Health inspection·March 11, 2022

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Observation of Resident #52's bolus feeding on 03/08/22 at 3:00 PM given by Agency Nurse A revealed the resident tolerated the first 250 ml carton of formula and began to tap her hand on the feeding syringe half way through the second carton. At that time Agency Nurse A stopped the feeding and asked the resident if she was feeling ok and Resident #52 nodded her head no. The agency nurse asked the resident if she was feeling uncomfortable and full and the resident nodded her head yes. Resident #52 then began to grimace and gag and appeared as though she was going to vomit. Agency Nurse A stated she was going to call the doctor and document the incident as this was the first time working with the resident. Review of Resident #52's nurses notes dated 01/17/22 documented by RN B revealed the following: Late entry 01/16/22 at 16:30 [4:30 PM] while administering bolus via gtube half way through second carton resident reached up to stop me but right as she touched me she began to vomit severely. Emesis appeared to be all tube feeding. Continued to monitor resident frequently and noted resident covered in emesis on her neck and chest around 9 PM. Resident continued to nod her head when asked if [NAME] as not feeling well. RN held evening meds and 11 PM bolus due to continued vomiting and nausea. 01/17/2022 4:10 AM RN continued making frequent round to monitor this resident due to n/v with gtube and inability to verbalize help along with answering questions as well as before v/s: 185/108 89% on room air O2 applied at 2 lpm via n/c Lung sounds clear to bilateral upper lobes but completely diminished through lower lobes daughter notified and requested to have resident transferred to the ER Review of Resident #52's hospital records revealed she was admitted to the hospital on [DATE] with the diagnosis of pneumonia secondary to likely aspiration where she was treated with antibiotics. The resident was discharged and transferred back to the facility on [DATE]. Review of the unsigned 24-hour report on the following dates for Resident #52 revealed: 02/06/22 - not tolerating 2 cartons of gtube bolus, becomes congested, coughs, asks you to stop. etc. dietary referral for higher calorie, less volume feeding? 02/07/22 - not tolerating 2 cartons of gtube bolus, becomes congested, coughs, asks you to stop, etc. dietary referral for higher calorie, less volume feeding? 02/08/22 - not tolerating 2 cartons of feeding becomes congested coughs. Dietary referral for increased calorie decreased volume. Interview on 03/09/22 at 1:46 PM with RN B revealed she was the nurse who sent Resident #52 to the hospital. During her 3:00 PM bolus feeding, the resident put her hand up and told her to stop her feeding during her second formula carton (250 ml) so she stopped. Resident #52 began to vomit right away and there had been times the resident was not able tolerate the 2 cartons (500 ml) of formula and the resident always let her know when she was full. After Resident #52 vomited, she cleaned her up, and she and the aides began to monitor her more frequently and she called the NP about an hour after the incident and she was not able to get in touch with him. She further stated she should have tried contacting the medical director if she was not able to get in touch with the NP. Later that night around 9:00 PM, RN B found Resident #52 with emesis again and she did not appear well and did not know long it had been since the resident had vomited as the last time she remember checking on her (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 2 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some was around 8:00 PM. At that time RN B called Resident #52's family and they asked the resident be sent out to the hospital. RN B further stated she should have tried to contact the resident's physician after she was not able to get in touch with the NP but had let ADON C know about the incident. RN B said she wrote the vomit incident in the 24 hour report for the resident to have higher calories and less volume and she thought the communication would make to dietary. She also said LVN E had continued the communication form and put an entry to reduce the volume of Resident #52 was receiving. RN B also said resident ran the risk of aspiration if they were not able to tolerate a bolus feeding. RN B had not let anyone else know the resident was not tolerating her feeding because it had only happened to her once or twice before. Interview on 03/11/22 at 8:45 AM with LVN D revealed she cared for Resident #52 and administered her bolus feedings and never had a problem giving them to her. She further stated she was not aware the resident was not tolerating the volume of her bolus feedings or she would have contacted the physician. Interview on 03/10/22 at 2:30 PM with ADON D revealed she took the position of ADON mid-January 2022. She stated she had cared for Resident #52 and administered her