Health inspection·January 7, 2026

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #1) of 4 residents reviewed for nutrition. -On 01/07/26 the facility failed to ensure Resident #1 received appropriate treatment to prevent complications of enteral feeding when LVN A did not connect the resident's g-tube to the feeding pump, causing the formula to waste onto the floor for approximately 1.5 hours. This failure could place residents who receive enteral feeding at risk for inadequate nutrition and hydration, which could cause a decline in health.Findings included: Record review of Resident #1's face sheet, dated 01/07/26, reflected a [AGE] year-old female who admitted to the facility on [DATE] with diagnoses that included: type II diabetes (body's inability to control blood sugar levels), gastrostomy status (g-tube placement), dysphagia, pharyngeal phase (difficulty moving food from the throat to the esophagus), muscle wasting atrophy (loss of muscle tissue and mass), and malignant neoplasm of endometrium (cancer of the uterus). Record review of Resident 1's Nursing Home Comprehensive MDS assessment, dated 12/22/25, reflected her BIMS score was 00, which indicated it could not be determined either due to refusal or inability to participate. The MDS Assessment under Section GG-Functional Abilities, reflected Resident #1 was dependent on staff for most ADLs. The MDS Assessment under Section K-Swallowing/Nutritional Status reflected Resident #1 required a feeding tube for nutrition. Record review of Resident 1's care plan, revised on 01/07/26, reflected the resident required tube feeding and would remain free of side effects or complications with interventions that included: obtaining and monitoring diagnostic work as ordered and reporting results to MD, receiving a speech therapy evaluation and treatment as ordered, and following current feeding orders. Record review of Resident #1's consolidated physician orders, dated 01/07/26, reflected in part the following:-NPO (nothing by mouth) diet related to dysphasia, pharyngeal phase. Starte date: 12/19/25-G-Tube: every shift Diabetic Source 1.5 at 55ml/hr. x 22 hr./day with 175 ml water q 4 hr. flush. Start date: 12/19/25-G-Tube: downtime 8:00 AM-10:00 AM one time a day. Start date: 01/07/26. Discontinue date: 01/07/26-G-Tube: downtime 8:30 AM-10:00 AM one time a day. Start date: 01/08/26 Record review of a video provided by Resident #1's RP, dated 01/07/26 at 12:16 PM, revealed the resident's G-tube was disconnected from the pump and closed off. The video also revealed a puddle of formula on the floor from when the pump was running without being connected to Resident #1's G-tube. Record review of Resident #1's progress notes, dated 01/07/26 at 1:13 PM written by the DON, reflected the following: [MD] notified that [Resident #1's] G-tube feeding was noted disconnected, resulting in approximately 30 minutes of feeding wastage. [Resident #1] assessed; no acute distress noted. [MD] provided new order to extend tube feeding by an additional 30 minutes to compensate for missed volume. RP made aware. Will continue to monitor. In an observation and interview on 01/07/26 at 10:45 AM, Resident #1 was observed to be lying Page 1 of 3 455626 455626 01/07/2026 Oakmont Guest Care Center 2712 N Hurstview Hurst, TX 76054

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 455626 Page 2 of 3 455626 01/07/2026 Oakmont Guest Care Center 2712 N Hurstview Hurst, TX 76054

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 455626 Page 3 of 3