Oakbend Medical Center

“CONTRACTED SERVICES CFR(s): 482.12(e)(1) The governing body must ensure that the services performed under a contract are provided in a safe and effective manner. This Standard is not met as evidenced by: 37490 Based on review of contract for services and interviews, the Governing Body failed to exercise effective oversight of contracted services to ensure the quality and safety of services provided. Findings include: Record review of the Business Associate Agreement for services provided on the Medical Stablization Unit, Wharton Campus showed the following: 1.3 Unit Staff Qualifications. Each Unit Staff Member, where applicable, shall at all times (i) be licensed in the State of Texas to provide the services which he/she is assigned to perform for the Program, if a license is required to perform such services; (ii) be qualified to provide the services which he/she is assigned to perform; and (iii) be legally authorized to work in the United States. Hospital must approve of, and if applicable, credential each Unit Staff Member prior to such individual providing services at Hospital. 1.4 Standards of Performance. Contractor shall assist Hospital in performing quality and competency reviews to ensure that all Unit Staff members who perform services at Hospital under this Agreement provide services only upon the properly executed orders and subject to the supervision of the patient ’ s treating physician in the Program, and in accordance with proper procedures. Contractor shall assist Hospital in monitoring the treatment rendered in the Program, report any treatment information and data required for Hospital to administer its compliance program, and consult with Hospital regarding performance improvement measures for the Program. Exhibit B: Unit Staff 1. A sufficient number of registered nurses, LVNs, CNAs and unit techs to staff the Program twenty-four hours (24) per day it being expected that the Program will be staffed at all times to meet any applicable Hospital regulatory requirements; Contractor shall make its best efforts to utilize efficient, safe, and compliant staffing patterns, which on average Contractor shall staff between a 7:1 and 9:1 patient-to-nurse ratio and between a 7:1 and 9:1 patient-to-unit tech. Contractor shall provide Hospital with access to Contractor staffing schedules and patterns for Cross refer Tag(s) A0392 and A0622”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 37490 Based on record review and interview the facility failed to ensure the patient’s right to be involved in the decision making process by failing to disclose specific risks and hazards on informed consent for surgical procedures in 1 of 1 medical records reviewed (patient ID# 27). Findings include: Review of the Texas Medical Disclosure Panel, Informed Consent Chapter 601, showed the following information: 601.2 Procedures Requiring Full Disclosure of Specific Risks and Hazards-List A: 602.1 Anesthesia Treatments and Procedures (b) General. (1) Permanent organ damage. (2) Memory dysfunction/memory loss. (3) Injury to vocal cords, teeth, lips, eyes. (4) Awareness during the procedure. 602.8 Hematic and Lymphatic System Treatments and Procedures (a) Transfusion of blood and blood components. (1) Serious infection including but not limited to Hepatitis and HIV which can lead to organ damage and permanent impairment. (2) Transfusion related injury resulting in impairment of lungs, heart, liver, kidneys, and immune system. (3) Severe allergic reaction, potentially fatal. 602.13 Nervous System treatment and Procedures (c) Spine operation, including laminectomy, decompression, fusion, internal fixation or procedures for nerve root or spinal cord compression; diagnosis; pain; deformity; mechanical instability; injury; removal of tumor, abscess or hematoma (excluding coccygeal operations). (1) Weakness, pain, numbness or clumsiness. (2) Impaired muscle function or paralysis. (3) Incontinence, impotence or impaired bowel function (loss of bowel/bladder control and/or sexual function). (4) Migration of implants (movement of implanted devices). (5) Failure of implants (breaking of implanted devices). (6) Adjacent level degeneration (breakdown of spine above and/or below the level treated). (7) Cerebrospinal fluid leak with potential for severe headaches. (8) Meningitis (infection of coverings of brain and spinal cord). (9) Recurrence, continuation or worsening of the condition that required this operation (no improvement or symptoms made worse). (10) Unstable spine (abnormal movement between bones and/or soft tissues of the spine. Review of medical record for patient (ID# 27) for scheduled procedure date of service 4/27/2026 showed Disclosure and Consent- Medical and Surgical Procedures: Redo decompression bilateral at L4-5 with bilateral facetotomy and neuroforaminal decompression, Bilateral neuroforaminal decompression L5-S1 combined posterior to body and posterolateral spinal fusion L4-5 and L5-S1, pedicle screws and rods, illiac bone graft. Procedures Requiring Full Disclosure of Specific Risks and Hazards initialed by the patient included, Anesthesia 1B, Hematic and Lymphaatic System 9A, and Nervous System Treatments and Procedures 14C. Procedures and specific risks for Anesthesia, Hematic and Lymphatic system and Nervous System Treatments and Procedures did not have all required specific risks per the Texas Medical Disclosure Panel. Interview with Quality staff (ID 51) on 7/1/2026 at 2:15 PM, she acknowledged missing disclosures on consent forms.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 37490 Based on record review and interview, the facility failed to ensure nursing staff implemented and carried out physician orders for 1 of 4 patients (ID# 31). Findings included: Medical record review for patient ID#31 on 6/30/2026 at 11:52 PM with Quality staff ID# 51 showed: History and Physical Note:... Past Medical History Hypertension Type 2 Diabetes Mellitus Plan 7. Type 2 Diabetes Me litus with Hyperglycemia Resume Metformin 500 mg twice daily. hold Glipizide 5 mg daily. Sliding scale Regular insulin low dose Accuchecks before meals and at bedtime. Diabetic diet. Glucose currently elevated at 296 mg/dL and requires monitoring during withdrawal treatment. Medication order for INSULIN REGULAR HUMAN LOW DOSE, Subcutaneous, thirty (30) minutes before meals and at bedtime. Instructions: REGULAR INSULIN SLIDING SCALE (LOW DOSE REGIMEN) <70 HYPOGLYCEMIA PROTOCOL AND CALL MD 70-150 0 UNITS 151-200 4 UNITS 201-250 5 UNITS 251-300 6 UNITS 301-350 8 UNITS 351-400 10 UNITS GREATER THAN 400 10 UNITS AND CALL MD Documented Blood Glucose levels for the patient were: 06/29/2026 22:04 198mg/dL 06/30/2026 09:31 296 mg/dL Medication administration record showed: REGULAR INSULIN SLIDING SCALE (LOW DOSE REGIMEN) Sched Dt/Tm Admin Dt/Tm Charted Dt/TmAdm Dose Adm 06/30/2026 07:30 06/30/2026 10:26 06/30/2026 10:26 6 LOW DOSE Blood Glucose 296 mg/dL 06/30/2026 10:22 Qualirty staff ID# 51 at the time of the review confirmed there was no order and no results for capillary blood sugar checks as ordered. Also, blood sugar of 198mg/dL on 6/29/26 received no intervention. 