Health inspection·November 28, 2025

F 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.These failures could place residents at risk of delay in care, worsening of health conditions, adverse reactions, hospitalization, and death.Findings included:Record review of CR #1's undated face sheet indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of malignant neoplasm (cancerous tumor) of lower-inner quadrant of left female breast, secondary and unspecified malignant neoplasm of axilla (the space below the shoulder through which vessels and nerves enter and leave the upper arm) and upper limb lymph nodes, secondary neoplasm of bone, secondary neoplasm of unspecified adrenal gland, anemia (a condition of not having enough healthy red blood cells to carry oxygen to the body's tissues) in neoplastic disease, chronic combined systolic (congestive) and diastolic (congestive) heart failure, and acute kidney failure (rapid loss of the kidney's ability to remove waste). Further review of CR #1's face sheet under Advanced Directive indicated she was full code.Record review of CR #1's MDS dated [DATE] indicated she had a BIMS score of 15 indicating cognition was intact.Record review of CR #1's orders with a start date of 11/16/25 indicated vital signs to be taken every shift.Record review of CR#1's baseline care plan dated 11/6/25 revealed she needed nursing services for the following: wound management, pain management, laboratory testing, dialysis treatment, oncology, and physician services-other specialty/clinic follow-up appointment.Record review of CR #1's care plan dated 11/16/25 indicated she needed hemodialysis r/t ESRD. Interventions included: check and change dressing daily at access site, document. Do not draw blood or take B/P in arm with graft. Monitor labs and report to doctor as needed. Monitor vital signs/labs. Notify MD of significant abnormalities. The client is at risk of abnormal vital signs and labs r/t current diagnosis and conditions.Record review of progress note dated 11/24/25 at 8:00 pm entered by LVN B, read, late entry: guest was clean and dry at this time. Hands are cold to touch and O2 could not be obtained at this time. Guest responding verbally to baseline.Record review of progress notes dated 11/24/25 9:30pm by LVN B documented O2 obtained at this time. Hands are warm to the touch. Pulse oximetry measures 94% on RA.Record review of progress notes dated 11/25/25 12:54 am by LVN B documented Spoke with representative from Clinical Lab. Blood glucose measured 42. Blood was drawn at dialysis between 1:00pm-2:00pm. MD notified.Record Page 1 of 7 676436 676436 11/28/2025 Thrive Rehabilitation of Pearland 3406 Business Center Drive Pearland, TX 77584

F 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few review of the Lab Results Report dated 11/25/25 indicated a low critical glucose value of 42.During a telephone interview with the Family Member on 11/25/25 at 12:33 pm, the Family Member said a family friend was there to visit CR #1 around 8:00 pm on 11/24/25 and the family friend told her CR #1 was fine. The Family Member said RN A told her the last set of vitals for CR #1 were taken at 10:30 pm on 11/24/25.During a telephone interview with CNA B on 11/25/25 at 12:49 PM, she said she checked on CR #1 between 5:45 am to 5:50 am on 11/25/25. CNA B said she went into CR #1's room and told her I'm going to check on you before I leave. CR #1 responded to CNA B softly mmm, ok. CNA B said the last set of vitals for CR #1 were done around 10:00 pm on 11/24/25. CNA B said she had a hard time getting an O2 reading because CR #1's hands were extremely cold. CNA B said she reported this to LVN B. CNA B said she and LVN B even tried to take an O2 reading from CR #1's toes and that did not work. CNA B said LVN B went in about 30 minutes later and was able to take the O2 reading. During a telephone interview with LVN B on 11/25/25 at 12:59 PM, she said the last time she saw CR #1 was at 5:00 AM (11/25/25). LVN B said she peeked into the room and saw that CR #1 was sleeping, no vitals were taken at that time. LVN B said the night before on 11/24/25, she and CNA B had trouble getting an O2 reading for CR #1. LVN B said she waited and came back later and was able to get a reading, she said the O2 reading was above 92. LVN B said the chest x-ray was done last night on 11/25/25 between 1:45 am and 2:45 am, she could not remember the exact time.During an interview with CNA A on 11/25/25 at 10:54 AM, she said during shift change this morning (11/25/25), CNA B told her all residents in the 600 hall were checked at approximately 4:00 am and everyone was fine. CNA A said at 6:30 am she went to CR #1's room to take her vitals and she was not responsive. She said CR #1 was lying on her back in bed and her fingers were cool. CNA A said she told RN A that CR#1 was not responsive. CNA A said when EMS arrived, the EMTs had stated CR #1 had been gone awhile. CNA A said on 11/24/25, CR #1 