Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Bend Medical Center during CMS and state inspections, most recent first.
Two residents’ advance directive records did not align with their stated DNR wishes. One resident had a signed resuscitation consent indicating DNR, but no physician signature and no OOH DNR form in the chart despite stating she wanted DNR status and wearing a DNR bracelet. Another resident had a DNR order and signed consent in the record, but no OOH DNR form was filed even though staff said the SNF unit was considered out-of-hospital and the resident stated he wanted DNR status.
Insufficient staffing and delayed call light response affected multiple residents. A resident with CHF, CAD, CVA, anxiety, heart failure, and depression reported being left on the commode for over an hour and waiting long periods for help, while another resident with angina, ESRD, a respiratory condition, a surgical wound, and diabetes reported repeated delays when calling for toileting assistance. Family and staff interviews described delayed response times, limited nursing coverage, and missed or late care, with staff acknowledging that call lights were everyone’s responsibility and that insufficient staffing contributed to the delays.
Infection control failures occurred when a CNA placed soiled linen on the floor and later on a couch with ungloved hands, and another CNA carried clean linen against her scrub instead of keeping it protected from contamination. Staff also failed to sanitize medication carts/workstations between resident rooms during med pass, including for a resident on contact isolation for VRE and another resident on enhanced barrier precautions. The DON and Infection Preventionist stated staff are expected to perform hand hygiene and sanitize equipment between residents, and the facility policy required cleaning and disinfection of shared equipment before use for another patient.
Water Leakage and Ceiling Damage in Hall B A ceiling tile between rooms [ROOM NUMBERS] was stained, the lighting panel had water pooling on both sides, and the smoke damper panel was leaking water onto the floor. The Facilities Director stated that hot air near Hall A met cold air in Hall B, creating moisture, and that the air duct above the hallway was producing water and pooling in the ceiling.
Pest Control Program Not Maintained: Two residents’ rooms and a common shower area had roaches, spiders, and ants noted during survey. A resident with syncope/fall history and another resident with angina, UTI, ESRD, a respiratory condition, a surgical wound, and diabetes each reported seeing roaches in their rooms, with one CNA killing a roach without notifying the nurse. Staff also reported pests in the public shower, while the DON said she had not been told about roaches or spiders and the pest control records were not clearly separated between the hospital and SNF.
Failure to Submit Quarterly PBJ Staffing Data: The facility failed to submit complete and accurate PBJ staffing data to CMS for one quarter. Record review showed no staffing submission for the quarter, and the Quality Director stated the prior coordinator had said she was submitting the data, but the facility later learned it had not been submitted and that she no longer worked at the facility.
A CNA did not change gloves or perform hand hygiene while providing incontinent and catheter care to a resident with a compromised immune system, despite facility policy and the resident's care plan requiring these infection control measures. Staff interviews confirmed knowledge of proper procedures, but the observed care did not meet infection prevention standards.
Advance directive records did not match residents’ DNR wishes
Penalty
Summary
The facility failed to ensure two residents had advance directive status that matched their expressed wishes. Resident #161 was admitted with a diagnosis of acute cystitis and had a physician order for full code status in the order inquiry, but the electronic medical record showed no code status indicated and the paper chart did not contain an OOH DNR form. Her chart did include an undated Resuscitation order/Consent Form signed by the resident indicating she requested do not resuscitate, but the form was not signed by a physician. During interview and observation, Resident #161 stated she had an OOH DNR form completed at home, wished to have DNR status, and showed a purple DNR bracelet on her wrist. The DON stated the form in her chart was not completed because the physician had not signed it. Resident #163 was admitted with a diagnosis of a closed fracture of the epiphysis of the proximal fibula and had a physician order for do not resuscitate. His admission MDS showed a BIMS score of 12, indicating no cognitive impairment, and the electronic medical record reflected a DNR code status. However, his paper chart did not contain an OOH DNR form, only a Resuscitation order/Consent Form dated and signed by the resident requesting do not resuscitate, with the physician signature present. The Quality Director stated the skilled nursing unit was considered out-of-hospital and residents should have an OOH DNR form if this code status was requested, while the DON stated the form used in the chart was sufficient and that an OOH DNR form was not needed. Resident #163 stated he wished to have DNR status.