46010 Based on record review and interview, the facility failed to ensure there were adequate numbers of staffing in the Wharton campus, 3rd floor medical detox unit, by having a shortage of patient care technicians/certified nursing assistants in 3 of 14 shifts reviewed. Findings Included: Request for staffing grid or matrix for Wharton campus 3rd floor medical detox unit was made to facility leadership on 6/29/26 at 08:30 entrance meeting. Repeat request for staffing grid or matrix for Wharton campus 3rd floor medical detox unit made to Director of Quality Staff ID #51 and Nursing AVP Staff ID #53 on 7/1/2026 at 12 noon. Interview with Nursing AVP Staff ID # 53 on 7/1/2026 at 1:35 pm. She stated that the 3rd floor medical detox unit was not included in the facility’s staffing plan. She stated that the facility utilized a 1 nurse:7-9 patient ratio and 1 patient care technician or certified nursing assistant : 10-12 patient ratio in the Wharton campus medical detox unit. Record review of the contract for “The Haven” medical detox stabilization unit executed 09/08/2024 by CEO staff ID # 71. This contract stated “Contractor shall make its best efforts to utilize efficient, safe, and compliant staffing patterns, which on average contractor staff shall staff between a 7:1 and 9:1 patient-to-nurse ratio and between a 7:1 and 9:1 patient-to-unit tech.” Record review of staffing sheets with Nursing AVP Staff ID #53 on 7/1/26 at 1:15 pm for 3rd floor medical detox unit from period 6/21/2026 until 6/29/2026. She confirmed the following findings were below the contract stipulated ratios: 6/21/26 12:00 midnight census 21 patients, Staffing sheet stated census 21 - 3 nurses worked (1:7 ratio), and 2 patient care techs/certified nursing assistants worked (1:10 & 1:11 ratio). 6/23/26 12:00 midnight census 24 patients, Staffing sheet stated census 24 - 3 nurses worked (1:8 ratio), and 2 certified nursing assistants worked (1:12 ratio). 6/24/26 12:00 midnight census 22 patients, Staffing sheet stated census 22 - 3 nurses worked (1:7 & 1:8 ratio), and 2 certified nursing assistants worked (1:11 ratio). Interview 7/1/2026 at 1:25pm with Nursing AVP Staff ID #53. She confirmed she was unaware that the contract for the facility stated that the nursing assistant ratio was 1 CNA/patient care tech per 7-9 patients. She stated that she would discuss with CNO Staff ID# 52 to address the staffing variance.”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 46010 Based on interview and record review, the facility failed to ensure that Registered Nurses assessed and documented their findings for patients who presented to the emergency room and had patient care engagement with a licensed vocational nurse (LVN) in 5 of 20 ED charts reviewed (Patient ID #19, 21, 22, 25 and 30). Findings included: Medical record review with Director of Quality Staff ID #51 on 6/30/26 at 11:45 am for the following: Patient ID #19 presented for care on 6/2/26 at 12:28. The patient was seen with vital signs, “systems assessment” and triage documented by LVN Staff ID # 58. Patient ID #21 presented for care on 6/3/26 at 08:52 am. The patient was seen with vital signs, “systems assessment” and triage documented by LVN Staff ID #58. Patient ID #22 presented for care on 6/3/26 at 09:58 am. The patient was seen with vital signs, “systems assessment” and triage documented by LVN 63. The patient was discharged home after medical care by LVN Staff ID #63 at 12:41 pm. The chart was “co-signed” by RN Staff ID # 89 on 6/3/26 at 5:34 pm (more than 4.5 hours after discharge). There was no evidence of assessment or engagement by an RN prior to discharge. Patient ID # 25 presented for care on 3/20/26 at 3:51pm. The patient was seen with vital signs, “systems assessment” and triage documented by LVN Staff ID #58. There was no RN assessment performed in the ED prior to transfer to an inpatient unit. Patient ID #30 presented for care on 6/3/26 at 06:57 am. The patient was seen with vital signs, “systems assessment” and triage documented by LVN staff ID # 63. The patient received medical care and was discharged home by LVN Staff #58 on 6/3/26 at 1:30 pm. There was no evidence of registered nurse assessment or engagement. Record review of facility policy titled “Emergency Department/Assessment and Reassessment” policy, revised 05/23, stated “Procedure: A. A licensed practitioner/phyisican/registered nurse with appropriate clinical privileges determines the scope of assessment and care of patients in need of emergency care. B. Each patient presenting to the emergency department will be triaged by an RN within 10 minutes of arrival. Initial triage will contain chief complaint and details of present illness, vital signs along with height weight, mode of arrival, risk of suicide, acuity and allergies. Licensed practitioner/physician/RN will address life-threatening conditions at this time.” Record review of facility policy titled “Emergency Care Center Triage & Patient Classification”, revised 09/2020 stated “Procedure: An RN will triage all patients arriving to the Emergency Center to identify life-threatening conditions and prioritize patients according to acuity.” It further stated “F. Patients will be placed in the treatment area based on acuity and available resources ...1. Quick Care Area: Any patient determined by the triage RN to meet ESI triage level 3,4,5 will be moved to the Quick Care Area. The EC provider or mid-level provider will conduct a medical screening exam and the RN will complete and document a full primary assessment. 2.Acute Care Area: Any patient determined by the RN to meet ESI triage level 2 or 3 will be moved immediately to acute care area. The ED provider will conduct a medical screening exam and the RN will complete and document a full primary assessment” ... Record review of signed job description for “Emergency Care Center - Licensed Vocational Nurse” Staff ID # 63 with Human resources manager staff ID # 88 included the following “Job specific performance expectations - 9. Triages patient in an effective manner. 10.Triage according to patient acuity and protocol. 11. Places patients in appropriate treatment area. 12. Utilizes nurse/triage protocols effectively to institute/expedite patient care..” Interview with Record review with Quality Director staff ID # 51 confirmed she was unable to locate evidence of RN assessments or triage within the ED encounter record for patient ID # 19, 21, 22, 25 and 30. Interview with Staff LVN #63 on 7/1/26 at 07:30 am. She confirmed that she does help triage and perform triage assessments on patients who present to the ED. She stated she then provides “report to the provider and RN.” She stated she was unaware if the RN documents their own assessment after she provides report. Interview with ED Charge RN Staff ID # 74 on 6/30/25 at 09:45 am. She stated that the ED does utilize LVNs and RNs for care provision in the EDs at all 3 campuses. She stated that the RNs are responsible for performing assessments on patients who are seen by LVNs. She stated that the LVNs who engage with patients, can forward their notes to the RNs for co-signature. She stated that this was not a mandatory component of the EMR platform so she was unaware if it is done on every patient. Interview with AVP Staff ID #53 on 6/30/26 at 2:55 pm. She stated she was unaware that the Job Description for the Licensed Vocational Nurse in the ED included triaging patients. She stated this was likely an oversight with responsibilities brought over from the Registered Nurse job description.”

“CONTROLLED DRUGS KEPT LOCKED CFR(s): 482.25(b)(2)(ii) Drugs listed in Schedules II, III, IV, and V of the Comprehensive Drug Abuse Prevention and Control Act of 1970 must be kept locked within a secure area. This Standard is not met as evidenced by: 46010 Based on observation, review of documents and interviews with facility staff, the facility failed to properly secure Schedule III and IV drugs, as patient’s personal medications of suboxone and clonazepam, were found in an unlocked blue bins in the unit-based medication room. This potentially could have resulted in misappropriation of scheduled drugs. The facility also failed to have a written procedure on the securing of scheduled drugs, from the patient’s home medications supply at admission, into the pharmacy. Findings Included: Observation during a tour of the 3rd floor unit-based pharmacy/medication storage room on 6/30/2026 at 2:05 pm, with director of quality staff ID # 51 and Nursing leader staff ID # 53 included a door with a keypad code entry situated above door handle. Nursing leader staff ID # 53 utilized door code to access the pharmacy. Upon entry to the pharmacy, multiple blue bins with patient room numbers on blue bin labels, and multiple bags of home medications, labeled with patient stickers, were noted in these open bins. (12 sets of bags). Observation included a sealed clear bag “patient valuables envelope” with patient sticker for Patient ID #29 in a bin labeled with patients room number. A bottle labeled from a commercial pharmacy with “tramadol 50 mg” tablets with patient ID #29 facility sticker affixed to outside of the bag. The visible medication list stored in the sealed bag stated tramadol #85 for quantity. Observation included a sealed clear bag “patient valuables envelope” with patient sticker for Patient ID #28. Two bottles labeled from a commercial pharmacy, “Kroger” with clonazepam 1mg tablets are noted among other medications. The quantity list on the medication inventory list shows one bottle of clonazepam with #1 for quantity. Record review of facility policy titled “Management of the Environment of Care: Security of Staff and Medications” effective 08/25/2024, stated “Security of the pharmacy and medication storage areas shall be maintained in accordance with federal laws, the laws of this state, and local laws.” Medications are stored to prevent diversion, contamination, pilferage, and theft. Medications are secured so that unauthorized personnel can not obtain access ... “ The policy further stated “Medications may be accessible only to authorized personnel, including: Licensed personnel with legal access to medications, and within their scope of practice, pharmacy technicians ...” It further stated “Pharmacy lock up procedures: Pharmacy lock up procedures shall ensure that medications are secure and that the pharmacy is free of hazardous conditions. Lock-up procedures shall include but shall not be limited to ensuring that: controlled drugs are secure...” Interview at the time of tour with Nursing AVP at the time of tour Staff ID #53 on 6/30/2025 at 2:10 pm. She confirmed that the facility has a process whereby they complete the patient belonging investory and patient medication inventory on admission to the unit. She confirmed that the forms utilized have space for a nurse to write down quantities of all medications, irregardless of schedule/controlled status. She confirmed that the nurses place all medications and the list in a sealed bag and it is stored in the blue bin with the patient’s room number on the wall in unit based pharmacy/medication room. She confirmed that the clonazepam is a scheduled IV controlled medication and tramadol is a schedule III medication by the Drug Enforcement Agency and would meet requirement for secure storage. She confirmed that storage, in a clear bag, in a blue bin on the wall, would allow anyone with access to the pharmacy to have access to these medications. She also confirmed that we were unable to locate a policy or process which verifies/counts the medications upon return to patient at discharge and documents this verification.”

“ACCESS TO LOCKED AREAS CFR(s): 482.25(b)(2)(iii) Only authorized personnel may have access to locked areas. This Standard is not met as evidenced by: 46010 Based upon observation, interview with staff and record review, it was determined that the facility failed to ensure that only authorized personnel had access to the Wharton 3rd floor unit medication storage room. Findings Included: Observation during a tour of the 3rd floor unit-based pharmacy/medication storage room on 6/30/2026 at 2:05 pm, with director of quality staff ID # 51 and Nursing leader staff ID # 53 included a door with a keypad code entry situated above door handle. Nursing leader staff ID # 53 attempted to access the pharmacy per survey team request. She stated that she did not “remember the code.” Hospital leaders staff ID #53 and 51 then requested that nearby Patient Care Technician Staff ID # 82 assist. PCA Technician came over to the pharmacy door and verbally provided a code to Nursing leader #53, which she then utilized to access the unit based medication room. Upon entry to the room, a pyxis was noted to be present in the room. In addition, multiple blue bins with patient room numbers on labels, and multiple bags of home medications were noted in the open bins. (12 sets of bags). Record review of facility policy titled “Management of the Environment of Care: Security of Staff and Medications” effective 08/25/2024, stated “Security of the pharmacy and medication storage areas shall be maintained in accordance with federal laws, the laws of this state, and local laws.” Medications are stored to prevent diversion, contamination, pilferage, and theft. Medications are secured so that unauthorized personnel can not obtain access ... “ The policy further stated “Medications may be accessible only to authorized personnel, including: Licensed personnel with legal access to medications, and within their scope of practice, pharmacy technicians ...” Interview at the time of tour with Nursing AVP at the time of tour Staff ID #53 on 6/30/2025 at 2:05 pm. She confirmed that only “nurses” should know the code and have access to this room. She stated “we will have to change the door code.””