was confused and anxious. CNA A said she immediately reported the change to RN A on 11/24/25. CNA A said CR #1 left for dialysis the morning of 11/24/24 and returned later that evening. She said CR #1 seemed more settled and not as anxious when she returned from dialysis.During a follow-up interview with CNA A on 11/26/25 at 11:00 am, she said CR #1's baseline was vibrant and responsive, she would be able to let staff know if something was wrong. CNA A said on the morning of 11/24/25, CR #1 was quite confused, and she was making statements that did not make any sense. CNA A said CR #1 would press the call light and she when entered her room, CR #1 did not need anything. CNA A said after she turned off the call light, and before she could exit the room, CR #1 would press the call light again. CNA A said this happened multiple times on the morning of 11/24/25. CNA A said when CR #1 returned from dialysis that evening, CR #1 was calmer, and she ate a little bit of her food which was normal for her. CNA A said the last time she saw CR #1 was towards the end of her shift (6:00 pm) and said CR #1 was calm, clean, and content.During an interview with RN A on 11/25/25 at 10:37 AM, she said she did her walking rounds on 11/25/25 at 6:00 am. RN A said she looked into CR #1's room from the doorway and CR #1 appeared to be sleeping. RN A said at 6:35 am, CNA B alerted her that she could not get vitals off CR #1 and CR #1 was cold. RN A immediately called for a crash cart, nursing backup and initiated CPR. RN A said she called 911 around 6:40 am and said it was not very long before EMS arrived because they were located right around the corner from the facility. RN A said when EMS arrived, they took over. RN A said the EMTs rolled CR #1 over and told her there was pooling of blood in her back and there was no use to do CPR anymore. She said EMS called the death at 7:05 am. RN A said the day before (11/24/25), CR #1 was not feeling well. RN A said the NP ordered for labs to be drawn at dialysis, CBC, BMP and ordered a stat chest x-ray. RN A said she did not document a change of condition because the NP was in the building, and the NP saw CR #1 that same day. RN A said CR #1 676436 Page 2 of 7 676436 11/28/2025 Thrive Rehabilitation of Pearland 3406 Business Center Drive Pearland, TX 77584

F 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few came back from dialysis at the end of her shift yesterday (11/24/25), at approximately 6:00 pm. RN A said the risk to the resident when they are not provided treatment in a timely manner could compromise their health and they could die.During a follow-up interview with the Family Member on 12/1/25 at 3:16 pm, the Family Member said no one had notified her about CR #1's change of condition on 11/24/25. The Family Member said about a week before CR #1 passed away, the MD had recommended for blood work to be taken at dialysis because the lab people were having a hard time drawing her blood. The Family Member said CR #1 had disappearing veins. The Family Member said RN A told her the night shift had a hard time taking CR #1's vitals on 11/24/25. The Family Member said CR #1 should have been checked at least every 2 hours because she had to be repositioned.During a telephone interview with the NP on 11/28/25 at 12:46 pm, she said on the morning of 11/24/25, RN A told her CR #1 was feeling weak. The NP said she ordered some labs and a chest x-ray. The NP said she saw CR #1 on 11/24/25 before she left for dialysis and CR #1 told her she was feeling ok. The NP said no one contacted her for the results of the x-rays or labs, but she did see the results the on her computer the next morning. The NP said a blood glucose level of 42 was a result she saw often. She said if CR #1 was on any type of medication for low blood glucose levels, she would have reviewed the medications and ordered an A1C . The NP said she could not recall CR #1 having medication for low blood glucose level. She said for a one-time low blood glucose level, the sample could have been sitting around for a while.During a follow-up telephone interview with LVN B on 11/26/25 at 11:39 AM, she said she attempted to contact the MD on 11/25/25 at about 1:00 am to let her know the lab results. LVN B said she could not get a hold of the MD, so she sent a text, but never got a response. LVN B said in the event of an emergency she would contact the DON. LVN B said when she saw the lab results, she thought that the low number for glucose was completely off because CR #1's blood was collected between 1 and 2 pm, and her blood was dialyzed. LVN B said the facility's lab technician picked up the blood 4 to 5 hours later. She said she did not attempt to call anyone else about the low blood glucose level. LVN B said she talked to CR #1 on the evening of 11/24/25 and she was at her baseline when she talked to her. LVN B said the risk to the resident when a critical lab result was not reported to the physician was