feet from the furthest door. o On 10/30/25- Contractor on site for exit site that is temporarily closed with expected completion of 11/5/25.Education:DON/ADON in-serviced staff on Abuse and Neglect completed on 10/28/25.o DON/ADON in-serviced staff on Falls on completed on 10/28/25. o All areas of egress were evaluated and no other areas noted to be of concern on 10/29/25.o On 10/29/25, the Administrator and DON educated staff on immediate reporting of environmental hazards.o On 10/29/25, Administrator and DON educated staff and residents on new exit; on egress for smokers no hazards were identified.o Regional VP of Operations in-serviced the Administrator on 10/29/25 on proper egress and ramps for door exits.o On 10/29/25 Administrator In serviced the Maintenance Director/assistant on appropriate egress and hazards. o Facility had in-serviced staff on accident, prevention, supervision, and resident 675891 Page 3 of 5 675891 10/30/2025 Bridgeport Medical Lodge 2108 15th Street Bridgeport, TX 76426

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few transport safety completed on 10/30/25. During an observation on 10/29/25 at 5:45 pm, the DON immediately went and removed the sliver, metal ramp on 300 hall and brought it back into the building. During an observation and interview on 10/30/25 at 12:30 p.m., the Maintence Director measured the 300-hall ramp and it was 34 inches in length, and the doorway entrance was 44 inches in length. Surveyor asked Maintenance Director to call Life Safety Directors to get a understanding on how to make the ramp be in compliance. During an observation on 10/30/25 at 12:52 pm surveyor heard Maintence Director, the Admin and the contractor talking with Life Safety Director about ramp regulations. The admin stated he could see how the ramp could be a hazard. During an interview on 10/30/25 at 1:00 p.m., the Director of Rehabilitation stated Resident #1 was now using a custom 20 x 20-inch self-propelling wheelchair with tilt in space frame in a low-profile model. It has a custom molded cushion to relieve pressure on sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) and ischial tuberosities (the paired bony prominences of the lower pelvis). The low profile assists with increased weight distribution within base of support, and it has bilateral trunk (both sides of the torso) supports to assist with positioning and decrease lateral lean in upright posture. During an observation and interview on 10/30/25 at 1:20 p.m., Resident #1 stated she was so happy that she had a new wheelchair. Surveyor observed Resident #1 self-propelling herself in the therapy room. During an observation and interview at 2:00 p.m., surveyor observed Laundry Aide C, Wound Care Nurse and Maintenance Director assisted residents down the 200-hall ramp one at a time. Observed Wound Care Nurse in serviced residents only use 200 hall door for smoke breaks. Wound Care Nurse explained 300 hall door was for exiting the facility. During an observation at 4:15 pm the 300-hall door had caution tape and closed sign blocking anyone from using it on both sides. During interviews between 4:20 pm and 5:00 pm, LVN E, LVN F, CNA G and CNA H revealed staff were knowledgeable about updated smoke protocols, residents not pushing each other, abuse and neglect, reporting accidents and hazards. During an interview on 10/30/25 at 5:00 pm Laundry Aide D revealed she was knowledgeable about updated smoke protocols, residents not pushing each other, abuse and neglect, reporting accidents and hazards. During an interview on 10/30/25 at 5:10 pm wound Care Nurse revealed she was knowledgeable about updated smoke protocols, residents not pushing each other, abuse and neglect, reporting accidents and hazards. During an interview on 10/30/25 at 5:15 pm ADON, revealed she was knowledgeable about updated smoke protocols, residents not pushing each other, abuse and neglect, reporting accidents and hazards. During an interview on 10/30/25 at 5:20 pm Dietary aide and Dietary supervisor stated no one was to exit out 300 hall door, no residents should be pushing other residents, report hazards immediately to Maintenance Director and Admin at anytime. During an interview on 10/30/25 at 5:40 p.m., the Admin stated he had a meeting with the Maintenance Director, and they went over Long-term care (LTC) egress ramps in Texas must follow the Texas Accessibility Standards ([NAME]) and the Texas Building and Life Safety Code, which are based on ADA guidelines. Key rules included a maximum slope of 1:12 for accessible routes, a minimum clear width of 36 inches, handrails