Health inspection·February 8, 2024

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. This failure could place residents at risk of not receiving needed care and services or continuity of care. Findings include: Record review of Resident #294's face sheet, dated 02/08/24, revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses which included fracture of left femur, Type 2 Diabetes Mellitus, Hypertension, and Malignant neoplasm of lung. Review of Resident #294's MDS section dated 02/05/24 showed her admission MDS was not completed yet. Review of Resident #294's Order Summary Report, dated 02/02/24, revealed orders: Fracture left femur with routine healing; Physical Therapy /Occupational Therapy /Speech Therapy and wound care to evaluate and treat as warranted. Baclofen Oral Tablet, give 10 mg by mouth three times a day for Pain. Acetaminophen Tablet, give 650 mg by mouth every 6 hours for Pain. Lantus SoloStar Subcutaneous Solution Pen-injector, Inject 20 unit subcutaneously one time a day for Diabetes Mellitus. Metformin Oral Tablet 850 MG, Give 1 tablet by mouth two times a day for Diabetes Mellitus. Review of Resident #294's care plan dated 02/06/24 showed no care plan for fracture of left femur, pain management, wound care for surgical wound or Type 2 Diabetes Mellitus. Record review of Resident #241's face sheet, dated 2/8/2024 revealed he was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675568 If continuation sheet Page 2 of 11 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 675568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Nursing & Rehabilitation Center 9001 N Loop El Paso, TX 79907 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)

F 0655 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #241's electronic census listing revealed he was discharged on 01/22/2024 and readmitted on [DATE]. Review of Resident #241's electronic diagnosis listing accessed 02/08/2024 revealed he had diagnoses including dysphagia (problems with swallowing). Residents Affected - Few Review of Resident #241's MDS assessment (discharge - return anticipated) dated 01/22/2024 revealed he was unable to participate in an interview to determine his cognitive status. Staff assessed him as having problems with short-term memory and severely impaired cognitive skills for daily decision making. He required assistance with setup for eating, and moderate assistance with oral hygiene, toileting, upper body dressing and personal hygiene. He required maximal assistance with showering, lower body dressing and putting on/taking off footwear. He had not had a significant weight loss over the past month. He was receiving a mechanically altered therapeutic diet. Review of Resident #241's order dated 02/01/2024 revealed he was to receive 60 ml of FiberSource HN (tube feeding formula) per hour with 250 ml of water every shift. His order dated 02/01/2024 revealed his g-tube site (where the feeding tube enters the body) was to be cleaned every shift. Record review of Resident #241's History and Physical dated 02/06/2024 for admission [DATE] revealed that during his admission to a local hospital beginning on 01/22/2024 he underwent a PEG tube (a feeding tube into the stomach to deliver nutritional liquid) placement. Review of Resident #241's entire care plan with a last review date of 01/19/2024 revealed no active care plan addressing the care of his feeding tube or care related to him receiving his nutrition and hydration though a feeding tube. In an interview on 02/08/24 at 10:38 AM the MDS LVN revealed that when a resident was discharged to the hospital and returned, the old care plan should be locked, and a new care plan started. She said that Resident #241's care plan should have been locked and restarted to include his use of a feeding tube for nutrition. Interview on 02/08/24 at 10:55 AM DON stated that the admitting nurse should add baseline care plan based on the resident's diagnosis at the time of admission for all newly admitted residents. The residents record shows that the baseline care plan only includes resident wishes to be discharged to her home, resident needs in room socialization and sensory stimulation, and has an order for do not resuscitate. DON stated that when the facility admits a new resident, the admitting nurse is responsible for creating the baseline care plan. Unfortunately, the admitting nurse had several admissions that day and it was overlooked. The ADON is responsible for auditing all new admissions and she probably missed it as well. Interview on 02/08/24 at 09:26 AM with MDS nurse stated that nursing department is responsible for the baseline care plan. MDS nurse stated that the admitting nurse should initiate the baseline care plan within 48 hours and it should include diagnosis, medications, and referrals. Record review of the facility's Baseline Care Plans policy, undated, revealed: Completion and implementation of the baseline care plan within 48 hours of a resident's admission is intended to promote continuity of care and communication among nursing home staff, increase resident safety, and safeguard against adverse events that are most likely to occur right after (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675568 If continuation sheet Page 3 of 11 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 675568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Nursing & Rehabilitation Center 9001 N Loop El Paso, TX 79907 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)