“COMPETENT DIETARY STAFF CFR(s): 482.28(a)(3) There must be administrative and technical personnel competent in their respective duties. This Standard is not met as evidenced by: 37490 Based on observation, interview, and record review, the facility failed to ensure that 3 of 3 staff assigned food handling and preparation duties were trained & competent in their duties and had training/knowledge of food safety measures in the MSU (medical Stabilization Unit)(Staff # 80, 81 and 82). Findings include: Observation on 6/30/2026 at 11:02 with PCT staff (ID# 82) during tour of the nutrition room on the Medical Stabilization Unit (MSU) at the Wharton campus showed the following: Cabinets and shelving that housed commercial packed snacks, drinks, disposable cups and utensils for patients/ staff use. Also, rolling carts with disposable serving trays that patient meals would be transported on. Three microwaves were observed for use. Thermometer for food heating were in the drawer with sanitizing pies to be used between each use. One commercial coffee pot and one commercial tea brewer were available for use. One side-by side refrigerator/freezer. The refrigerator side contained pre-made patients meals and staff prepared sandwiches in Ziploc bags. The freezer contained breakfast sandwiches and hot pockets. Meals in the refrigerator/ freezer were labeled with the date of preparation and expiration date. Staff (ID# 82) at the time of observation stated that they retrieve the meals from a big freezer downstairs in the kitchen. She stated that all the food is brought over from a sister campus that has a working kitchen. She stated that the meals are placed in the refrigerator on the unit for patients and are heated in the microwave by the PCT staff. She stated the meals are good until the expiration date on the label. She went on to say that the PCT staff also prepares the sandwiches for the days the patients have those for lunch. She confirmed that she does not have a food handlers permit. She stated that there are no logs kept for heating patient meals, transporting food from one facility to another or calibration of the thermometer used when reheating food. She stated that she has never logged those things. Observation on 6/30/2026 at 11:20 behind one of the microwaves in the nutrition room on the MSU, the surveyor found a white 3 ring binder labeled Wharton Food Travel Log. Staff ID# 82 stated that she had never seen this binder. The binder contained log sheets for thermometer calibration and food reheating logs. Observation on 6/30/2026 at 1:45 PM in the 1st floor kitchen at the Wharton campus showed dietary staff supervisor (ID# 90) emptying a cooler bag with meals from a shopping cart in the doorway of a commercial cooler/freezer. He stated that he brings over prepared patient meals and other items for the patients at the Wharton campus. He removes meals from the freezer and places them in the cooler for the staff to get for the next few patient meal times and places new meals in the freezer. Outside the cooler/freezer there was a temperature log sheet for the current month that was completed for weekdays only (Monday-Friday). Several months of logs were available for the surveyor(s) to review (Dec. 2025- current date) that showed temperatures only recorded for weekdays. During these observations, staff (ID# 90) stated that once frozen items are removed from the freezer, they are good for 3 days (72) hours. He confirmed that the items are not labeled when they are taken out of the freezer. He stated that he completes the log for the freezer/cooler temperature log and confirmed that there are no temperatures recorded by MSU staff on the weekends although they access the are area after hours and on weekends. Observation on 6/30/2026 at 1:55 PM in the MSU nutrition room showed RN (ID# 80) along with her WOW (workstation on wheels), she stated she was getting a cup of coffee on her break. Record review of facility Food and Nutrition policy titled “Storage Procedures”, showed the following: I. PURPOSE To provide for safe and sanitary storage of food and non-food supplies. IV. REFRIGERATED/FROZEN STORAGE B. Record equipment temperatures daily on the monitoring log. G. Prepared perishables are to be stored in a refrigerator covered, until used (within 72 hours). Record review of facility Food and Nutrition policy titled “ Recording Food Temperatures” showed the following: I. PURPOSE To serve food at a palatable sand safe temperature/records must be kept utilizing thermometers. II. PROCEDURES A. Food thermometer has a notch near the bottom of the probe. This probe must be inserted beyond the the notch to obtain an accurate reading. b. Record the item and the temperature on the Food Temperature Checklist. C. Sanitize thermometer prior to use and in between food items being tested. Record review of the Texas Food Establishment Rules, 25 TAC §§228 read: §228.33(d) Certified Food Protection Manager and Food Handler Requirements: (d) Except in a temporary food establishment and the certified food manager, all food employees shall successfully complete an accredited food handler training course, within 60 days of employment §228.42. Food Contamination Prevention. (a) Eating, Drinking, or Using Tobacco. (2) of this subsection, an employee shall eat, drink, or use any form of tobacco only in designated areas where the contamination of exposed food; clean equipment, utensils, and linens; unwrapped single-service and single-use articles; or other items needing protection cannot result. Interview with Food and Nutrition Director (ID# 84) on 7/1/2026 at 10:58 AM, she stated that she works for Morrison Healthcare Food Services and they are contracted to provide food and nutrition services. She stated that she was not aware of the Texas Food Establishment Rules but was familiar with the Food and Drug Administration (FDA) /Food Code. She confirmed that any person handling and preparing food should have a food handlers certificate. She stated she keeps a copy of all of the dietary staff permits/certificates to ensure they have them. She went on to say that she is aware that the food for the Wharton Campus which includes the MSU unit receives it food that is prepared at a sister facility. She was not aware that the cooler/freezer that the food is stored in the kitchen was not having the temperatures checked everyday. She did confirm that food that is removed from the freezer and placed in the cooler/refrigerator is only good for 73 hours or 3 days. She was also not aware that the unit has staff without this knowledge was preparing food on the unit. She stated that they are supposed to be using a thermometer to warm the food to at least 165ºF. The thermometer should be calibrated weekly. She stated that the staff does prepare sandwiches for patients and assumes they would have the proper utensils in the preparation area to do so. She stated that nurses should not be taking their breaks in areas where food is prepared and the WOW should not be permitted in that area. She went on to say that she has not been to that unit to observe the staff and the storage and food preparation area. Interview with Human Resources staff (ID# 88) on 7/1/2026 at 11:05 AM confirmed that PCT staff on the MSU do not have requirements for food handling certification in the job description, nor do they require it as part of the onboarding.”

