Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
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 At Pearland during CMS and state inspections, most recent first.
During a lunch meal service, the facility did not follow the planned menu, resulting in residents receiving meals without the required fried rice or a suitable substitute, and serving green beans instead of oriental vegetables. The menu was not posted, and there was no substitution list available. The Dietary Manager and kitchen staff confirmed that rice was not available and no alternative starch was provided, contrary to facility policy.
A resident and her representative were not provided with timely access to requested medical records despite multiple written requests. The facility required completion of forms and payment before releasing records, but did not follow up with the appointed representative to resolve the matter, resulting in the records not being provided as required.
Several resident rooms experienced brown water and low water pressure following plumbing repairs, with staff and maintenance failing to promptly identify or address the issue. Observations and interviews confirmed that water quality checks were not performed after pipe work, resulting in unsanitary conditions and inadequate water supply for residents.
A resident with paraplegia and multiple medical conditions did not receive scheduled showers or adequate grooming assistance as required by their care plan. Despite being fully dependent for ADLs and having no documented refusals, the resident received infrequent bed baths and lacked grooming support, as confirmed by both the resident's statements and staff interviews. Facility staff could not provide consistent documentation of hygiene care, and the facility's policy for supporting dependent residents with ADLs was not followed.
Two residents, one with significant cognitive and physical impairments and another with dementia and wandering behaviors, were involved in an incident where one resident instructed the other to engage in inappropriate sexual contact. The event occurred despite staff training and facility policies on abuse prevention, as the resident with wandering tendencies was able to interact unsupervised with the vulnerable resident. The incident was reported by the victim and confirmed through interviews and documentation, highlighting a failure in supervision and protection.
A resident with a healing tracheostomy was admitted without physician orders for site care. Facility records, including the care plan and MAR, lacked documentation of the tracheostomy status. Staff interviews revealed that the trach site was closed upon admission, and minor drainage was not reported to the physician. The facility's policy required documentation of site care, which was not adhered to.
A facility failed to maintain a safe, clean, and homelike environment due to a linen shortage affecting six residents. Observations revealed multiple rooms without sheets and supply carts lacking linen. Staff interviews indicated persistent linen shortages, with the Administrator citing supply issues from an out-of-state vendor. The Maintenance Director suggested CNAs might be hiding or discarding linen. A resident's representative reported stained linens, and the Laundry Aide confirmed the shortage, noting continuous washing couldn't meet demand. No linen policy was provided during the survey.
A resident with multiple medical conditions, including cerebral palsy and gastrostomy, was not provided with pleasure feeding as ordered by the physician. Despite a modified barium swallow study indicating the resident could eat by mouth, observations and staff interviews revealed that the resident was consistently fed via a feeding tube without a meal tray for oral feeding. The DON admitted the order was unclear and had not been clarified with the physician, and the facility's policy did not address dietary requirements.
A facility failed to provide sufficient nursing staff to meet the needs of residents, resulting in inadequate care for three residents. Observations revealed that residents were not repositioned or changed in a timely manner, leading to soiled diapers and offensive odors. Interviews with staff highlighted the challenges of inadequate staffing, with CNAs responsible for a high number of residents and unable to complete all necessary care tasks.
The facility failed to provide palatable and safe-temperature food for residents in Dove Hall receiving room trays. Observations showed food trays in a warmer without doors, leading to cold meals. Residents reported ongoing issues with cold food, particularly those served last. A test tray evaluation confirmed food temperatures were below required levels, with the Dietary Manager acknowledging the absence of hot covers and unheated carts as contributing factors.
The facility failed to maintain food safety and sanitation standards, with unlabeled food, improper cooler temperatures, and unclean equipment observed. The dishwashing process was compromised due to malfunctioning equipment and inadequate sanitization. Staff training and hygienic practices were insufficient, with a staff member failing to change gloves or wash hands after handling trash.
The facility failed to provide adequate staffing and supplies, resulting in residents not receiving timely incontinent care and repositioning. Observations showed residents left in soiled diapers, and interviews revealed insufficient CNAs and a lack of linens and briefs. The Administrator and DON were unaware of the extent of these deficiencies, impacting resident dignity and care.
A resident with a stage 4 pressure ulcer did not receive proper wound care, as the sacral wound was found without a covering dressing, contrary to physician's orders. The Wound Care Nurse and Charge Nurse were unaware of the missing dressing, and there was no documentation of the wound's measurements since admission. The facility's policy on wound monitoring was not followed, leading to a deficiency in care.
The facility failed to provide sufficient nursing staff, resulting in missed medications and inadequate care for residents. Critical medications were not administered, and residents with incontinence were not changed or repositioned during the night shift. Staff were aware of the shortages but did not take appropriate action to address the issue.