bolus feedings a few times and the resident was able to let staff know when she was full by putting her hand up but she never vomited or gagged during her feedings and this would occurred halfway through the second carton formula. ADON D stated she was aware Resident #52 had been sent out to the hospital in January after vomiting and she had returned with no new feeding orders. ADON D further stated the 24-hour reports were taken to the staff morning meetings and reviewed but she did not recall seeing/reading the entries of Resident #52, asking for a decreased volume due to not tolerating the feedings and does not know why they were missed but should not have been. If they would have seen the entries they would have called the doctor to let him know. Interview on 03/10/22 at 3:46 PM with the Interim DON revealed she took over as interim DON on 02/15/22 and she was not aware Resident #52 was not tolerating her bolus feedings. If Resident #52 was not tolerating her feedings, the doctor or RD should have been contacted to adjust her feedings. She further stated the 24 hour reports were taken to the morning meetings daily and the nursing staff or the ADON would review it for any changes. The Interim DON further stated risk of residents not tolerating a feeding or fluid overload could lead to weight loss, aspiration pneumonia, and weight loss. Interview on 03/09/22 at 12:00 PM with the RD revealed she was just notified today, 03/09/22, Resident #52 was not tolerating her feedings due to fluid overload. He said if this occurrence was happening more than once would have needed to know so he could assess and adjust the feedings because there was a risk of becoming overloaded with fluid. The RD further stated risk of fluid overload could cause diarrhea and emesis and if the resident was vomiting that could lead to aspiration. He also stated if he would have been made aware of Resident #52's first incident in January 2022, when the resident was sent out to the hospital, he would have made changes at that time. Interview on 03/10/22 at 10:27 AM with the NP revealed he was made aware two days prio on 03/08/22 that Resident #52 was not tolerating two cartons of formula during her bolus feedings. He stated he would have expected to have been called if the resident was vomiting due to the risk of aspiration pneumonia because it the pneumonia was not treated it could be fatal. Interview on 03/10/22 at 9:33 AM with the Physician revealed he had never seen a resident receive 500 ml for one feeding and he would normally suggest 250 ml to 360 ml in one feeding, but he usually (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 3 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 0580 Level of Harm - Immediate jeopardy to resident health or safety left that decision to the RD. He stated he or the NP should have been called if Resident #52 was not tolerating her feeding more than once so changes could have been made to lower her fluid volume due to the risk of getting pneumonia from aspirating. Review of the facility's policy and procedure entitled, Acute Condition Changes - Clinical Protocol revised March 2018 reflected the following: Residents Affected - Some 1. The Physician and/or Nurse Practitioner will help identify individuals with a significant risk of having acute changes of condition during their stay 3. Direct care staff will be trained in recognizing subtle but significant changes in the resident and how to communicate these changes 8. The nursing staff will contact the physician based on the urgency of the situation they will call and page the physician and request prompt response An Immediate Jeopardy/Immediate Threat was identified on 03/10/22. The Administrator and Interim DON were notified of the Immediate Jeopardy on 03/10/22 at 1:45 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/04/20 at 3:16 PM and reflected the following: The Registered Dietitian will educate licensed nursing staff on the following procedure for notification of the RD on 03/10/22. For emergent request the RD should be consulted via phone for assistance. If the RD does not respond to the message/voicemail within one hour, the facility should contact the Nutritional Life Styles (NLS) office for assistance. NLS has a senior manager on call every day. The facility can also reach out to their corporate RD account manager for assistance. Staff should contact their RD withing 24 hours of admission on an enteral feeding for review The Director of Nursing or designee will review 24 hour reports and nurses notes the following day to ensure notification had been completed. All Registered Dietitian referrals will be place on the consultant referral form and kept in the NLS binder. Licensed nurses will be in-serviced by Regional Quality Improvement Nurse on Acute Change in Condition and related to tube feeding intolerance on 03/10/22. The Director of Nursing or designee will review 24 hour reports and nurses noted daily to ensure Physician notification has occurred timely. In-servicing will be completed by 03/10/22. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 4 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 0580 Education will consist of the following procedure: Level of Harm - Immediate jeopardy to resident health or safety Stop the tube feeding Residents Affected - Some Notify the Physician Assess the resident Notify the Registered Dietitian Notify the on-call nurse (ADON D and Interim DON) New agency nurses will be educated through Agency Orientation Checklist All non-present nurses will be in-serviced prior to next scheduled shift or via phone The Registered Dietitian will review current tube feeding residents by 03/10/22 then monitor clinical records nurse's notes bi-weekly times three months then monthly on-going. The Director of Nursing or designee with oversight from the Administrator will monitor the above listed processes daily times two then weekly times six. Discrepancies will be addressed immediately and QAPI will be updated and addressed. Monitoring of the facility's Plan of Removal included the following: Interviews were conducted on 03/11/22 starting at 8:45 AM and continued through 1:56 PM with ten staff members from various shifts regarding in-services which included bolus g-tube proficiency, assessment, physician notification, and Registered Dietitian when a resident is not tolerating a bolus feeding. The staff members were able to: Assess the resident during and after bolus feeding. What to do if resident has an emergent tube feeding change in condition. Who to notify in case a resident is not tolerating a feeding. When the RD should be contacted when a resident admits. What to do if a resident need a general referral. Where and what to document the incident if a resident does not tolerate a feeding. Interviewed staff members from various shifts were: LVNs C, E, G, K, L, H and RNs B, F, I, J ADON D and Interim DON were provided in-service training on how often the 24-hour reports were to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 5 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 0580 be reviewed and monitored. Level of Harm - Immediate jeopardy to resident health or safety The Administrator was notified on 03/11/22 at 3:30 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 03/11/22, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the Plan of Removal. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 6 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that a resident who was fed by enteral feeding received the appropriate treatment and services to prevent complications for one (Residents #52) of five residents reviewed for tube feedings. The facility failed to notify Resident #52's Physician and the Dietitian when she was not tolerating her 3:00 PM 500 ml bolus feeding. The resident was seen gagging during her feeding and tapping on the feeding syringe, alerting staff to stop her feeding. Resident #52 was admitted to the hospital on [DATE] with pneumonia possibly from aspiration when she was found in vomit about five hours after her 3:00 PM bolus feeding. An Immediate Jeopardy was identified on 03/10/22. While the Immediate Jeopardy was removed on 03/11/22, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility's continuation of in-servicing and monitoring the plan of removal. These failures placed residents at risk if aspiration pneumonia due to fluid overload or even death. Findings included: Review of Resident #52's MDS assessment dated [DATE] reflected the resident was an [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: aphasia (loss of ability to understand or express speech), CVA, dementia, hemiplegia (paralysis of one side of the body), malnutrition, and other speech/language deficits following CVA. The assessment further reflected Resident #52 usually understands-misses some part/intent of message but comprehends most conversation. She required total dependence on feeding/staff perform every time during entire 7-day period. The assessment also reflected the resident had a feeding tube seven days for proper calories. Review of Resident #52's care plan reflected she had a peg tube and was at risk for aspiration with an onset of 03/09/20. Approaches included to monitor for s/s of aspiration, fever, cough, rales/rhonchi, wheezing, and altered mental status. The approaches also included notifying the MD as needed. Review of Resident #52's Nurse Medication Administration Record dated March 2022 reflected the following: TF Isosource 1.5 calorie liquid formula bolus give two cartons (500ml) via g-tube twice daily 8A, 3A, and one carton (250ml) once a day at 11P with a start date of 01/24/22. Review of Resident #52's nurses notes dated 01/17/22 documented by RN B revealed the following: Late entry 01/16/22 at 16:30 [4:30 PM] while administering bolus via gtube half way through second carton resident reached up to stop me but right as she touched me she began to vomit severely. Emesis (vomit) appeared to be all tube