Thrive Rehabilitation Of Pearland
Inspection Findings
F-Tag F0773
F 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
doorway check only are not permitted unless preferred by the patient. Monitoring of the plan of removal included the following (11/27/25 - 11/28/25):Record review of in-service dated 11/26/25 provided by the DON indicated a verbal 1 on1 with CNA B covered vital signs- how to obtain, change of condition and when to notify nurse of abnormal vitals.Record review of in-service dated 11/26/25 provided by the DON indicated a verbal 1 on 1 with RN A that covered reporting change of condition, documenting all efforts made and providing a report to oncoming nurse, hand off communications. Rounds must include walking in
the room and looking at residents to observe respiratory status and condition.Record review of in-service dated 11/26/25 provided by the DON indicated a verbal 1 on 1 with LVN B that covered what to do if no response from MD, critical labs and MD notification. Notify supervisor, DON, ADON, Administrator and Medical Director. Rounds must include walking in the room and looking at the guest.Record review of in-service dated 11/26/25 indicated all nursing staff covered how to perform vital signs.Record review of in-service dated 11/26/25 provided by the DON indicated all nursing staff went over the change of condition policy. Notification of doctor, RP, emergency contact. If primary doctor does not answer, Medical Director needs to be notified of COC. Notify DON and RP as well.Record review of in-service dated 11/26/25 provided by the DON indicated all nursing staff went over checking and reporting abnormal vitals, who to notify when a critical lab value is received, follow change of condition and call doctor for intervention, if doctor not available call Medical Director. All nursing staff went over the Handoff Communication & Rounds policy. Walking rounds must be done at the beginning and end of each shift with oncoming and outgoing nurses. Progress notes must be completed stating patient status.Record review of the IDT Meeting Sign-in sheet dated 11/26/25 indicated state concerns and root cause analysis were discussed. Attendees included
the MD, Administrator, DON, ADON, MDS Nurse, and Unit Manager.Interviews were conducted on 11/27/25 -11/28/25 with all nursing staff (via phone and in person) on all shifts (6:00 am - 6:00 pm and 6:00 pm - 6:00 am) and included RN A, RN B, LVN B, LVN C, LVN D, LVN E, LVN F, MA A, CNA A, CNA B, CNA C, CNA D, CNA E, CNA F, CNA G, CNA H, CNA I, Wound Care Nurse, Unit Manager, DON, and Administrator to verify the in-services were conducted and to validate the staff understanding of the information presented to them. Nursing staff were able to identify the proper procedures to follow when a change of condition occurred in a resident, vitals could not be obtained, or when a resident had abnormal vitals. All licensed clinical staff knew when to complete a change of condition for a resident and who to notify, what to do when a critical lab result was reported and who to notify, and what a walking round should include and when to do a walking round. The Administrator was notified on 11/28/25 at 2:48 p.m., the Immediate Jeopardy was removed. The facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place.
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Thrive Rehabilitation of Pearland in Pearland, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Pearland, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Thrive Rehabilitation of Pearland or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.