The facility failed to provide pharmaceutical services, resulting in four residents not receiving their prescribed medications, including insulin, anticoagulants, and an IV antibiotic. Blood glucose levels were not checked, and sliding scale insulin was not administered as ordered. The DON and the physician were unaware of the missed medications until notified by the surveyor.
The facility failed to ensure that four residents were free from significant medication errors, including missed doses of Coumadin, insulin, and IV antibiotics. The deficiency was attributed to staffing issues, where two nurses did not redistribute care of the residents, resulting in incomplete medication administration. The DON and Administrator were not aware of the missed medications until informed by the surveyor.
The facility failed to conduct and document a comprehensive facility-wide assessment, missing critical components such as the resident profile and facility resources needed. This oversight was identified during a review and interview with the Corporate RN and the new Administrator, who acknowledged the mistake and began working on the assessment. The facility's policy mandates an annual assessment to ensure the capacity to meet resident needs during normal and emergency operations.
The facility failed to provide a private meeting space for the residents' monthly council meetings, which were held in the dining room. Despite attempts to ensure privacy, multiple staff members, visitors, and other residents were observed entering and exiting the dining room during the meetings. Residents expressed their desire for a private space to speak freely without fear of being overheard by staff. The Administrator suggested using the conference room adjacent to her office for future meetings.
The facility failed to ensure foods were properly stored, labeled, and dated in the kitchen, placing residents at risk of food-borne illness. Observations revealed several food items in the refrigerator and condiment refrigerator were not labeled or dated. Interviews with kitchen staff and the Administrator confirmed inconsistencies in following proper food labeling practices, especially after the departure of the kitchen supervisor and Dietary Manager.
A resident with dementia and anxiety disorder was administered Olanzapine without a signed informed consent. The facility's process for obtaining consent was not followed, and the medication was given daily over a seven-day period. Interviews with staff confirmed the oversight, and the facility's policy did not include information on informed consent for antipsychotic medications.
A resident was administered Olanzapine without an appropriate diagnosis or consent. The facility's DON and ADON confirmed the lack of a valid diagnosis and consent, and the MHNP acknowledged the medication was given for behaviors not supported by the resident's documented conditions.
A CNA failed to perform proper hand hygiene during incontinent care for a resident with dementia and mobility issues, leading to potential cross-contamination. The DON confirmed the lapse in infection control practices, despite existing facility policies.
A resident with a tracheostomy did not receive care consistent with professional standards, as a respiratory therapist failed to use a pulse oximeter, did not hyper-oxygenate the resident, and contaminated the sterile field. The therapist also used non-sterile gloves, increasing the risk of infection. The facility lacked adequate supervision and training for respiratory therapists.
Failure to Follow Menus and Provide Required Meal Components
Penalty
Summary
The facility failed to follow the posted lunch menu as required, resulting in residents receiving meals that did not match the planned menu. During observation of the lunch service, trays were found to include an egg roll, chicken nuggets, green beans, banana pudding, juice, and water, but lacked the required fried rice or any substitute starch. There was also no posted menu or substitution list available in the dining room. The Dietary Manager confirmed that the menu should have included fried rice and oriental vegetables, but these items were not served. The Dietary Manager was unaware of why the rice was not included and noted that the vegetables served were green beans instead of the specified oriental vegetables. Further investigation revealed that rice was not available in the dry storage room, and food invoices showed no documentation that rice had been ordered for several delivery dates. The staff member responsible for preparing the meal stated she did not prepare fried rice due to the lack of rice and did not use an alternative starch, as she was concerned it might be needed for another meal. She also did not contact the Dietary Manager for guidance on substitutions. The facility's policy requires menus to meet nutritional needs, be posted, and substitutions to be made with nutritionally equivalent items, but these procedures were not followed during the observed meal service.
Failure to Provide Timely Access to Resident Medical Records
Penalty
Summary
The facility failed to provide a resident and her representative with timely access to her personal and medical records upon request. The resident, who was cognitively intact and her own responsible party, had multiple diagnoses including type 2 diabetes mellitus with foot ulcer, chronic kidney failure, essential hypertension, chronic pain, muscle weakness, and urinary tract infection. Despite several written requests for her medical records sent by her representative, the facility did not provide the requested records within the required timeframe. Interviews with the facility's medical records staff revealed that the process for releasing records required completion of specific forms, notarization as applicable, and payment of any associated fees before records would be released. The staff member acknowledged receiving documentation requesting the records but stated that no payment had been received from the resident's representative. Furthermore, after being told by the representative not to call his phone number and to communicate through his appointed representative, the staff did not reach out to the appointed representative to resolve the matter. The facility's administrator was unaware of any unaddressed requests for records and indicated that all such requests were processed by the medical records staff. The facility's policy required validation of the request, notification of costs, and receipt of payment before releasing records, with a stated timeline of two days after payment. However, in this case, the resident and her representative were not provided with the requested medical records as required by regulation.
