Oak Ridge Manor: Infection Control Failures - TX
The complaint inspection, completed December 30, 2025, cited Oak Ridge Manor under the infection control tag for failures during perineal care — the routine, intimate process of cleaning incontinent residents. The violation was tagged at a level of minimal harm or potential for actual harm, affecting some residents.
The facility's own policy, dated May 2022, is direct: gloves must be doffed and discarded if visibly soiled. Hand hygiene is required before and after glove use. What inspectors found was staff skipping that step, moving from a dirty brief to a clean one without changing gloves, and then making contact with oxygen equipment attached to the resident's face.
The Director of Operations, interviewed December 29, said she felt gloves should have been changed between dirty and clean briefs. That's not a complicated clinical judgment. It's the kind of thing covered in the first week of a nursing assistant course.
The DON, interviewed the following morning, went further. She said that if there was any amount of fecal matter present during perineal care, gloves had to be changed before putting the clean brief on the resident. She acknowledged the failure was partly hers. "The failure occurred with herself having not monitored enough," the inspection report states, capturing her words, "as well as staff possibly needing more training."
She also said CNAs received training throughout the year, with additional sessions as needed, conducted by herself or the assistant director of nursing.
That's worth sitting with. The training happened. The policy existed. The expectation was clear. And still, staff moved from soiled gloves to oxygen tubing.
Oxygen tubing sits against a resident's face, near their nose and mouth, sometimes for hours at a stretch. For elderly residents, many of whom have compromised immune systems and underlying lung conditions, a respiratory infection is not a minor complication. It can mean hospitalization. For some, it means something worse.
The DON said as much herself, without prompting. She connected the specific act, touching oxygen tubing with contaminated gloves, to the specific risk, respiratory infection. That's not a regulatory finding dressed up in clinical language. That's the facility's own nursing director describing the harm that her staff's lapse could produce.
Oak Ridge Manor's perineal care policy lists its purpose plainly: maintain resident dignity, reduce embarrassment, prevent infections and skin irritation, preserve skin condition. The gap between that stated purpose and what inspectors found isn't a paperwork problem. It's a care problem.
Incontinence care is among the most frequent and physically demanding tasks CNAs perform. It's also among the most consequential for infection control. Fecal bacteria introduced to the wrong surface, the wrong equipment, the wrong part of a resident's environment, can travel. Glove changes exist precisely because that transfer is predictable and preventable.
The DON's acknowledgment that she hadn't monitored enough is, in the context of inspection reports, unusual in its directness. Administrators more often attribute failures to individual staff conduct, documentation gaps, or policy interpretation. Here, the person responsible for nursing oversight said plainly that the breakdown included her own.
What the inspection record doesn't say is how many residents were affected, how many times the lapse occurred before a complaint triggered the inspection, or whether any resident developed a respiratory infection traceable to contaminated gloves. The violation level, minimal harm or potential for actual harm, reflects what inspectors could document, not necessarily the full scope of what happened.
For the residents who depend on staff to manage their most basic physical needs, the calculation is simpler. They cannot change their own gloves. They cannot move the oxygen tubing out of reach. They are, in the most literal sense, dependent on the person standing next to them doing the job correctly.
The DON said her expectation was for staff to make sure everyone was clean and dry. At Oak Ridge Manor in December 2025, that expectation wasn't being met.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Ridge Manor from 2025-12-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 20, 2026 · Our methodology
OAK RIDGE MANOR in BROWNWOOD, TX was cited for violations during a health inspection on December 30, 2025.
The violation was tagged at a level of minimal harm or potential for actual harm, affecting some residents.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.