feeding. Continued to monitor resident frequently and noted resident covered in emesis on her neck and chest around 9 PM. Resident continued to nod her head when asked if she was not feeling well. RN held evening meds and 11 PM bolus due to continued vomiting and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 7 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 0693 nausea. Level of Harm - Immediate jeopardy to resident health or safety 01/17/2022 4:10 AM Residents Affected - Some RN continued making frequent round to monitor this resident due to n/v with gtube and inability to verbalize help along with answering questions as well as before v/s: 185/108 89% on room air O2 applied at 2 lpm via n/c Lung sounds clear to bilateral upper lobes but completely diminished through lower lobes family member notified and requested to have resident transferred to the ER Review of Resident #52's hospital records revealed she was admitted to the hospital on [DATE] with the diagnosis of pneumonia secondary to likely aspiration where she was treated with antibiotics. The resident was discharged and transferred back to the facility on [DATE]. Review of the unsigned 24-hour report on the following dates for Resident #52 revealed: 02/06/22 - not tolerating 2 cartons of gtube bolus, becomes congested, coughs, asks you to stop. etc. dietary referral for higher calorie, less volume feeding? 02/07/22 - not tolerating 2 cartons of gtube bolus, becomes congested, coughs, asks you to stop, etc. dietary referral for higher calorie, less volume feeding? 02/08/22 - not tolerating 2 cartons of feeding becomes congested coughs. Dietary referral for increased calorie decreased volume. Observation and interview of Resident #52's bolus feeding on 03/08/22 at 3:00 PM given by Agency Nurse A revealed the resident tolerated the first 250 ml carton of formula and began to tap her hand on the feeding syringe halfway through the second carton. At that time Agency Nurse A stopped the feeding and asked the resident if she was feeling ok and Resident #52 nodded her head indicating no. The agency nurse asked the resident if she was feeling uncomfortable and full and the resident nodded her head indicating yes. Resident #52 then began to grimace and gag and appeared as though she was going to vomit. Agency Nurse A stated she was going to call the doctor and document the incident as this was the first time working with the resident. Interview on 03/09/22 at 9:30 AM with LVN C revealed she cared for Resident #52 during the 6:00 AM to 2:00 PM shift and she never had any concerns with the resident's gtube feeding during her shift. She stated she heard about a month ago, the weekend staff were saying Resident #52 was not tolerating her feeding but did not get more information to the time of the feeding or the staff caring for the resident. Interview on 03/09/22 at 1:46 PM with RN B revealed, she was the nurse who sent Resident #52 to the hospital on [DATE]. She said during her 3:00 PM bolus feeding the resident put her hand up and told her to stop her feeding during her second formula carton (250 ml) so she stopped. Resident #52 began to vomit right away and there had been times the resident was not able tolerate the 2 cartons (500 ml) of formula and the resident always let her know when she was full. After Resident #52 vomited, she cleaned her up, and she and the aides began to monitor her more frequently and she called the NP about an hour after the incident, and she was not able to get in touch with him. Later that night around 9:00 PM, RN B found Resident #52 with emesis again and she did not appear well and did not know long it had been since the resident had vomited as the last time she remembered checking on her was around 8:00 PM. At that time, RN B called Resident #52's family and they asked the resident be (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 8 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 0693 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some sent out to the hospital. RN B further stated she should have tried to contact the resident's physician after she was not able to get in touch with the NP but had let ADON C know about the incident. RN B said she wrote the vomit incident in the 24-hour report for the resident to have higher calories and less volume and she thought the communication would make to dietary. She also said LVN E had continued the communication form and put an entry to reduce the volume of Resident #52 was receiving. RN B also said resident ran the risk of aspiration if they were not able to tolerate a bolus feeding. RN B had not let anyone else know the resident was not tolerating her feeding because it had only happened to her once or twice before. Interview on 03/11/22 at 8:45 AM with LVN D revealed she cared for Resident #52 and administered her bolus feedings and never had a problem giving them to her. She further stated she was not aware the resident was not tolerating the volume of her bolus