Failure to Maintain Sanitary Water Quality and Adequate Water Pressure
Penalty
Summary
The facility failed to provide adequate housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment in several resident rooms. Observations revealed that multiple rooms had brown water coming from faucets and very low water pressure, with water barely trickling out. These issues were noted in at least four rooms, with brown water observed for several minutes in some cases and low water pressure in others. Staff interviews confirmed that brown water was present in several rooms, and some staff members reported waiting for the water to run clear before using it. The facility's maintenance assistant indicated that recent plumbing work, including pipe changes and water shut-offs, likely contributed to the presence of sediment and brown water, as well as clogged faucet filters causing low water pressure. The facility administrator acknowledged that staff had not reported the brown water issue prior to the surveyor's observations and admitted that water quality checks were not performed after the plumbing work was completed. The facility's maintenance policy requires maintaining the building in a safe and operable manner, including compliance with regulations and routine maintenance, but these procedures were not followed to ensure water quality and pressure were restored after plumbing repairs. As a result, residents were exposed to unsanitary water conditions and inadequate water supply in their rooms.
Failure to Provide Scheduled Showers and Hygiene Assistance for Dependent Resident
Penalty
Summary
The facility failed to provide necessary assistance with activities of daily living (ADLs), specifically in maintaining grooming and personal hygiene, for a resident who was completely dependent due to paraplegia and other significant medical conditions. The resident, who had normal cognition and was dependent for all mobility and self-care, did not receive scheduled showers three times a week as required by his care plan for multiple weeks. Documentation showed missed or insufficient bathing during several specified weeks, and there was no evidence of the resident refusing these services during the period in question. Medical records indicated that the resident had a history of complete paraplegia, type 2 diabetes, heart failure, a stage 4 sacral pressure ulcer, neurogenic bowel, and neuromuscular bladder dysfunction. The resident was bedbound, required an indwelling catheter, and was admitted with multiple pressure ulcers. Despite these needs, the resident reported only receiving bed baths at most once a week and denied ever refusing care or requesting it at times when staff could not accommodate. Observations noted poor grooming, including long yellow nails and an untrimmed beard, and the resident expressed a desire for grooming assistance that was not offered. Interviews with facility staff revealed inconsistencies in the provision and documentation of showers and bed baths. Staff cited the use of a Shower Tech and CNAs for bathing duties, but could not provide consistent or complete records of care provided. The ADON and DON acknowledged expectations for regular hygiene care but were unable to produce documentation supporting that the resident received the scheduled showers or baths. The facility's own policy required assistance with ADLs for residents unable to perform them independently, including hygiene and grooming, but this was not consistently implemented for the resident in question.
Failure to Prevent Resident-to-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from abuse, neglect, and exploitation, specifically failing to ensure that one resident was free from sexual abuse by another resident. On the date of the incident, a resident with significant cognitive and physical impairments, including cerebral palsy, intellectual disabilities, and dependence on staff for most activities of daily living, was subjected to inappropriate sexual contact by another resident. The perpetrator, who had recently been admitted and was known to wander throughout the facility due to dementia and altered mental status, instructed the victim to touch his private parts and body. The incident was reported by the victim to the Activity Director, who then relayed the information to supervisory staff. The victim's care plan documented cognitive impairment and a need for staff assistance with most activities, while the perpetrator's care plan noted wandering behavior and risk of elopement but did not indicate any prior aggressive or sexual behaviors. The two residents were not roommates and lived on separate halls, but the perpetrator was observed pushing the victim's wheelchair and interacting with him in common areas. Staff interviews confirmed that the incident was disclosed by the victim and that the perpetrator initially denied, then later admitted to the inappropriate contact during the facility's investigation. There was no direct witness to the abuse, but the victim consistently described the incident to multiple staff and family members. Documentation and interviews revealed that the facility's staff had been trained on abuse prevention, reporting, and resident rights, and that the facility had policies prohibiting abuse and neglect. However, the incident occurred despite these measures, as the perpetrator was able to access and interact with the vulnerable resident without adequate supervision or intervention. The deficiency was identified as past noncompliance, with the incident placing all residents at risk of abuse and neglect that could result in emotional and mental trauma.
Failure to Document and Report Tracheostomy Site Care
Penalty
Summary
The facility failed to ensure that a resident was admitted with physician orders for immediate care, specifically regarding the care of a healing tracheostomy site. The resident, a male with anoxic brain damage and chronic respiratory failure with hypoxia, was admitted without documented physician orders for tracheostomy site care. The care plan, medication administration record (MAR), and minimum data set (MDS) did not reflect the resident's tracheostomy status or the need for site care. Additionally, nursing notes and skin assessments conducted during the resident's stay did not document any tracheostomy site care or mention the healing tracheostomy. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's tracheostomy site. An LVN noted that the tracheostomy site was closed upon admission and questioned the need for dressing. Another LVN observed scant drainage from the site but did not report it to the physician, believing it was part of the healing process. The Director of Nursing (DON) stated that even minor drainage should have been reported to the physician to clarify the need for an order. The facility's policy on trach care required documentation of the procedure, site condition, and resident response, which was not followed in this case.