“THERAPEUTIC DIETS CFR(s): 482.28(b), (b)(1) §482.28(b) Menus must meet the needs of patients. (1) Individual patient nutritional needs must be met in accordance with recognized dietary practices. This Standard is not met as evidenced by: 37490 Based on recordand interview, the facility failed to meet individual patient nutritional needs for 1 of 2 patients (ID# 31). Findings include: Record review of facility policy titled “Prioritization of Nutritional Care,” showed the following: II. PURPOSE A. A nutrition screen is completed by a Registered Nurse during the admission assessment which includes assessment of general nutrtional status for each patient. C. The admission assessment is utilized to assist in determining patient acuity. The Registered Dietician utilizes the admission assessment and other sources of information and/or referral to assign nutritional risk level. Medical record review for patient ID#31 on 6/29/2026 at 11:52 PM with Quality staff ID# 51 showed: History and Physical Note:... Past Medical History Hypertension Type 2 Diabetes Mellitus Plan 7. Type 2 Diabetes Me litus with Hyperglycemia Resume Metformin 500 mg twice daily. hold Glipizide 5 mg daily. Sliding scale Regular insulin low dose Accuchecks before meals and at bedtime. Diabetic diet. Glucose currently elevated at 296 mg/dL and requires monitoring during withdrawal treatment. Progress Note 7/1/2026 Continue metformin 500 mg twice daily. Hold glipizide. Continue low-dose sliding-scale regular insulin. Accu-Cheks before meals and at bedtime. Continue diabetic diet and monitor blood glucose closely during withdrawal treatment (There is no dabeticdiet ordered). Medication order for INSULIN REGULAR HUMAN LOW DOSE, Subcutaneous, thirty (30) minutes before meals and at bedtime. Instructions: REGULAR INSULIN SLIDING SCALE (LOW DOSE REGIMEN) <70 HYPOGLYCEMIA PROTOCOL AND CALL MD 70-150 0 UNITS 151-200 4 UNITS 201-250 5 UNITS 251-300 6 UNITS 301-350 8 UNITS 351-400 10 UNITS GREATER THAN 400 10 UNITS AND CALL MD Documented Blood Glucose levels for the patient were: 06/29/2026 22:04 198mg/dL 06/30/2026 09:31 296 mg/dL 06/30/2026 15:18 295 mg/dL 0630/2026 21:21 170 mg/dL 0701/2026 09:04 341 mg/dL Medication adminsitration record showed: REGULAR INSULIN SLIDING SCALE (LOW DOSE REGIMEN) Sched Dt/Tm Admin Dt/Tm Charted Dt/TmAdm Dose Adm 06/30/2026 07:30 06/30/2026 10:26 06/30/2026 10:26 6 LOW DOSE Blood Glucose 296 mg/dL 06/30/2026 10:22 06/30/2026 11:30 06/30/2026 16:07 06/30/2026 16:07 6 LOW DOSE Blood Glucose 296 mg/dL 06/30/2026 15:59 6/30/2026 16:30 06/30/2026 18:180 6/30/2026 18:18 Not Given Medication Refused 06/30/2026 21:00 06/30/2026 22:01 06/30/2026 22:01 4 LOW DOSE Blood Glucose 170 mg/dL Diet order: 6/29/2026 22:54 Regular. Patient Care Technician ID# 82 on 6/30/2026 at 11:02 AM stated that the unit tries to stick to meal times that are scheduled at 8:00 AM, 12 Noon, and 5:00 PM. The patients also get a snack in the evening. Snacks are packed based on the diet orders for the patient. She stated that none of the current patients are on special diets, but there are low and zero sugar options for diabetic patients. Interview with rgistered Dietician staff ID# 85 on 7/1/2026 at 09:00 A.M. stated that the dieticians do cover patients on the MSU (Medical Stabilization) unit. The dieticians get consulted based on the nutritition screen that is performed by the nurses. For patietns on the MSU unit we typically do not want to restrict their diets but will see patients that have untrolled diabetes and specific allegies and sensativities. She confirmed that none of the current patietns on the MSU unit were being followed by the dieticians at this moment. When reviewing chart for patietnt ID# 31, she stated that the nurses nutrition screen did not tigger a consult and that it should have. The screen stated “diabetic diet,: but was entered as “other.” She explainrd that she was not aware that “other” was an option for the nurses to select during the screen and would look into it. Record review of medial record for patient (ID# 31) provided to the surveyor(s) 7/6/2026 showed no RN Admission Assessment.”

“MAINTENANCE OF PHYSICAL PLANT CFR(s): 482.41(a) The condition of the physical plant and the overall hospital environment must be developed and maintained in such a manner that the safety and well-being of patients are assured. This Standard is not met as evidenced by: 37490 Based on observation, interview and record review, it was determined that the facility was not maintained to assure the safety of staff and patients. Findings include: Record review of facility policy titled “Management of Hazardous Waste and Materials,” showed the following: Objectives A. To establish and maintain a program that will safely control hazardous materials and waste 3. Container Labeling: a. The receiving clerk will verify that all containers received for use will: (1) Be clearly labeled as to the contents; (2) Note the appropriate hazard warning; and (3) List the name and address of the manufacturer, importer, or responsible party. b. It is the policy of Oak Bend Medical Center that no container will be released for use until the above data is verified. c. Every manager/supervisor in each department will ensure that all secondary containers are labeled with either an extra copy of the original manufacturer ’ s label or with generic labels which have a block for identity and blocks for the hazard warning. For help with labeling, please see our hazard communication coordinator. 4. Storage: a. Hazardous chemicals will be stored in appropriately labeled containers maintained for this purpose. Containers will be properly labeled with a description of the hazard(s) they represent. (Refer to Container Labeling.) b. Storage areas are to be clean and organized. Areas where hazardous chemicals are maintained should be kept under lock and key until they are needed. L. Linen Management: 1. Under Standard Isolation Precautions, all used patient linens are considered contaminated with potentially infectious waste. 2. Contaminated linen will be bagged, in a yellow fluid resistant bag provided by a vendor, at the site of use, without prior sorting or rinsing. 3. Environmental Services will pick up bagged linens from the patient care areas. Carts will be transported to the linen department. 4. Environmental Services employees will use appropriate personal protective equipment while handling contaminated linen. 5. Linens will be picked up and laundered by a vendor that is experienced in the handling of hospital linens. Observation of the facility loading dock on 6/30/2026 at 10:45 showed the following: Dumpster filled beyond capacity, with lids unable to fully close. Solid waste and debris including cardboard, plastic bags, disposable cups, gloves, packaging materials scattered throughout the loading dock and surrounding ground surfaces. Several full soiled linen collection carts and bins with soiled microfiber mop heads (that may be contaminated with blood or other potentially infectious materials). A white plastic drum/container that did not display visible manufacture label or product identification, hazard communication label, or other contents identification. One damaged electrical box with the cover late broken and partially missing, leaving internal wiring exposed and easily accessible. The loading dock pavement had visible accumulation of dirt, staining, accumulation of leaves showing the area was not maintained in a clean and sanitary condition. Interview with Facilities Manager (ID# 72) on 6/30/2026 at 11:00 AM, he confirmed the above mentioned findings. He stated that the loading dock is a shared responsibility between environmental services staff and facilities staff. He stated that he thinks the white plastic drum/container contained a chemical that is used in the cooling tower.”

