Inspection·February 13, 2023

F 0757 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete In an interview on 02/13/2023 at 9:30 a.m., this Surveyor reviewed Resident #122's physician order with the DON. The DON said the order for the ABT was missing the diagnosis and the stop date. She said she did not know why the resident was receiving the ABT. In a later interview on 02/13/2023 at 9:50 a.m., she said she texted Resident #122's doctor and he said the ABT was for hepatic encephalopathy. She said the doctor said he would come and add the stop date today. She said the system was when a resident was admitted to the facility the admission orders go to the physician electronically. The physician then noted agreement/changes/discontinued orders. Then the orders were sent to the pharmacy electronically. The pharmacy printed the medications on the MAR and medications were sent to the floor. They should always put a diagnosis for medications. This should have been caught by the pharmacy or the nurse. They would be responsible for ensuring the medications are correct. She said there was no direct policy or protocol for receiving orders for medications. Event ID: Facility ID: 455770 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 455770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Bend Medical Center 1705 Jackson St Richmond, TX 77469 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 - Some 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. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interviews, and record review the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored securely in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for two (Resident #72 and Resident #120) of seven residents reviewed for storage of medications. The facility failed to ensure: -Resident #72's medication was kept in a secure location. Resident #72 had physician's ordered Nystatin (antifungal medication used in skin treatments) powder at the bedside. -Resident #120 medication was kept in a secure location. Resident # 120 had no physician's order for Timolol Maleate Solution 0.5 % eye drops sitting on top of the bedside table. These deficient practices could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion. Findings included: Resident #72 Record review of Resident #72's clinical record revealed a [AGE] year-old female admitted to the facility on [DATE]. Her diagnosis included necrotizing fasciitis (a bacterial infection that destroys tissue under the skin) of left abdomen. Record review of Resident #72's baseline care plan dated 02/06/2023 revealed: Problem: Impaired skin integrity; Goal: Skin integrity impairment risk stabilized, decreased chances of skin breakdown; Implementation: Assess for adverse effects of medications; Continued review of the care plan did not reveal Resident #72 could keep the Nystatin powder at the bedside. Record review of Resident #72's physician's order dated 02/07/2023 revealed Nystatin powder 100,000 units per Gram. Apply to groin daily. Continued review of the physician's orders did not reveal an order to keep at the bedside. Observation on 02/12/23 at 9:00 AM in room [ROOM NUMBER] B revealed Resident #72 in bed. Resident was not interviewable. A bottle of Nystatin powder 100,000 units per Gram was on a table in the resident room. In an interview on 02/12/2023 at 9:11 AM, LVN A stated Resident #72 did not have a physician's (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455770 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 455770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Bend Medical Center 1705 Jackson St Richmond, TX 77469 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 order to keep her Nystatin powder at the bedside. LVN A stated the medication was to be kept in the medication room or on the medication cart. LVN A stated Nystatin powder required a physician's order to administer. LVN A stated it was the responsibility of the nurse to make sure there were no medications at the bedside. LVN A continued and stated the risk of the medication at the bedside was that a visitor or someone who should not have it could take it. Residents Affected - Some Resident #120 Record review of the admission sheet (undated) for Resident #120 revealed an [AGE] year-old female admitted to the facility on [DATE]. Her diagnoses included fall wedge fracture of 1st lumber. Record review of Resident #120's admission MDS dated [DATE] did not mention the BIMS score. Record review of Resident #120's Baseline care plan, dated 01/31/2023 revealed the following care plan: Problem: Impaired skin integrity Goal: Skin integrity impairment risk stabilized, decreased chances of skin breakdown Implementation: Assess for adverse effects of medications. Resident #120 was not care planned for having meds at bedside. Observation and interview on 02/12/2023 at 8:42a.m., of Resident #120, in her room, revealed a bottle of Timolol Maleate Solution 0.5 % eye drops sitting on top of the bedside table. Resident #120 said her family member brought the eye drops and she administered herself day and night for glaucoma. Record review of Resident #120's physician's order revealed she was not prescribed the above-mentioned medication of Timolol Maleate Solution 0.5 % eye drops. There