Oasis at Pearland

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 (Resident #3) of 8 residents reviewed for pharmaceutical services. The facility failed to ensure Resident #3 received Clonazepam 0.5 mg and Phenobarbital 32.4 mg, both medications ordered for seizures, as ordered as evidenced by gaps in administrations on 11/1/25-11/3/25, 11/10/25 and 11/18/25. This failure could place the residents at risk of not receiving medications as ordered by the physician and risk of seizures (sudden surge of abnormal electrical activity in the brain that can cause changes in behavior, awareness, or muscle control).

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #1) of eight residents reviewed for dignity. The facility failed to ensure Respiratory Therapist A provided privacy to Resident #1 while providing oral care and tracheostomy (surgically created opening in the windpipe to assist with breathing) suctioning on 6/9/2026. These failures could place the residents at risk of not having the right to a dignified existence maintained.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that menus were followed in accordance with the national guidelines in 1 of 1 kitchen reviewed at lunch meal in that: The facility failed to ensure that the menus were followed. This failure could place all residents who ate food from the kitchen at risk of weight loss and diminished quality of life. Observation on 12/31/2025 at 12:20pm during the lunch service revealed the lunch tray included one egg roll, 3 chicken nuggets, approximately 2 ounces of green beans, banana pudding, juice and water. No bread was observed on the tray. Further observation revealed no posted menu in the dining room and no substitution list. Interview on 12/31/2025 at 12:40pm with the Dietary Manager revealed that the menu was supposed to be posted but she did not get a chance to print it and that was why it was not posted. [...]

Inspectors wroteBased on records review and interview, the facility failed to provide the resident\ resident representative with access to personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically), or, if not, in a readable hard copy form or such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) for 1of 1 residents (CR#1) reviewed record access. CR #1 and her representative were not provided with requested medical records. This failure had the potential to prevent residents from obtaining medical services needed to maintain their health. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 4 of 93 resident rooms (room [ROOM NUMBER], 107, 140, and 146) reviewed for environment.- The facility failed to have clean water, and the water was brown when the faucet was turned on, in rooms [ROOM NUMBERS].- The facility failed to have water pressure, and the water barely came out of the faucet, in Rooms 106, 107, 140 and 146. These failures could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 1 out of 5 residents (Resident #1) reviewed for ADLs.- The facility failed to provide scheduled showers, three times a week to Resident #1 for the weeks of 8/25/25-8/30/25, 9/1/25-9/6/25, and 9/15/25-9/20/25. This failure could place residents at risk of skin breakdown, infection, and reduced feelings of self-worth.

Inspectors wroteBased on record review and interview, the facility failed to transmit encoded, accurate, and complete MDS data to the Center for Medicaid/Medicare System (CMS) System for 1 of 3 closed records (CR #83) reviewed for Minimum Data Set (MDS) transmission. CR #83's discharge MDS assessment was not completed and transmitted within 14 days of CR's discharges. This failure could place residents at-risk of not having their assessment and care plan completed timely, which could result in denial of services and or payment for services. Findings Include: Record review of CR #83's Face sheet dated 06/12/25 revealed a 63-years old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate with Pre-admission and Resident Review program (PASRR) (Screening process for individuals with mental illness or intellectual/developmental disabilities) under Medicaid and initiate services within 20 days after the date that the services are agreed upon in the Interdisciplinary Team meeting( IDT) (meeting with professionals from various disciplines to discuss resident needs and develop a comprehensive care plan), to ensure that individuals with intellectual developmental disabilities receive the care and services they need in the most appropriate setting for 1 of 18 residents (Resident#35) reviewed for PASRR. The facility failed to complete and submit therapy evaluations for Habilitative services for PT, and OT services agreed upon in an IDT meeting on 08/15/2025 addressing Resident #35's needs. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 8 residents (Resident #86) reviewed for significant medication errors. The facility failed to ensure Midodrine (a blood pressure (BP) medication given to elevate hypotension (low blood pressure) was administered as ordered by the physician. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health. Findings Included: Record review of Resident #86's undated face sheet, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infections for 1 of 8 residents (Resident #80) observed for infection control. The facility failed to ensure CNA A followed appropriate infection control and hand hygiene procedure during incontinent care for Resident #80 on 06/10/2025. The failure could place the resident at risk for infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident was free from abuse, neglect and exploitation for 2 of 5 (Resident #1 and CR#2) residents reviewed for abuse. The facility failed to ensure Resident #1 was free from sexual abuse when CR #2 told Resident #1 to hold his (CR#2's) penis and touch his body on 3/14/2025. The noncompliance was identified as Past Non-Compliance. The PNC IJ began on 03/14/2025 and ended on 3/17/2025. The facility corrected the noncompliance before the survey began. This failure placed all residents in the facility at risk of abuse and neglect that could result in emotional and mental trauma.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 4 sampled residents (CR #3) were admitted with physician orders for immediate care, in that: The facility failed to have physician's orders that indicated CR #3's need for dressing to healing tracheostomy. This failure places residents with medical needs at risk for a decrease in their quality of care.

