Health inspection·May 19, 2023

F 0693 Level of Harm - Minimal harm or potential for actual harm and recommendations. Continue to offer enhance meals to meet nutritional needs. Monitor meal intake and record every meal. Diet as ordered. *Resident has a PEG tube due to dysphagia and is at risk for aspiration. Resident does not allow staff to flush or use tube for feeding. Residents Affected - Few Goal: Resident will have stable weights and labs and will have no s/s of aspiration 08/02/23. Approaches: Keep head of bed elevated during feeding. Monthly weights, Site care qd, notify MD as needed Review of Resident #14's physician order summary reflected: TF: Diabetisource calorie liquid 60 ml per hour times 22 hours via pump was discontinued 10/21/2022. Resident #14's medications were discontinued via g-tube on 01/23/23. Review of Resident #14's physician chart order for 04/04/23 revealed a physician order to obtain a GI consult for removal of the resident's g-tube. Observation and interview on 05/18/23 at 9:35 AM revealed Resident #14 was lying in bed. Resident #14 stated she had a g-tube; however, she no longer needed it. Resident #14 stated she could eat by mouth. She stated she had been able to eat by mouth for months now. She stated she could take her medications by mouth and drank fluids by mouth. She stated she had requested for her g-tube to be removed but did not know the status of her request. Resident #14's g-tube appeared to be intact. Resident #14 stated she did not like looking at the g-tube, and she wanted it taken out. Resident #14 stated she had told the nurses; however, she could not recall which nurse she had told or how long it had been since she mentioned it to a nurse. Interview on 05/19/23 at 11:38 AM with the RD revealed she acquired the facility November 2022. The RD stated Resident #14 had been non-compliant with her g-tube. She stated Resident #14's g-tube had not been in use, and the resident took everything by mouth. The RD stated Resident #14's weight was stable. The RD stated back in November 2022 Resident #14 was eating 75%-100% of her meals and was only receiving water flushes and medications via g-tube. The RD stated Resident #14's feedings were stopped prior to November 2022. She stated Resident #14's flushes were discontinued 03/27/23, due to the resident refusing the flushes. The RD stated Resident #14 had informed her several times she no longer wanted the g-tube. The RD stated she was not aware Resident #14 still had her g-tube. The RD stated once flushes were discontinued the plan was to remove the g-tube. The RD stated she recommended for the g-tube to be removed back in March 2023. The RD stated the risk for the resident to continue to have the g-tube was that it could affect her quality of life. The resident did not need the g-tube if she was able to eat and drink by mouth. Interview on 05/19/23 at 12:06 PM with LVN B revealed Resident #14's g-tube was not in use. She stated Resident #14 could eat, drink, and take medications by mouth. LVN B stated she could not recall how long Resident #14's g-tube was not in use. LVN B stated she was not sure if they had a referral for a GI consult. LVN B stated it was the ADON's responsibility to follow-up with referrals and scheduling appointments. LVN B stated there was no risk to the resident to still have a g-tube. Interview on 05/19/23 at 12:12 PM with the ADON revealed she was responsible for residents on the 100 Hall. She stated Resident #14 still had a g-tube; however, the g-tube was not being used. The ADON stated Resident #14 had been able to eat by mouth for about four months. The ADON stated Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 2 of 7 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 05/19/2023 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 - Minimal harm or potential for actual harm Residents Affected - Few #14 had been refusing flushes, and the flushes had been discontinued for over a month. The ADON stated she had not seen Resident #14 recently and was not aware that Resident #14 wanted her g-tube removed. The ADON stated Resident #14 did have a referral for a GI consult but was unsure when it was provided. She stated she contacted a GI doctor; however Resident #14 was denied because the doctor was not accepting new patients. The ADON stated she had not scheduled an appointment yet due to her still gathering paperwork. When asked what paperwork was she referring to, the ADON stated insurance. She stated the facility was still looking for a GI doctor. The ADON stated she was not sure when the referral was provided; however, she stated she would look for the referral and would provide it to surveyor. Follow-up interview on 05/19/23 at 3:05 PM with the ADON revealed she reviewed Resident #14's clinical record, and she had located the written referral which was provided 04/04/23. The ADON stated as of 01/06/23 Resident #14's medications via g-tube were discontinued and the flushes were discontinued in March 2023 per the Dietitian. The ADON stated she was responsible for following up with referrals. She stated she did not have any documentation regarding her contacting the GI doctor when the referral was first written. Since Resident #14 was denied, she had not followed up with the referral. The ADON stated since there was no immediacy for the g-tube to be removed there was no risk to the resident. The ADON left the office and returned stating Resident #14 was seen by the MD today and was sent to the hospital to get the g-tube removed. The ADON stated Resident #14 requested her g-tube be removed. Interview on 05/19/23 at 4:17 PM with the MD revealed he was aware Resident #14's g-tube was not being used. The MD stated Resident #14 could eat, drink, and take medications by mouth. The MD stated he had provided a referral on 04/04/23 for a GI consult; however, the facility was having problems with finding a GI doctor. The MD stated he visited Resident #14 today and ordered for resident to go to the ER to remove the g-tube. Interview on 05/19/23 at 4:54 PM with the DON revealed according to staff documentation Resident #14 had been refusing water flushes, and the water flushes were discontinued 03/27/23. The DON stated Resident #14 was able to eat and take medication by mouth for months now. The DON stated it was mentioned today (05/19/23) that Resident #14 wanted her g-tube removed; however, prior to today there was a GI consult referral. The DON stated she was only aware that the ADON was working on the referral but was having issues scheduling the appointment. The DON stated it was the ADON's responsibility to follow-up with referrals; however, she was unsure what happened on this situation. The DON stated her expectation was to follow-up with the referral and if the resident was denied the ADON needed to continue to try different providers. She stated it was her responsibility to check on the status of the referrals. The DON stated the risk of not following up with referrals was that it could cause a delay in service. A facility policy regarding referrals was requested; however, it was not provided prior to exit. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 3 of 7 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 05/19/2023 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 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #71) of 4 residents reviewed for pharmaceutical services. RN A failed to follow the facility policy for administering medication through gravity when administering medications via Resident #71's g-tube. These failures could put residents who received medications via g-tube at risk for aspiration. Findings included: Review of Resident #71's MDS assessment, dated 03/26/23, revealed the resident was a [AGE] year-old male admitted to the facility on [DATE]. The assessment reflected Resident #71 had severely impaired cognition and had diagnoses which included unspecified severe protein-calorie malnutrition and on peg tube for nutritional approach. Review of Resident #71's May 2023 Physician Orders reflected there were no orders for medication administration method. Observation on 05/18/23 at 8:13 AM revealed RN A pulled the following medications and placed them in a separate cup: - Aspirin 81 mg, 1 tablet daily by g-tube (blood pressure) - Acidophilus 1 capsule, daily by g-tube (supplement) - Amiodarone 200 mg, 1 tablet daily by g-tube (low blood pressure) - Coreg 25 mg, 1 tablet daily by g-tube (blood pressure) - Diltiazem 90 mg, 1 tablet daily by g-tube (blood pressure) - Gabapentin 100 mg, 1 capsule three times by g-tube (neuropathy) - Hydralazine 10 mg, 1 tablet daily by g-tube (blood pressure) - Keppra 500 mg, 1 tablet daily by g-tube (seizure) - Lisinopril 20 mg, 1 tablet daily by g-tube (blood pressure) - Prostat 60 ml, daily by g-tube (supplement) - Sertraline 25 mg, daily by g-tube (depression) - Lasix 40 mg, daily by g-tube (edema) (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 4 of 7 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 05/19/2023 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 0755 - Simethicone 80 mg, daily by g-tube (gastrointestinal) Level of Harm - Minimal harm or potential for actual harm - Loratadine 10 mg daily by g-tube (allergy); and - Tramadol 50 mg daily by g-tube (pain). Residents Affected - Few RN A crushed all the medications together and mixed with 60 ml water. RN A had orders to cocktail the medications. RN A went to Resident 71's room, positioned Resident #71, checked for the g-tube placement and residual, and flushed the g-tube with 15 ml of water. RN A was observed administering medication by pushing through the g-tube with a plunger than allowing the mixed medication to flow by gravity. She then flushed the g-tube with 15 ml water by plunging with a syringe. Interview on 05/18/23 at 8:36 AM with RN A revealed she was aware there was no order to administer medication through g-tube by gravity for Resident #71, but she did not call the doctor or notify the DON. She stated she knew she was supposed to go through the orders before medication administration and verify the route of administration. She stated she had been pushing the medication with a plunger because administering by gravity was slow. She stated it was her responsibility and best nursing standard of practice to check the orders before administration of any medication. RN A stated failure to check orders and administering medication through plunging could lead to aspiration. She stated she had done training on medication administration via gastrostomy tube. Interview on 05/18/23 at 9:10 AM with the DON revealed her expectation was for the nurses to follow the physician orders and check the orders before medication administration. The DON stated RN A was not supposed to use a plunger without a physician order. She stated she was not sure what their policy stated. The DON stated the resident did not have orders for either to administer through gravity or push. She stated RN A reported it to her, and they contacted the doctor since Resident #71 did not have orders. She stated they were issued orders reflecting they could push the medications. The DON stated it was the nurses' responsibility to clarify orders before they administered medications, and RN A failed to clarify. She stated she had trained the nurses on medication administration via g-tube. The DON stated the risk of plunging the medication was that it could cause Resident #71 to experience distress and aspiration. Review of the facility's current policy entitled Administering Medication Through Enteral Tube, dated March 2015 reflected the following: .1. Verify that there is physician's medication order for this procedure. .11. confirm placement of feeding tube. .17. Reattach syringe (without plunger) to the end of the tubing. 18. Administer medication by gravity flow . a. Pour diluted medication into the barrel of the syringe while holding the tubing slightly above the level of insertion. b. Open the clam and deliver medication slowly. c. Clamp tubing (or begin flush) before the tubing drains completely . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 5 of 7 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 05/19/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, record review, and interview, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for three (Hall 100, 200 and 400 Medication Cart) of four medication carts and one refrigerator reviewed for pharmacy services. 1. The facility failed to ensure expired medications in nurse medication carts for Hall 100, 200, 400 and refrigerator were removed and destroyed. 2. The facility failed to ensure insulin were dated with opening dates. The failure placed residents at risk of receiving medications that were ineffective due to having expired medications on the cart, in the refrigerator and due to not putting opening date on insulin pens/vials. Findings included: 1. Observation on 05/18/23 at 4:22 PM of the nurse's medication cart used for the 100 Hall with LVN C revealed two insulin vials of glargine 100 unit/ml with an opening date of 03/30/23 and 03/23/23 that were opened and partially used. Interview on 05/18/23 at 4:35 PM with LVN C revealed it was all nurses' responsibility to check the carts for expired medications every shift and put them in the destruction boxes. She stated she did not check the cart after it being handed over to her because she forgot. She stated the insulins were good for 28 days after being opened. She stated the side effects of giving expired medication would be that it was not effective. She stated she had completed training on labeling and storage of medications. 2. Observation on 05/18/23 at 4:40 PM of the nurse's medication cart used for the 200 Hall with LVN D revealed, one insulin pen of Levemir was open, partially used, and without an opening date. 3. Observation on 05/18/23 at 4:46 PM of the nurse's medication cart used for the 400 Hall with LVN E revealed, one insulin aspart flex pen opened and partially used with no open date and one Lispro insulin pen with open date of 04/14/23 that was opened and partially used. Interview on 05/18/23 at 4:51 PM with LVN D revealed it was all nurses' responsibility to put an opening date on insulin vial/pen after removing from the refrigerator. She stated she was supposed to check her cart at the beginning of the shift, but she did not check, she forgot. She stated the insulins are good for 28 days after being opened. She stated the effects of not putting opening date on insulin vials/pen they would not be sure when it expired. She stated she had completed training on labeling and storage of insulin. Interview on 05/19/23 at 11:19 AM with the DON revealed her expectation was that all nurses checked their carts for expired medications every shift. The DON stated it was all nurses' responsibility to ensure insulin had an open date when they removed it from the refrigerator. She stated the insulins were good for 28 days after opening. She stated the insulins that did not have open dates and (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 6 of 7 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 05/19/2023 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 0761 Level of Harm - Minimal harm or potential for actual harm those that were expired were destroyed, and they ordered more from pharmacy. The DON stated failure to put an open date on insulins would result in staff not being able to tell when the insulin expired. The failure to remove the expired insulin from the cart was that if they were administered to residents then they would not be effective. The blood sugars would not be controlled appropriately. She stated ADONs were supposed to check the carts and the refrigerator once a week for expired medications and dates and labeling. Residents Affected - Few 4. Observation on 05/19/23 at 11:55 AM of the facility only refrigerator revealed two Tylenol 650 mg suppository, with use by date 04/26/23. with instruction to discard 04/17/23. Interview on 05/19/23 at 12:00 PM with LVN B revealed it was all nurses' and managers' responsibility to check and ensure medications were labeled and not expired. She stated the side effects of giving expired medication was they would not work and would not be effective. She stated all expired medications were supposed to be removed from the refrigerator and carts and put in destruction boxes for the Pharmacist to destroy. She stated she had done training on storage and labelling of medications. Interview on 05/19/23 at 12:34 PM with the DON revealed her expectation was for all nurses to check the refrigerator for expired medications and the ADONs to follow -up. The DON stated she checked the refrigerator and verified the temperature logs, but she did not go through each medication in the refrigerator because she expected the nurse and the ADON to check each medication for expiry dates. She stated if staff were not checking the refrigerator for expired medications and medications were administered to residents, they would not be effective. She stated she had done training on refrigerator monitoring with staff on 09/06/22. Interview on 05/19/23 at 12:47 PM with ADON G, who was responsible for monitoring the 300 and 400 halls, revealed it was her responsibility to go behind the nurses to check whether they are removing the expired medications on carts and refrigerators and to ensure the insulins have open dates. ADON G stated she had checked the carts and refrigerator, but she did not check on expiry dates. She stated she only checked whether they were clean and organized because she was busy with other duties. ADON G stated failure to check for the expired medication and put open dates on insulin could result in the staff not knowing whether the medications were still potent for resident use. Interview on 05/19/23 at 3:20 PM with ADON F, who was responsible for monitoring the medication carts on 100 and 200 Hall, revealed it was her responsibility to check the nurses' carts for expired medications and open dates for the insulins. ADON F stated it was her expectation that nurses checked their carts and the refrigerator every shift and before they administered any medication. She stated failure to check the carts and refrigerator for expired medications could result in the medications being ineffective. ADON F stated insulin were good for 28 days. She stated she had not done training on expired medications. Record review of the facility's current Storage of Medication policy, revised April 2019, reflected the following: .5. Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 676143 If continuation sheet Page 7 of 7