Inspection visit
Health inspection
2 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 2 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0727
Level of Harm - Potential for
minimal harm
Residents Affected - Many
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on
a full time basis.
Based 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.
Findings included:
Record review of facility's sign in sheets dated November 2023, December 2023 and January 2024
revealed the facility had 2 shifts that runs from 6 a.m. to 6 p.m. and 6 p.m. to 6 a.m.
Record review of a timesheet for all nursing staff who worked on November 2023, December 2023 and
January 2024 reflected there was not an RN coverage on some weekends and weekdays.
Record review of the facility's monthly schedule for the month of November 2023, December 2023 and
January 2024 revealed there was no RN coverage on the following days 24 hours periods: 11/3/2023,
11/4/2023, 11/05/2023, 11/11/2023, 11/12/23 and 11/19/2023, 12/02/2023, 12/03/2023, 12/09/2023,
12/10/23, 12/16/23, 12/17/23 and 12/24/23, 1/6/24, 1/7/24, 1/21/24, 1/27/24, 1/28/24 and 1/30/24
Record review of the facility's sign in sheet for the month of November 2023, revealed there was no RN
coverage on 11/3/2023, 11/4/2023, 11/05/2023, 11/11/2023, 11/12/23 and 11/19/2023 (weekday).
Record review of the facility's sign in sheet for the month of December 2023, revealed there was no RN
coverage on 12/02/2023, 12/03/2023, 12/09/2023, 12/10/23, 12/16/23, 12/17/23 and 12/24/23 (weekday).
Record review of the facility's sign in sheet for the month of January 2024, revealed there was no RN
coverage on 1/6/24, 1/7/24, 1/21/24, 1/27/24, 1/28/24 and 1/30/24
During an interview on 01/30/24 at 09:30 AM, regarding the RN coverage, the Administrator stated that the
facility's DON was out for a surgical procedure and they did not have an RN on 1/30/24. Administrator said
she was an RN and she can function as a nurse also.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 3
Event ID:
676436
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676436
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Thrive Rehabilitation of Pearland
3406 Business Center Drive
Pearland, TX 77584
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0727
Level of Harm - Potential for
minimal harm
Residents Affected - Many
During an interview on 01/30/2024 at 12:00 PM, the Administrator stated that the facility had struggled to
provide 8-hour RN coverage. She stated that she was trying to get an RN from nursing agency. She stated
when they do not have RN coverage, they rely on their LVNs and she lives 2 miles away from the facility
and most of the weekends she takes calls.
During an interview on 01/30/2024 at 3:45 PM, the Administrator stated that it had been a struggle to
provide RN coverage. She knew that LVNs were supposed to work under RN supervision and the facility did
not have any staffing waivers.
During an interview on 01/30/ 24 at 3:45 PM, the Administrator stated that the facility does not have any
specific staffing policies on RN coverage. She stated that they follow state regulation that the facility should
have a registered nurse for at least 8 consecutive hours a day. She stated she would be hiring RN next
week.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676436
If continuation sheet
Page 2 of 3
Printed: 05/15/2026
Form Approved OMB
No. 0938-0391
Department of Health & Human Services
Centers for Medicare & Medicaid Services
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENTIFICATION NUMBER:
(X2) MULTIPLE CONSTRUCTION
676436
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
01/30/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Thrive Rehabilitation of Pearland
3406 Business Center Drive
Pearland, TX 77584
For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.
(X4) ID PREFIX TAG
SUMMARY STATEMENT OF DEFICIENCIES
(Each deficiency must be preceded by full regulatory or LSC identifying information)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based 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.
The findings were:
Observations on 01/30/24 10:53 AM revealed [NAME] A was not wearing beard restraint/beard guard with
approximately a 1/2 inch to 1 inch beard to his chin. [NAME] A was further observed taking dishware from
the dish room area throughout the kitchen and hanging cooking utensils above the food prep table near the
steam table.
Observations on 01/30/24 at 11:30 AM revealed [NAME] A cooking without a beard restraint/beard guard.
During an interview on 01/30/24 at 11: 50 AM, [NAME] A said he had not been wearing a beard guard and
that hair restraints. [NAME] A said he did not have any beard net and had been working with the facility for
2 weeks. He DM was not available. He further stated by not wearing a beard guard, it could cause food
contamination.
During an interview on 01/30/24 at 3:42 PM., the Administrator stated [NAME] A should have been wearing
a beard guard because he used to work with the Military. The Administrator provided cook A with a face
mask to use to cover his facial hair.
Administrator further stated by not wearing a beard guard, it could allow hair to fall in the food on dishes
and spread germs.
Record review of the facility's policy titled Nutrition Services Policies and Procedures, revised 06/2019,
revealed Subject: Dress Code, Policy: The Nutrition/Culinary Services Department employees will adhere to
a facility dress code that facilitates safe, sanitary meal production and service, and will present a
professional appearance .Procedures: Culinary staff involved in food production adheres to the department
dress code that includes: . 12. Appropriate hair restraints (such as hats, hair covers or nets, beards
restraints) while involved food production activities.
Record review of the Federal Food Code 2022 reflected:
2-402.11 Effectiveness. (Hair Restraints) 1. Code of Federal Regulations, Title 21, Sections 110.10
Personnel. (b) (1) Wearing outer garments suitable to the operation (4) Removing all unsecured jewelry (6)
Wearing, where appropriate, in an effective manner, hair nets, head bands, caps, beard covers, or other
effective hair restraints .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
676436
If continuation sheet
Page 3 of 3
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Back to topCitations
2 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F727 - Except when waived under paragraph (f) or (g) of this section, the
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the January 30, 2024 survey of Thrive Rehabilitation of Pearland?
This was a inspection survey of Thrive Rehabilitation of Pearland on January 30, 2024. The surveyor cited 2 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at Thrive Rehabilitation of Pearland on January 30, 2024?
Yes, 2 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full tim..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.