Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Oasis Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
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.
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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Illustrative
What surveyors actually found near you
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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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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 20 | 0 |
| Pebble Creek Nursing Center | 3.1 mi | ★★★★★ | 10 | 0 |
| Las Ventanas De Socorro | 3.2 mi | ★★★★★ | 24 | 0 |
| El Paso Health & Rehabilitation Center | 3.5 mi | ★★★★★ | 11 | 0 |
| Vista Hills Health Care Center | 3.7 mi | ★★★★★ | 16 | 1 |
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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.