Insufficient staffing and delayed call light response
Penalty
Summary
The facility failed to provide sufficient and competent nursing staff to meet resident needs and to ensure that a licensed nurse was in charge on each shift. Survey findings identified that nursing staff did not respond to resident call lights in a timely manner on June 14, 15, and 16, 2026. The deficiency involved 4 residents out of 7 reviewed: residents with diagnoses and care needs including CHF, CAD, CVA, anxiety, heart failure, depression, osteomyelitis, amputation, anemia, ESRD, wound infection, diabetes, syncope, fracture, seizure disorder, angina, UTI, respiratory condition, surgical wound, and diabetes. Resident #1 was admitted with CHF, CAD, CVA, anxiety, heart failure, and depression. Her MDS showed moderate cognitive impairment and dependence or need for supervision with toileting hygiene, dressing, footwear, toilet transfer, sit-to-stand, sit-to-lying, and chair/bed transfers. Her care plan included fall risk precautions, call light and personal items within reach, hourly rounding, support for anxiety, and oxygen for ineffective breathing. In interview, she said call light waits lasted over an hour, she was left on the commode for an hour several times, this happened almost daily on both shifts, and she sometimes had trouble with oxygen being disconnected. She said she could not toilet alone because she was unsteady, felt unsafe, and said her bottom hurt after waiting so long. Resident #5 was admitted with angina, UTI, ESRD, a respiratory condition, a surgical wound, and diabetes. His MDS showed normal cognition, an indwelling catheter, and need for assistance with ADLs. His care plan included fall precautions, supervision with toileting, and hourly rounding. He and a family member reported repeated long waits after using the call light, including when he needed help to get to the restroom and when he called from the restroom. The family member stated the main concern was that staff did not respond in a timely manner. Resident #3’s family member reported staff were not seen for much of the day, that the resident could not ambulate, and that it took staff a long time to come in. Resident #4 stated the facility was short staffed and said there was only one nurse on one of the days, and that delayed medication and care affected her pain. Staff interviews confirmed that responding to call lights was everyone’s responsibility, that delayed response could lead to falls or other injury, and that call lights were not answered timely due to insufficient staffing. The DON stated delayed call light response could affect residents through falls, declining health, and dissatisfaction, and the QA Supervisor stated the facility did not have a call light policy.
Infection Control Failures With Linen Handling and Cart Sanitization
Penalty
Summary
The facility failed to maintain infection prevention and control practices during care for a resident with multiple medical conditions, including hemorrhagic stroke, cancer, diabetes, CVA, and hemiplegia, who required assistance with multiple activities of daily living. During observation, CNA A removed soiled linen from the resident’s bed, placed it on the floor, picked it up with ungloved hands, and then placed it on a couch. The resident’s care plan identified infection risk and directed staff to perform practices to prevent the spread of infections and infectious diseases. The facility also failed to follow infection prevention practices when handling clean linen for another resident, a 64-year-old female admitted with syncope/fall, fracture and other trauma, cancer, hypertension, hip fracture, and seizure disorder. CNA B transported clean linen for this resident’s room by carrying it against her scrub. During interview, CNA B stated she had been told to place clean linen in a bag because everything had to be sanitized, and she acknowledged that carrying linen against her scrub contaminated the linen and could transfer contamination to the resident. The resident’s care plan identified infection risk and included interventions to prevent the spread of infection and infectious diseases. In addition, the facility failed to ensure staff sanitized workstations or carts between resident rooms during medication pass and when entering or exiting rooms. RN A entered the room of a resident on contact isolation for VRE with her workstation containing medications, gave medications, and exited without sanitizing the workstation before going to the next resident’s room. CNA A was observed doing the same when entering another resident’s room, also without sanitizing the workstation before exiting the prior room or entering the next room. The resident on contact isolation had acute cystitis, heart failure, hypertension, and UTI with MDRO, and the other resident had amputation, anemia, CAD, heart failure, hypertension, renal insufficiency, diabetes, and wound infection and was on enhanced barrier precautions. The DON and Infection Preventionist stated staff are expected to perform hand hygiene and sanitize equipment between residents, especially for isolation precautions, and the facility policy stated that if common equipment is used, it must be cleaned and disinfected before use for another patient.
