Inspection·November 6, 2025

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 1 of 7 Residents (Resident #1) whose records were reviewed for care plans. The facility failed to ensure Resident #1's care plan was revised to reflect the use of oxygen. This deficient practice could place Residents at risk of not receiving the care and services they needed.Findings included: Record review of Resident # 1's face sheet, dated 11/5/25 revealed a 74 - year old male admitted on [DATE] with diagnosis included : Unspecified Dementia (a condition where the cause of cognitive decline is unknown), respiratory failure with hypoxia (a condition where the body does not receive enough oxygen), and general anxiety disorder (a mental health condition marked by persistent worry about everyday life events) Record review of Resident # 1's quarterly MDS, dated [DATE], revealed a BIMS score of 2 which indicated a severe cognitive deficit. Record review of Resident #1's physician orders dated 11/5/25 revealed an order for oxygen dated on 9/26/25 at 2-4 liters as needed. Record review of Resident #1's care plan which was dated 7/25/25 revealed there was not a care plan update to include the resident's use of oxygen. During an observation on 11/05/2025 at 8:30 a.m., Resident #1 was sleeping with an oxygen concentrator set up on the floor besides the resident's bed; the resident was not interviewed due to his overall cognitive status. During an interview on 11/5/25 at 8:35am C.N.A.-A stated Resident #1 used oxygen on an as needed basis sometimes in the a.m. hours. During an interview on 11/5/25 at 9:00am ADON-B stated Resident #1's current care plan did not include the use of oxygen. ADON-B stated he thought only a resident's use of oxygen on a full-time basis was care planned. During an interview on 11/5/25 at 9:20am with DON stated that Resident #1's oxygen use was not included in the current care plan. The DON stated oxygen use on an as needed basis needed to be care planned to reflect the resident's total treatment. Record review of the facility's policy named Care Plans, Comprehensive Person-Centered dated 12-2016 revealed Assessments of residents are ongoing and care plans are revised as information about the residents and the resident's conditions change. Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455789 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 455789 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/06/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oak Park Nursing and Rehabilitation Center 7302 Oak Manor Dr San Antonio, TX 78229 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)