Health inspection·October 31, 2025

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Immediate jeopardy to resident health or safety **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 needs respiratory care was provided such care, consistent with professional standards of practice for 1 resident (Residents #1) of 7 residents reviewed for respiratory care. -The facility failed to ensure that Residents #1, who required continuous oxygen therapy, received adequate oxygen when his portable oxygen tank ran out of oxygen while the resident was in the community at an appointment on 10/29/2025. Resident #1 was transported to the local hospital and diagnosed with acute hypoxia (low levels of oxygen) The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 10/29/25 and ended on 10/30/25. The facility had corrected the non-compliance before the state's investigation began. This failure could place residents who receive oxygen therapy at risk of receiving inadequate oxygen support, which could result in serious harm or death.Findings included:Record review of Resident #1's face sheet, dated 10/31/25, reflected a [AGE] year-old male who was initially admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses that included: Chronic Obstructive Pulmonary Disease (lung disease) and acute and chronic respiratory failure. Record review of Resident 1's Nursing Home PPS MDS assessment, dated 09/12/25, reflected his BIMS score was 11, which indicated moderate cognitive impairment. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 required supervision to moderate assistance with most ADLs. The MDS Assessment under Section I-Active Diagnoses reflected Resident #1 had a primary medical condition of cardiorespiratory with other comorbidities that included chronic lung disease, asthma, and respiratory failure. Further review of this document, under Section O-Special Treatments, Procedures, and Programs, reflected Resident #1 received continuous oxygen therapy. Record review of Resident 1's care plan, revised 09/08/25, reflected the resident had altered respiratory status/difficulty and was on continuous oxygen therapy r/t acute and chronic respiratory failure with hypoxia. Interventions included: administering medication as orders, monitoring for effectiveness and s/sx of respiratory distress and reporting to the MD. Record review of Resident #1's consolidated physician orders, dated 10/31/25, reflected in part the following: -Oxygen at 2-4 lpm via nasal cannula continuous for COPD -start date: 10/31/25-Continuous BIPAP at night at bedtime-start date: 09/09/25 Record review of Resident #1's progress notes, dated 10/29/25 at 1:45 PM by ADON A, reflected the following: [Resident #1] on the way from dental appointment. [CNA D] report [Resident #1] is having SOB in transport although resident is on oxygen tank via nasal canula. [MD] informed HGB was 6.4 and [Resident #1] is now having SOB. Order given to send to [local hospital]. Transport pulled over van and 911 called. Record review of Resident #1's hospital records, dated 10/29/25, reflected in part the following: Chief Complaint: hypoxic- pt on 02 at baseline, was being transported to doctor's appointment by [transportation service] and ran out of 02, leading to hypoxia w/ Spo2 50% on EMS arrival. EMS implemented CPAP PTA and sats came up 100%. History of present illness:[Resident #1] is a 74 y.o. male with past medical history of chronic respiratory Residents Affected - Few Page 1 of 4 455626 455626 10/31/2025 Oakmont Guest Care Center 2712 N Hurstview Hurst, TX 76054

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few failure secondary to COPD and chronic diastolic CHF was transported from his long-term facility to a dental appointment where apparently he had longer than usual stay and his tank ran out of oxygen. EMS called and patient was noted to be hypoxic. The patient was then brought to the hospital for further evaluation. Upon arrival, the patient noted to be in acute on chronic respiratory failure with hypoxia and hypercapnia (high levels of carbon dioxide). In the ED, chest x-ray showed peripheral infiltrate (fluid/substance in lungs) over the right lower lobe. The patient was having difficulty breathing but was on BiPAP when interviewed. The patient denied any chest pain. Does complain of some shortness of breath. Denies any nausea vomiting or abdominal pain. No headache or blurry vision. In an interview on 10/31/25 at 10:43 AM, ADON A stated she worked at the facility for about 1 and 1/2 years. She stated Resident #1 had a dental appointment at the VA and he left the facility around 8:00 AM with a full portable oxygen tank. ADON A stated Resident #1 was escorted to his appointment by CNA D, and the appointment was expected to last about 30 mins because Resident #1 was only picking up new dentures. However, ADON A stated the appointment lasted longer than expected. She stated a full portable oxygen tank could last 