Thrive Rehabilitation of Pearland

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 16.0% based on 4 errors out of 25 opportunities, which involved 2 of 4 residents (Resident #22 and Resident #82) reviewed for medication administration. 1. MA J failed to properly verify and dispense Furosemide (diuretic) according to physician's order with a start date of 01/10/2026 for Resident #22 when on 04/08/2026 MA J dispensed and was going to administer Resident #22 with two 80MG tablets instead of one 80MG tablets until surveyor intervention. 2. [...]

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 observed for sanitization. The facility failed to ensure foods were properly stored, labeled, and dated. These failures placed all residents who consumed food served by the kitchen at risk of food-born illness. Observation of the kitchen on 4/7/2026 at 8:15 a.m. revealed the following: Insulated dome covers and bases and plates were stored on a 5-tiered shelf adjacent to the steam table and next to a floor drain. These stored items had crumb like beige particles noted over the insulated bases on the lowest shelf. There were two unopened packets of ketchup on the bottom shelf in between the insulated bases. There was a cup of white solution on the 3rd shelf covered undated or labeled. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided a PASRR level II evaluation for 2 of 4 (Resident # 17 and Resident #4) residents reviewed for resident assessments. The facility failed to correctly identify Resident #17 and Resident #4 as having a mental illness in their PASRR Level 1 Screening and completing a PASRR Level II.This failure could place residents with documented mental illness diagnoses at risk of not receiving needed care and therapy services in the appropriate setting.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #82) of 3 residents reviewed for enteral nutrition. -The facility failed to ensure LVN A followed the appropriate procedure for verifying tube placement, administering flushes and medication during enteral tube medication administration. -The facility failed to ensure LVN A inserted small amount of air into the tube to listen for stomach gurgling sound or aspirate stomach content to check for placement. -The facility failed to ensure LVN A used the appropriates amount of water to dilute medication and to flush in between medication administration. These failures could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles and included the expiration date when applicable for 2 (400 hall cart and 600 hall cart) out of 3 medication carts reviewed for labeling and storage of drugs. The facility failed to ensure Resident # 31's Ipratropim Bromide 0.02 mg/Albuterol sulfate (a medication that helps open the airways and reduces breathing difficulties) 2.5ml/3 ml inhalation solution was labeled with the expiration date and discarded after 14 days according to facility policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents with pressure ulcers receive necessary treatments and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 (CR #1) of 5 residents reviewed for wound care. The facility failed to ensure that CR#1, who was identified as being at risk for pressure ulcer development, received necessary preventative interventions to maintain skin integrity. CR#1 was admitted to the facility on [DATE] with skin intact but was an identified risk for pressure ulcers. On 02/02/26, CR#1 was placed in her comfort chair at 1:10 p.m. and remained there until the morning of 02/03/26 at an unknown time. CNA A observed an open dark purple wound on CR #1's sacrum at 6:15 a.m. while providing peri care on 02/03/26. [...]

Inspectors wroteBased on interviews and record review the facility failed to promptly provide lab results outside of clinical reference ranges to the ordering practitioner for 1 (CR# 1) of 8 residents reviewed for lab services. The facility failed to report a critical Glucose level of 42 to the physician when CR #1 had a change in condition on 11/24/25. CR# 1 was pronounced deceased at the facility on 11/25/25 by EMS. An Immediate Jeopardy (IJ) was identified on 11/26/25. The IJ template was provided to the facility on [DATE] at 4:06 p.m. While the IJ was removed on 11/28/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide notice as soon as practicable before transfer or discharge for 1 of 5 residents reviewed for admission, transfer, and discharge. -CR #1 was notified on 10/07/25 that she had to transfer to another facility or discharge somewhere else by 10/07/25. This failure could place residents at risk of not receiving appropriate care and required notifications being made.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 7 residents (Resident #3) reviewed for care plan revisions.- The facility failed to ensure Resident #3's care plan was updated to reflect his new diet of Level 4 (food is pureed smooth with no lumps or bumps) pureed after a choking incident (7/31/25) and had Level 6 (food cut into small, bite sized pieces that are tender and soft) soft and bite sized on 9/26/25. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 7 residents (Resident #5) reviewed for oxygen.- The facility failed to ensure Resident #5 had a physician's order for oxygen, when he was being administered 3L O2 via NC on 9/26/25. This failure could place residents at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #5) reviewed for dialysis.- The facility failed to ensure Resident #5 had a physician's order for hemodialysis (machine filters the blood when kidneys do not work) on 9/26/25, when he went to dialysis 3 x week on Tuesday, Thursday, and Saturday. This failure could place residents at risk of complications of hemodialysis, not receiving proper care and/or treatment, and missed treatments.

