Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Oasis Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Oxygen Therapy Deficiencies: A resident receiving O2 had no oxygen-in-use sign posted outside the room while staff confirmed the sign was required to alert staff and visitors that oxygen was present. Another resident’s O2 concentrator filter was observed dirty with dust and lint, and staff, including the DON and ADON, acknowledged there was no documented process for filter maintenance or staff training on the task.
Food Storage and Labeling Deficiencies in Kitchen Areas: The facility failed to store food in sealed containers and to label/date food items in dry storage, the refrigerator, and the freezer. Observations found cereal not dated, corn meal and tortillas not sealed, dessert topping not labeled or dated, spice bottles with grease build-up and one unlabeled bottle containing a white powder, and food particles on the freezer shelf.
Call lights were not kept within reach for two residents with severe cognitive impairment and mobility-related needs. One resident had weakness, dementia, and required assistance with transfers and other mobility tasks, while the other had a history of falls and multiple fractures. During observation, both residents’ call lights were found on the floor underneath the bed, and one resident stated she could not reach it if she needed help. The DON and Administrator stated staff were responsible for keeping call lights within reach.
A resident with DM2, CVA, hemiplegia, and moderate cognitive impairment had jagged fingernails with black debris underneath on repeated observations, and he stated he wanted them cleaned and trimmed. Staff said CNAs were responsible for routine nail care and grooming, usually weekly or as needed, while nursing staff were responsible for monitoring nails; however, the resident reported the service had not been offered since the prior week.
An unlabeled medication bottle was observed in a resident’s room near the bedside drawer while the resident, who had cognitive impairment and dementia, was eating breakfast. The resident said it was an ointment used sometimes, but staff could not verify the contents because the bottle had no label. Interviews with CNA, Medication Aide, RN, ADON, DON, and the Administrator confirmed that unlabeled medications were not acceptable and that the contents could not be identified.
Improper Storage of Eye Drop Bottles in Medication Cart: Multiple eye drop bottles removed from their original boxes and labeled for multiple residents were found stored together in one plastic bin in the South Low Side medication cart. An LVN said she was unaware the bottles needed to be kept in a divided container to prevent cross contamination, and the RN stated staff had been trained to store them in plastic bins with dividers. The facility did not provide its Medication Storage policy before exit.
Infection Control Lapses With Open Gauze Storage: The facility failed to maintain infection control practices when an open package of 4 x 4 gauze pads was found in a crash cart on the South Side without a sealed container, and an opened bag of 4 x 4 gauze pads was found in a treatment cart stored in an unsealed plastic bag. The DON and an LVN stated opened gauze packages were to be kept in sealed containers to prevent cross contamination, and the facility policy referenced infection control precautions for resident care equipment and articles.
Two residents with significant physical and cognitive impairments were found to have their call lights placed out of reach, despite care plans requiring accessibility. Both residents were unable to summon assistance when needed, and staff interviews confirmed the call lights were not accessible at the time of observation. Facility staff acknowledged the importance of call light placement and noted the absence of a specific policy addressing this issue.
A test tray of lunch was served at 120°F, below the facility's required 140°F, as confirmed by observation and staff interviews. Dietary staff, CNAs, and the DON acknowledged the policy and their responsibilities, but the food was not served at the correct temperature, in violation of facility policy.
Surveyors identified several deficiencies in food service sanitation, including undated and unlabeled food items, improperly sealed and freezer-burned foods, uncovered meal trays during distribution, improper placement of soiled trays, inadequate water temperatures for dishwashing, and the presence of staff personal belongings in the kitchen. Staff interviews confirmed these practices were not in line with facility policy and could lead to cross-contamination and improper food handling.
Surveyors observed that a resident's insulin pen on a medication cart had a smeared and illegible open date, despite facility policy and staff statements requiring clear dating upon opening. Multiple LVNs and the DON confirmed that dates should be placed to avoid smearing, but inconsistent practices led to the deficiency for a resident with diabetes and severe cognitive impairment.
The facility failed to maintain complete and accurately documented medical records for five residents. Specifically, the Initial Skin Assessment for one resident was not signed by the LVN ADON, and the Care Plan Conference Forms for four other residents were not signed and dated by the Social Worker at the time of completion. This lack of proper documentation was confirmed through interviews and record reviews with the staff involved.
