Health inspection·December 30, 2025

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 . 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 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 Residents Affected - Many Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Based on interviews and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 6 of 6 kitchen staff (DC -E, DC-F, DS-G, DS-H, DS-I, and DC-J) reviewed for qualified dietary staff.The facility failed to ensure that DC-E, DC-F, DS-G, DS-H, DS-I, and DC-J met the requirements for food handling by obtaining a current and valid Food Handler's Certificate.This failure could place residents at risk of not having their nutritional needs met and placing them at risk for food born illnesses.The findings included:Record review of food handlers certificates posted in the main dining room was dated as follows:- DC-E -09/27/2022,-DC-F 12/16/2022,-DS-G 09/27/2022,-DS-H 11/28/2022,- DS-I 12/04/2022, and-DC-J did not have a food handler's certificate posted. All certificates indicated that the certificate was valid for 3 years.During an interview on 12/30/2025 at 10:54 am, the DM stated he was responsible for ensuring the dietary staff's food handler's certifications was current. He stated he assumed the certificates posted in the main dining room were valid until the end of the year. The DM explained he notified the dietary staff in a meeting that they had until December 31 this year to renew their certifications. He stated all dietary staff were currently enrolled in the online food handler's course. He stated the dietary staff were required to complete the course and post examination during work hours. He stated his expectation was for staff to monitor the expiration date of their food handler's certification and register for the training course prior to the expiration date. The DM stated consequences for residents of the dietary staff failing to maintain a current food handlers' certification were possible cross-contamination issues or mishandling of food. He stated to his knowledge no resident had suffered from a food borne illness recently.During an interview on 12/30/2025 at 11:18 am, the ADMN stated the DM was responsible for monitoring the expiration dates of the dietary staff's food handler's certificates. He stated he was responsible for monitoring the DM. The Admin. stated consequences for residents of failure of the dietary staff to maintain current certification may be food that is not properly prepared. He stated his expectations were for the dietary staff to keep their certification up to date, to stay on top of the expiration dates and keep up to date on all training.Record review of an email dated 12/29/2025 the Director of Program Development with the online company that provided the facility with the food handler's online training and certification, indicated the expiration dates were clarified as being 3 years from the date of completion.During an interview on 12/30/2025 at 12:23 pm, DC-F stated she was not aware until recently that her food handler's certificate had expired. She stated she was registered for the online training course but did not state an anticipated completion date. DC-F could not state potential consequences for residents for failing to renew her food handler's certification. She stated her boss was responsible for monitoring expiration dates on the food handler's certificates.During an interview on 12/30/2025 at 12:31 pm, DS-G stated she was aware her food handler's certification had expired and intended to renew it during the holiday vacation but did not have time. She stated she had completed the online course and was going to take the post examination after work. She explained the consequences for residents of failing to keep her food handler's certification current may be a resident could have gotten the wrong food, or food may have been served at a wrong temperature. She stated staff and management was responsible for monitoring expiration dated. She explained that the DM had reminded her for the past month of the need to renew her certification.A policy on the dietary staff maintaining a current food handler's certification was requested on 12/30/2025 at 11:18 am. During the exit conference on 12/30/2025 at 2:30 pm, the Admin. stated the facility did not have a policy specific to food handler's certifications. Record (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 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 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 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 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 5 (CNA-A, CNA-B and CNA-C) staff observed during incontinent care for 2 (Res #4 and Res. #5) of 2 residents. The facility failed to ensure CNA-A, CNA-B, and CNA C performed proper peri-care (incontinent care) and proper hand hygiene during peri-care for Resident #4 and Resident # 5. These failures placed residents of the facility at risk of infections from improper incontinent care and hand hygiene while performing incontinent care.Findings included: Resident #5Record review of the Resident #5's Face Sheet dated 12/30/2025, revealed she was a [AGE] year-old female. Resident #5 had diagnoses of a fractured shaft of left radius, muscle wasting and lack of coordination. Record review of Resident #5's MDS assessment Section C, Cognitive Patterns dated 12/12/2025, revealed a BIMS score of 13 (cognitively intact). Record review of Resident #5's Comprehensive Care Plan initiated 12/28/2025 revealed the following focused areas:Incontinence: Resident is incontinent of bowel/bladder related to age related deficits. Goal: The resident will be clean and odor free through next review date . Interventions for the focus on incontinent care included checking frequently for wetness and being soiled, change as needed. Resident #4Record review of Resident #4's Face Sheet dated 12/30/2025, revealed she was an [AGE] year-old female. Her admission to the facility was on 11/13/2025. Resident #4 was in the facility for orthopedic aftercare, and diagnosed with muscle wasting, abnormalities of gait and mobility, with other lack of coordination and muscle weakness. Record review of Resident #4's MDS quarterly dated 12/13/2025 Section C, Cognitive Patterns, revealed a BIMS score of 5 (severe impairment). Record review of Resident #4's Comprehensive Care Plan initiated 12/03/2025 revealed the following focused areas:Incontinence: Resident is incontinent of bowel/bladder related to age related deficits. Goal: The resident will be remain free from skin breakdown due to incontinence and brief use through the review date. Interventions for the focus on incontinent care included care at least every 2 hours. During an observation on 12/29/2025 at 10:06 AM, CNA-A and CNA-B performed peri-care on Resident #5.CNA-B did not changed her gloves between dirty to clean, nor remove her dirty gloves prior to adjusting Resident #5's nasal canula (oxygen tubing). During an interview on 12/29/2025 at 10:15 AM, CNA-A and CNA-B stated their gloves should have been changed after cleaning the resident with clean gloves to be applied prior to placing the clean brief on resident. During an interview on 12/29/2025 at 10:15 AM, CNA-B stated her gloves should have been changed after cleaning the resident with clean gloves to be applied prior to placing the clean brief on resident. CNA-B stated after applying Resident #5's clean brief she should have taken the gloves off and cleaned and/or sanitized her hands prior to helping Resident #5 with her oxygen tubing. CNA-B stated in not doing so, the resident could have possibly gotten bowel on her gloves which would have contaminated the tubing. CNA B stated it could have caused an upper respiratory infection. During an observation on 12/29/2025 at 10:22 AM, CNA-C performed peri-care on Resident #4. CNA-C had not changed her gloves between removing Resident #4's dirty briefs and putting on residents' clean brief. During an interview on 12/29/2025 at 10:30 AM, CNA-C stated she had thought if the resident did not have a BM, she did not have to change her gloves prior to placing the clean brief on the resident. CNA-C stated the CNA's have training every year and/or as needed. During an interview on 12/29/2025 at 10:32 AM, RN-D stated gloves should have been changed and hand hygiene performed between the changing of dirty and clean briefs when doing peri care with resident. She stated if hand hygiene was not done properly, it could have possibly caused an infection or a urinary tract infection. Residents Affected - Some (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 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. Event ID: Facility ID: 675944 If continuation sheet Page 6 of 6