Oak Ridge Manor

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

fractured her left arm at home. Resident #5 was able to move her left fingers without increased pain.

Fingers appeared to be normal color with no swelling. Resident #5 denied numbness or tingling in her left fingers. She stated she had pain in her left arm, but the pain was managed with medication.During an

interview on 12/30/2025 at 10:45 am, the DON stated she and the ADON was responsible for creating care plans. She was responsible for monitoring for accuracy. Her expectation was for all care plans to be accurate and timely. The DON was unable to state any adverse effects to a resident if a care plan was not accurate.During an interview on 12/30/2025 at 11:02 am, the MDSC stated she and the DON were responsible for creating and updating care plans. She stated the DON was responsible for monitoring the care plans for accuracy. The MDSC stated the DON was good about checking the 24-hour report daily for any changes that may need to be included on the care plan. She stated occasionally issues may have been missed due to miscommunication. She stated she reviews physician orders routinely and verified information on the care plans was up to date. The MDSC explained that personnel from the corporate office randomly audits resident records, including care plans. She stated adverse effects on a resident without an accurate care plan may be if staff were not aware of how to care for a resident or what needed to be monitored with a resident.During an interview on 12/20/2025 at 11:18 am, the ADMN stated his expectations for the care plans was for each to be resident-centered on every individual. He stated during

the daily IDT meetings leadership determined if an issue needed to be addressed on the care plan. He stated that if so, the care plan should be updated immediately.Record review of the facility policy titled Comprehensive Care Planning , undated, revealed in part The facility will develop and implement a comprehensive person-centered care plan for each resident, . to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment., and When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing or currently has a weakness or need associated with that CAA, and how the risk, weakness or need affects the resident. Documentation regarding these assessments and the facility's rationale for deciding whether to proceed with care planning for each area triggered will be recorded in the medical record. and If the decision to proceed to care planning is made, the interdisciplinary team (IDT) . will develop and implement the comprehensive care plan .

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Ridge Manor

2501 Morris Sheppard Dr Brownwood, TX 76801

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 0802 Level of Harm - Minimal harm or potential for actual harm

review of https://texas-sos.appianportalsgov.com/rules-andmeetings?$locale=en_US&interface=VIEW_TAC_SUMMARY&queryAsDate=05%2F30%2F2025&recordId=215659 accessed on 12/30/2026 indicated Certificate period. A food handler certificate issued by an accredited food handler program shall be valid for two years.

Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

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Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

12/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Oak Ridge Manor

2501 Morris Sheppard Dr Brownwood, TX 76801

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

During an interview on 12/29/2025 at 10:35 AM, Director of Operations stated she felt gloves should have been changed between dirty and clean briefs. During an interview on 12/30/2025 at 9:25 AM, the DON stated, when providing peri care if there was any amount of fecal matter, the gloves should have been changed prior to putting the clean brief on the resident. The DON stated the CNA's received training throughout the year and extra as needed, with herself or the ADON performed the training. The DON stated her expectations were for staff to follow the facility policy, and make sure everyone was clean and dry. She stated not changing their gloves and then touching the oxygen tubing could have caused respiratory infections. The DON stated the failure occurred with herself having not monitored enough as well as staff possibly needing more training. Record review of facility policy Personal Care, Perineal Care dated 05/11/2022 revealed: Purpose: This procedure aims to maintain the resident dignity and self worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation, and. Preserving the residents skin condition.Definitions: People incontinence; The unintentional loss of solid or liquid stool. Urinary incontinence; The involuntary loss or leakage of urine.Start 10) Perform hand Hygiene 11) [NAME] gloves And all other PPE per standard precautions.Back:.24) Doff PPE 25) Perform hand hygiene.Important Points: -Doffing and discarding of gloves are required if visibly soiled. -Always perform hand hygiene before and after glove use.

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