F 0655 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few admission, and to ensure resident is informed of the initial plan for delivery of care and services by receiving a written summary of the baseline care plan. The facility will develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan will: - be developed within 48 hours of a resident admission. - include the minimum healthcare information necessary to properly care for a resident, including but not limited to: *Initial goals based on admission orders. *Physician orders. *Dietary orders. *Therapy services. *Social services. *PASARR recommendations. The baseline care plan will reflect the resident's stated goals and objectives and include interventions that address his or her current needs. It will be based on the admission orders, information about the resident available from the transferring provider, and discussion with the resident. Facility staff will implement the interventions to assist the resident to achieve care plan goals and objectives. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675568 If continuation sheet Page 4 of 11 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 675568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Nursing & Rehabilitation Center 9001 N Loop El Paso, TX 79907 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: Record review of Resident #241's face sheet, dated 2/8/2024 revealed he was [AGE] years old, was initially admitted to the facility on [DATE], and readmitted on [DATE]. Record review of Resident #241 ' s electronic census listing revealed he was discharged on 01/22/2024 and readmitted on [DATE]. Review of Resident #241 ' s electronic diagnoses listing accessed 02/08/2024 revealed he had diagnoses including dysphagia (problems with swallowing). Review of Resident #241's MDS assessment (discharge – return anticipated) dated 01/22/2024 revealed he was unable to participate in an interview to determine his cognitive status. Staff assessed him as having problems with short-term memory and severely impaired cognitive skills for daily decision making. He required assistance with setup for eating, and moderate assistance with oral hygiene, toileting, upper body dressing and personal hygiene. He required maximal assistance with showering, lower body dressing and putting on/taking off footwear. He had not had a significant weight loss over the past month. He was receiving a mechanically altered therapeutic diet. Review of Resident #241's order dated 02/01/2024 revealed he was to receive 60 ml of FiberSource HN (tube feeding formula) per hour with 250 ml of water every shift. His order dated 02/01/2024 revealed his g-tube site (where the feeding tube enters the body) was to be cleaned every shift. Record review of Resident #241 ' s History and Physical dated 02/06/2024 for admission [DATE] revealed that during his admission to a local hospital beginning on 01/22/2024 he underwent a PEG tube (a feeding tube into the stomach to deliver nutritional liquid) placement. Observation on 02/06/2023 at 3:37 PM of the water bag attached to Resident #241 ' s feeding pump had been written on with a marking pen. In an interview on 02/06/2024 at 03:44 PM LVN D revealed that the rate of flow for the water for Resident #241 ' s tube feedings had been written on the water bag with a marking pen. She said a marking pen should not be used to write directly on the water bag because the ink could leach through into the water. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675568 If continuation sheet Page 5 of 11 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 675568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Nursing & Rehabilitation Center 9001 N Loop El Paso, TX 79907 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)

F 0693 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few In an interview on 02/08/24 at 7:41 AM the DON revealed some tube feeding water bags should not be written on with a marker because it could go through the plastic into the water. The DON stated she was not sure which bags this would apply to and would need to check on it. The DON did not provide any additional information regarding Resident #241 ' s water bag prior to exit. Record review of the facility policy Gastrostomy Tube Care dated 02/13/2007 revealed that the formula and/or feedings should be labeled but did not outline what types of labels were to be used. Record review of the facility policy Hydration dated 10/05/2016 revealed that the facility was to provide each resident with sufficient fluid intake but did not address hydration for residents receiving tube feeding. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675568 If continuation sheet Page 6 of 11 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 675568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Nursing & Rehabilitation Center 9001 N Loop El Paso, TX 79907 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings were: Record review of Resident #27s admission record dated 02/06/2024 indicated she was admitted to the facility on [DATE] with diagnoses of dementia, muscle wasting and atrophy (waste away). She was [AGE] years of age. Record review of Resident #27's care plan revised date 10/19/21 indicated in part: Focus: The resident has bladder incontinence r/t related to) Alzheimer's Disease and Dementia. The resident has bowel incontinence r/t Alzheimer's Disease and Dementia. Goals: The resident will not have any complications r/t incontinence. Interventions: Provide pericare after each incontinent episode. Record review of Resident #27's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. Urinary and Bowel continence = Always incontinent. During an observation on 02/06/24 at 09:34 AM CNA A performed incontinent care for Resident #27. CNA A sanitized his hands and then put some gloves on. CNA A then undid the resident's brief and it was noted to be wet with urine. The CNA wiped the resident's vaginal and rectal area with some wet wipes. Resident #27 had urinated and had a bowel movement. After the CNA finished wiping the resident's urine and bowel movement, he removed the soiled brief. While still wearing the same gloves, CNA A then applied the clean brief on the resident and dressed the resident. Lastly CNA A placed a mechanical lift sling under the resident then pulled the privacy curtain out of the way while still wearing the same gloves then after that he removed his gloves. During an interview on 02/08/24 at 10:40 AM ADON C said there were no designated trainers for CNAs when hired on or afterwards. The ADON said the new CNAs were placed with other CNAs at first during their orientation to get trained by the CNAs that were already working there. During a telephone interview on 02/08/24 at 02:24 PM CNA A said he usually changed his gloves once they became contaminated. The CNA said he had gotten nervous and had not changed his gloves after they became contaminated when he had performed incontinent care for Resident #27. CNA A said if he did not change his gloves that could lead to cross contamination and the spread of germs. CNA A said he had received training on infection control and glove use but that he had just gotten nervous and had not done the steps correctly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675568 If continuation sheet Page 7 of 11 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 675568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Nursing & Rehabilitation Center 9001 N Loop El Paso, TX 79907 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)

F 0726 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/08/24 at 02:40 PM the DON said the expectation was for CNAs to change their gloves if they became contaminated during personal care. The DON said the staff were supposed to change their gloves to prevent the spread of infections. The DON was made aware of the incontinent care performed by CNA A. The DON said the CNA should have changed his gloves prior to placing the new brief and doing the other things while still wearing the same gloves. The DON said the CNA was supposed to change his gloves to prevent cross contamination. The DON said they did on-going training with staff and did CNA proficiencies upon hire and yearly. During an interview on 02/08/24 at 02:52 PM the Administrator was made aware of the incontinent care performed by CNA A. The Administrator said the staff were expected to change their gloves when contaminated and that they did training and training over and over about glove changes at proper times. The Administrator acknowledged the issue and would continue with staff training. The Administrator agreed that staff would get nervous and forget the steps. Record review of the facility's document titled CNA proficiency audit dated 01/16/2024 and signed by CNA A indicated in part: Skills checked on were hand washing, perineal care female and infection control awareness. Record review of the facility's document titled Job description certified nursing assistant dated 2014 indicated in part: The following is a non-exhaustive criteria that relates to the job of a certified nursing assistant and it is consistent with the business needs of the facility. These are legitimate measure of the qualifications for a certified nursing assistant and are related to the functions that are essential to the job of a certified nursing assistant. Accountable for personal care (i.e., grooming, bathing, catheter care, pericare and dressing) and observation of residents within patient care policy guidelines Identify and report any condition requiring management attention. Record review of the facility's document titled Nursing personal care- perineal care dated 05/11/2022 indicated in part: It is essential that residents using various devices, absorbent products, external collection devices etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice and the manufacturer's recommendations. Purpose- this procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation and observing the resident's skin condition. Start: Perform hand hygiene- Put on gloves and all other PPE per standard precautions, chose your PPE (Personal Protective Equipment) by considering the type of exposure, the durability and appropriateness for the task. Limit resident exposure to the perineal care-provide privacy at all times. Back: Reposition the resident to their side, gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area, remove gloves and PPE, perform hand hygiene. Important points: Do not wipe more than once with the same surface, removing and discarding of gloves are required if visibly soiled, always perform hand hygiene before and after gloves use. Record review of the facility's document titled Infection control policy and procedure manual 2019 updated 3/2022 indicated in part: Gloving- gloves are worn for three important reasons - To the likelihood that hands of personnel contaminated microorganisms from a resident or a fomite (materials which are likely to carry infection, such as clothes, utensils, and furniture) can transmit these microorganisms to another resident in this situation gloves must be changed between resident contacts and hands washed after gloves are removed. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between resident contact is an infection (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675568 If continuation sheet Page 8 of 11 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 675568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Nursing & Rehabilitation Center 9001 N Loop El Paso, TX 79907 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)

