Health inspection·December 30, 2025

F 0600 Level of Harm - Actual harm Residents Affected - Few video, undated, revealed a 40 second clip which showed Resident #1 lying in bed with mechanical lift sling under her body, CNA A standing next to the bed. CNA A rolled Resident #1 away from her (Resident #1 is on her left side) toward the wall and adjusted her pants. CNA A then rolled Resident #1 back towards her (Resident #1 is being rolled back to her right side) grabbed her wrist and pulled her over. At 0:13 seconds CNA A was heard saying Save those fake-ass tears, you weren't trying to cry before you hit me. CNA A was observed lifting Resident #1's head up and adjusting the nightgown. At 0:21 seconds, Resident #1 was lying in bed with top part of her body exposed, CNA A used a body wipe to clean under the right armpit and crossed over Resident #1's body to wipe left armpit area. At 0:33 seconds, CNA A lifted Resident #1's head to place shirt over head when Resident #1 used her left hand to hit CNA A on her right forearm. CNA A then used her right hand and hit Resident #1 on the left side of her forehead (audible sound of hand making contact with flesh) and said Stop. Video ends at 0:40 seconds. Interview with Resident #1 could not be conducted. Resident #1 had expired, unrelated to the incident, on [DATE].Attempted interview on [DATE] at 2:14 PM, with CNA A revealed no answer to phone call to last known number, voicemail left with call back number. Interview on [DATE] at 2:18 PM, the Agency Director revealed, CNA A was not an employee but an independent contractor with his agency. Her access to the platform was removed on [DATE]. She was disqualified from accepting any positions. Background checks and abuse/neglect training was verified by agency. Interview on [DATE] at 4:10 PM, the DON revealed she was notified of the alleged abuse of Resident #1 via a call from the resident's family member. The family member informed both the Administrator and the DON on [DATE] that when he reviewed the footage from the electronic monitor in Resident #1's room, he observed CNA A strike Resident #1 in the face while providing assistance with ADL care. The DON stated that CNA A was scheduled to work on [DATE] from 6:00 AM-2:00 PM but clocked out early stating she had stomach issues and became incontinent at work. There was no prior care concerns related to CNA A. She stated the facility then started an abuse investigation that resulted in a confirmed finding. Safe rounds was performed on all residents under CNA A's care along with abuse in-service of staff. The Administrator and DON provided in-services related to employee burn out and stress. The DON said on Monday's and Friday's she checks in with staff to inquire if they are feeling overwhelmed. She stated that once a week, spot checks are conducted. The facility initiated a stop and watch form that allows staff members to fill out and report to administration. If they feel, a coworker is suspected of abuse or neglect.Interview on [DATE] at 10:00 AM, the Administrator revealed CNA A was an agency staff without any prior resident complaints or concerns. He stated he became aware of the incident when notified by Resident #1's family member. Staff member CNA A exited the building prior to knowledge of the incident, facility investigation initiated responsible parties were notified, in-service staff for abuse and staff burnout were initiated. Administrator conducted a meeting with agency director to ensure that future agency staff members come highly recommended.Interview on [DATE] at 2:38 PM, CNA B revealed she worked with CNA A and did not suspect abuse of any residents. She stated that CNA A had family issues with her grandchildren and had to finically provide for them. She stated that if she suspected abuse or neglect, she would report it to the administrator immediately. Interview on [DATE] at 1:27 PM with agency CNA C revealed she had a cheat sheet that helps with the resident's care: Report abuse to the nurse or administrator immediately. She stated she had worked a lot of shifts and had been trained on abuse and neglect. She was able to name the types of neglect and abuse. Interview on [DATE] at 2:33 PM with agency LVN D revealed she was trained on abuse and neglect. She stated if she suspected abuse or neglect go and report it to the administrator.it has to be investigated. Today ([DATE]) was her first day working in this building. Interview on [DATE] at 3:06 with LVN (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675891 If continuation sheet Page 2 of 4 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 12/30/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few E revealed he had worked with CNA A before and did not suspect abuse or neglect. He was able to name types of abuse and signs of neglect. Interview on [DATE] at 2:58 PM- with CNA A revealed she did not call prior because she was waiting on the advice of her lawyer. She stated this was a last-minute shift, the day of the incident. She stated she was at the hospital with her grandson who was on a ventilator and that her husband was dead and she was the only one responsible for her bills, so she took the last-minute shift because she needed the money. She stated she had stomach issues, maybe something she ate prior to coming to work and she had diarrhea. CNA A stated she had worked with Resident #1 before. She stated Resident #1 was swinging at her and CNA A stated she just blacked out. CNA A stated she knew Resident #1 had a camera, due to the sign outside. CNA A stated she looked up and saw the camera and freaked out. She stated she just panicked and unplugged the camera and then plugged it back in. She stated she left afterwards and told the staffing coordinator that she messed her