were no orders for self-administration. Observation and interview on 02/12/2023 at 8:55 a.m., with LVN A, she said residents were not supposed to have any medications at bedside because they could react with any other medications given to them per their orders. LVN A said home meds had to be sent to the pharmacy to verify. Home meds were kept in the med room in their cubie. She said, I have taken care of Resident #120 multiple times. I don't know how the eye drops got in her room. LVN A said the resident did not have orders for it. In an and record review on 02/12/2023 at 1:15 p.m. This Surveyor reviewed Resident #120's physician orders with LVN A. LVN A said the resident did not have an order for eye drops. In an interview on 02/13/23 at 9:50 a.m., the DON said residents were not allowed to have medication in their rooms. She said if a resident was deemed safe to self-administer medication, they would also need a doctor's order. She said she was not aware of Resident #120 having meds at bedside. Record review of the facility's policy, Medication Management Storage, review dated 03/23/2022, read in part Policy: Medications, biologicals, and devices shall be stored to ensure their integrity, stability, and effectiveness. All drugs and biologicals will be controlled, secured, and distributed (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455770 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 455770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Bend Medical Center 1705 Jackson St Richmond, TX 77469 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 - Some FORM CMS-2567 (02/99) Previous Versions Obsolete in accordance with applicable standards of practice and consistent with Federal and State laws and regulations . Medications may be stored only in authorized locations .All drugs and biologicals must be stored in a manner to prevent access by non-authorized individuals . Record review of facilities Home Medications policy (revision/Review Date: 7/2020) revealed read in part: .Procedure: For patients who will bring medications from home to the Skilled Nursing Unit: 1. Their medications must be contained in a bag or container that seals tight. 2. Home Medications must have the appropriate label from the pharmacy. 2. All home medications will be sent to our pharmacy to be verified.6. Patients' home medication must be kept locked up at all times; except when dispensing them. This is a State requirement and can also be a HIPAA violation . Event ID: Facility ID: 455770 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 455770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Bend Medical Center 1705 Jackson St Richmond, TX 77469 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 0851 Level of Harm - Potential for minimal harm Residents Affected - Many Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data. Based on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, in that: The facility failed to submit staffing information to CMS for the 4th quarter of the fiscal year 2022. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. The findings included: Review of the facility's staff roster, undated indicated the following: 1 Administrator 1 Manager 1 MDS 1 MA 5 LVNs 3 RNs 5 CNAs Record review of the facility CMS form 672 (Resident Census and Conditions of Residents) dated 02/12/2023 provided by Director of Quality indicated a total of 7 residents in the facility. Record review of the PBJ Staffing Data Report, FY Quarter 4 2022 (July 1 - September 30), dated 02/10/2023, revealed the facility had failed to submit data for the quarter. In an interview on 2/13/2023 at 9:37 a.m., with Administrator (on phone) and the Director of Quality. Director of Quality said that a Payroll Based Journal had not been submitted. She said in the 4th quarter the facility did not have a DON and the Administrator acted as an interim DON. She said the Administrator was clinical he did not have experience of submitting the staffing report. She said they were familiar with the requirement for reporting staffing to CMS but did not know who did the reporting for the facility. She said the facility did not have a Payroll Based Journal for submission to CMS policy. Record review of the CMS, Electronic Staffing Data Submission Payroll-Based Journal, Long-Term Care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455770 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 455770 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/13/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Bend Medical Center 1705 Jackson St Richmond, TX 77469 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 0851 Level of Harm - Potential for minimal harm Facility Policy Manual, Version 2.6, June 2022, section 1.2 Submission Timeliness and Accuracy, revealed Direct care staffing and census data will be collected quarterly, and is required to be timely and accurate. Further review revealed Report Quarter 4 date range as July 1-September 30. Policy manual revealed, Deadline: Submissions must be received by the end of the 45th calendar day (11:59 PM Eastern Time) after the last day in each fiscal quarter in order to be considered timely. Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455770 If continuation sheet Page 7 of 7