Cascades At Galveston

F 0725 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

hemiparesis following nontraumatic intracerebral hemorrhage affecting left non-dominant side and cirrhosis of liver (a chronic condition where healthy liver tissues is replaced by scar tissue, leading to impaired liver function). He was [AGE] years old. Record review of Resident #4's quarterly MDS assessment dated [DATE REDACTED] revealed he had a BIMS of 14, indicating no cognitive impairment. He was frequently incontinent of urine and bowel, was dependent on staff for transfers and required substantial/maximal assistance with toileting hygiene. In an interview on 10/16/25 at 11:55am, Resident #4 said during the evening shift, the staff were lazy. He said they waited more than 2 hours for assistance and had to be wet and nasty until they come help with incontinent care. He said took his brief off and threw it on the floor so he his skin did not break down. In an interview on 10/28/25 at 9:44pm, RN B said the staffing ratios for the facility could be better. She said they used to schedule 3 nurses each shift, but now they scheduled 2 nurses with 4 CNAs.

She said they met the residents' needs, but said the residents deserved more attention. Record review of a Resident Council Department Recommendation/Concern dated 10/3/2025 and signed by the ADON, revealed the residents voiced a concern about the night shift staff only changing residents one time right

before shift change, and noted sometimes they did not see the CNAs. The ‘Department Response' section stated observations of night shift were conducted and staff were observed making rounds and answering call lights. The ‘Resolution' section stated, staff were reminded of the importance of maintaining skin integrity by ensuring (every 2 hour) rounds for peri-care, turning and repositioning. In an interview on 10/29/25 at 3:52pm, the Administrator said they used the facility's PPD and census to create the facility's nursing staff schedule. He said he made sure the ratio of CNAs to residents was 1:15. He said if they took into account the higher functioning residents then it was feasible. He said according to the facility's star rating, they had more staff than the national average. He said when they received a grievance from resident council, he visited the facility at night a few times to observe. He said he did not observe any issues with the care being provided. In an interview on 10/29/25 at 4:42pm, the ADON said the facility had a weekly scheduling meeting to create the schedule. She said they used the facility census and PPD (a metric used to analyze costs and staffing) to determine how many staff to schedule. She said she attended the weekly scheduling meeting with the CNA Coordinator and DON. She said they did not have a DON at that time.

She said she was not sure if the facility looked at resident's acuity when creating the schedule, but that it could be important to look at. In a telephone interview on 10/29/25 at 5:15pm, the CNA Coordinator said

they had a weekly scheduling meeting to create the schedule. She said they used the facility census and PPD to determine how many staff to schedule. She said she used what she knew about the residents, including how many brief changes each resident required throughout the day, to create the staff assignments. Record review of the facility assessment, dated 4/30/25, revealed it did not include information regarding the level of staff needed to meet the needs of each resident. Record review of the facility policy for Sufficient and Competent Nursing dated August 2022 read in part, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to providing nursing and related care and services for all residents in accordance with resident care plans and the facility assessment.staffing numbers and the skill requirements of direct care staff are determined by the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

11/25/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cascades at Galveston

3702 Cove View Blvd Galveston, TX 77554

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 0838 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

FORM CMS-2567 (02/99) Previous Versions Obsolete

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Based on interview and record review the facility failed to ensure the facility assessments were documented and facility-wide assessments determined what resources were necessary to care for residents competently during both day-to-day operations and emergencies for 1 of 1 facility (Facility) reviewed for facility assessment. The facility failed to ensure the facility assessment contained information regarding the level of staff needed to meet the needs of each resident. This failure could place residents at risk of inadequate care or treatment. Findings include: Record review of the facility assessment, dated 4/30/25, revealed it did not include information regarding the level of staff needed to meet the needs of each resident. In an interview on 10/29/25 at 3:52pm, the Administrator said he was unsure if the facility assessment included the level of staff needed. He said they did not use the facility assessment when creating the nursing staff schedule. He said they used the facility's PPD and census. He said he made sure

the ratio of CNAs to residents was 1:15. He said if they took into account the higher functioning residents then it was feasible. He said according to the facility's star rating, they had more staff than the national average. Record review of the facility assessment policy (undated) read in part, A facility assessment is conducted annually to determine and update the capacity to meet the needs of and competently care for residents during day-to-day operations (including nights and weekends) and emergencies.the facility assessment is used to inform staffing decisions. staffing needs are considered for each shift, including day, evening and night shifts, and adjusted as necessary based on changes in the resident population. Record

review of the facility policy for Sufficient and Competent Nursing dated August 2022 revealed in part, Our facility provides sufficient numbers of nursing staff with the appropriate skills and competency necessary to providing nursing and related care and services for all residents in accordance with resident care plans and

the facility assessment.staffing numbers and the skill requirements of direct care staff are determined by

the needs of the residents based on each resident's plan of care, the resident assessments and the facility assessment.

Event ID:

Facility ID:

If continuation sheet