The facility failed to ensure a resident received appropriate pressure ulcer care as ordered, resulting in a missing wound dressing on a stage IV pressure ulcer. Despite staff training to report such issues immediately, the protocol was not followed, leading to potential risks for the resident.
Oxygen Therapy Deficiencies
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for two residents receiving oxygen therapy. For Resident #32, who had COPD, chronic respiratory failure with hypoxia, pan lobular emphysema, and a BIMS score of 7, the record showed that oxygen therapy was part of the care plan and that staff were to administer oxygen as ordered, monitor respiratory status, and maintain oxygen equipment in safe working condition. During an observation, the resident was seen wearing a nasal cannula and receiving oxygen while eating breakfast, but there was no oxygen warning sign posted outside the room at that time. Interviews with an LVN, another LVN, a CNA, the DON, and the Administrator confirmed that oxygen-in-use signs were required outside rooms of residents receiving oxygen therapy and were intended to alert staff, visitors, and others that oxygen was present. They stated that the signs were needed so appropriate safety precautions could be followed and that the absence of the sign could allow staff or visitors to enter without knowing oxygen was in use. The facility policy titled Oxygen Administration stated that no smoking signs were to be placed when oxygen was administered and stored, and also stated that oxygen-in-use signs were not required on individual resident rooms if the facility was non-smoking. For Resident #12, who had ESRD, dependence on renal dialysis, cognitive communication deficit, unspecified dementia without behavioral disturbance, and a BIMS score of 7, the record review showed no documentation in the care plan addressing oxygen concentrator filter maintenance. During observation, the resident’s oxygen concentrator air filter was noted to be dirty and covered with dust and lint. CNA A, RN F, the ADON, the DON, and the Administrator all acknowledged that the filter was dirty. The ADON stated the facility did not have a specific policy for cleaning or maintaining oxygen concentrator filters, staff were told to follow manufacturer recommendations, and there was no documentation showing when filters were cleaned or who cleaned them. The DON stated that central supply was responsible for cleaning filters and nursing staff were responsible for cleaning the concentrators, and that the facility had not provided in-service education regarding oxygen concentrator filter maintenance.
Food Storage and Labeling Deficiencies in Kitchen Areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen and food storage areas. During observation with the Dietary Supervisor, four bowls of cereal on a meal tray in the dry storage room were wrapped in plastic wrap but not dated, and a large uncovered plastic container labeled Yellow Corn Meal contained a large plastic bag of yellow corn meal that was not sealed, with residual corn meal around the sides of the container. In the food preparation area and refrigerator, two opened plastic bags of corn tortillas that had been removed from their original packages were stored without being sealed or dated, and a sealed plastic container of pink dessert topping was not labeled or dated. Also observed were 21 spice bottles on a rack directly above the food preparation sink with grease build-up and residue around the tops and sides, along with a glass spice bottle containing a white powdered substance that was not labeled. In the freezer, an opened box containing pasta with cheese was stored in a plastic bag that was not sealed, and the bottom shelf had food particles.
Call Lights Not Kept Within Reach for Two Residents
Penalty
Summary
The facility failed to ensure call lights were within reach for 2 residents who were reviewed for call light placement. Resident #22 had diagnoses including generalized muscle weakness, gait and mobility abnormalities, lack of coordination, unspecified dementia, and cognitive communication deficit. Her quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment, and documented that she required assistance with multiple mobility-related tasks. Her care plan directed staff to keep the call light within reach and to encourage her to use it to call for assistance. During observation, Resident #22’s call light was found underneath her bed and not within reach. CNA A stated the resident frequently repositioned herself in bed and the call light could fall to the floor, but it was expected to remain within reach. CNA B later observed the call light underneath the bed as well and stated staff were responsible for checking that call lights were placed within residents’ reach. The resident was also observed in bed with the call light on the floor, and she was confused and unable to answer questions about it. Resident #89 had a history of a ground-level fall with multiple fractures, including pelvic fractures and an L2 burst/compression fracture. Her quarterly MDS showed a BIMS score of 3, indicating severe cognitive impairment, and her care plan identified fall risk related to confusion, gait and balance problems, incontinence, and noncompliance with walker use. Her care plan also directed staff to ensure her call light was within reach. During observation, her call light was found on the floor underneath her bed, and she stated she could not locate it and would not be able to reach it if she needed help. The DON and Administrator stated that staff were responsible for ensuring call lights remained within residents’ reach.
Failure to Provide Nail Care and Grooming
Penalty
Summary
The facility failed to ensure Resident #92, a male with a history of diabetes mellitus type 2, cerebral infarction, hemiplegia, and moderate cognitive impairment, received needed assistance with nail care as part of ADL support. His care plan identified an ADL self-care performance deficit related to cerebral infarction with left-sided hemiplegia and directed staff to provide one-person assistance with personal hygiene. During observation on 06/23/26, his right-hand fingernails were jagged with black debris underneath, and he stated he had his fingernails cleaned the prior week and wanted them cleaned and trimmed. On 06/24/26, his right-hand fingernails were still jagged with black debris underneath. During interview, the resident stated staff had not offered nail care since the prior week. CNA J and LVN I stated CNAs were responsible for nail care and grooming, typically every Sunday, and that nursing staff were responsible for monitoring residents’ nails. The DON stated CNAs provided nail grooming every Sunday or as needed if nails were long or dirty, and the Administrator stated nursing staff were responsible for nail care and that daily Champion rounds included checking residents’ appearance and fingernails. The facility’s Nail Care policy stated nail management includes cleansing, trimming, smoothing, and cuticle care and is usually done during the bath to promote cleanliness and prevent infection and injury.
Unlabeled Medication Bottle Found in Resident Room
Penalty
Summary
The facility failed to ensure Resident #12’s room was free from accident hazards when an unlabeled white medication bottle was observed in the resident’s room on the top of a drawer. Resident #12 was a [AGE]-year-old female admitted to the facility with diagnoses including cognitive communication deficit, dysphasia, and unspecified dementia. Her quarterly MDS reflected a BIMS score of 07, indicating moderate cognitive impairment. The care plan did not indicate that she had been assessed as capable of self-administering ointment independently. During the observation, Resident #12 was sitting and eating breakfast when the unlabeled medication bottle was seen in her room. Resident #12 stated that it was an ointment for pain that she used sometimes. Staff interviews confirmed that unlabeled medications were considered unsafe because the contents could not be verified. CNA A stated that staff were expected to report unlabeled medications to nursing staff, and Medication Aide, RN F, ADON, DON, and the Administrator all stated that unlabeled medications in resident rooms were not acceptable because the contents could not be identified. The ADON stated that medications are not permitted to be kept at the resident’s bedside and that if an unlabeled medication was discovered, the physician and supervisor should be notified and an incident report completed. The DON and Administrator stated they could not identify the contents of the bottle because it had no label, and the DON stated the bottle appeared empty and unlabeled. The Administrator stated that all medication containers should be properly labeled regardless of their contents and that residents should not have unlabeled medications at their bedside.
Improper Storage of Eye Drop Bottles in Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with professional standards for one medication cart, the South Low Side Medication Cart. During observation, multiple eye drop bottles that had been removed from the manufacturer’s containers and labeled with multiple residents’ names were stored together in one plastic bin in a drawer of the cart. The LVN stated she was not aware that eye drop bottles removed from the original containers needed to be stored in a container with dividers to prevent cross contamination. In an interview, the Regional Compliance Nurse stated that nurses had been trained to store eye drop bottles in plastic bins with dividers when the bottles had been removed from the original boxes to prevent cross contamination. The state surveyor requested the facility’s Medication Storage policy, but it was not provided prior to exit.
