Health inspection·October 30, 2024

F 0812 cooler. Level of Harm - Minimal harm or potential for actual harm - an opened can of applesauce was covered with saran wrap and was not dated in the walk-in cooler. Residents Affected - Many - a container of a white liquid substance was covered with saran wrap and was not dated or labeled in the walk-in cooler. - a large tray of a green gelatinous substance was covered with saran wrap and was not labeled or dated in the walk-in cooler. - a large tray of partially served brownies was covered with saran wrap and was not labeled or dated in the walk-in cooler. - a opened bag of crinkle cut French fries was unsecured, not labeled or dated in the walk-in freezer - an opened bag of a tan food item was unsecured, not labeled or dated in the walk-in freezer. - the walk-in coolers temperature gauge read 48 degrees Fahrenheit at the time of investigation; an internal temperature gauge was not observed in the walk-in cooler. In an observation and interview on 10/30/24 at 12:06 PM, [NAME] B stated she was the assistant to the Dietary Supervisor and was in charge in the supervisor's absence. [NAME] B stated all foods, prepared or out of their original packaging, stored in the dry storage area, walk-in cooler or freezer should be sealed, dated, and labeled. [NAME] B stated they always use saran wrap to cover or re-wrap foods to be stored. [NAME] B stated she was uncertain of who placed the opened, unlabeled, and undated food items in the food storage areas, but she would discard the items before the end of her shift. [NAME] B stated the dietary supervisor had taken the internal thermometer out of the walk-in cooler to replace it, but she guessed he had not. [NAME] B looked in the walk-in cooler for an internal thermometer, which she could not locate, and directed the surveyor to the thermometer next to the cooler door which read 48 degrees Fahrenheit. [NAME] B stated the temperature of the walk-in cooler was off because the latch at the top of the door would sometimes prevent the door from closing correctly. [NAME] B stated they would check the door to ensure it was closed. [NAME] B stated they were trained to ensure their hair was properly restrained while in the kitchen. [NAME] B stated improper food storage and improper hair restraint practices could lead to food illness. [NAME] B stated she would ensure all dietary staff properly restrained their hair and report all findings to her supervisor. In an observation and interview on 10/30/24 at 12:25 PM, DCH A stated he was trained to ensure his hair was fully restrained when he was in the kitchen. DCH A stated he was primarily washed dishes, did not prepare foods but he would prepare silverware when needed. DCH A stated he tried to restrain his hair, but it would often fall out of the hair net. DCH A stated if his hair was not properly restrained hair could get in food or in the silverware. Following the interview, DCH A placed a second hair restraint over his hair and returned to the kitchen. In a telephone interview on 10/30/24 at 4:14 PM, the Dietary Supervisor stated [NAME] B made him aware of the issues observed in the kitchen prior to his interview with the surveyor. The Dietary Supervisor stated all opened foods should be sealed, labeled and dated with a discard date when stored. The Dietary Supervisor stated food not in their original packaging should be placed in a storage container or a Ziploc bag and saran or cling wrap should not be utilized to seal foods for storage. He (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455626 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 455626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Guest Care Center 2712 N Hurstview Hurst, TX 76054 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 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many stated it was expected for all individuals who entered the facility's kitchen to ensure their hair was fully restrained, as not doing so could lead to contaminated food which would make residents sick. The Dietary Supervisor stated he was not aware of the missing thermometer in the walk-in cooler or that the cooler was observed with a temperature outside of range. The Dietary Supervisor stated the walk-in coolers door did not close all the way because of a latch at the top and he guessed the staff did not ensure the door was closed properly. The Dietary Supervisor stated not storing food at the proper temperature could cause foodborne illness. The Dietary Supervisor stated he would Inservice staff on food storage, preparation and hair restraints to ensure all policies and regulations were followed in the future. In an interview on 10/30/24 at 4:52 PM, the Administrator stated he was aware of the issues observed in the kitchen prior to his interview with the surveyor. He stated it was expected for all foods stored in the facility's kitchen to be properly packaged, sealed, labeled, dated, and stored at the proper temperature. He stated it was expected for all dietary staff and any persons who entered the kitchen to fully restrain their hair prior to entrance. He stated improper food storage and failing to properly restrain hair could lead to food contamination and bad food would be served to residents. He stated he had maintenance look at the walk-in cooler door, the top latch was adjusted and oiled and the door properly closed. He stated he would in-service all dietary staff on food storage, preparation and hair restrains. He stated he planned to conduct random kitchen checks to ensure the kitchen was in compliance at all times in the future. Record review of the facility's policy entitled Preventing Foodborne Illness- Food Handling, revised October 2017, read in part: POLICY STATEMENT: Food will be stored, prepared, handled and served so that the risk of foodborne illness is minimized. POLICY INTERPREPTATION AND IMPLEMENTATION: 1. This facility recognizes that the critical factors implicated in foodborne illness are: a. poor personal hygiene of food service employees; b. inadequate cooking and improper holding temperatures . 5. Functioning of the refrigeration and food temperatures will be monitored at designated intervals throughout the day and documented according to state specific requirements. Federal standards require that refrigerated food be stored below 41 [degrees Fahrenheit] . 12. Hair nets or caps and/ or beard restraints must be worn to keep hair from contacting exposed, clean equipment, utensils and linens. Record review of the e Food and Drug Administration Food Code, accessed on 10/31/24 at https://www.fda.gov/media/164194/download, read in part: .2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLE .3-501 Temperature and Time Control 3-501.11 Frozen Food. Stored frozen FOODS shall be maintained frozen. 3-501.12 Time/Temperature Control for Safety Food, Slacking. TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is slacked to moderate the temperature shall be held: (A) Under refrigeration that maintains the FOOD temperature at 5oC (41oF) or less; or .3-202.11 Temperature. (A) Except as specified in (B) of this section, refrigerated, TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be at a temperature of 5oC (41oF) or below when received. P (B) If a temperature other than 5°C (41°F) for a TIME/TEMPERATURE CONTROL FOR SAFETY FOOD is specified in LAW governing its distribution, such as LAWS governing milk and MOLLUSCAN SHELLFISH, the FOOD may be received at the specified temperature. (C) Raw EGGS shall be received in refrigerated equipment that maintains an ambient air (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455626 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 455626 B. Wing A. Building (X3) DATE SURVEY COMPLETED 10/30/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakmont Guest Care Center 2712 N Hurstview Hurst, TX 76054 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 0812 Level of Harm - Minimal harm or potential for actual harm temperature of 7oC (45oF) or less. 5 (D) TIME/TEMPERATURE CONTROL FOR SAFETY FOOD that is cooked to a temperature and for a time specified under §§ 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57oC (135oF) or above . Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455626 If continuation sheet Page 4 of 4