Linen Shortage and Environmental Deficiency
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for six residents, as observed during a survey. Multiple rooms were found without sheets on the beds, and supply carts in various halls lacked sheets. Interviews with staff, including a CNA and a Restorative Aide, revealed that linen shortages were a persistent issue, with insufficient linen available to meet residents' needs. The CNA mentioned waiting for linen from the laundry, and the Restorative Aide noted that linen was rarely available when she started her shift. The Administrator acknowledged the linen shortage, attributing it to supply issues with a company in another state that had experienced a disaster. Despite placing orders for linen, towels, and other supplies, the facility had not received the April order, and the recent order had not been delivered. The Administrator admitted to asking staff to dispose of stained sheets prematurely, exacerbating the shortage. The Maintenance Director/Housekeeping and Laundry Supervisor suggested that CNAs might be hiding or discarding linen, and he confirmed that linen availability was an ongoing issue. Interviews with other staff and a resident's representative highlighted further concerns. The Regional Nurse mentioned plans to source supplies from a local vendor, while a resident's representative reported stained and inadequate linens, leading her to bring in personal supplies. The Laundry Aide confirmed the shortage, stating that linens were often stained and had holes, and that they struggled to keep up with demand despite continuous washing. The facility lacked a linen policy, and no policy was provided during the survey.
Failure to Provide Ordered Pleasure Feeding
Penalty
Summary
The facility failed to ensure that services provided to a resident met professional standards of quality, specifically regarding pleasure feeding as ordered by the physician. The resident, a male with multiple diagnoses including volvulus, cerebral palsy, and gastrostomy, was admitted and readmitted to the facility with orders for pleasure feeding of puree textures upon family request. Despite a modified barium swallow study indicating the resident could eat by mouth, observations and interviews revealed that the resident was not provided with a meal tray for pleasure feeding during the observed lunch meal. The resident was instead fed via a feeding tube, and there was no documentation in the nurse progress notes indicating that the resident was given a pleasure tray or had refused to eat. Interviews with facility staff, including CNAs and the Director of Nursing (DON), confirmed that the resident was consistently fed via a feeding tube and that no meal trays were provided for oral feeding. The DON acknowledged that the order for pleasure feeding was unclear and admitted to not contacting the physician for clarification. The facility's policy on oral medication administration did not address dietary requirements, contributing to the oversight. This lack of adherence to the physician's order for pleasure feeding could place residents at risk for weight loss and further decline in health status.
Inadequate Staffing Leads to Neglect in Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of residents, specifically impacting three residents who were reviewed for sufficient staffing. The facility's assessment tool indicated a staffing plan based on the needs of the resident population, which included residents with behavioral needs, those requiring injections, tracheostomy care, and ventilator or respirator support. However, observations and interviews revealed that the facility did not have enough staff to provide necessary care, such as repositioning and incontinent care, for residents who were dependent on assistance for activities of daily living. Resident #1, a male with multiple diagnoses including muscle wasting and intellectual disabilities, was observed on multiple occasions with a soiled diaper and an offensive odor in his room, indicating a lack of timely incontinent care. His care plan required regular checks for incontinence and prompt changes to prevent skin breakdown and maintain dignity. Similarly, Resident #2, who had aphasia and cognitive deficits, was also observed with an offensive odor in his room and was not repositioned or changed in a timely manner, despite being dependent on assistance for personal hygiene and toileting. Resident #9, a female with dementia and a history of falling, reported being wet and not having been changed since early morning. Observations confirmed her sheets were drenched with urine, and a CNA noted that she had not been changed on the previous shift. Interviews with staff, including CNAs and the Director of Nursing, highlighted the challenges of inadequate staffing, with CNAs responsible for a high number of residents and unable to complete all necessary care tasks. The facility's staffing policy stated that sufficient numbers of staff with the necessary skills and competencies should be provided, but the observations and interviews indicated that this was not being achieved.
Failure to Maintain Safe Food Temperatures
Penalty
Summary
The facility failed to provide food that was palatable and at a safe and appetizing temperature for residents in Dove Hall who received room trays from the facility's kitchen. Observations revealed that food trays were placed in a warmer without doors, and the food was covered with saran wrap. Residents reported receiving cold food, particularly those served last, and expressed that the issue had been ongoing despite previous complaints. The Dietary Manager and Administrator were aware of the problem, but the issue persisted, affecting the quality of meals served to residents. During a test tray evaluation, the food temperatures were found to be below the required levels, with baked beans at 110°F, beef brisket at 97°F, cold potato salad at 67°F, cold pureed potato salad at 57.8°F, pureed beans at 92.6°F, and pureed meat at 95.3°F. The Dietary Manager acknowledged that the food temperatures were low due to the absence of hot covers and unheated carts. The facility's policy on food preparation and service emphasized compliance with safe food handling practices, which was not adhered to in this instance, leading to the deficiency.