Infection Control Lapses With Open Gauze Storage
Penalty
Summary
The facility failed to establish and 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. During observation and interview on 06/24/26 at 10:00 a.m. on the South Side, the DON observed an open paper package of 4 x 4 gauze pads in the crash cart that was not stored in a sealed container. The DON stated that opened packages of 4 x 4 gauze pads needed to be stored in sealed containers to prevent cross contamination. During a separate observation and interview on 06/24/26 at 10:37 a.m., LVN G, the Wound Care Nurse, was observed with an opened bag of 4 x 4 gauze pads in the treatment cart that was opened and stored in a plastic bag that was not sealed. The Wound Care Nurse stated they had been trained to store opened bags of 4 x 4 gauze pads in sealed containers to prevent cross contamination. Review of the facility's undated policy and procedures on Fundamentals of Infection Control Precautions stated that infection control measures include hand hygiene, gloving, and resident care equipment and articles, and that practices should reflect the most current CDC guidelines.
Failure to Ensure Call Lights Within Reach for Dependent Residents
Penalty
Summary
The facility failed to ensure that call lights were within reach for two residents who required substantial to maximal assistance with activities of daily living and had moderate cognitive impairment. Both residents had significant physical limitations, including muscle weakness, limited range of motion, and a history of falls, which increased their dependence on staff for assistance. Despite care plans specifying that call lights should be within reach to allow residents to request help, observations revealed that the call lights for both residents were clipped to bed sheets and positioned between the mattress and headboard or bed rail, making them inaccessible to the residents. During interviews, both residents confirmed they could not reach their call lights and were unsure how to summon help when needed. One resident reported being in pain and needing assistance with a bowel movement but was unable to call for help due to the call light's placement. Staff interviews corroborated that call lights were not within reach for these residents at the time of observation, and staff acknowledged the importance of call light accessibility for timely assistance. Further interviews with facility staff, including a CNA, LVN, Social Worker, Corporate Nurse, and DON, confirmed that call lights should always be within reach of residents unless otherwise care-planned for resident preference. The DON also noted that the facility did not have a specific policy addressing call light placement. The deficiency was identified through direct observation, resident and staff interviews, and review of care plans and assessments.
Failure to Serve Hot Food at Required Temperature
Penalty
Summary
The facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for one test tray reviewed during a lunch service. Observation of a test tray revealed that the lunch entrée alternative, ribs, was served at 120°F, which is below the facility's required serving temperature of 140°F as stated in their policy. Multiple staff interviews confirmed that hot foods are expected to be served at or above 140°F to ensure satisfaction and safety for residents. Staff members, including dietary personnel, CNAs, and the DON, acknowledged their roles in ensuring food is served at the correct temperature and recognized that food below the required temperature could result in residents not eating their meals or potential illness. Record review of the facility's Dietary Services Policy and Procedure Manual confirmed the requirement for all hot foods to be cooked and held for service at temperatures of 140°F or above. The deficiency was identified through direct observation, temperature measurement, and staff interviews, which collectively demonstrated a failure to adhere to the established policy for serving hot food at the appropriate temperature.
Multiple Food Service Sanitation Failures Identified
Penalty
Summary
Surveyors observed multiple failures in the facility's kitchen regarding the storage, preparation, distribution, and serving of food under sanitary conditions. Disposable plastic cups containing syrup in the main kitchen fridge were not dated or labeled with their contents. Additionally, corn dogs and red onions stored in the freezer were found with visible freezer burn, and the red onions were not properly sealed. Staff interviews confirmed that food items should be dated, labeled, and properly sealed to prevent contamination, and that items with freezer burn should be disposed of. During meal delivery, a CNA was seen transporting a meal cart with uncovered trays through a hallway, and soiled trays with leftover food were placed in close proximity to undelivered trays. The meal cart was left uncovered for extended periods, and some plates were not properly covered with heat-retaining lids. Staff interviews acknowledged that these practices were incorrect and could result in cross-contamination and cold food being served to residents. The facility's policies require all trays to be covered during distribution and prohibit soiled trays from being placed with undelivered trays. Additional deficiencies included improper water temperatures in the three-compartment sink used for washing kitchen utensils, with the rinse and wash compartments not meeting the facility's policy requirements. Staff personal belongings, such as water bottles and chocolate, were found in the kitchen area, which is against facility policy. Staff interviews confirmed that personal belongings should not be in the kitchen due to the risk of cross-contamination. Facility policies reviewed by surveyors supported the need for proper food storage, labeling, temperature control, and the exclusion of personal items from food preparation areas.