Inspectors wroteBased on observation, record and interview the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 6 of 6 residents reviewed for environment. 1-The facility did not have an adequate supply of linen as multiple rooms #103, #108, #109, #117, #124, #125 were observed with no sheets on the beds. 2-The facility did not have linen readily available to meet residents' needs. This failure could cause residents to have skin breakdown, infections and dignity issues.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided by the facility, as outlined by the comprehensive care plan, met professional standards of quality for one (Resident #1) of six residents observed for pleasure feedings. The facility failed to ensure that Resident #1's received pleasure feeding as ordered by the physician. These failures could place residents at risk for weight loss and further decline in health status.

Inspectors wroteBased on observation, record review and interview the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 3 of 6 residents (Resident #1, Resident #2 and Resident #9) reviewed for sufficient staffing. -The facility failed to ensure there were sufficient staff per the facility assessment and failed to provide repositioning for Resident #1 and Resident. -The facility failed to provide Incontinent care to Residents #1 and Resident #2 and Resident #9. with bowel/bladder incontinence on 6/27/2024 and 6/28/2024. These failures could place residents at risk of their needs not being met, skin breakdown, and loss of dignity. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, and at a safe and appetizing temperature for of the 1 (Dove Hall) of 4 halls for residents who receive room trays from the facility's kitchen. The facility did not maintain proper temperatures for room service trays for lunch on Dove hall. These failures could affect all residents who eat in their rooms and residents who received pureed meals by placing them at risk of weight loss, altered nutritional status and diminished quality of life.

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 dietary services. (1) The facility failed to ensure food was labeled and dated. (2) The facility failed to ensure that equipment was cleaned. (3) The facility failed to ensure that the dish machine sanitizer was working properly. (4) The facility failed to ensure that staff were properly trained to do they duties. (5) The facility failed to ensure that food on the steam was at the correct holding temperature. (6) The facility failed to ensure staff maintained proper hygienic practices. (7) The facility failed to ensure refrigerator maintain 41 degrees or below. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable physical, mental, and psychosocial well-being of each resident for 3 of 6 residents (Resident #1, Resident #2 and Resident #9 ) reviewed for facility administration in that: -The facility Administrator and DON failed to ensure the facility had sufficient staff to ensure timely incontinent care and/or repositioning were provided for (Resident #1, Resident #2, and Resident #9). -The facility Administrator failed to ensure the facility had adequate linen, towels, briefs and wipes to care for the facility residents in a timely manner. -The facility DON failed to supervise CNAs to ensure they were providing timely incontinent care and repositioning as ordered. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that, based on the comprehensive assessment of a resident, 1 resident (Resident #3) of 3 residents reviewed for pressure sores received the necessary treatment and services consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. 1-Resident #3 had a large pressure sore that was not properly dressed. 2-The Charge Nurse and Treatment Nurse were not aware that the dressing was not on the wound. 3-The facility had no documentation of measurements of the pressure sore since admission. The failure placed this resident at risk for worsening of the pressure ulcer and/or possible infection.