Deficiencies in Food Safety and Sanitation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by multiple deficiencies observed in the kitchen. Food items, such as liquid eggs, were not labeled or dated, and the cooler's thermometer indicated a temperature of 44 degrees, which is above the safe range. Additionally, the stove and fryer were not properly cleaned, with burnt food particles and black oil observed. In the dry storage room, non-food items like a coffee cup and a bottle of pink liquid soap were improperly stored, indicating a lack of adherence to safe food handling practices. The dishwashing process was compromised due to malfunctioning equipment and inadequate sanitization. The dish machine's temperature did not exceed 90 degrees, and the sanitizer was not properly dispensed, as evidenced by the litmus paper not changing color. The lid with the tubing did not fit the sanitizer bottle, preventing proper sanitization. Furthermore, there was no fan to facilitate air drying of dishes, and the dish machine's operational requirements were not met, with wash and rinse temperatures below the required 120 degrees F. Staff training and hygienic practices were also inadequate. A dietary aide reported insufficient cleaning materials and a lack of proper training. During an observation, a staff member failed to change gloves or wash hands after handling trash, which was only corrected after being pointed out. The facility's policies on food preparation, storage, and dishwashing were not followed, leading to potential risks of food contamination and foodborne illness for residents consuming meals prepared in the kitchen.
Inadequate Staffing and Supplies Lead to Resident Care Deficiencies
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, impacting the care of three residents. The Administrator and Director of Nursing (DON) did not ensure sufficient staffing levels to provide timely incontinent care and repositioning for residents. Observations revealed that residents were left in soiled diapers for extended periods, indicating a lack of adequate care. Interviews with staff highlighted that the facility was operating with fewer CNAs than needed, making it difficult to meet the residents' needs. Additionally, the facility faced issues with inadequate supplies, including linens, towels, briefs, and wipes. The Administrator admitted to problems with linen supply due to issues with the vendor and acknowledged that there was not enough linen available. This shortage led to residents using stained and inadequate bedding, further compromising their dignity and care. The facility's supply closet was found to be insufficiently stocked, with only a limited number of briefs and wipes available. Interviews with the Administrator and DON revealed a lack of awareness regarding the extent of the care deficiencies. The Administrator was unaware of the residents not receiving timely care, and the DON believed that the staffing levels were adequate despite evidence to the contrary. The facility's failure to provide necessary resources and supervision placed residents at risk of skin breakdown, infection, and loss of dignity.
Deficiency in Pressure Ulcer Care
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care for a resident, leading to a deficiency in treatment and services consistent with professional standards of practice. The resident, who was admitted with a stage 4 pressure ulcer on the sacral region and a deep tissue injury on the right heel, did not have the sacral wound properly dressed. During an observation, it was noted that the sacral wound was packed with gauze but lacked a covering dressing, which was confirmed by the Wound Care Nurse (WCN) and the Certified Nursing Assistant (CNA) present. The Charge Nurse was unaware of the missing dressing, and there was no documentation of the wound's measurements since the resident's admission. The facility's records revealed that the sacral wound was to be cleaned and covered daily, as per a physician's order, but this was not adhered to. The WCN acknowledged that the wound should have been covered to prevent contamination and infection. Additionally, the facility's policy on wound monitoring was not followed, as there were no recorded measurements of the sacral wound in the resident's electronic record. The Director of Nursing (DON) confirmed that the WCN was responsible for ensuring wound care was completed, and if absent, other designated nurses would take over. However, the lack of communication and documentation led to the deficiency in care for the resident's pressure ulcer.
Staffing Shortages Lead to Missed Medications and Inadequate Care
Penalty
Summary
The facility failed to provide sufficient nursing staff with the appropriate competencies and skill sets to meet the needs of residents, resulting in missed medication administration, inadequate monitoring of vital signs, and insufficient ADL care. Specifically, residents did not receive their prescribed medications, including anticoagulants, insulin, and blood pressure medications, which were critical for managing their health conditions. For example, Resident #34 did not receive Eliquis, Toprol, or Trileptal, and her blood glucose levels were not monitored as ordered. Similarly, Resident #65 missed doses of IV antibiotics, Haldol, Levetiracetam, and Oxcarbazepine, and her blood glucose was not checked as required. The facility also failed to provide adequate care for residents with bowel and bladder incontinence during the night shift. Residents reported not being changed or repositioned, leading to prolonged exposure to wet and soiled linens. Resident #19 was found sitting on a soaking wet bed, and Resident #41 reported that no CNA was available during the night shift, resulting in him lying in urine-soaked bedding. Resident #50 and Resident #59 also reported not receiving timely assistance with incontinence care, leading to discomfort and potential health risks. Interviews with staff revealed that the facility was aware of the staffing shortages but failed to take appropriate action to address the issue. The DON and Administrator were informed of the staffing problems but did not ensure that the remaining staff redistributed care responsibilities or provided additional support. This lack of action resulted in residents missing critical medications and not receiving necessary care, placing them at risk for adverse health outcomes.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to provide pharmaceutical services, including dispensing and administering all drugs and biologicals, to meet the needs of four residents. This deficiency was observed when one of the three nurses assigned to the South Hall called off from her shift, and the remaining staff did not redistribute the assignments. As a result, several residents did not have their blood glucose levels checked as ordered, which determined if sliding scale insulin was to be administered. Additionally, residents did not receive their morning and/or afternoon medications as ordered by their physician, including critical medications such as insulin, anticoagulants, and an IV antibiotic. Resident #34, who had severe cognitive impairment and multiple diagnoses including type 2 diabetes mellitus and epilepsy, did not receive her prescribed medications, including Eliquis, Toprol, and Trileptal. Her blood glucose levels were not checked at the scheduled times, and no sliding scale insulin was administered. Similarly, Resident #65, who had moderately impaired cognition and multiple diagnoses including type 2 diabetes mellitus and schizophrenia, missed several doses of her medications, including an IV antibiotic, Haldol, Levetiracetam, and Oxcarbazepine. Her blood glucose levels were also not checked, and sliding scale insulin was not administered. Resident #87, who had severely impaired cognition and multiple diagnoses including type 2 diabetes mellitus and atrial fibrillation, did not receive her prescribed medications, including Apixaban, Amiodarone, and Metoprolol Tartrate. Her blood glucose levels were not checked, and sliding scale insulin was not administered. Resident #91, who had intact cognition and multiple diagnoses including diabetes mellitus and congestive heart failure, did not receive his prescribed medications, including Coumadin, Hydralazine HCl, and Carvedilol. His blood glucose levels were not checked, and sliding scale insulin was not administered. The DON and the physician were not aware of the missed medications until notified by the surveyor.
Medication Administration Failures
Penalty
Summary
The facility failed to ensure that four residents were free from significant medication errors. Resident #91 did not receive Coumadin as ordered by the physician, placing him at risk for a blood clot. Additionally, Residents #34, #65, and #87 did not have their blood glucose levels checked as ordered, which determined if sliding scale insulin was to be administered. Resident #34 also did not receive Metoprolol Tartrate as ordered, and her blood sugar was not checked, resulting in not having blood sugar levels to determine amounts of insulin to be administered. Resident #65 did not receive a dose of IV antibiotic for a sacral pressure ulcer infection, and Resident #87 did not receive Metoprolol Tartrate as ordered, and her blood sugar was not checked, resulting in not having blood sugar levels to determine amounts of insulin to be administered. Missed medications included insulin, anticoagulants, and one IV antibiotic. The DON was not aware of the residents missing their medications prior to surveyor notification, and the physician was not notified until after the surveyor notified the DON. Resident #34, who has severe cognitive impairment, did not receive several medications on the morning of 04/22/24, including Eliquis, Toprol, and Trileptal Oral suspension. Her blood glucose levels were not checked at noon or 6:00 p.m., and no sliding scale insulin was administered. Resident #65, who has moderately impaired cognition, did not receive several medications on 04/22/24, including IV Ertapenem Sodium Solution, Haldol, Levetiracetam solution, and Oxcarbazepine. Her blood glucose was not checked as ordered, and sliding-scale insulin was not given. Resident #87, who has severely impaired cognition, did not receive several medications on 04/22/24, including Apixaban, Amiodarone, and Metoprolol Tartrate. Her blood glucose was not checked as ordered, and sliding-scale insulin was not administered. Resident #91, who has intact cognition, did not receive Coumadin, Hydralazine HCl, or Carvedilol as ordered on 04/22/24. His blood glucose was not checked as ordered, and sliding-scale insulin was not given. The deficiency was attributed to staffing issues on the South Hall, where there were only two nurses instead of the scheduled three. The nurses did not redistribute care of the South 3 residents, resulting in incomplete medication administration. The DON was responsible for finding replacement staffing but did not take appropriate action when informed of the staffing shortage. The Administrator was not aware of the missed medications until informed by the surveyor. The Corporate RN and NP were also not informed of the missed medications until after the surveyor's notification. The facility's failure to ensure proper medication administration placed the residents at higher risk for hyperglycemia, blood clots, and sepsis.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The Facility Assessment Tool was incomplete, missing critical components such as the resident profile, services and care offered, and facility resources needed. This deficiency was identified during a record review and interview with the Corporate RN, who acknowledged that the tool presented was merely a guide and not the actual assessment. The Corporate RN had been communicating the need for a proper assessment since December 2023, emphasizing its importance for determining staffing needs. Further interviews revealed that the new Administrator was unaware that the document presented was not the actual facility assessment. Upon realizing the mistake, the Administrator began working on the assessment with department heads. The facility's policy, dated Qtr 3, 2018, mandates an annual assessment to ensure the facility's capacity to meet resident needs during normal and emergency operations. The policy outlines specific data points and resources that must be reviewed, including resident census data, physical characteristics of the facility, equipment and supplies, and personnel details. The failure to complete the facility assessment as required by the policy could affect the residents by not ensuring that the necessary resources are available to provide appropriate care. The assessment is crucial for aligning resident needs with available resources, planning for emergencies, and making informed decisions about staffing, training, and equipment. The absence of a completed assessment indicates a significant oversight in the facility's operational planning and preparedness.