F 0726 control hazard. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675568 If continuation sheet Page 9 of 11 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 675568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Nursing & Rehabilitation Center 9001 N Loop El Paso, TX 79907 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)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Few 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. Finding include: Record review of Resident #27s admission record dated 02/06/2024 indicated she was admitted to the facility on [DATE] with diagnoses of dementia, muscle wasting and atrophy (waste away). She was [AGE] years of age. Record review of Resident #27's care plan revised date 10/19/21 indicated in part: Focus: The resident has bladder incontinence r/t Alzheimer's Disease and Dementia. The resident has bowel incontinence r/t Alzheimer's Disease and Dementia. Goals: The resident will not have any complications r/t (related to)incontinence. Interventions: Provide pericare after each incontinent episode. Record review of Resident #27's MDS dated [DATE] indicated in part: Cognitive Skills for Daily Decision Making = Severely impaired - never/rarely made decisions. Urinary and Bowel continence = Always incontinent. During an observation on 02/06/24 at 09:34 AM CNA A performed incontinent care for Resident #27. CNA A sanitized his hands and then put some gloves on. CNA A then undid the resident's brief and it was noted to be wet with urine. The CNA wiped the resident's vaginal and rectal area with some wet wipes. Resident #27 had urinated and had a bowel movement. After the CNA finished wiping the resident's urine and bowel movement, he removed the soil brief. While still wearing the same gloves, CNA A then applied the clean brief on the resident and dressed the resident. Lastly CNA A placed a mechanical lift sling under the resident then pulled the privacy curtain out of the way while still wearing the same gloves then after that he removed his gloves. During an interview on 02/08/24 at 10:40 AM ADON C said there were no designated trainers for CNAs when hired on or afterwards. The ADON said the new CNAs were placed with other CNAs at first during their orientation to get trained by the CNAs that were already working here. During a telephone interview on 02/08/24 at 02:24 PM CNA A said he usually changed his gloves once they became contaminated. The CNA said he had gotten nervous and had not changed his gloves after they became contaminated when he had performed incontinent care for Resident #27. CNA A said if he did not change his gloves that could lead to cross contamination and the spread of germs. CNA A said he had received training on infection control and glove use but that he had just gotten nervous and had not done the steps correctly. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675568 If continuation sheet Page 10 of 11 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 675568 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/08/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Oasis Nursing & Rehabilitation Center 9001 N Loop El Paso, TX 79907 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)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 02/08/24 at 02:40 PM the DON said the expectation was for CNAs to change their gloves if they became contaminated during personal care. The DON said the staff were supposed to change their gloves to prevent the spread of infections. The DON was made aware of the incontinent care performed by CNA A. The DON said the CNA should have changed his gloves prior to placing the new brief and doing the other things while still wearing the same gloves. The DON said the CNA was supposed to change his gloves to prevent cross contamination. The DON said they did on-going training with staff and did CNA proficiencies upon hire and yearly. During an interview on 02/08/24 at 02:52 PM the Administrator was made aware of the incontinent care performed by CNA A. The Administrator said the staff were expected to change their gloves when contaminated and that they did training and training over and over about glove changes at proper times. The Administrator acknowledged the issue and would continue with staff training. The Administrator agreed that staff would get nervous and forget the steps. Record review of the facility's document titled Nursing personal care- perineal care dated 05/11/2022 indicated in part: It is essential that residents using various devices, absorbent products, external collection devices etc., be checked (and changed as needed) on a schedule based upon the resident's voiding pattern, professional standards of practice and the manufacturer's recommendations. Purpose- this procedure aims to maintain the resident dignity and self-worth and reduce embarrassment by providing cleanliness and comfort to the resident, preventing infections and skin irritation and observing the resident's skin condition. Start: Perform hand hygiene- Put on gloves and all other PPE per standard precautions, chose your PPE by considering the type of exposure, the durability and appropriateness for the task. Limit resident exposure to the perineal care-provide privacy at all times. Back: Reposition the resident to their side, gently perform care to the buttocks and anal area, working from front to back without contaminating the perineal area, remove gloves and PPE (Personal Protective equipment), perform hand hygiene. Important points: Do not wipe more than once with the same surface, removing and discarding of gloves are required if visibly soiled, always perform hand hygiene before and after gloves use. Record review of the facility's document titled Infection control policy and procedure manual 2019 updated 3/2022 indicated in part: Gloving- gloves are worn for three important reasons - To the likelihood that hands of personnel contaminated microorganisms from a resident or a fomite (materials which are likely to carry infection, such as clothes, utensils, and furniture) can transmit these microorganisms to another resident in this situation gloves must be changed between resident contacts and hands washed after gloves are removed. Wearing gloves does not replace the need for hand washing because gloves may have small inapparent defects or be torn during use, and hands can become contaminated during removal of gloves. Failure to change gloves between resident contact is an infection control hazard. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675568 If continuation sheet Page 11 of 11