theoretically their health could get worse from not feeling good, to getting rushed to the hospital, or even death. LVN B the same risks could apply to a resident when a change of condition occurred, and the resident was not closely monitored.During an interview with the DON on 11/25/25 at 4:59 PM, she said the CNAs take vitals for the nurses and med aides. The DON said if there was an abnormal reading from the vitals, the CNA would redo the vitals and if the reading was still abnormal, this would get reported to the nurse. The DON said the expectation for nurses when they are rounding was to get the report from the nurse for the previous shift; in the morning, the nurse should check that the resident was in bed, make sure they're breathing . She said in the afternoon when nurses make the rounds, they should be checking residents to see if they are awake and alert. The DON said the nurse should notify her or the MD if there were any abnormal readings or having trouble with getting a reading for vitals. The DON said when a critical lab result was not reported to the physician, the nurses should physically look at the resident to see if they were ok. She said if the lab results were skewed, the nurses may need to get another order for a lab draw to get a valid number. The DON said the risk to the resident when a critical lab result was not reported would result in a delay of care. The DON said the risk to the resident when a change of condition occurred, and the resident was not closely monitored was the resident would continue to decline.Interview with the Administrator on 11/26/25 at 4:00 pm, she said the system they used for CR #1 with having her blood drawn at dialysis instead of the facility was not a good one. She said CR #1 refused to get her blood drawn at 676436 Page 3 of 7 676436 11/28/2025 Thrive Rehabilitation of Pearland 3406 Business Center Drive Pearland, TX 77584

F 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few the facility. The Administrator said LVN B should have called the DON first and then the Medical Director since she was unable to get a hold of the doctor. The Administrator said the risk to the resident when a critical lab result was not reported to the physician was, they could decline or die. The Administrator said the risk to the resident when a change of condition occurred, and the resident was not closely monitored was they could decline or die.Record review of the facility's Job Description for Licensed Vocational Nurse dated 05/2017 read in part . 6. Position Responsibilities/Duties: b. completes initial and ongoing assessments by gathering data in a timely manner, incorporating functional/development age factors into the assessment process. c. correctly differentiates between normal and abnormal clinical findings and intervenes in accordance with clinical standards of practice and per physician orders. f. proficiently and accurately monitors and reports resident condition changes to the Registered Nurse, attending physician, family, and interdisciplinary team members .Record review of the facility's policy titled Change of Condition, dated 08/2017 read in part . 1. Acute medical changes or any sudden or serious change in condition manifest by a marked change in physical, mental, and psychosocial status: a. Licensed nurse will notify the physician, b. If unable to contact attending physician or alternate physician, notify the Medical Director. c. Notify and inform legal surrogate for any change of condition. 2. Using the Interact Tool SBAR - notify physician for all signs and symptoms manifested by the patient. The form will be used to initiate change of condition documentation for any decline or improvement .On 11/26/25 at 4:06 p.m., the Administrator was informed that an Immediate Jeopardy situation was identified due to the above failures.The following Plan of Removal was submitted by the facility and accepted on 11/27/25 at 10:07 a.m.:The following was the Immediate Plan for Removal for F684 Quality of Care Version 2. 1. Corrective and appropriate actions to be implemented for the affected residents identified in the deficiencies.1. Immediate Action: Upon discovery of CR #1 unresponsive on 11/25/25, RN A initiated CPR immediately after being notified by CNA B that no vital signs could be obtained. 