Inspectors wroteBased on observations, interviews, and record reviews, 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 infections for 1 of 7 residents (Resident #1) reviewed for infection control. - RN N failed to wear a gown during incontinence care on 9/26/25, when Resident #1 was on EBP.- RN N failed to change her gloves during incontinence care on 9/26/25, after removing the dirty brief and putting a clean one on for Resident #1.- RN N failed to clean Resident #1's suprapubic catheter (a tube inserted into the abdomen and directly into the bladder to drain urine) away from the insertion site and instead cleaned towards the insertion site on 9/26/25. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a person-centered care plan to meet practicable physical needs for 1 (Resident #2) reviewed for care plans. Based on record reviews and interviews facility failed to develop or implement a care plan with goals or interventions related to use of adaptive devices for Resident # 2. On 10/23/2025 at 05:05 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/24/2025, the facility remained out of compliance at a severity level of isolation with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place Residents at risk of not receiving necessary care and services for not having their individual medical, physical, psychological and/or emotional needs met.

Inspectors wroteThe facility failed to provide adequate supervision to prevent accidents for 1 (Resident # 2) of 1 resident reviewed for accident and supervision. Based on record reviews and interviews, the facility failed to ensure adequate supervision when CNA C transferred Resident # 2 alone using a stand and pivot method instead of a two-person transfer. The facility failed to ensure CNA C improperly transferred Resident # 2 by performing a two person transfer alone using a stand and pivot method on 07/07/2025 at 15:20 p.m. On 10/23/2025 at 05:05 p.m., an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 10/24/2025, the facility remained out of compliance at a severity level of isolation with potential for more than minimal harm due to the facility continuing to monitor the implementation and effectiveness of their plan of Removal. [...]

Inspectors wroteThe facility failed to provide and document sufficient preparation and orientation to resident or resident's family member on the facility bed-hold policies for 1 of 5 residents (Resident # 1) reviewed for discharge. S/S 1/D Based on interview and record review, the facility failed to provide discharge notice and document sufficient preparation and orientation to residents or resident's family member on the facility's bed -hold policies for 1 of 5 Residents (Resident # 1) reviewed for discharge rights. This failure could place residents at risk of not receiving notice of the facility's bed hold policy during transfer from the facility to a hospital which could result in anxiety, distress and displacement.

Inspectors wroteThe facility staff failed to ensure residents received treatment and care in accordance with professional standards of practice in performing physician ordered daily pain monitoring for 1 of 3 residents (Resident # 2) reviewed for pain assessment. Based on record reviews and interviews the facility failed to ensure Resident # 2 was assessed for pain according to physician's orders on 07/07/2025 and 07/08/2025. This failure could place, dependent residents at risk of experiencing pain, injuries, bruises, and fractures from possible accidents which could result in a diminished quality of life and hospitalizationFindings include: Record review of Resident # 2's face sheet dated 08/18/2025, revealed an [AGE] year-old male admitted on [DATE] following a joint replacement surgery on 06/25/2025. His diagnoses included: [...]

Inspectors wroteBased on interviews, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (CR#1) of 7 residents reviewed for quality of care. The facility failed to send CR#1 to the hospital when her blood sugar was extremely low, despite EMS being called before and arriving 13 hours before her eventual transport to the local hospital. The facility failed to monitor CR#1's blood sugar for approximately 13 hours after it was documented as critically low. This lapse led to a second hypoglycemic episode during which CR#1 was found unresponsive and required emergency medical care. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 (CR#1) of 7 residents reviewed for change of condition, in that,The facility failed to consult with or establish contact with the MD or on-call medical personnel for guidance on 6/12/25 at 5:30pm, when CR#1 had a serious medical event, in which she was noted to have an altered mental status and her blood sugar was critically low. CR#1 experienced a second event 13 hours later and was noted to be unresponsive, which resulted in immediate hospitalization where she was treated for hypoglycemia and an Altered Mental Status. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and complete a baseline care within 48 hours of a resident's admission for 3 of 25 residents (Resident #18, Resident #24, and Resident #126) reviewed for baseline care plan . The facility failed to complete a baseline care plan within 48 hours of admission for Resident #18, Resident #24, and Resident #126 This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs were met.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 (Dryer #2 the one in the middle) of 3 dryers reviewed for accident hazards. The facility failed to check and clean the lint filters at appropriate times: - The facility failed to clean the lint filter in Dryer #2 for 19hrs, which caused a buildup of lint on the filter, above the filter, and around the filter. This failure could place residents at risk of harm and hospitalization by causing a fire risk to the facility.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals used in the facility were secured properly and labeled and stored in accordance with currently accepted professional principles in 1 of 2 medication carts reviewed. (Hall 500/600 cart) The facility failed to ensure the nurse's medication cart (500/600 hall) was locked. This failure could place residents at risk, by placing them at risk of drug diversions, misuse of medications, an adverse reaction, and/or not receiving the therapeutic benefits of their medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the kitchen. The facility failed to ensure on 01/28/2028 at 8:15 AM that a cling wrapped bunch of bacon in the refrigerator and cans of thickening agent were labeled and dated with the delivery date. The facility failed to ensure a bag of sausage patties was sealed. These failures had the potential to place residents at risk of serious complications from foodborne illness because of their compromised health status.