3-4 hours, but Resident #1 was away from the facility for approximately 5 hours. ADON A stated around 1:00 AM, CNA D notified her that Resident #1 was complaining of shortness of breath. ADON A stated she advised them to pull the van over and call 911, and Resident #1 was transported to the local hospital. ADON A stated she had never experienced a resident running out of oxygen while away from the facility because the nurses always ensured they had full portable oxygen tanks before leaving, and the residents returned when expected. She stated the facility immediately held an IDT meeting and implemented interventions to prevent this from happening again. ADON A stated they updated the procedures for oxygen care to include sending an extra portable oxygen tank to appointments with residents who were on continuous oxygen therapy and training all staff on oxygen care. ADON A stated she had designated aides who escorted residents to all appointments with other aides who could assist if needed, and she ensured those staff were trained on how to check the oxygen tanks for oxygen levels and settings. She also stated that nurses were responsible for ensuring that the oxygen tanks were full and functioning while preparing the residents for their appointments, and aides were expected to assist with checking the oxygen tanks and reporting any issues to the nurses. In an interview on 10/31/25 at 12:35 PM, with the Assistant Administrator and DON, the DON stated the expectation was for the nurses to check all oxygen tanks before a resident left the facility to ensure the portable oxygen tanks were full and working properly. The DON stated the incident of Resident #1 running out of oxygen at his appointment was a huge learning lesson for the facility because it had never happened. The DON stated they updated the procedures to ensure that it did not happen again. The Assistant Administrator stated they prioritized in-servicing all dayshift staff since that was when resident appointments took place; however, the training was ongoing to include all staff before the start of their shifts. The DON stated not ensuring residents received adequate oxygen at all times could place them at risk of inadequate oxygen and death. In an interview on 10/31/25 at 12:51 PM, CNA D stated she worked at the facility since August 2025. She stated she escorted Resident #1 to his dental appointment on 10/29/25. CNA D stated she and the nurse checked Resident #1's portable oxygen tank before leaving the facility and it was full. She stated they left the facility at about 8:00 AM, and Resident #1 was fine during the ride to his appointment. She stated his appointment time was 9:00 AM; however, they waited a long time for the resident to be called back. CNA D stated after waiting at the clinic and waiting for transportation to pick them back up, it was 1:00 PM. CNA D stated they were on the van returning to the nursing facility when Resident #1 stated he could not feel any oxygen coming out of his cannula. CNA D stated she checked, and the oxygen was 455626 Page 2 of 4 455626 10/31/2025 Oakmont Guest Care Center 2712 N Hurstview Hurst, TX 76054

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few very low, so she called ADON A, and they were told to pull over and call 911. She stated Resident #1 was still able to talk but she could tell that he was having a hard time breathing. CNA D stated Resident #1 remained conscious until the EMTs arrived and transported him to the local hospital. She stated she escorted a lot of residents on appointments and that was the first time a resident ran out of oxygen. CNA D stated the following day she was in-serviced on oxygen care, which included a new procedure to take an extra portable oxygen tank on appointments with residents who were on continuous oxygen. CNA D stated the aides knew to check oxygen tanks to make sure they were full and to report any issues to the nurse. She stated the aides were not allowed to change or adjust the oxygen equipment. In an observation and interview on 10/31/25 at 3:08 PM, Resident #1 stated he had just returned to the facility from the hospital and felt better. Resident #1 stated he was admitted to the hospital for 2 days because they found that he also had pneumonia. Resident #1 stated he did not feel any symptoms of pneumonia while at the facility. He stated he resided at the facility for about 5 months and had never run out of oxygen at any time. Resident #1 stated he was at his dental appointment for a long time because the VA was slow. He stated he was fine while waiting at the appointment; however, on the way back to the facility, he remembered feeling like he could not breathe, and he let the aide know. Resident #1 stated he tried to remain calm, but it was scary not being able to breathe. He stated he felt himself blacking out before hearing 911 arrive, and that was all he could recall. Observation of Resident #1 revealed