feedings. Interview on 03/10/22 at 2:30 PM with ADON D revealed she took the position of ADON mid-January 2022. She stated she had cared for Resident #52 and administered her bolus feedings a few times and the resident was able to let staff know when she was full by putting her hand up but she never vomited or gagged during her feedings and this would occurred halfway through the second carton formula. ADON D stated she was aware Resident #52 had been sent out to the hospital in January after vomiting and she had returned with no new feeding orders. ADON D further stated the 24-hour reports were taken to the staff morning meetings and reviewed but she did not recall seeing/reading the entries of Resident #52, asking for a decreased volume due to not tolerating the feedings and does not know why they were missed but should not have been. She said if they would have seen the entries they would have called the doctor to let him know. Interview on 03/10/22 at 3:46 PM with the Interim DON revealed she took over as interim DON on 02/15/22 and she was not aware Resident #52 was not tolerating her bolus feedings. She said if Resident #52 was not tolerating her feedings, the doctor or RD should have been contacted to adjust her feedings. She further stated the 24-hour reports were taken to the morning meetings daily and the nursing staff or the ADON would review it for any changes. The Interim DON further stated risk of residents not tolerating a feeding or fluid overload could lead to weight loss and aspiration pneumonia. Interview on 03/09/22 at 12:00 PM with the RD revealed she was just notified today, 03/09/22, that Resident #52 was not tolerating her feedings due to fluid overload. He said if this occurrence was happening more than once, he would have needed to know so he could assess and adjust the feedings because there was a risk of becoming overloaded with fluid. The RD further stated risk of fluid overload could cause diarrhea and emesis and if the resident was vomiting that could lead to aspiration. He also stated if he would have been made aware of Resident #52's first incident in January 2022, when the resident was sent out to the hospital, he would have made changes at that time. Interview on 03/10/22 at 10:27 AM with the NP revealed he was made aware two days prior on 03/08/22 that Resident #52 was not tolerating two cartons of formula during her bolus feedings. He stated he would have expected to have been called if the resident was vomiting due to the risk of aspiration pneumonia because it the pneumonia was not treated it could be fatal. Interview on 03/10/22 at 9:33 AM with the Physician revealed he had never seen a resident receive 500 ml for one feeding. He stated he would normally suggest 250 ml to 360 ml in one feeding, but he usually left that decision to the RD. He stated he or the NP should have been called if Resident #52 was not tolerating her feeding more than once so changes could have been made to lower her fluid volume due to the risk of getting pneumonia from aspirating. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 9 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 0693 Review of facility's policy and procedure entitled Enteral Tube Feeding via Syringe (Bolus) revised November 2018 reflected the following: Level of Harm - Immediate jeopardy to resident health or safety Purpose Residents Affected - Some The purpose of this procedure is to provide nutritional support to residents unable to obtain nourishment orally Reporting 1. Report complications promptly to the supervisor and the Attending Physician. An Immediate Jeopardy/Immediate Threat was identified on 03/10/22. The Administrator and Interim DON were notified of the Immediate Jeopardy on 03/10/22 at 1:45 PM. The facility was asked to provide a Plan of Removal to address the Immediate Jeopardy. The Facility's Plan of Removal for Immediate Jeopardy was accepted on 08/04/22 at 3:16 PM and reflected the following: The Registered Dietitian will educate licensed nursing staff on the following procedure for notification of the RD on 03/10/22. For emergent request the RD should be consulted via phone for assistance. If the RD does not respond to the message/voicemail within one hour, the facility should contact the Nutritional Life Styles (NLS) office for assistance. NLS has a senior manager on call every day. The facility can also reach out to their corporate RD account manager for assistance. Staff should contact their RD withing 24 hours of admission on an enteral feeding for review The Director of Nursing or designee will review 24 hour reports and nurses notes the following day to ensure notification had been completed. All Registered Dietitian referrals will be place on the consultant referral form and kept in the NLS binder. Licensed nurses will be in-serviced by Regional Quality Improvement Nurse on Acute Change in Condition and related to tube feeding intolerance on 03/10/22. The Director of Nursing or designee will review 24 hour reports and