Illegible Insulin Pen Labeling Found on Medication Cart
Penalty
Summary
Surveyors found that the facility failed to ensure drugs and biologicals were labeled in accordance with professional standards, specifically regarding the labeling of insulin pens. During an observation of a medication cart, a smeared and illegible date was found on an insulin pen assigned to a male resident with Type 2 diabetes mellitus and severe cognitive impairment. The resident's care plan indicated a risk for hyper/hypoglycemia, and physician orders required the use of NovoLOG insulin three times daily. Interviews with multiple LVNs and the DON confirmed that insulin pens are to be dated upon opening, with the date placed in a manner to prevent smearing, preferably on the paper label. However, the observed pen's date was not legible, and staff acknowledged that this could result from improper placement or smudging of the date. Review of the facility's medication storage policy confirmed that medications requiring an open date should be clearly dated when opened. Despite this policy, the insulin pen in question did not have a legible open date, and staff interviews revealed inconsistent practices regarding where and how the date was applied. The deficiency was identified through direct observation, record review, and staff interviews, all of which indicated a failure to maintain clear and legible labeling of insulin pens as required.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain complete and accurately documented medical records for five residents. Specifically, the facility did not ensure that the Initial Skin Assessment for one resident was signed by the LVN ADON, and the Care Plan Conference Forms for four other residents were not signed and dated by the Social Worker at the time of completion. This lack of proper documentation was confirmed through interviews and record reviews with the staff involved, who admitted to not signing the forms on the date they were completed. For Resident #1, the Initial Skin Assessment was completed but not signed or dated by the LVN ADON. The LVN ADON acknowledged that she had completed the assessment but could not recall why she had not signed it. The DON and ADON were responsible for ensuring that assessment forms were signed and dated by licensed staff when completed, but this was not done in this case. The resident had a complex medical history, including conditions such as hypertension, diabetes, and dementia, and had expired at the facility. For Residents #2, #3, #4, and #5, the Care Plan Conference Forms were completed but not signed and dated by the Social Worker at the time of completion. The Social Worker admitted to sometimes signing the forms later and was unaware of any facility policy requiring forms to be signed on the date of completion. The DON confirmed that the forms should be signed on the date they are completed to ensure accuracy and completeness. Each resident had various medical conditions, including chronic kidney disease, diabetes, dementia, and pressure ulcers, which required accurate and timely documentation for proper care management.
Failure to Provide Appropriate Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure that Resident #5 received appropriate pressure ulcer care as ordered by the wound care physician. On 03/29/2024, it was observed that Resident #5, who has a stage IV pressure ulcer on the right lateral foot, did not have the required wound dressing in place. The wound care nurse and LVN ADON confirmed that the dressing was missing and that the weekend wound care nurse, who was still in training, had not yet performed the treatment for the day. The CNAs had been trained to report missing dressings immediately to the charge nurses, but this protocol was not followed in this instance. Resident #5 has a complex medical history, including respiratory failure, vitamin D deficiency, hypertension, neuromuscular dysfunction, benign prostatic hyperplasia, urinary retention, paraplegia, amputation of the left leg above the knee, and GERD. The resident is also oxygen-dependent and has a suprapubic catheter. The care plan for Resident #5 included turning every two hours while in bed and specific wound care instructions, which were not adhered to on the day of the observation. Interviews with various staff members, including the DON, LVN Charge Nurse, and CNAs, revealed that while they had been trained to report missing wound dressings, the protocol was not followed. CNA E admitted to noticing the missing dressing but failed to report it due to being busy with other residents. The weekend wound care nurse also confirmed that she had not yet completed the treatment for Resident #5. This lapse in care could potentially lead to increased pain, infection, and further complications for the resident.
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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 El Paso
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Giles Nursing And Rehabilitation Center | 2.1 mi | ★★★★★ | 22 | 0 |
| Pebble Creek Nursing Center | 3.1 mi | ★★★★★ | 8 | 0 |
| Las Ventanas De Socorro | 3.2 mi | ★★★★★ | 24 | 0 |
| El Paso Health & Rehabilitation Center | 3.5 mi | ★★★★★ | 0 | 0 |
| Vista Hills Health Care Center | 3.7 mi | ★★★★★ | 17 | 1 |
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