“FACILITIES, SUPPLIES, EQUIPMENT MAINTENANCE CFR(s): 482.41(c)(2) Facilities, supplies, and equipment must be maintained to ensure an acceptable level of safety and quality. This Standard is not met as evidenced by: 46010 Based on observations, interviews and record review, the facility failed to ensure equipment was inspected and maintained to ensure an acceptable level of quality. The facility failed to: 1) Ensure that equipment in Emergency Department clinical areas, available for patient use, were maintained to an acceptable quality including a. Emergency Department Stretchers free of tears and wear precluding proper infection control practices and b. Emergency Department Metal Bedside tables and carts free of reddish-brown colored staining with corrosion Findings included: Observations conducted on 6/30/2026 at 09:45 am of the Wharton campus emergency department exam rooms revealed that rooms labeled “A”, “2” and “9” were equipped with stretchers which had a large tears (6-9 inches long) on anterior facing surfaces. Observations conducted on 6/30/2026 at 09:45 am of the Wharton campus emergency department exam rooms revealed that ED room “A” had a bedside table with multiple areas of patchy, rough appearing texture with reddish-brown discoloration along metal base with void of paint/surface covering. ED room “2” has a metal cart, positioned adjacent to stretcher with table surface and single drawer. This is observed to have multiple areas of patchy, reddish-brown discoloration with void in surface finish. ED room “9” has a metal cart, positioned adjacent to stretcher with table surface and single drawer. This is observed to have multiple areas of patchy, reddish-brown discoloration with void in surface finish. Interview with facilities manager Staff ID # 72 on 6/30/2026 at 09:45 am with facility tour. He confirmed the mattress tears observed in Wharton ED Rooms #A, 2 and 9. He confirmed the reddish-brown discoloration which he confirmed was likely rust. He confirmed that he participated in environment of care rounds most recently on 6/24/26 and these items were identified as action items. Interview with nursing leader staff ID # 53 on 6/30/2026 at 09:45 am with facility tour. She confirmed that the aforementioned equipment issues with torn stretchers and rust had been identified on 6/24/26 environmental rounds. She confirmed that the facility has alternative back-up supplies which should be exchanged to remove damaged items from clinical areas. Record review of the facility’s environmental rounds from Wharton Hospital with Director of Quality on 6/29/2026 at 12:45 pm showed Environemnt of Care report labeled as completed on 6/24/2026 which identified “torn mattresses on ED stretchers” (unspecified quantity) and “Rust on metal equipment” (unspecified rooms/quantity). There was no documentation of in process work orders provided.”

“PATIENT RIGHTS: INFORMED CONSENT CFR(s): 482.13(b)(2) The patient or his or her representative (as allowed under State law) has the right to make informed decisions regarding his or her care. The patient’s rights include being informed of his or her health status, being involved in care planning and treatment, and being able to request or refuse treatment. This right must not be construed as a mechanism to demand the provision of treatment or services deemed medically unnecessary or inappropriate. This Standard is not met as evidenced by: 46010 Based on interview and record review, the facility failed to fully uphold the patients’ right to informed decision making regarding their care and treatment. Two (2) of five sampled patient records failed to contain completed consent for treatment (Patient ID #12) and procedural consent. (Patient ID # 1). Findings included: Record review of facility policy titled “Infromed Consents, General Guidelines”, revised 01/2023, stated “It is the policy of OakBend Medical Center that each patient or legal representative be provided with information regarding tests, studies, operative and invasive procedures that allow the patient or representative to make an informed choice regarding his/her healthcare while maintaining optimum patient respect and dignity. It is the legal responsibility for the physician or licensed independent practitioner who will perform the surgical or diagnostic procedure or treatment to give information required to provide informed consent and to ensure signature is obtained from the patient. It is NOT the responsibility of hospital employees to provide this information, though they may be involved in obtaining signatures.” It further stated “Procedure: B. The patient has the right to give or withhold consent before receiving medical treatment, and has the right prior to making this decision, to be fully advised of the risks and consequences for the treatment, alternatives to the treatment, risks and consequences of alternative treatments, and expected results of refusal. Refusal of care or participation in treatment will not put the patient at risk of retaliation or compromise their care or treatment. When a practitioner other than a physician performs the procedure, he/she may obtain the informed consent. Example: a registered nurse that inserts a PICC line may obtain the informed consent. 5. Hospital staff may prepare the informed consent form. Hospital staff may witness the patient or representative ’ s signature after validation that the patient or representative has received and understands the information necessary to provide informed consent. Documentation of informed consent may also be found in other areas of the medical record, such as progress notes, history and physical, or other areas as appropriate.” Record review of two (2) sampled patient medical records who presented for treatment in December 2024 and January 2025. Patient ID #1 Disclosure and Consent - Medical and Surgical Procedures failed to have a date and time that the physician signed the consent form and the section for reason for patient incapacity is not completed. Patient ID #12 presented to the facility on 01/28/2025. His consent for treatment is dated 01/28/2025. The patient signature line stated “Inmate” and the witness area is signed. Medical records reflected the patient was awake, alert and oriented and had mental capacity to sign his consent for treatment. The above findings were verified by Quality Director Staff ID #51 on 1/31/2025 at 2:30 pm. She confirmed that Patient ID #1 procedural consent should have date and time and reson for incapacity completed. She confirmed that Patient ID #12 should have signed his own consent for treatment, irrespective of his status as an inmate.”

“PATIENT RIGHTS: FREE FROM ABUSE/HARASSMENT CFR(s): 482.13(c)(3) The patient has the right to be free from all forms of abuse or harassment. This Standard is not met as evidenced by: 46010 Based on interview, and record review, the facility failed to investigate an allegation of abuse per its policy (Patient ID #1). Findings included: HHSC Intake TX00526949 complainant stated “Staff RN (ID# 59) proceeded to pull on her arm, with he help of Staff RN ID #60, which resulted in a surprising sound that I later learned was associated with her shoulder.” Record review of Patient ID #1 medical record showed a PICC Insertion Record dated 12/13/2024 which stated “Pt notably contracted in both arms. RN Staff ID #60 assisted the patient in positioning the arm more appropriately. Notable pop heard and felt when moving arm into position.” Record review of Patient ID #1 medical record showed a Shoulder Xray 12/13/2024 order at 21:46. The Xray result on 12/13/2024 at 22:50 stated “Findings: Osseous structures: Deformed appearance of the proximal right humerus. Radiographic appearance is suspicious for sequela of a remote injury. Cross-section imaging can be obtained to further evaluate if there is concern for an acute on chronic injury. Osteopenia. Degenerative change within the acromioclavicular and glenohumeral joint Joints: No glenohumeral dislocation. Soft tissues: Swelling throughout the right shoulder region. Right-sided PICC line. Distal tip projects over the cavoatrial region. Tracheostomy tube noted Recommendations: If the patient has persistent pain, a follow-up radiographic evaluation in 10-14 days, MRI, or three phase bone scan would be recommended to exclude an occult injury. IMPRESSION: 1. Deformed appearance to the proximal right humerus. Radiograph appearance is suspicious for sequela of remote injury.” Record review of facility policy titled “Patient Rights: Non-Abuse Policy”, revised 01/2008, stated “ GENERAL STATEMENT : It is the policy of OakBend Medical Center that no patient shall be subjected to negligence, verbal or physical abuse by any member of the staff. II. DEFINITIONS: A. Negligence Omission of any action that would have been taken by a reasonable person under the same circumstances or commission of something that a reasonable person would not have done under the same or similar circumstances. Physical Abuse Any willful, angry or violent touching of a patient that could or would produce bodily harm.” The policy further stated “ PROCEDURE A. Any suspected negligence or patient abuse shall be thoroughly investigated by the Chief Nursing Officer (CNO) and reported to the CEO. B. If a decision to terminate is rendered, the employee’s director shall proceed with the policies relating to immediate termination of employment. C. The CNO will report any licensed or unlicensed staff to the appropriate authority as deemed by the State of Texas Nurse Practices Act.” Interview with Chief Nursing Officer Staff ID #53 on 01/31/2025 at 08:45 am. She confirmed that she was made aware of the incident concerning the humeral head fracture for Patient ID #1 which was acquired on 12/13/2024 evening with positioning for PICC line placement on 12/16/2024 morning as part of the facility safety huddle analysis with leadership. She confirmed that the facility failed to fully analyze all aspects of the case. She confirmed that the procedure nurse was a contracted service and she had not reported him to the Texas State Board of Nursing per policy. She reported he was no longer allowed to practice at their facility per agreement with contracted service.”