Water Leakage and Ceiling Damage in Hall B
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment on Hall B. During observation, a ceiling tile between rooms [ROOM NUMBERS] was stained with a brown and yellow stain about 7 inches wide in the shape of one-fourth of a circle. The lighting panel on the ceiling between rooms [ROOM NUMBERS] had water pooling on both the right and left sides, and the smoke damper panel between rooms [ROOM NUMBERS] was leaking water with a slow stream dropping onto the floor. In interview, the Facilities Director stated that hot air near Hall A met cold air in Hall B and created moisture, and that the air duct above the hallway was producing water and pooling in the ceiling. Record review of the facility's Physical Environment policy stated that the facility is committed to providing an environment that is safe, functional, and supportive, and that risks are assessed and identified to mitigate and better manage those risks.
Pest Control Program Not Maintained
Penalty
Summary
The facility failed to maintain an effective pest control program for two residents’ rooms and the surrounding areas reviewed for pests, including the common shower area. Resident #4, a 64-year-old female admitted with syncope/fall, cancer, hypertension, hip fracture, and seizure disorder, had normal cognition on her MDS and required assistance and supervision with toileting, dressing, and footwear. Resident #5, a male admitted with angina, UTI, ESRD, a respiratory condition, a surgical wound, and diabetes, also had normal cognition on his MDS and required assistance with ADLs; his bowel and bladder assessment noted an indwelling catheter. Resident #4 stated she saw two roaches in her room and felt she was in an unclean environment, worried the roaches would crawl on her while she slept, and said CNA B killed them. Resident #5 stated his family member killed a roach in his room, and both he and the family member confirmed seeing it; he reported feeling disgusted, anxious, and panicked. CNA B said she saw a roach in front of Resident #4’s door on 06/12/2026, killed it, and discarded it without notifying the nurse. The Case Manager said staff reported roaches, spiders, and ants in the public shower and that she would notify the House Supervisor, who would call the exterminator. The DON said she had not been told about roaches or spiders, though she knew of ants. The facility management supervisor said pest control came every Monday, with the last SNF-specific visit on 06/09/2026, and the pest control invoices showed visits for various areas such as the cafeteria, kitchen, bathrooms, breakrooms, offices, and building, but the records were not differentiated between the hospital and the SNF.
Failure to Submit Quarterly PBJ Staffing Data
Penalty
Summary
The facility failed to electronically submit complete and accurate direct care staffing information to CMS no less frequently than quarterly based on payroll and other verifiable and auditable data. Record review of the PBJ Staffing Data Report for Quarter 2 of 2026, generated on 6/17/26, showed that the facility did not submit staffing data for that quarter. During an interview on 6/17/26 at 5:30 pm, the Quality Director stated that the coordinator was responsible for submitting staffing data to CMS and that the previous coordinator had told the facility she was submitting the data, but the facility later discovered that she had not submitted it and she no longer worked at the facility.
Failure to Follow Infection Control and Hand Hygiene During Incontinent Care
Penalty
Summary
Certified Nursing Assistant (CNA) B failed to follow proper infection control and hand hygiene procedures while providing incontinent and catheter care to a male resident with a history of septic arthritis and a compromised immune system. During the observed care, CNA B did not change gloves or perform hand hygiene after removing a soiled brief and before applying a clean one, despite facility policy and the resident's care plan requiring these steps to prevent infection. Both CNA B and another CNA initially washed their hands and donned personal protective equipment, but CNA B continued to use the same gloves throughout the entire process, only removing them and washing hands after care was completed. Interviews with staff revealed that they were aware of the correct procedures, including the need to change gloves and perform hand hygiene when moving from dirty to clean tasks, but CNA B acknowledged not following these protocols during the observed care. The facility's infection control policy, revised in June 2024, requires standard precautions for all residents, including proper hand hygiene and glove changes to prevent cross-contamination. The failure to adhere to these procedures was confirmed through observation, staff interviews, and record review.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Richmond
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Richmond Health Care Center | 0.5 mi | ★★★★★ | 0 | 0 |
| Paradigm At The Brazos | 0.8 mi | ★★★★★ | 0 | 0 |
| Cambridge Health And Rehabilitation Center | 1.2 mi | ★★★★★ | 8 | 0 |
| Rosenberg Health & Rehabilitation Center | 2 mi | ★★★★★ | 7 | 1 |
| Fort Bend Healthcare Center | 4.1 mi | ★★★★★ | 0 | 0 |
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