Thrive Rehabilitation Of Pearland
Thrive Rehabilitation of Pearland in Pearland, TX — inspection on November 28, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
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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