“STAFFING AND DELIVERY OF CARE CFR(s): 482.23(b) The nursing service must have adequate numbers of licensed registered nurses, licensed practical (vocational) nurses, and other personnel to provide nursing care to all patients as needed. There must be supervisory and staff personnel for each department or nursing unit to ensure, when needed, the immediate availability of a registered nurse for care of any patient. This Standard is not met as evidenced by: 46010 Based on interview and record review, the facility failed to ensure nursing staff reported unusual events/assessments, which occurred during an invasive procedure and resulted in an injury to a patient, to a licensed provider (Patient ID #1). Findings Included: Record review of facility policy titled “Emergency Department Nursing Assessment and Reassessment Policy”, last revised 05/2023, stated “ POLICY/PURPOSE (Facility) will provide patient care, treatments and services based on information collected from an interdisciplinary assessment of the patient’s relevant physical, psychological, and social needs. There will be established guidelines for the triage, initial assessment and reassessment of patients presenting to (facility) emergency departments. Reassessments (system re-review) will be completed at regular intervals determined by the patient response and/or changes in condition or diagnosis ... D. Reassessment (system re-review) will be obtained every four hours from the initial assessment. If there is a change in patient’s condition or diagnosis, a reassessment (system re-review) will be documented at that time.” Record review of contracted vascular access team policy titled “PICC Insertion Policy and Procedure,” last revised 10/2023, stated “Complications: Insertion complications and other relevant clinical assessments should be reported to the licensed independent practitioner by the vascular access specialist and documented in the progress notes/nursing notes in the patient’s medical record.” It further stated “Procedure 36. The clinician verbalizes possible complications of the procedure related to the patient’s condition.” Record review of Patient ID #1 electronic medical record showed a PICC Insertion Record dated 12/13/2024 which stated “Pt notably contracted in both arms. RN Staff ID #60 assisted the patient in positioning the arm more appropriately. Notable pop heard and felt when moving arm into position.” Record review of Patient ID #1 medical record showed a Shoulder Xray 12/13/2024 order at 21:46. The Xray result on 12/13/2024 at 22:50 stated “Findings: Osseous structures: Deformed appearance of the proximal right humerus. Radiographic appearance is suspicious for sequela of a remote injury. Cross-section imaging can be obtained to further evaluate if there is concern for an acute on chronic injury. Osteopenia. Degenerative change within the acromioclavicular and glenohumeral joint Joints: No glenohumeral dislocation. Soft tissues: Swelling throughout the right shoulder region. Right-sided PICC line. Distal tip projects over the cavoatrial region. Tracheostomy tube noted Recommendations: If the patient has persistent pain, a follow-up radiographic evaluation in 10-14 days, MRI, or three phase bone scan would be recommended to exclude an occult injury. IMPRESSION: 1. Deformed appearance to the proximal right humerus. Radiograph appearance is suspicious for sequela of remote injury.” Telephone Interview with RN Staff ID #59 on 1/31/2025 at 09:35 am. He confirmed that he did not inform ED Physician Staff ID #61 about the “pop” heard and felt while manipulating flexion contractures to optimize positioning for PICC line placement. Telephone Interview with Physician Staff ID #61 on 1/30/2025 at 4:15 pm. He reported he was not notified by Vascular Team Staff RN #59 that there were any possible complications related to PICC line placement. He stated he had no contact with Staff RN #59 that shift.”

“SUPERVISION OF CONTRACT STAFF CFR(s): 482.23(b)(6) All licensed nurses who provide services in the hospital must adhere to the policies and procedures of the hospital. The director of nursing service must provide for the adequate supervision and evaluation of all nursing personnel which occur within the responsibility of the nursing service, regardless of the mechanism through which those personnel are providing services (that is, hospital employee, contract, lease, other agreement, or volunteer). This Standard is not met as evidenced by: 46010 Based upon record review and interview, the facility failed to ensure that 1 of 1 contracted Registered Nurses (RN #59) reviewed had completed facility specific orientation and onboarding, according to facility policies and procedures. Findings Included: Record Review of Staff RN #59 employee file failed to reveal any facility specific education or orientation. Record Review of facility policy titled “Agency and/or Contract Orientation, Competency and Evaluation of Staff”, last revised 11/2020, stated, “Policy statement: All agency and contracted staff will meet the same standard regarding staff qualifications, orientation, and competency assessment as any employee of (facility).” Interview with Director of Nursing Staff ID #53 on 01/31/2025 at 09:05 am. She stated that nursing department has an onboarding period which includes classroom time and electronic modules. She confirmed that ongoing education included annual skills evaluations/validations. She confirmed the facility has a process for new staff hires, current staff and agency nurses for completing this onboarding process through HR Generalist Staff ID #66. However, she confirmed they have not included contracted nurses in this process up to this point.”