clothes and left. CNA A stated she knew it was wrong, but she needed the money. She stated she never had issues before and she stated she had been interviewed by the state before regarding abuse and neglect but not related to anything she did. CNA A stated she had received abuse training from both the agency and the facility. She was able to name the different types of abuse and stated suspicion of abuse was to be reported to the Administrator immediately. Record Review of Portable X-Ray dated [DATE] revealed; SKULL 3V Findings; AP oblique and lateral views of the skull demonstrate a diffuse osteoporosis. No skull fracture is present the bilateral orbits are intact. The soft tissues are unremarkable. There is no radiopaque foreign body. Right Hand Rt 2V; AP, lateral and oblique views of the right hand are submitted. The bones are osteoporotic. No acute dislocation or fracture is visualized. There is no bony erosion or destruction. The mild-to-moderate osteoarthritis is visualized in the 1st carpometacarpal joint. The soft tissues are unremarkable without radiopaque foreign body. Record review of Criminal History Conviction Name Search Result dated [DATE] revealed, no matching records for CNA A. Record review of Provider Detail Public Search dated [DATE] revealed CNA A's NA Certification Status Active, Certificate Issue Date [DATE]. Initial Certificate Issue Date [DATE]. Certificate Expires [DATE] Record review of Employability Status Check Search Results dated [DATE] CNA A revealed; Unemployable? NO. NAR Status Active. NAR; Active, Unemployable NO. MAR: Active Unemployable NO. Record review of CNA A's Staffing Agency Training dated [DATE] revealed Test Name: Abuse and Neglect (Child, Domestic, Elder) and Human Trafficking. Score 80% Record review of Agency Facility orientation dated [DATE] revealed As an agency staff member, I understand and acknowledge that it is my responsibility to provide quality of care consistent with resident's needs. Signed by CNA A.Record review of a document titled, Other dated [DATE] at 12:44 PM revealed; Person Preparing Report: ADON obtained a statement from CNA A I came in the morning not feeling well. As you can see in the video my pants were already messed. I was not feeling well but I had already started getting her dressed so I figured I should finish. I was frustrated and burnt out and needed a break. I lashed out on her and hit her then noticed the camera and I unplugged it. I know I shouldn't have done it but I did and can not deny it ADON asked CNA A Did you reach out to another CNA or charge nurse for support? CNA A stated no. I was ready to go home I was sick. Record review of a document titled Other prepared by the ADON dated [DATE] at 12:44 PM revealed, at 12:47 PM family notified facility regarding findings on the in-room security camera. Purple bruising noted to top of right hand measuring 4.6cm X 2.5cm. Also noted 0.1x0.5x0.1 open area above bruising. Resident unable to give description. Incident was not witnessed. Full skin assessment completed. ROM WNL to right hand with no c/o or s/s of pain or discomfort noted to area. XRAY FACE AND RIGHT HAND. Record review of Progress Notes authored by ADON dated [DATE] at 3:57 PM revealed, at 12:47 PM family notified facility regarding findings on the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675891 If continuation sheet Page 3 of 4 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 12/30/2025 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 0600 Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete in-room security camera. Purple bruising noted to top of right hand measuring 4.6cm x 2.5cm. Also noted 0.1 x 0.5x.0.1 open area above bruising. Area cleansed with NS and steristrip applied. Physician informed. Will continue to monitor areas. Record review of Trauma informed Care Assessment-PTSD dated [DATE] revealed, a PTSD Screening with no probable cause findings for Resident #1.Record review of New Patient Referral Form dated [DATE] revealed, referral for psychology was submitted for Resident #1. Record review of Root Cause Analysis undated revealed, On September19, 2025, facility video surveillance captured a CNA striking a resident in the head. This action constitutes abuse and violates the residents' rights, facility policies, and federal/state regulations. Staff Action: CNA had already left for the day and then removed from the reminder of her shifts immediately following discovery. Corrective Actions: Staff Action: Immediate removal of CNA from duty. Disciplinary process initiated, including termination and reporting to the Contract Nurse Agency and law enforcement. EDUCATION; Facility wide re-education on: Abuse/neglect policies. Resident rights and staff burn out. Leadership Oversight: DON/Administrator to conduct unannounced rounds on all shifts for two weeks. Random staff/resident interviews conducted to validate awareness of abuse prevention practices. Culture & Prevention: Re-incorporation of anger management, stress-de-escalation, and conflict resolution resources into orientation and annual training. Leadership rounding to reinforce zero-tolerance culture and provide staff support. Record review of Inservice and Training dated [DATE] revealed, Topic: abuse and neglect. Trainer was the ADON. Record review of in-service training report dated [DATE] revealed, Subject Stress Reduction/Potential Burnout conducted by DON. Review of Abuse and Neglect -Clinical protocol revised [DATE] revealed; The facility will ensure that each resident has the right to be free from, among other things, physical or mental abuse and corporal punishment. The facility will provide a safe resident environment and protect residents from abuse. Event ID: Facility ID: 675891 If continuation sheet Page 4 of 4