nurses noted daily to ensure Physician notification has occurred timely. In-servicing will be completed by 03/10/22. Education will consist of the following procedure: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 10 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 0693 Stop the tube feeding Level of Harm - Immediate jeopardy to resident health or safety Assess the resident Residents Affected - Some Notify the Registered Dietitian Notify the Physician Notify the on-call nurse (ADON D and Interim DON) New agency nurses will be educated through Agency Orientation Checklist All non-present nurses will be in-serviced prior to next scheduled shift or via phone The Registered Dietitian will review current tube feeding residents by 03/10/22 then monitor clinical records nurse's notes bi-weekly times three months then monthly on-going. The Director of Nursing or designee with oversight from the Administrator will monitor the above listed processes daily times two then weekly times six. Discrepancies will be addressed immediately and QAPI will be updated and addressed. Monitoring of the facility's Plan of Removal included the following: Interviews were conducted on 03/11/22 starting at 8:45 AM and continued through 1:56 PM with 10 staff members from various shifts regarding in-services which included bolus g-tube proficiency, assessment, physician notification, and Registered Dietitian when a resident is not tolerating a bolus feeding. The staff members were able to: Assess the resident during and after bolus feeding. What to do if resident has an emergent tube feeding change in condition. Who to notify in case a resident is not tolerating a feeding. When the RD should be contacted when a resident admits. What to do if a resident needed a general referral. Where and what to document the incident if a resident does not tolerate a feeding. Interviewed staff members from various shifts were: LVNs C, E, G, K, L, H and RNs B, F, I, J ADON D and Interim DON were provided in-service training on how often the 24-hour reports are to be reviewed and monitored. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 11 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 0693 Level of Harm - Immediate jeopardy to resident health or safety The Administrator was notified on 03/11/22 at 3:30 PM, the Immediate Jeopardy was removed. While the immediacy was removed on 03/11/22, the facility remained out of compliance at a scope of pattern and a severity level of actual harm that is not Immediate Jeopardy, due to the facility continuing in-servicing and monitoring the plan of removal. Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 12 of 13 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 676143 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/11/2022 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Mansfield Medical Lodge 301 N Miller Rd Mansfield, TX 76063 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 Based on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three (Residents #2, #16, and #66) of three residents reviewed for infection control. Residents Affected - Some MA M failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #2, #16, and #66. These failures could place residents at-risk of cross contamination which could result in infections or illness. Findings included: Observation on 03/09/22 at 8:27 AM of MA M revealed she failed to disinfect the reusable blood pressure cuff with a disinfecting wipe between blood pressure readings on Residents #2, #16, and #66. Interview on 03/09/22 at 10:02 AM with MA M revealed she was aware of the requirement to disinfect the blood pressure cuff between residents, but the presence of the surveyor made her nervous. She revealed that not disinfecting equipment between residents can cause infections to be passed from one to another. Interview on 03/09/22 at 10:15 AM with the DON revealed the expectation was that staff would disinfect all reusable medical equipment between each resident use, to avois cross contamination. The DON stated staff had disinfecting wipes available to them, and they were usually stocked on the stand holding the blood pressure monitor. She revealed she completed a staff in-service training in February of 2022 on disinfection of reusable medical equipment. Review of facility in-service sign in sheet for Disinfection of Reusable Medical Resources, dated February 2022, revealed MA M had signed the sign-in sheet. Review of facility's undated policy on Disinfection of Reusable Patient Equipment revealed that all reusable medical equipment is required to be disinfected between each resident use, using EPA approved disinfectant. Review of disinfecting wipes stocked on the stand holding the blood pressure cuff revealed they are effective against SARS COVID-19, with a 1-minute dwell time, according to the Environmental Protection Agency registration number when it was checked against the EPA website. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 13 of 13