Health inspection·September 24, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #34's weights revealed: 08/31/2024 Weight was 137 pounds and on 09/18/2024 weight was 126.2 pounds. A weight loss of 7.88% in 19 days. Record review of Resident #50's electronic face sheet revealed: [AGE] year-old male admitted [DATE] with diagnoses of Type II Diabetes Mellitus, Dysphagia (difficulty swallowing), Mild cognitive impairment, Generalized Anxiety Disorder. 2. Record review of Resident # 50's Quarterly MDS dated [DATE] revealed: Section C-Cognitive patterns had a BIMS score of 04 (severe cognitive impairment). Section H-Bowel and Bladder- Indwelling catheter (suprapubic) (above the pubic bone). Section I- Active Diagnosis- Neurogenic Bladder, Diabetes Mellitus. Section N-Medications Insulin injections 7 (received insulin injections 7 of 7 days). Record review of Resident # 50's Care Plan dated 08/07/2024 revealed: No care plan, goals, interventions for diagnosis of Type II diabetes mellitus. Record review of Resident # 50's Physician orders dated 09/01/2024 revealed: Trulicity Subcutaneous .5mL (milliliters) every Saturday. Insulin glargine 20 units SQ (subcutaneous) two times a day, Admelog Solostar insulin PRN (as needed) per insulin sliding scale, Metformin 500 mg ½ tab by mouth two times a day. Ensure foley catheter bag is in privacy bag every shift. Urinary catheter to gravity drainage every shift. During an interview on 09/24/ 2024 at 12:08 PM, the DON stated the MDS Coordinator initiated the care plan. The DON stated she was responsible for overseeing the care plans was accurate. The DON stated the staff met weekly and reviewed care plans. The DON stated she was not sure why the failure occurred, other than just being pulled in different directions and not being notified by staff of changes. The DON stated her expectations was that all care plans would be correct and address all problems. The DON stated the effect on the residents could be not all disciplines being aware of residents needs and interventions that should be in place. Review of facility's policy titled Comprehensive Care Planning (no date) The facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment When developing the comprehensive care plan, the 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. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on the changing goals, preferences and needs of the resident and in response to current interventions. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675944 If continuation sheet Page 2 of 6 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 675944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 of 3 residents (Residents #50, #258, and #8) reviewed for indwelling urinary catheter. 1. The facility failed to ensure Resident #50's and Resident #258's catheter bag was off the floor and protect from potential contaminants on the floor. 2. The facility failed to ensure Resident #50, Resident #258, and Resident #8 had a related diagnoses for urinary catheter in the physician orders This deficient practice could place residents with indwelling urinary catheters at-risk for urinary tract infections and/or pain. Findings included: Resident #50 Review of Resident #50's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: Dysfunction of the bladder, dementia, and brain bleed. Review of Resident #50's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 04 which indicated severe cognitive impairment. Further review of MDS Section H Bladder and Bowel revealed indwelling catheter. Review of Resident #50's Comprehensive Care Plan last reviewed 08/14/2024, revealed: Focus: resident has Suprapubic (above the pubic bone) catheter. Goals: resident will show no signs or symptoms of Urinary infection and resident will be/remain free from catheter-related trauma. Interventions: The resident has 18French/10cc suprapubic cath. Position catheter bag and tubing below the level of the bladder and in a privacy bag. Change catheter as ordered. Check tubing for kinks and maintain drainage bag off the floor. Ensure tubing is anchored to the residents' leg or linens so that tubing is not pulling on the urethra. Review of Resident #50's electronic physicians orders revealed, Urinary Catheter 16 French/10 cc to gravity with no related diagnoses entered, order date 06/03/2024. During an observation on 09/22/24 at 1:26 PM, Resident #50 was resting in bed with his catheter bag sitting on the floor at bedside with privacy bag in place. Resident #258 Review of Resident #258's electronic face sheet revealed an [AGE] year-old male admitted to the facility on [DATE] with diagnosis to include: Dysfunction of the bladder, Depression, and urinary tract infection. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675944 If continuation sheet Page 3 of 6 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 675944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #258's Entry MDS assessment dated [DATE], revealed admission on [DATE] from hospice. Review of Resident #258's Comprehensive Care Plan initiated 09/18/2024, revealed: Focus: resident has Indwelling Suprapubic Catheter: Neurogenic bladder. Goals: The resident will show no signs or symptoms of Urinary infection. Interventions: The resident has (Size) (Type of Catheter). Position catheter bag and tubing below the level of the bladder and in a privacy bag. Change the catheter as ordered. Check tubing for kinks and maintain the drainage bag off the floor. Ensure tubing is anchored to the residents' leg or linens so that tubing is not pulling on the urethra. Review of Resident #258's electronic physicians orders revealed, Urinary Catheter 16 French/30 cc to gravity with no related diagnoses entered, order date 09/21/2024. Further review of physicians' orders revealed, Ensure foley bag is in a privacy bag while in bed or chair, ordered date 09/21/2024. During an observation on 09/23/24 at 9:24 AM, Resident #258 was sitting in his recliner with his catheter bag sitting on floor beside recliner with no privacy bag. During an observation on 09/24/24 at 10:30 AM, Resident #258 was sitting in his recliner with his catheter bag sitting on floor beside recliner with no privacy bag. Resident #8 Review of Resident #8's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: Dysfunction of the bladder, dementia, and urinary tract infection. Review of Resident #8's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Further review of MDS Section H Bladder and Bowel revealed indwelling catheter. Review of Resident #8's Comprehensive Care Plan last reviewed 08/07/2024, revealed: Focus: resident has Suprapubic (above the pubic bone) catheter. Goals: resident will be/remain free from catheter-related trauma. Interventions: The resident has 16French suprapubic cath. Change catheter as ordered. Check tubing for kinks and maintain drainage bag off the floor. Ensure tubing is anchored to the residents' leg or linens so that tubing is not pulling on the urethra. Review of Resident #8's electronic physicians orders revealed, Suprapubic (above the pubic bone) Catheter 16 French/30 cc to gravity with no related diagnoses entered, order date 06/03/2024. During an interview on 09/24/24 at 11:17 AM, the DON stated all urinary catheters must have a related diagnosis connected with them in the physicians' orders. She stated she was not aware that the orders did not have the diagnosis. She stated it was her responsibility to ensure this is done. She stated a catheter bag should never be on the floor because it causes contamination and possible infection. Review of facility policy titled, Catheter Care, revised February 2007, revealed in part: General Guidelines .10. Be sure the catheter tubing and drainage bags are kept off the floor. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675944 If continuation sheet Page 4 of 6 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 675944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 3 (Resident #259, Resident #8, and Resident #32) of 3 residents reviewed for respiratory care. Residents Affected - Some 1. The facility failed to obtain a Physician's order for Resident #259's continuous supplemental oxygen. 2. The facility failed to ensure Residents #8's nasal cannula and Resident #259's nebulizer was kept in a bag while not in use. 3. The facility failed to ensure Resident #8's and Resident #32's humidifier bottles (bottled water) were changed out weekly per physician orders. These failures could place residents who received oxygen therapy at risk of oxygen toxicity, respiratory infections, nose bleeds, and nasal discomfort. Findings included: Resident #259 Review of Resident #259's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: heart failure, respiratory failure, and sleep apnea. Review of Resident #259's Entry MDS assessment dated [DATE], revealed admitted on [DATE]. Review of Resident #259's Comprehensive Care Plan initiated 09/21/2024, revealed: Focus: Resident has Oxygen Therapy. Goal: Resident will have no signs or symptoms of poor oxygen absorption. Interventions: Oxygen settings at LPM per nasal cannula. Monitor for signs and symptoms of respiratory distress and report to medical director. Review of Resident #259's electronic physicians orders revealed no evidence of any orders related to oxygen therapy. During an observation on 09/23/24 at 10:52 AM, Resident #259 was in bed wearing oxygen at 2 LPM via nasal canula. Observed nebulizer lying on nightstand not in bag and not dated. Resident #8 Review of Resident #8's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: Dysfunction of the bladder, dementia, and urinary tract infection. Review of Resident #8's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 11 which indicated moderate cognitive impairment. Further review of MDS Section O: special treatments, procedures, and programs revealed oxygen therapy. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675944 If continuation sheet Page 5 of 6 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 675944 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/24/2024 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Review of Resident #8's Comprehensive Care Plan last reviewed 08/07/2024, revealed: Focus: Resident has Oxygen Therapy. Goal: Resident will have no signs or symptoms of poor oxygen absorption. Interventions: Oxygen settings at 2 LPM continuously. Monitor for signs and symptoms of respiratory distress and report to medical director. Review of Resident #8's electronic physicians orders revealed, May use oxygen at 2 LPM via nasal cannula as needed for shortness of breath, ordered 08/15/2016 and change bottled water and clean filter on oxygen concentrator every night shift on Tuesday ordered 12/12/2022. During an observation on 09/24/24 at 9:10 AM, Resident #8's nasal cannula was lying on her nightstand not in a bag. Observed no date on humidifier bottle (bottled water) and there was no bag to place the tubing in. Resident #32 Review of Resident #32's electronic face sheet revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: respiratory failure, depression, and heart abnormality. Review of Resident #32's Quarterly MDS assessment dated [DATE], revealed a BIMS score of 10 which indicated moderate cognitive impairment. Further review of MDS Section O: special treatments, procedures, and programs revealed oxygen therapy. Review of Resident #32's Comprehensive Care Plan last reviewed 07/10/2024, revealed: Focus: Resident has Oxygen Therapy. Goal: Resident will have no signs or symptoms of poor oxygen absorption. Interventions: Oxygen settings at 2 LPM continuously. Monitor for signs and symptoms of respiratory distress and report to medical director. Review of Resident #32's electronic physicians orders revealed, May use oxygen at 2 LPM via nasal cannula every shift, ordered 06/20/2022 and change humidifier bottle and clean filter on oxygen concentrator every night shift on Sunday ordered 12/12/2022. During observation and interview on 09/24/24 at 08:57 AM, Resident 32's humidifier bottle (bottled water) had no date and the bag containing the oxygen tubing was dated 08/26/2024. Resident #32 stated she didn't wear oxygen all of the time but sometimes needed it. She stated she used it at least a couple of days a week. During an interview on 09/24/24 at 11:17 AM, the DON stated residents must have an order for oxygen. The DON stated oxygen tubing should aways be stored in a bag when not on the resident. She stated bags and tubing are changed when soiled or dirty. The DON stated humidifier bottles (bottled water) were to be changed weekly and dated when changed. She stated if a bottle is not dated that indicated it was not changed. She stated tubing should never be laid out on a nightstand when not in use. She stated this could lead to contamination and possible infection. She stated it was her responsibility to ensure this is done. Review of facility policy titled, Respiratory Policies and Procedures 2.0 Nasal Cannula, revised June 1, 2007, revealed in part: Process: 1. Verify physicians orders .15. Replace entire set-up every seven days. Date and store in treatment bag when not in use. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675944 If continuation sheet Page 6 of 6