for ramps with a rise greater than 6 inches, and level landings at the top and bottom of each run. General slope and surface requirements Running slope: No steeper than 1:12 (1 inch of rise for every 12 inches of horizontal run). Cross slope: No steeper than 1:48. Changes in level: Any abrupt change greater than (1/4) inch must be beveled and changes greater than (1/2) inch must be addressed with a ramp or stair. Admin stated the contractor should have ramp completed for 300 hall by 11/05/25 During an interview on 10/30/25 at 5:50 pm, the DON stated staff did a clean sweep to make sure residents did not have hazards in their room and around the facility. DON stated management will be doing extra rounds to assist staff and residents with wheelchair transport. The DON was 675891 Page 4 of 5 675891 10/30/2025 Bridgeport Medical Lodge 2108 15th Street Bridgeport, TX 76426

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few knowledgeable about new smoking procedures and fall policy. DON stated there was nothing the facility could have done to prevent this incident from happening. The DON stated the facility had not had issues with the ramp and the past, and residents pushing other residents. During an observation and interview at 10/30/25 at 6:00 pm, surveyor observed Quality Assurance Nurse and Wound Care Nurse taking residents one by one down the 200-hall ramp. Resident #1, Resident #2, Resident #3, and Resident #4 were knowledgeable about not using 200 hall door and residents not pushing each other. During an over-the-phone interview at 10/30/25 at 6:05 pm the V.P. of Operations stated he went over the state requirements and regulations for the ramp with the Administrator . During an interview between 6:10 pm to 6:30 pm, LVN J, LVN K and CNA L revealed staff were knowledgeable about updated smoke protocols, residents not pushing each other, abuse and neglect, reporting accidents and hazards. Record review of a Resident Smoking in-service, dated 10/29/25, with nursing staff reflected: Residents are to enter building and exit building from door across from therapy using concrete ramp [200 hall] 300 hall exit door is an emergency exit only. The in-services additionally covered facility policy and procedures titled, Smoking Policy-Residents, dated 03/2023, reflected, .This facility should establish and maintain safe resident smoking practices. Record review of accident prevention, supervision, and resident transport safety in-service dated 10/29/25 reflected: the class covered facility policy titled, Accidents and Incidents-Investigating and Reporting revised 11/2024, reflected: .All accidents or incidents involving residents, employees, visitors, venders, etc. occurring on [facility] premises shall be investigated and reported to the Administrator . Record review of Immediate reporting of environmental hazards and unsafe resident behaviors class dated 10/29/25 covered facility policy, Hazardous Areas, Devices and Equipment revised 07/2017 reflected: All hazardous area, devices and equipment in the facility will be identified and addressed appropriately to ensure resident safety and mitigate accident hazards to the extent possible.Identification of hazards.A. hazard is defined as anything in the environment that has the potential to cause injury or illness. Examples of environmental hazards include, but are not limited to: E. Irregular floor surfaces Assessments and Analysis of Hazards.2. Any element of the resident environment that has the potential to cause injury and that is accessible to a vulnerable resident is considered hazardous.Interventions.10. Interventions will be accompanied by communication with staff and leadership, residents, family and visitors.12.Training on safety and interventions to reduce hazard risks will be ongoing.Monitoring to ensure that recommendations are implemented consistently and correctly will be a component of the safety and accident prevention program. Record review of construction quote, dated 10/30/25 reflected, a description of concrete with slope, concrete includes fiber mesh and material reinforcement, slab to be finished with a gradual slope for drainage, price includes materials, equipment, and labor, client responsible for providing clear access to site and adequate water/power supply. Quote accepted and signed on 10/30/25 by contractor and facility The Administrator was informed the Immediate Jeopardy was removed on 10/30/25 at 6:30 pm. The facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolation due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. 675891 Page 5 of 5