Inspectors wroteBased on observation, interview and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing care to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 8 of 10 residents (Resident #34, Resident #65, Resident #87, Resident #91, Resident #19, Resident #41, Resident #50 and Resident #59) reviewed for sufficient staffing. -The facility failed to ensure there were sufficient staff per the facility assessment, and failed to provide care for residents including blood pressure and blood sugar monitoring, medicaiton administration, repositioning, and incontinent care. - Resident #34, Resident #65, Resident #87, and Resident #91 did not receive their morning and/or afternoon medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including dispensing and administering of all drugs and biologicals, to meet the needs of 4 residents (Residents #34, #65, #87, and #91) of 10 residents reviewed for medication administration. -Facility staff did not redistribute assignments of residents when one of three nurses assigned to the South Hall called off from her shift. -Resident #34, Resident #65, and Resident #87 did not have their blood glucose levels checked as ordered, which determined if sliding scale insulin was to be administered on 04/22/24. -Resident #34, Resident #65, Resident #87, and Resident #91 did not receive their morning and/or afternoon medications as ordered by their physician on 04/22/24. -Resident #34, Resident #65, and Resident #87 had parameters for administering blood pressure medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 4 residents (Residents #34, #65, #87, and #91) of 10 residents reviewed for medication administration were free of significant medication errors. -Resident #91 did not receive Coumadin (anticoagulant) as ordered by the physician in the afternoon of 04/22/24, placing him at risk for a blood clot. -Resident #34, Resident #65, and Resident #87 did not have their blood glucose levels checked as ordered, which determined if sliding scale insulin was to be administered on 04/22/24. -Resident #34 did not receive Metoprolol Tartrate (for high blood pressure) as ordered by the physician, 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. [...]

Inspectors wroteBased on record review and interview, the facility failed to conduct and document a facility wide assessment to determine the resources necessary to competently care for residents during day-to-day and emergency operations for 1 of 1 facility in that: -The Facility Assessment Tool was not completed. This failure could affect residents by not having the necessary resources to ensure appropriate care is provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private meeting space for the residents' monthly council meetings for 11 of 11 confidential residents reviewed for resident council. -The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. -The facility failed to ensure foods were properly stored, labeled, and dated. This failure could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on interview, and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 5residents (Resident #58) reviewed for resident rights, in that: The facility failed to obtain a signed consent for antipsychotic medication, Olanzapine was administered to Resident #58. The failure affected residents who received psychoactive medications without informed consents and placed them at risk of receiving treatments without informed consent.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #58) reviewed for unnecessary medications. The facility failed to have an appropriate diagnosis or indication for the use of Resident #58's Olanzapine (antipsychotic medication used to treat severe agitation associated with certain mental/mood conditions schizophrenia, bipolar mania). The facility's failure could place residents at risk for psychotropic medication side effects, adverse consequences, decreased quality of life, dependence on unnecessary medications; and could increase the risk of death in older adults with mental health problems related to dementia.

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 infection for 1 of 5 residents (Resident #19) reviewed for infection. -The facility failed to ensure CNA I performed hand hygiene during incontinent care on Resident #19. This failure could lead to the spread of infection to residents, resident illness, and/or resident distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #1) of three residents reviewed for tracheostomy care and tracheal suctioning was provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. -RT A did not utilize a pulse-ox to monitor Resident #1's tolerance of the suctioning procedure. -RT A did not hyper-oxygenate Resident #1 prior to suctioning. -RT A contaminated a sterile field and required surveyor intervention to have her obtain a new sterile field. -RT A did not wear a sterile glove when she picked up the inner cannula and inserted it into the trachea. -RT A was not able to determine the difference between a sterile glove and a clean glove. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent falls for 1 (CR#1) of six residents reviewed for accidents, hazards, and supervision. - The facility failed to provide adequate supervision and proper bed mobility for CR#1 when the facility wound care doctor and wound care nurse failed to supervise resident while doing wound care causing CR#1 to fall from the bed and hit her head on 7/18/23 and be rushed to the hospital and life flighted to another local hospital by helicopter for an emergency procedure. -The facility failed to care plan and put additional services in place for CR #1 when she had her 1st fall on 7/18/23. CR #1 had a 2nd fall on 10/28/23 causing her additional pain and suffering. An Immediate Jeopardy (IJ) was identified on 11/7/23 at 2:39 p.m. [...]