Lack of Private Meeting Space for Resident Council Meetings
Penalty
Summary
The facility failed to provide a private meeting space for the residents' monthly council meetings, which were held in the dining room. Despite the Activities Director's attempt to post a sign and request staff to stay out, multiple staff members, visitors, and other residents were observed entering and exiting the dining room during the meetings. This lack of privacy was confirmed through interviews with residents who expressed their desire for a private space to speak freely without fear of being overheard by staff. The Activities Director acknowledged the issue but stated that no other rooms were available, as the only potential alternative was being used for dialysis storage. The Administrator was aware that the meetings were held in the dining room and had attended a previous meeting where a 'don't enter' sign was posted. However, the Administrator was informed of the surveyor's observations of staff and visitors entering the dining room during the meetings. The Administrator suggested that the conference room adjacent to her office could be used for future meetings, as it would provide the necessary privacy. Record reviews of the Resident Council Minutes from the past three months confirmed that the meetings were consistently held in the dining room, with varying numbers of residents in attendance. The facility's Resident Council policy supports residents' rights to organize and participate in council meetings, but the current practice did not align with the policy's intent to provide a private forum for residents to voice their concerns and suggestions for improvement.
Failure to Properly Store, Label, and Date Food Items
Penalty
Summary
The facility failed to ensure foods were properly stored, labeled, and dated in the kitchen, which could place residents at risk of food-borne illness. During an observation and interview with Cook A, it was found that several food items in the refrigerator were not labeled with a use-by date, including puree pumpkin pudding, salad mix, croissants, bagels, and pancakes. Additionally, the condiment refrigerator contained several items such as potato salad, ham, turkey, sliced cheese, shredded cheese, tomatoes, bell peppers, and jalapenos that were not labeled or dated. Cook A mentioned that the food should be labeled and dated with the open date and that the evening staff was responsible for cleaning and checking for expired items. However, this practice was not being followed consistently, especially after the kitchen supervisor left eight days prior to the observation. In an interview with Cook B, it was confirmed that the cooks were responsible for labeling the food and that opened food should be labeled and dated. The Administrator acknowledged that the Dietary Manager had left two weeks ago and that a new Dietary Manager was scheduled to start soon. The Administrator also mentioned that she was overseeing the kitchen in the interim and that whoever was putting away food after delivery was responsible for labeling it. The facility's Food Receiving and Storage policy and the Texas Food Code were reviewed, both of which require proper labeling and dating of stored food to ensure safety. The failure to adhere to these standards was evident in the observations made during the survey.
Failure to Obtain Informed Consent for Antipsychotic Medication
Penalty
Summary
The facility failed to inform residents in advance of the risks and benefits of proposed care and treatment, specifically for one resident who was administered antipsychotic medication without a signed consent. Resident #58, a female with diagnoses including unspecified dementia and anxiety disorder, was given Olanzapine without the necessary informed consent. The comprehensive MDS assessment indicated that Resident #58 was unable to complete the BIMS, and the care plan noted the use of psychotropic medication with a focus on monitoring for adverse reactions and effectiveness. Despite this, the facility did not obtain a signed consent for the administration of Olanzapine, which was documented in the MAR as being administered daily over a seven-day period. Interviews with the DON and ADON revealed that the facility's process for obtaining informed consent for psychotropic medications was not followed. The DON stated that nurses should ensure appropriate diagnoses and consents are in place before administering such medications. The ADON, who was recently hired, confirmed that Resident #58 was receiving Olanzapine for behaviors related to dementia but acknowledged that no current consent for treatment was on file. The ADON mentioned working on a process to ensure all consents are signed prior to administering psychotropic medications. The MHNP confirmed that Olanzapine was prescribed for Resident #58 due to behaviors previously identified by the facility, despite dementia not being an appropriate diagnosis for antipsychotic medication. The MHNP was unaware that the facility lacked a signed informed consent and stated that such consent should be obtained before administering antipsychotic medications. The facility's policy on administering medications did not include information related to antipsychotic medication informed consent, further contributing to the deficiency.
