Federal inspectors found the man sleeping beside an oxygen concentrator during their November visit, yet his care plan dated from July made no mention of respiratory support. The oversight left him without proper documentation for a therapy he received on an as-needed basis, sometimes during morning hours.
The resident was admitted with respiratory failure and hypoxia, a condition where the body doesn't receive enough oxygen. His physician ordered oxygen therapy at 2-4 liters as needed on September 26, but the care plan was never revised.
A certified nursing assistant told inspectors the resident used oxygen on an as-needed basis, particularly in the morning. The assistant director of nursing acknowledged the care plan didn't include oxygen use, explaining he thought only full-time oxygen therapy required documentation.
"I thought only a resident's use of oxygen on a full-time basis was care planned," the assistant director told inspectors.
The director of nursing confirmed oxygen use wasn't included in the current care plan. She acknowledged that as-needed oxygen therapy needed documentation to reflect the resident's total treatment.
The resident scored 2 on his cognitive assessment, indicating severe cognitive deficits that prevented inspectors from interviewing him about his care. His diagnoses included unspecified dementia, respiratory failure with hypoxia, and generalized anxiety disorder.
Federal regulations require nursing homes to develop complete care plans within seven days of comprehensive assessments and revise them as residents' conditions change. The facility's own policy from December 2016 states that assessments are ongoing and care plans must be revised as information about residents and their conditions changes.
The care plan failure occurred despite clear evidence of the resident's oxygen needs. Medical orders dated November 5 showed the September 26 oxygen prescription remained active. Staff observed the resident using the therapy, yet failed to document it in his care plan for over a month.
Inspectors classified the violation as having minimal harm or potential for actual harm, affecting few residents. However, the deficiency could place residents at risk of not receiving necessary care and services.
The gap between the resident's actual treatment and his documented care plan illustrates broader problems with care coordination. When treatments aren't properly documented, incoming staff may not understand a resident's full medical needs.
For residents with severe cognitive impairments like this man, accurate care plans become even more critical. These residents cannot advocate for themselves or explain their medical needs to staff who may not be familiar with their conditions.
The oxygen therapy oversight occurred during a complaint inspection, suggesting someone raised concerns about care quality at the facility. The inspection report doesn't specify what prompted the federal review.
Oak Park Nursing and Rehabilitation Center operates at 7302 Oak Manor Drive in San Antonio. The facility must submit a plan of correction to continue participating in Medicare and Medicaid programs.
The November inspection focused specifically on care plan compliance, reviewing records for seven residents. The facility failed to meet federal standards for one of those residents, though the scope suggests broader systemic issues with care plan management.
Care plans serve as roadmaps for daily care, ensuring all staff understand each resident's medical needs, preferences, and goals. When plans aren't updated to reflect current treatments, residents may not receive consistent care across shifts.
The 74-year-old man continues to receive oxygen therapy while living with severe dementia and anxiety disorder. His case demonstrates how administrative failures can disconnect residents from the documented care they're supposed to receive.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Oak Park Nursing and Rehabilitation Center from 2025-11-06 including all violations, facility responses, and corrective action plans.
Additional Resources
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