Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oak Ridge Manor during CMS and state inspections, most recent first.
Six dietary staff members were found to be working without current Food Handler's Certificates, with some certificates expired and one missing entirely. The Dietary Manager and Administrator were aware of the issue, and staff had been notified to renew their certifications, but several had not completed the process. The facility lacked a specific policy for maintaining current food handler certifications.
Staff failed to follow infection control protocols during peri-care for two residents, including not changing gloves between dirty and clean tasks and not performing proper hand hygiene. These lapses occurred despite facility policy and staff training requirements, and were acknowledged by both direct care staff and nursing leadership during interviews.
A resident with an indwelling urinary catheter and a fractured arm did not have these conditions addressed in her care plan, despite documentation in her medical record and assessments. Observations confirmed the presence of both the catheter and the arm cast, but the care plan lacked measurable objectives or interventions for these needs. Staff interviews indicated that care plan updates could be missed due to miscommunication, and the facility's policy required comprehensive, person-centered care planning based on resident assessments.
The facility failed to develop comprehensive care plans for two residents, one with a knee immobilizer and weight loss, and another with Type II Diabetes Mellitus. Despite physician orders, these issues were not addressed in their care plans, potentially impacting their care. The DON cited being pulled in different directions and lack of staff notification as reasons for the oversight.
The facility failed to maintain catheter hygiene and proper documentation for residents with indwelling urinary catheters. Observations showed catheter bags on the floor, contrary to facility policy, and physician orders lacked related diagnoses. This oversight was acknowledged by the DON, highlighting a lapse in care standards.
The facility failed to provide proper respiratory care for three residents, including not obtaining a physician's order for oxygen therapy, not storing respiratory equipment properly, and not changing humidifier bottles as required. These actions were against the facility's policy and could lead to contamination and infection risks.
Expired Food Handler Certifications Among Dietary Staff
Penalty
Summary
The facility failed to employ sufficient dietary staff with the appropriate competencies, skill sets, and accreditations to carry out the functions of the food and nutrition service department. Specifically, six kitchen staff members did not have current and valid Food Handler's Certificates as required. Record review showed that the posted certificates for these staff members were expired, and one staff member did not have a certificate posted at all. The certificates were found to be valid for three years from the date of completion, but the facility was operating under the assumption that they were valid until the end of the year. Interviews revealed that both the Dietary Manager (DM) and the Administrator (ADMN) were aware of the expired certifications, with the DM stating that staff had been notified to renew their certificates by the end of the year and that all were enrolled in the online course for renewal. However, staff interviews indicated a lack of awareness regarding expiration dates and the consequences of not maintaining current certification. The facility did not have a specific policy regarding the maintenance of current food handler's certifications for dietary staff. The DM was responsible for monitoring certification expiration dates, while the ADMN was responsible for overseeing the DM. Despite reminders and enrollment in renewal courses, several staff members had not completed the necessary training or examinations to renew their certifications at the time of the survey. The absence of current food handler's certifications among dietary staff was identified through interviews, record reviews, and the lack of a facility policy addressing this requirement.
Failure to Follow Infection Control Protocols During Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper peri-care and hand hygiene practices observed among three CNAs during incontinent care for two residents. Specifically, CNA-B did not change gloves between cleaning a resident and adjusting the resident's nasal cannula, potentially contaminating the oxygen tubing. Both CNA-A and CNA-B acknowledged during interviews that gloves should have been changed after cleaning the resident and before applying a clean brief, and that hand hygiene should have been performed prior to assisting with the oxygen tubing. For another resident, CNA-C did not change gloves between removing a soiled brief and applying a clean one, believing that glove changes were unnecessary if there was no bowel movement. Interviews with nursing staff, including an RN and the Director of Operations, confirmed that gloves should be changed and hand hygiene performed between dirty and clean tasks during peri-care. The Director of Nursing (DON) also stated that gloves should be changed if any fecal matter is present before putting on a clean brief. Both residents involved had significant medical histories, including muscle wasting, lack of coordination, and incontinence, with one resident being cognitively intact and the other severely impaired. The facility's own policy required glove changes and hand hygiene before and after glove use, but these procedures were not followed during the observed care. The DON acknowledged that insufficient monitoring and possibly inadequate staff training contributed to the failure to adhere to infection control protocols.
Failure to Develop Comprehensive Care Plan for Resident with Catheter and Fracture
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan for a resident with multiple complex medical needs. Specifically, the care plan did not address the presence of an indwelling urinary catheter or a fractured left radius, despite these conditions being documented in the resident's medical record and Minimum Data Set (MDS) assessment. The resident's diagnoses included a left arm fracture, obstructive and reflux uropathy, and other chronic conditions, and the MDS indicated the use of an indwelling catheter and a recent fracture, both of which triggered care area assessments. Observations confirmed the resident had an indwelling urinary catheter and her left arm was immobilized in a cast and sling. Interviews with the resident revealed she experienced pain in her left arm, which was managed with medication, and she denied numbness or tingling. Despite these findings, the comprehensive care plan reviewed did not include interventions or objectives related to the catheter or the arm fracture. Interviews with facility staff, including the DON, MDSC, and administrator, revealed that responsibility for care plan creation and monitoring was shared among the interdisciplinary team. Staff acknowledged that issues could be missed due to miscommunication and that care plans were expected to be accurate and updated promptly. The facility's policy required comprehensive, person-centered care plans based on assessments, but in this case, the care plan did not reflect the resident's current needs as identified in the assessment and observations.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, which resulted in deficiencies in addressing their specific medical needs. Resident #34, a female with a history of fractures and depression, did not have a care plan addressing her left knee immobilizer or significant weight loss. Despite physician orders indicating the need for a knee immobilizer and monitoring of skin condition, as well as a notable weight loss of 7.88% over 19 days, these issues were not reflected in her care plan. This oversight could potentially impact the resident's care and recovery. Similarly, Resident #50, a male with Type II Diabetes Mellitus, dysphagia, and severe cognitive impairment, lacked a care plan addressing his diabetes management. Although physician orders included specific diabetes medications and insulin administration, these were not incorporated into his care plan. The absence of a comprehensive care plan for his diabetes could lead to inadequate management of his condition. The Director of Nursing (DON) acknowledged the oversight, attributing it to being pulled in different directions and not being notified of changes by staff, which could result in not all disciplines being aware of the residents' needs and necessary interventions.
Failure to Maintain Catheter Hygiene and Documentation
Penalty
Summary
The facility failed to provide appropriate care for residents with indwelling urinary catheters, leading to potential risks of urinary tract infections. Specifically, the facility did not ensure that the catheter bags for three residents were kept off the floor, which is a critical measure to prevent contamination and infection. Observations revealed that the catheter bags of two residents were found on the floor, one with a privacy bag and the other without, indicating a lapse in maintaining hygiene standards. Additionally, the facility's policy on catheter care, which mandates that catheter tubing and drainage bags be kept off the floor, was not adhered to. Furthermore, the facility did not ensure that the physician orders for the urinary catheters included related diagnoses for the three residents. This omission was acknowledged by the Director of Nursing, who stated that it was her responsibility to ensure that all urinary catheters have a related diagnosis in the physician orders. The lack of related diagnoses in the orders could lead to inadequate monitoring and management of the residents' conditions, further increasing the risk of complications associated with catheter use.
Deficiencies in Respiratory Care for Residents
Penalty
Summary
The facility failed to provide appropriate respiratory care for three residents, leading to deficiencies in their care. Resident #259 did not have a physician's order for continuous supplemental oxygen, which is a necessary protocol for administering such therapy. Additionally, the nebulizer for Resident #259 was observed lying on the nightstand without being stored in a bag, which is against the facility's policy for preventing contamination. Resident #8's nasal cannula was also found on the nightstand without being stored in a bag, and the humidifier bottle was not dated, indicating it had not been changed as per physician orders. Resident #32's humidifier bottle was similarly undated, and the oxygen tubing bag was dated over a month prior, suggesting it had not been replaced weekly as required. The Director of Nursing (DON) confirmed that residents must have an order for oxygen and that equipment should be stored properly to prevent infection. The facility's policy mandates that the entire respiratory setup be replaced every seven days and stored in a treatment bag when not in use. These oversights could potentially expose residents to risks such as oxygen toxicity and respiratory infections.
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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 Brownwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brownwood Nursing And Rehabilitation | 0.2 mi | ★★★★★ | 11 | 0 |
| Pecan Bayou Nursing And Rehabilitation | 0.2 mi | ★★★★★ | 6 | 0 |
| Songbird Lodge | 0.4 mi | ★★★★★ | 15 | 0 |
| Cross Country Healthcare Center | 1.8 mi | ★★★★★ | 1 | 0 |
| Care Nursing & Rehabilitation | 6.8 mi | ★★★★★ | 3 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.