Inappropriate Use of Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that psychotropic medications were not given unless necessary to treat a specific condition as diagnosed and documented in the clinical record for one resident. Specifically, Resident #58 was administered Olanzapine, an antipsychotic medication, without an appropriate diagnosis or indication. The resident's diagnoses included unspecified dementia and anxiety disorder, but there was no documented diagnosis justifying the use of Olanzapine. The resident's care plan and physician's orders did not provide a valid reason for the medication, and the facility lacked a current consent for treatment with the antipsychotic medication. Observations revealed that Resident #58 was frequently found in bed with eyes closed, appearing to be sleeping, which could be indicative of the medication's side effects. Interviews with the Director of Nursing (DON) and Assistant Director of Nursing (ADON) confirmed that the facility did not have the appropriate diagnosis or consent for the use of Olanzapine. The DON acknowledged that dementia was not an appropriate diagnosis for an antipsychotic medication and highlighted the risks associated with unnecessary antipsychotic use, such as falls, weight loss, heart conditions, and decreased socialization. The Mental Health Nurse Practitioner (MHNP) confirmed that Olanzapine was prescribed for mood disorder with psychotic disorder, but Resident #58 did not have this diagnosis. The MHNP stated that the medication was given due to previously identified behaviors and agreed to follow up for a possible discontinuation. The facility's policy on administering antipsychotic medications did not include dementia as an appropriate diagnosis, and the facility failed to obtain informed consent prior to administering the medication.
Inadequate Hand Hygiene During Incontinent Care
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during incontinent care for a resident. Specifically, a CNA did not perform hand hygiene after removing soiled gloves and before touching clean items, which could lead to cross-contamination. The resident involved was an elderly female with dementia and other mobility issues, requiring extensive assistance with activities of daily living (ADLs) and was always incontinent of bladder and bowel. During an observation, the CNA was seen handling the resident's clean brief, shirt, pants, sheet, and blanket without changing gloves or performing hand hygiene after cleaning the resident's soiled areas. Interviews with the CNA and the Director of Nursing (DON) revealed that the CNA had not recently undergone competency checks for incontinent care and had only received infection control in-service training a few months prior. The DON, who had recently started working at the facility, acknowledged that the CNA should have performed hand hygiene to prevent infection risks. The facility's policies on hand hygiene and infection control were reviewed and found to be in place, but not adequately followed by the staff.
Deficient Tracheostomy Care and Suctioning Practices
Penalty
Summary
The facility failed to provide appropriate respiratory care for a resident with a tracheostomy, as observed during a survey. The resident, who was admitted with acute respiratory failure and hypoxia, required tracheostomy care and suctioning. However, the respiratory therapist (RT A) did not follow professional standards of practice. Specifically, RT A did not use a pulse oximeter to monitor the resident's tolerance to the suctioning procedure and failed to hyper-oxygenate the resident before suctioning. Additionally, RT A contaminated the sterile field and did not wear sterile gloves when handling the inner cannula, which required surveyor intervention. During the procedure, RT A demonstrated a lack of understanding of sterile techniques. She double-gloved with gloves from a box by the door, incorrectly assuming they were sterile. RT A contaminated the sterile field by placing a non-sterile box on it and insisted that the gloves she used were sterile, despite being informed otherwise by the surveyor and another respiratory therapist (RT B). RT A's actions, including touching the tubing part of the new inner cannula with non-sterile gloves, increased the risk of infection for the resident. The facility lacked adequate supervision and training for respiratory therapists, as there was no RT Supervisor at the time of the incident. The Director of Nursing (DON) had recently left, and a new DON was yet to start. The Corporate RN acknowledged the deficiency in technique and planned to provide education to RT A. The facility's competency checklists and policies outlined the correct procedures for tracheostomy care, but these were not adhered to by RT A during the observed incident.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 522 citations issued within 25 miles in the last 12 months — including the 46 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pearland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Thrive Rehabilitation Of Pearland | 3.4 mi | ★★★★★ | 27 | 5 |
| Magnolia Crossing Nursing And Rehabilitation Cente | 3.9 mi | ★★★★★ | 6 | 0 |
| Park Manor Of South Belt | 4.7 mi | ★★★★★ | 2 | 0 |
| Richard A. Anderson (state Of Texas Veterans Land | 5 mi | ★★★★★ | 8 | 0 |
| Tuscany Village | 5.8 mi | ★★★★★ | 5 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.