Inspectors wroteBased on observation , record review and interview the facility failed to ensure that residents are free of significant medications errorsfor for 2 of (Resident #1 and Resident #2) of 6 residents reviewed for medications errors. The facility failed to ensure that Resident #1's medications were given as ordered by the physician. The facility failed to ensure that Resident #2's, medication Metoprolol for high blood pressure was given as ordered by the physician. This failure placed all resident who received medications at risk of not getting their medications as ordered which could result in resident not receiving the therapeutic benefits of the medication including increased pain, blood pressure and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 6 Residents (Resident #1 and Resident #2) reviewed for medical records accuracy, in that: Resident #1 and Resident #2 October 2023 MAR's and TAR's did not reflect documentation for medication and treatment done. Resident #1 and Resident #2 October 2023 nurse's notes did not why document reasons when medications were not given and why blood pressure medication was given. This deficient practice could affect residents whose records are maintained by the facility and could place them at risk for errors in care, and treatment. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #2) of 6 residents reviewed for comprehensive care plans. The facility failed to ensure Resident #2's comprehensive care plan included all care areas triggered on the assessment. This failure could place all residents at risk of not receiving proper care to develop and improve their mental, physical and psychosocial well-being.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of medications errors for (Resident #1) 1 of 6 residents' records reviewed of the MAR. Facility staff failed to follow the physician's orders for administering a narcotic (Norco) medication to R#1. This failure placed residents risk for not receiving the medications as ordered by the physician, which could cause excessive diarrhea.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident physician and notify the resident's representative when there was a significant change in the resident's physical mental or psychological status for 1 of 5 residents (Resident #1) reviewed for notification of change of condition. The facility failed to notify Resident #1's responsible party when there was lesion to the resident's nose which resulted in an open area on the nose bridge. This failure placed residents at risk of not being aware of any changes in their conditions and could result in the decline of the residents' health and well-being.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident was free from abuse and neglect for 1 (CR #50) of 7 residents reviewed for abuse and neglect. -The facility failed to ensure CR #50, was free from abuse when she was grabbed and hit by CNA F, causing bruising to the face, torso, and left arm. -RN H and CNA G failed to follow appropriate procedure and notify the facility's abuse coordinator and administrator immediately of knowing an incident of abuse involving CR #50 that occurred on 07/19/2022 and reported on 07/25/2022. The noncompliance was identified as past noncompliance (PNC). The Immediate Jeopardy (IJ) began on 03/01/2023. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of serious harm from possible abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to transmit a resident assessment within the required time frame for 5 of 7 (CR #24, CR #60, CR #90, CR #94, and CR #96) discharged residents reviewed for data encoding and transmission in that: - The Facility failed to complete and transmit a discharge MDS for CR #24, CR #60, CR #90, CR #94, and CR #96. - The facility failed to complete an accurate discharge assessment for CR #24's death. This failure could place discharged residents at risk of not having their assessments transmitted timely.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to correctly complete Level 1 assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for two (Resident #9 and Resident #14) of seven residents reviewed for PASRR. The facility failed to correctly complete a Level I PASRR Evaluation for Resident #9 and Resident #14. This failure could affect residents with a diagnosis of mental illness and could result in these residents not receiving needed services and or specialized care.

Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS. The facility failed to submit PBJ staffing information to CMS for the 4th quarter of the fiscal year 2022. The facility's failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours after the allegation were made, to the administrator of the facility, other officials, including the State Survey Agency (SSA), for 1 (CR #50) of 7 resident reviewed for reporting. -RN H and CNA G failed to report an incident of abuse involving CR #50 to the facility's abuse coordinator and administrator immediately of knowing the abuse occurred on 07/19/2022. -The facility failed to report an incident to the SSA, Health and Human Service Commission (HHSC) immediately but not later than 24 hours of an incident of abuse on 07/19/2022 involving CR #50. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 26 residents (Resident #14) reviewed for care plans, in that: -Resident #14 did not have a care plan until 25 days after she admitted . -Resident #14 did not have a baseline care plan to address her psychotropic medication use. These failures could affect all newly admitted residents to the facility by placing them at risk of not receiving the care and services for health promotion and continuity of care.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment, for 1 Residents (Resident #14) of 24 residents reviewed for comprehensive care plans. The facility did not develop a comprehensive care plan for Resident #14 within seven days after completion of the comprehensive assessment. This failure could place residents at risk for not receiving the required person-centered care.

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters (dumpster A) reviewed for garbage disposal. The facility failed to ensure the dumpster lid and door were secured. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 4 halls (South Hall) reviewed for call systems. The facility failed to install a functioning call light system for Resident #10's room. This failure could place residents at risk for a delay in care and services, increased falls, excessive wait times, pain, and a decreased quality of life.