911 was called at approximately 6:40 AM, and EMS assumed care upon arrival. When EMS determined the presence of post-mortem changes and pronounced death at 7:05 AM, the resident was respectfully prepared, and family/representatives were notified according to facility protocol.2. Immediate Action: RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition on 11/26/25. During this education, the DON/designee reviewed the Handoff Communication policy to clarify what are the expectations of correctly rounding residents at end and beginning of the shift.3. Immediate Action: CNA B and LVN B were provided with 1:1 education by DON/designee on how to obtain vital signs on 11/26/25 according to vital signs policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with both employees to clarify when immediate notification with licensed nurse or RN supervisor and/or physician notification is required for abnormal vital signs.4. Immediate Action: LVN B received 1:1 education from the DON/designee on the proper steps for reporting critical lab results and abnormal vital signs in accordance with the facility's Change of Condition policy. During this education, the DON/designee reviewed the Change of Condition file attachment to the policy with LVN B to clarify when immediate physician notification is required for critical labs and abnormal vital signs. The training education of LVN B reinforced the requirement to contact the Medical Director when the attending physician or NP is not available, ensuring timely escalation and resident safety. 5. Immediate Action: Inservice training was provided by DON/designee initiated on 11/26/2025 with all CNAs on when vitals signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed. Training initiated on 11/26/25 with 12 total 676436 Page 4 of 7 676436 11/28/2025 Thrive Rehabilitation of Pearland 3406 Business Center Drive Pearland, TX 77584

F 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few provided by DON/designee initiated on 11/26/2025 with all licensed nurses. Staff will not be allowed to provide direct care until training has been completed. Training initiated on 11/26/25 with 10 total licensed change of condition evaluation for residentsb. Notifying physicians for any change of conditionsc. Notifying the party responsible for change of conditions.d. Notifying Medical Director in case of attending physician not answering calls.e. Reporting critical and abnormal lab results to physician or covering physicianf. Reporting abnormal vital signs to physicians or covering physiciansg. Performing walking rounds at beginning and end of shift were doorway check only are not permitted unless preferred by the patient.2. Governing Body - QAPI committeea. Immediate Action: During the ad hoc QAPI Committee meeting on 11/26/25, a root cause analysis (RCA) revealed multiple system-level factors that contributed to the poor medical event follow up which includes handoff communication issue, monitoring follow up, training and possible competency gaps and timely physician notification. The RCA identified the root cause as the proper communication and handoff follow up for identified care issues and physician notification for changes of conditions for any medical events.b. The NHA will oversee corrective actions initiated on 11/26/25 and monthly thereafter during QAPI meetings which are based on the results of the RCA and plan of corrections for the findings during the survey. Any corrective actions not meeting the 100% compliance benchmark, as determined by medical records audits, medication administration pass audit will be reviewed and revised with the QAPI Committee for revision, further evaluation, and recommendations, with a designated person IDT member assigned to each corrective action. c. Any new issues found during medical record audits and medication pass administration audit will be presented to the QAPI team members for immediate action. The DON will monitor the immediate actions for implementation of monitoring/audit needs at least monthly for the next 3 months or until compliance is 100% or is achieved.3. Specific staff involved in implementing the corrective actions.a. Team Members: Medical Director, Nursing Home Administrator (NHA), Director of Nurses (DON), Assistant Director of Nurses (ADON). Each member will perform:i. Medical Director: Through the QAPI committee, the Medical Director will monitor the system, recommend changes, and oversee corrective action plans. This role includes identifying and implementing medical interventions to reduce medical events.ii. NHA: The NHA will oversee all corrective actions initiated on 11/26/25 and continue monthly reviews during QAPI meetings.iii. DON: The DON will oversee the investigation, reporting, and resolution of medication administration errors, ensuring patient safety and regulatory compliance. The DON will implement corrective actions, conduct audits, monitor staff adherence to policies, and collaborate with the ADON to provide ongoing training, reinforcing best practices in medication management.iv. ADON: This role will include educating staff and plays a critical role in addressing medical events intervention by providing targeted training and education to licensed nursing staff, ensuring compliance with facility policies and regulatory standards. The role includes conducting in-service sessions on proper medication administration, change of condition, overseeing competency evaluations, and implementing corrective action plans to prevent future errors while promoting a culture of accountability and continuous improvement.4. Identification of other residents who may need to be included (who may have been affected by the deficient practice:a. All residents were identified to be at risk for the identified deficient practice. On 11/26/2025, a random audit of all in-house patients was completed by DON/designee and found a total of 8 residents have abnormal vital signs that needed to be reported to physicians. i. A random audit of all vital signs taken on 11/26/2025 for all 60 residents completed by DON or designee showed that there was a total of 8 676436 Page 5 of 7 676436 11/28/2025 Thrive Rehabilitation of Pearland 3406 Business Center Drive Pearland, TX 77584