Inspectors wroteBased on observations, interviews, 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 infections for 1 of 1 facility and 2 of 4 residents (Resident #275 and Resident #278) reviewed for infection control. 1. The facility failed to ensure Resident #275 was placed on the appropriate contact isolation for E. Coli. 2. The facility failed to ensure CNA J wore appropriate PPE for EBP when providing a shower and incontinence care to Resident #278. 3. The facility failed to establish and provide documentation for a water management program as part of the infection control program. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to not employee and individual that was found guilty of mistreatment in a court of law for 1 of 12 employees reviewed (Med Aide G). The facility failed to perform an accurate criminal history background check on Med Aide G and allowed her to work at the facility for about 11 months, while she had a conviction that was an absolute bar to employment. This failure could place residents at risk for mistreatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided accurate Preadmission Screening and Resident Review (PASRR) screening for 1 (Resident #4) of 5 residents reviewed for resident assessments. The facility did not correctly identify Resident #4 as having a mental disorder on their PASRR Level 1 Screening. This failure could place residents with mental disorders at risk of not receiving specialized PASRR service which could contribute to a decline in physical, mental, psychosocial well-being, and quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #126) of 25 residents reviewed for pharmacy services. 1. The facility failed to administer two doses of Morphine Sulfate Oral Tablet 30 MG (Morphine Sulfate) for Resident #126 to prevent potential pain. 2. The facility failed to ensure the nurse's medication cart (500/600hall) did not have discontinued and/or expired medications. These failure could place residents at risk for adverse effects of pain, discomfort, increase side effects, not receiving the therapeutic effects of the medication, and a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs without adequate indications for its use for 1 of 3 residents (Resident #8) reviewed for unnecessary medications. The facility failed to ensure Resident #8's antibiotic (Bactrim-Sulfamethoxazole/Trimethoprim) was not administered after the discontinued date. This failure could place residents receiving antibiotics at risk for unnecessary and inappropriate antibiotic use and increased antibiotic-resistant infections.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 2 waste receptacles reviewed for garbage disposal. The left dumpster had its top right lid opened when no one was disposing of trash. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 2 resident reviewed for resident rights. (Resident #1 and Resident #2) Resident #1 and Resident #2 did not have a privacy covering on their catheter bags. This failure could place residents with urinary catheters at risk for decreased quality of life and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident who was incontinent of bowel/bladder and each resident with an indwelling catheter received appropriate treatment and services to prevent urinary tract infections, for 1 (Resident #1of 2 residents reviewed for incontinent care and for indwelling urinary catheters. Resident #1's catheter bag and tubing were sitting on the floor and the catheter bag was leaking. These failures could place residents with urinary catheters at risk for infections and injuries.

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 for 1 of 1 kitchen reviewed food and nutrition services. The facility failed to ensure dietary staff were wearing beard restraints who had facial hair. This failure could place resident who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 9 of 9 weekends and 2 weekdays reviewed for nursing services. - The facility failed to have registered nurse (RN) coverage for several weekends and some week days. This could place all residents at risk for not having their nursing care and medical needs assessed and met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 (Resident #8) of 1 resident reviewed for respiratory care, in that: The facility failed to set the oxygen flow rate at 2 liters of oxygen per minute as ordered on 10/24/2023for Resident #8. This deficient practice could place residents who used oxygen incorrect or inadequate respiratory support and could result in a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have the most recent survey of the facility posted in a place readily available to resident's, family members, and/or legal representatives for 10 of 10 residents reviewed for survey results. (Residents #1, #2, #4, #5, #6, #8, #63, #64, #65, #113) The facility did not have any survey results readily available to resident's, family members, and/or legal representatives. This failure could place residents, family members, and legal representatives at risk of not being informed of survey results.

Inspectors wroteBased on record review and interview the facility failed to inform the resident or his or her representative they are not required to enter into a binding arbitration agreement as a condition of admission, or as a condition to continue to receive care at the facility; and failed to inform the resident or representative they have the right to rescind or terminate the agreement within 30 calendar days of signing. Failure statement: [...]