Health inspection·January 15, 2026

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 observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for one of two resident's (Resident #1) reviewed for respiratory care. The facility failed to obtain physician orders for Resident #1's continuous oxygen. The facility failed to ensure Resident #1's nasal cannula was changed when it was touching the carpet on the floor, and it was placed back on Resident #1. These failures could place residents at risk for respiratory infections, an incorrect amount of oxygen, and the risk of lung infections.Findings included: Record review of Resident #1's face sheet, dated 01/14/26, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #1 had diagnoses which included hypertension (high blood pressure), dehydration, and right femur fracture (thigh bone fracture). Record review of Resident #1's Comprehensive MDS assessment, dated 01/12/26, reflected Resident #1 had a BIMS of 03, which indicated he had severe cognitive impairment. The MDS did not reflect Resident #1 was on oxygen therapy while at the facility. Record review of Resident #1's Comprehensive Care Plan, date initiated 01/06/26, reflected there was no indication of Resident #1's need for oxygen therapy. Record review of Resident #1's Physician's Order summary report, dated 01/14/26, reflected no physician order for oxygen use. Record review of Resident #1's physician order summary report, dated 01/15/26, and after state surveyor intervention reflected Oxygen: Oxygen at 2 L per nasal cannula every shift. Active 01/15/2026. During observations on 01/14/26 at 01:15 p.m., 02:15 p.m., and 03:00 p.m. indicated Resident #1 was lying in bed. The oxygen nasal cannula had a date of 1/11/26. The oxygen nasal cannula was off, thrown over to the opposite side of his bedside table, and the two prongs that inserted into the resident's nostrils were touching the carpeted floor. The oxygen concentrator and the humidifier were on and set at 2 L. The resident was not interview able. During an observation on 01/15/26 at 08:09 a.m. Resident #1 was lying in bed. The oxygen nasal cannula was on and had the label dated 1/11/26. The oxygen concentrator and humidifier were on. The oxygen concentrator was set at 2 L. During an interview with LVN A on 01/15/26 at 09:38 a.m. LVN A had been Resident #1's nurse on 01/14/26 and 01/15/26. LVN A stated Resident #1 could have been admitted with oxygen or his oxygen decreased overnight and it was placed on the resident urgently. She stated, I don't know.on our click offs we check off oxygen for an order of oxygen. If there was an order, it would be in the electronic health record. A nurse might have received a verbal order and forgot to enter it into the electronic health record. She stated it could have been any nurse that missed the oxygen order. LVN A stated they have in-serviced on oxygen protocols. LVN A stated an example of what could have happened, was if the resident had COPD (Chronic Obstructive Pulmonary Disease) and the oxygen was set too high, the resident could have been over oxygenated. LVN A stated that if a nasal cannula was found on the ground, it should be replaced to prevent infection due to germs being on the Residents Affected - Few (continued on next page) 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: 675394 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 675394 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/15/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oakwood Manor Nursing Home 225 S Main St Vidor, TX 77662 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)