he was wearing a nasal cannula that was connected to an oxygen concentrator set on 3 lpm, and the resident showed no signs of respiratory distress. Review of the facility's policy titled Oxygen Administration, undated, revealed in part the following: PurposeThe purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation1. Verify that there is a physician's order for this procedure2. Assemble the equipment and supplies as needed.Further review of this document reflected it did not address transporting residents on continuous oxygen therapy. The non-compliance was identified as past non-compliance (PNC). The Immediate Jeopardy began on 10/29/25 and ended on 10/30/25. The facility had corrected the non-compliance before the state's investigation began. The facility took the following actions to correct the non-compliance prior to the survey: Record review of a document provided by the Assistant Administrator titled AD HOC QA, dated 10/30/25, reflected an IDT meeting was held to discuss the failure and implement interventions. Record review of an in-service titled Transporting Residents on Oxygen, dated 10/30/25, reflected all staff, who were responsible for preparing residents and escorting them on appointments/outings, had been educated by ADON A on ensuring that residents receiving continuous oxygen therapy were transported with an extra portable oxygen tank. The education was ongoing to include all staff. Record review of an in-service titled Oxygen Tanks, dated 10/30/25, reflected all staff, who were responsible for preparing residents and escorting them on appointments/outings, had been educated by ADON A on ensuring that residents receiving oxygen therapy had oxygen tanks that were full and working properly. The education was ongoing to include all staff. Record review of an in-service titled Appointment Scheduling and Dashboard, dated 10/30/25, reflected central supply staff, ADON A, ADON B, and ADON C were all educated on monitoring appointments to ensure that residents who were on continuous oxygen therapy left the facility with a second regulator. In an interview on 10/31/25 at 10:43 AM, ADON A stated a chart audit was completed on all residents receiving oxygen therapy to ensure they had orders and care plans with appropriate intervention in place. Record review of a document provided by the Assistant Administrator titled Order Listing Report (O2), dated 10/30/25, reflected the facility had 20 residents receiving oxygen therapy, with 3 being on continuous oxygen therapy. Observation on 10/31/25 at 3:00 PM of the facility's oxygen closet revealed there were 36 extra 455626 Page 3 of 4 455626 10/31/2025 Oakmont Guest Care Center 2712 N Hurstview Hurst, TX 76054

F 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few portable oxygen tanks available and functioning. Interviews on 10/31/25 at various times from 9:30 AM-3:00 PM, conducted with the Assistant Administrator, DON, ADON A, ADON B, ADON C, nurses, MAs, and CNAs: CNA D (1st shift), LVN E (1st shift), CNA F (1st shift), CNA G (1st shift), MA H (1st shift), CNA I (1st/2nd double weekends), LVN J (2nd shift), CNA K (1st shift), LVN L (1st shift), CNA M (1st shift), CNA N (1st/2nd double weekends), LVN O (1st/2nd double weekends), CNA P (3rd shift), CNA Q (3rd shift), CNA R (2nd shift), LVN S (2nd shift), and CNA T (3rd shift) indicated they all participated in in-service trainings on 10/30/25. The nurses were able to state they were responsible for ensuring that residents who required oxygen therapy received treatment according to orders, always had adequate oxygen available, and residents who required continuous oxygen therapy had 2 full portable tanks when leaving the facility. The CNAs were able to state that while providing care to residents with portable oxygen tanks, they were responsible for checking the tanks to ensure there was adequate oxygen and to immediately notify the nurse of any issues. The Assistant Administrator, DON, and ADONs stated it was their responsibility to ensure the effectiveness of interventions. Interviews on 10/31/25 at various times from 10:00 AM-3:00 PM with Residents #1, #2, #3, #4, #5, #6, and #7, who all received oxygen therapy, revealed no concerns for respiratory care. All sampled residents denied ever running out of oxygen at the facility or while out in the community. Resident #1 stated the incident on 10/29/25 was the first time he had ever run out of oxygen since being admitted to the facility. Observations on 10/31/25 at various times from 10:00 AM-3:00 PM of Residents #1, #2, #3, #4, #5, #6, and #7, who all received oxygen therapy, revealed no s/sx of respiratory distress and they all had clean and working oxygen concentrators and portable oxygen tanks available Record reviews of EHRs for Residents #1, #2, #3, #4, #5, #6, and #7 revealed they all had orders and care plans that included appropriate interventions to address respiratory needs. 455626 Page 4 of 4