“PATIENT RIGHTS: CARE IN SAFE SETTING CFR(s): 482.13(c)(2) The patient has the right to receive care in a safe setting. This Standard is not met as evidenced by: 23032 Based on observation, interview, and record review the facility failed to uphold all patients’ right to receive care in a safe setting: A patient room with signage “under construction” was left unlocked and accessible to all current patients roomed on the Senior Behavioral Health Unit. Findings included: Review of facility policy titled “ Patient Bill of Rights,” last reviewed 01/2023, showed “ .... As a patient at OakBend Medical Center you have the right:... 17. To receive care in a safe setting...” Observation on 4/19/2024 at 10:15 AM on the Senior Care Unit-, 6th Floor -showed patient room door # 612 with signage posted that read “Under Construction-Work In Progress .” The door was observed to be unlocked and accessible. Observation inside of the unoccupied room showed the following: 3 mattresses stacked on one bed; another mattress rolled up and located in top of another bed. All 3 mattresses had canvas-type straps: with either loop handles or straps hanging down and accessible . In addition-there was a large 30 gallon trash can observed on a shelf-with what appeared to be large amount of white paper and other debris inside. There were 2 large windows. One side had some type of duct tape or strapping placed across the window. This tape was drooping down across the width of the window. Interview with Staff -D, at the time of observation , she stated the room should have been locked as there were hazards in the room that could be used for harm. Observation on 4/19/2024 at 11 AM with the Unit Secretary, she demonstrated that the locking mechanism was not broken on room # 612. When a key was inserted from the hallway into a locked door: if the key was turned to the left and the door was opened: the door would automatically lock when it was shut. If a key was inserted into the locked door from the hallway and turned to the right: the door would NOT lock automatically when shut. Turning the key to the right disabled the self-locking mechanism. Staff D said Housekeeping was recently in the room; or it could have been one of the workers who may have left the room unsecured. She said all of the unit staff know to turn the key to the left .”

“RN SUPERVISION OF NURSING CARE CFR(s): 482.23(b)(3) A registered nurse must supervise and evaluate the nursing care for each patient. This Standard is not met as evidenced by: 23032 Based on record review and interview , facility nursing staff failed to assess patient care needs related to prevention of skin breakdown. Nursing staff failed to perform and document accurate and consistent patient skin assessments per facility policy and professional standards of nursing practice [ citing Patient ID # 4] Findings included: TX00493913 Record review of facility policy titled “Assessment & Reassessment, last revised date 01/23, showed:”A daily head- to- toe patient assessment will be completed at least every 24 hours by an RN, with on-going assessment as patient condition warrants. A licensed nurse will reassess the patient according to unit specific time frames and if a patient has a change in condition. Record review of professional guidelines established by the American Nurses Association (ANA) titled : “Principals of Nursing Documentation: Guidance for Registered Nurses,” 2010, showed: -Clear, accurate, and accessible documentation is an essential element of safe, quality, evidence-based nursing practice; -The uses of Nursing Documentation include: Communication within the healthcare team. Timely documentation of the following types of information should be maintained in the patient’s health record : assessments; order acknowledgement, implementation, and management [*not all inclusive ]. On 4/19/2024 of the medical record of Patient ID # 4 was reviewed with Staff C, Unit Charge Nurse. Patient ID # 4’s medical record showed she was an 80 year old female patient admitted on 2/16/2024 with diagnosis of acute psychosis, depression, and anxiety. : 2/16/2024 (1657)-Nursing Admission Assessment showed : “bruise: left anterior knee & right anterior thigh. Erythema : lower left chest; groin and sacral .” Electronic Medical Record : “Skin Lesions:” -2/17/2024-(00:30): bruise : arm- lower left anterior; arm- lower right anterior -2/17/2024 (1900): 2 bruises : arm: lower right; arm: lower left. -2/18/2024-(1930) 6 bruises ( arm: lower left anterior; arm- lower right anterior; and left lower posterior ) -2/19/2024- no skin assessment notes -2/20/2024- “no lesions noted” -2/21/2024 (730) : rash x 2 -2/21/24 (1836): “ bruising to lower extremities: RIGHT leg: 7 small bruises to lower and 1 (one) to upper. LEFT leg: 3 small bruises to lower and 1 small bruise that is healing. Bruising to upper extremities: Arms: RIGHT: 4 large bruises to upper and lower due to blood draw; LEFT arm: 4 large bruises to upper and lower due to blood draw. Red heat rash on back. Red rash to lower abdomen and perineal areas. Red rash to buttocks.” -2/21/2024 (1915) : pressure ulcer/ wound -2/22/2024 - no skin assessment notes -2/23/2024- no skin assessment notes -2/24/2024 (0007): “no lesions noted.” -2/25/2024- no skin assessment notes -2/26/2024- no skin assessment notes -2/27/2024 - (2023): “no lesions noted” -2/28/2024 - (1950): “no lesions noted” -2/29/2024- (0730) - rash x 5 -3/1/2024- no skin assessment notes -3/2/2024 - (0900): “no lesions noted” -3/3/2024 - (0900): “no lesions noted” -3/4/2024 - (2000): no skin assessment notes -3/5/2024 (2013): “no lesions noted” -3/5/2024 (0:00) rash x 4 -3/6/2024 (9:00): OTHER: left anterior thigh -3/7/2024 (1900): no skin assessment notes -3/7/2024 ( 0709: bruise lower left leg-posterior - 3/08/2024 ( 08:30 ) [-last nursing skin assessment prior to discharge] : LESIONS: ERYTHEMA : chest lower left; groin; sacral- BRUISE: Knee-left anterior; Thigh- right anterior ~~~~~~~~~~ “SKIN ASSESSMENT” - FULL BODY DIAGRAMS: -2/17/2024 (0015): Front-facing body diagram: “ bruises” -line drawn to lower right arm and lower left arm. red rash -circle drawn around perineal area; “bruise”- line drawn to left knee. Back-facing body diagram: circle drawn around sacral area- “red rash.”No descriptive narrative note written. -2/29/2024 (1604) : Front-facing body diagram: bruise noted to left arm and left knee; 2 bruises noted to right upper thigh and fungal rash to ‘perineal area. Back- facing body diagram: 3 bruises notes to right lower arras; 4 bruises noted to left arm; fungal rash to buttocks. “Pt. has fungal rash on buttocks, groin area and bilateral thighs. Pt. has multiple bruises on hands, arms, right thigh, and left knee.” -3/5/2024 (1513) : Front-facing body diagram showed 2 bruises noted by “X” to left arm; 2 bruises noted by “X” to left leg; one bruise noted to left side. 2 bruises noted by “X” to right lower leg. Back-facing body diagram : 3 bruises to right arm; 3 bruises to left arm Purple rash noted to buttocks area. Written narrative read: “pt. has a fungal rash on buttock, groin area and bilateral thighs. Pt has multiple scattered brushing on hands, arms, right thigh, left knee, and posterior left knee.” ~~~~~~~~~~~~~~~~~~~~~~~ During an interview with Staff C, RN Charge Nurse during the record review, she stated the skin assessments reviewed for Patient ID # 4 were not consistent or performed per facility policy. Staff C said that skin assessments should be done every shift. She verified the nursing documentation on 3/3/2024 of “no lesions noted” was not congruent with the “Skin Assessment” [Full Body Diagram ] documented on 3/5/2024. This diagram showed multiple areas of lesions / (bruises) , as well as fungal rash to multiple areas. There was no documented skin assessment on 3/4/2024, as well as multiple other dates.”