F 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few residents potentially affected by the deficient practice. The assigned licensed nurse completed a review of the abnormal vital signs and was reported to the attending physician. ii. A random audit of all vital signs taken on 11/24/25 for NOC shift when incident happened was completed by DON or designee using the exception report from EMR and showed that there was a total of 8 residents meeting criteria. The following reviews and interventions were conducted by the 8 residents:1. BP monitoring parameters for 1 resident that is not on antihypertensive medication were added after the physician was notified.2. BP monitoring parameters for 1 resident that is below 100 SBP after the physician was notified.3. PR parameter for 1 resident that is not on any ACE, ARBs , Calcium or beta blocker was added after physician notification.4. 2 resident triggered as abnormal but after review is within normal limits of resident range of BP.5. 3 residents had over 100 PR but have medications administered5. Systemic Changes and Measures:iii. System Change: Training in change of condition, monitoring and reporting.6. Systemic Changes and Measures:a. System Change: Training in change of condition, monitoring and reporting will be included for new hires and will be reviewed yearly by DON and DSD during the annual performance review. The annual training calendar will include change of condition monitoring for its annual in-service for licensed nurses and CNAs beginning the month of November 2025. b. System Change: Starting 11/26/25, the ADON/designee will conduct a random audit of residents with change of condition to determine that physicians were notified following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.c. System Change: Starting 11/26/25, the ADON/designee will conduct a random audit of residents with change of condition to determine that monitoring occurred for 72 hours following an identified change of condition. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.d. System Change: Starting 11/26/26, weekly for 2 weeks and monthly thereafter 3 months, a random verification of licensed nurses' knowledge and training will be conducted by ADON/designee using a mock change of condition drill to test responses of nurses on what conditions including abnormal vital signs will be reported to physicians. Any findings will be reviewed with the DON for review, analysis and implementation of necessary corrective actions.7. Training and Education Started on 11/25/2026 by DON and/or Designee.a. Immediate Action: RN A provided 1:1 in-service by DON/designee on performing walking rounds and correctly entering resident rooms to visually observe and verify respiratory status and condition on 11/26/25.b. Immediate Action: CNA B and LVN B were provided 1:1 education by DON/designee on how to obtain vital signs on 11/26/25c. Immediate Action: LVN B was provided 1;1 education by DON/designee on reporting critical lab and reporting abnormal vital signs and on contacting Medical Director in case attending physician is not available.d. Immediate Action: Inservice training was provided by DON/designee initiated on 11/26/2025 with all CNAs on when vital signs should be obtained and reporting immediately to licensed nurses. Staff will not be allowed to provide direct care until training has been completed. Training initiated on 11/26/25 training was provided by DON/designee initiated on 11/26/2025 with all LNs. Staff will not be allowed to provide direct care until training has been completed. Training initiated on 11/26/25 with 10 total LVN and of condition evaluation for residentsii. Notifying physicians for any change of conditionsiii. Notifying the party responsible for change of conditions.iv. Notifying Medical Director in case of attending physician not answering calls.v. Reporting critical and abnormal lab results to physician or covering physicianvi. Reporting abnormal vital signs to physicians or covering physiciansvii. Performing walking rounds at beginning and end of shift were 676436 Page 6 of 7 676436 11/28/2025 Thrive Rehabilitation of Pearland 3406 Business Center Drive Pearland, TX 77584

F 0773 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few 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. 676436 Page 7 of 7