Oasis Nursing & Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 2 (Resident #32 and Resident #12) of 11 residents observed for oxygen management. The facility failed to maintain the oxygen concentrator filter for Resident #12. The facility failed on 06/23/2026 to ensure an oxygen warning sign was posted outside the room of Resident #32 while the resident was receiving oxygen therapy. These failures had the potential to expose residents receiving oxygen therapy delayed identification of oxygen-related needs, increase the risk of fire hazards associated with oxygen use, reduce airflow, decrease equipment efficiency, and potentially affect oxygen delivery to the resident.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage.1. - The facility failed to store food in the dry storage room in sealed containers. 2. - The facility failed to label and date food containers stored in the refrigerator.3. - The facility failed to keep 21 spice bottles stored on a rack directly above food preparation sink free of grease build-up and residual around the tops and sides of the bottles; failed to label a spice bottle that contained white powder.4. - The facility failed to keep the bottom shelf in the freezer free of food particles.5. - The facility failed to store food in the freezer in sealed containers. These failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #22 and Resident #89) of 9 residents reviewed for call light placement. The facility failed to ensure call lights were within reach for Residents #22 and #89. This failure could affect residents by not having access to call for assistance resulting in needs not being met.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene, for 1 of 19 residents ( Resident #92) reviewed for ADL care. The facility failed to ensure Resident #92 had trimmed and clean nails on 06/23/2026 and 06/24/2026. This failure could place residents who required assistance with ADL's at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's environment was as free from accident hazards as possible for 1 of 15 rooms (room # 7) reviewed for accidents. The facility failed to ensure Resident #12 did not have a white unlabeled medication bottle in room on 06/23/26. This deficient practice could place residents at risk of harm or injury and contribute to avoidable accidents.

Inspectors wroteBased on observations, and interviews, the facility failed ensure that all drugs and biologicals used in the facility were stored in accordance with professional standards for one (South Low Side Medication Cart) of five medication carts viewed for medication storage. -The facility failed to store eye drop bottles separately for multiple residents when eye drops bottles were removed from the manufacture's containers and were stored together in one plastic bin in the medication cart. This failure could affect residents that received medications from the facility by placing them at risk of cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, 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 for one of one treatment cart checked for cross contamination, and for one (South Side) of two Crash Carts reviewed for infection control. -The facility failed to ensure an opened package of 4 x 4 gauze pads was stored in a sealed container in the crash cart on the South Side of the facility. -The facility failed to ensure an opened package of 4 x 4 gauze pads was stored in a sealed container in the treatment cart. These failures could result in increased risk of infection to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Resident #52 and Resident #88) of 9 residents reviewed for call light placement. The facility failed to ensure call lights were at reach for Residents #52 and #88. This failure could affect residents by not having access to call for assistance resulting in needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature, for one test tray reviewed. A test tray of the food served at lunch on 04/16/25 on hall revealed the ribs were not hot and at an appetizing temperature. This failure could place residents who ate in their rooms at-risk of poor intake and/or foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. The facility failed to date 04/15/25 and label the contents of the disposable plastic cups that contained syrup located in the fridge in the facility's main kitchen. The facility failed to maintain corn dogs and red onions free from visible freezer burn. The facility failed to maintain the water temperature for 2 of 3 compartment sink per their policy. The facility failed to maintain the kitchen area free from staff personal belongings. The facility failed to cover and seal a meal cart containing the residents' meal trays while transporting them through zone/hallway # 6. These failures could place all residents who received meals from the main kitchen and place them at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals were labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date for one of three medications carts reviewed. - The high north hall nurse's cart had a smeared (illegible) dated insulin pen for Resident # 58 This failure could place residents at risk for harm by receiving ineffective insulin therapy.

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records that were complete and accurately documented for 5 (Resident #1, #2, #3, #4, and #5) of 5 residents reviewed for accurate medical records. 1. The facility failed to ensure LVN ADON C signed the Initial Skin Assessment when completed for Resident #1 on [DATE]. 2. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #2 on [DATE]. 3. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #3 on [DATE]. 4. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #4 on [DATE]. 5. The facility failed to ensure Social Worker signed and dated Care Plan Conference Form when completed for Resident #5 on [DATE]. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that residents receive care, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (Resident #5) of 5 residents reviewed for quality of care. The facility failed on 03/29/2024 to ensure the pressure ulcer on Resident #5's right lateral foot was covered with a dressing as ordered. This failure could result in increased pain, infections, development of new pressure ulcers, and decline in quality of life for residents.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care and the facility failed to ensure the baseline care plan was developed within 48 hours of a resident's admission for 2 of 8 residents (Resident #294 and Resident # 241) reviewed for baseline care plans. The facility failed to ensure Resident #294 had a baseline care plan that addressed her fracture of left femur (longest, strongest, thigh bone), pain management, wound care for surgical wound, Type 2 Diabetes Mellitus, Hypertension (high blood pressure), and Malignant neoplasm of lung (lung cancer). The facility failed to ensure Resident #241 had a baseline care plan that addressed his use of a feeding tube. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who receive enteral nutrition received treatment to prevent complications of enteral feeding for one (Resident #241) of six residents reviewed for tube feeding. Resident #241 was receiving hydration through a g-tube (a tube into the stomach for nutrition and liquids) from a plastic bag which had been labeled using a marking pen. This failure could place residents who receive liquids through a g-tube at increased risk of having marking pen chemicals in the liquid.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 2 residents (Residents #27) by 1 of 3 certified staff (CNA A) reviewed for competent staff, in that: CNA A failed to change his gloves once they became contaminated during incontinent care for Resident #27. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to 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 for 1 of 2 residents (Resident #27) reviewed for infection control. CNA A failed to change his gloves after they became contaminated during incontinent care while assisting Resident #27. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to fulfill automated data processing requirements that within 14 days after a facility completes a resident's assessment, a facility must electronically transmit MDS data to the CMS System, including the subset of items upon a resident's discharge for 1 (Resident #83) of 24 residents reviewed for MDS completion. Resident #83's Discharge MDS dated [DATE] was not transmitted to CMS within the 14-day date processing requirement. This failure could place residents at risk of the CMS not being aware of their condition for payment and quality of measure purposes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 (Resident #7, Resident #8, and Resident #9) of 5 residents reviewed for quality of care. 1. The facility failed to ensure Residents #7's and #9's catheter leg strap was in place to secure the catheter. 2. The facility failed to ensure Resident #8's and Resident #9's'catheter tubing and drainage bags were off the floor. This failure could place residents with foley catheters at risk of catheter pulling causing pain and/or infection and risk for infection due to improper care practices and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #7) of 6 residents reviewed for resident rights, in that: The facility failed to ensure Resident #7's bedroom horizontal venetian blinds did not have several broken slats with jagged edges within reach of the resident. This failure could place the resident at risk of injury when manipulating the window blinds.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident medical and nursing needs and described the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #7) of 6 residents reviewed for care plans in that: -The facility failed to follow the comprehensive person-centered care plan for risk of falling by applying a mat to bedside every shift for Resident #7. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs.