Health inspection·January 7, 2026

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few awake in bed under the covers and dressed in a gown, with only her chest up visible to the surveyor. Resident #1 had an enteral feeding pump that was in a corner on the opposite side from where the surveyor was standing to speak with the resident. The surveyor was able to see from the opposite side that the pump was running at a rate of 55 ml/hr. and there were no visible concerns from that position. Resident #1's thoughts were scattered but she was able to state that she was okay. Resident #1 also stated that she had not been at the facility long and she was a little nervous in her new environment. In an interview via phone on 01/07/26 at 12:25 PM, Resident #1's RP returned a missed call from the surveyor and stated that she was currently at the facility visiting. The RP stated she found that Resident #1 had not been fed for at least the past hour due to her G-tube not being connected to the feeding pump. The RP stated there was formula running on the floor from where LVN A turned on the pump and never connected Resident #1's G-tube. The RP stated she had a video recording that she was going to provide for the surveyor. Resident #1's RP stated she had a major concern about the resident not receiving her feeding as ordered and that she was unable to visit daily to ensure that it was being done. In an observation on 01/07/26 at 12:30 PM, the surveyor returned to Resident #1's room and found that Resident #1's G-tube had been re-connected to the feeding pump and running at 55 ml/hr. The surveyor observed that there was formula still on the floor from the previous spill. In an interview on 01/07/26 at 1:28 PM, LVN A stated she worked at the facility for 1.5 years. She stated she worked with Resident #1 today and was responsible for the resident's enteral feeding. LVN A stated she went in Resident #1's room between 9:00 AM and 9:30 AM to turn the enteral feeding pump off for two hours and administered medication. LVN A stated she returned to Resident #1's room after 2 hours, at approximately 11:30 AM, to turn the enteral feeding pump back on. LVN A stated when she turned the pump back on, she forgot to reconnect Resident #1's G-tube. LVN A stated it was busy during that time, and she was being called to assist another resident, so she made a mistake. LVN A stated there were enough staff working on the hall; however, as the nurse she had multiple residents to care for. LVN A stated she worked with residents on enteral feedings often and that was the first time she had forgotten to reconnect a G-tube. LVN A stated it was important to follow protocol and ensure that the G-tube was connected to the enteral feeding pump so that the resident received proper nutrition. In an interview on 01/07/26 at 1:40 PM, CNA B stated she worked at the facility since 11/2025. She stated she worked with Resident #1 today and at approximately 12:20 PM she went in the resident's room to clean her up and found that her family was visiting. CNA B stated as she was removing Resident #1' gown, she noticed that the resident's G-tube was still clamped off, and at the same time the family walked to the side of the bed and noticed that the formula was running from the enteral feeding pump onto the floor. CNA B stated she immediately called LVN A in the room and the nurse was shocked to see that Resident #1's G-tube was not connected to the pump, and she reconnected it. In an interview on 01/07/26 at 2:34 PM, the DON stated LVN A immediately reported to him that she forgot to reconnect Resident #1's G-tube when she restarted the resident's enteral feeding after the downtime. The DON stated LVN A reported that she turned the enteral feeding pump on at approximately 11:30 AM, so there was only about 30 minutes of formula wasted before the error was found. The DON stated he notified the MD and received a new order to decrease the next downtime by 30 minutes to make up for the missed formula, and the order would be ongoing until the MD made additional changes. The DON stated the MD informed him that a 30 min waste of formula would not harm Resident #1. The DON stated during enteral feeding downtime, the nurses were expected to disconnect and flush the G-tube to allow the residents the ability to move around as needed, then reconnected the G-tube when it was time to restart the feeding. The DON stated the aides and nurses were in the same clinical (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455626 If continuation sheet Page 2 of 3 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 01/07/2026 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 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete meetings, and they were all aware of the protocol for enteral feedings and the aides knew to immediately report any issues to the nurses. The DON stated an in-service to address the issue had already been started. The DON stated the aides and nurses alternated on doing rounds and would catch any issues with the enteral feeding during that time. The DON stated that forgetting to reconnect the G-tube would not place the residents at risk of harm because they could get an order from the MD to make up for any lost time. In an interview on 01/07/26 at 3:05 PM, the MD stated that he was notified that Resident #1's G-tube was not reconnected to the enteral feeding pump, and she lost approximately 30 mins of feeding time. The MD stated if the report was correct, Resident #1 would have lost about 1 oz of formula at 55 ml/hr., and that was not clinically significant enough to cause the resident any harm. The MD stated Resident #1 was overweight and her feeding downtime could actually be increased more; however, to satisfy the family he gave the facility an order to make up for the lost 30 mins. The surveyor asked the MD if Resident #1 would be at risk of harm if she missed over an hour of feeding and the MD stated he had never heard of anything like that happening due to how frequently the residents were checked; however, he would expect the facility to notify him if it did happen so that he could adjust the order based on the report. In an interview on 01/07/26 at 4:11 PM, LVN C stated she worked at the facility since 7/2025. She stated she worked with residents who received enteral feedings, and they followed the MD orders to provide the appropriate formula, rates, runtimes, and downtimes for the feedings. LVN C stated the feedings provided the residents with caloric and fluid intake for nutrition and hydration. LVN C stated during the enteral feeding downtime, the nurses would have to turn the pump off, flush the tube with water, clamp it off and completely disconnect the G-tube. LVN C stated when it was time to restart the enteral feeding, the nurses would have to check the G-tube for any residual before reconnecting it to the pump, turn the on the pump and ensure it was set to the correct rate, flush the tube and reconnect it to the pump. LVN C stated she always double checked the pump and G-tube to endure that everything was connected and running correctly before leaving the resident. She stated not reconnecting the G-tube to the enteral feeding pump could place the resident at risk for nutrition and hydration issues. She stated if this happened, the nurse would have to immediately report it to the MD, DON, and family. Review of the facility's policy titled Enteral Tube Feeding via Continuous Pump, undated, revealed in part the following:PurposeThe purpose of this procedure is to provide guidelines for the use of a pump for enteral feedings.Preparation1. Verify that there is a physician's order for this procedure.2. Review the resident's care plan and provide for any special needs of the resident.3. Assemble equipment and supplies needed.4. Ensure that the equipment and devices are working properly by performing any calibrations or checks as instructed by the manufacturer or this facility. Event ID: Facility ID: 455626 If continuation sheet Page 3 of 3