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Complaint Investigation

Cascades At Jacinto Rehab Lp

October 30, 2025 · Houston, TX · 1405 Holland
Citations 2
CMS Rating 2/5
Beds 148
Provider ID 675231
Healthcare Facility
Cascades At Jacinto Rehab Lp
Houston, TX  ·  View full profile →
Inspection Summary

Cascades at Jacinto Rehab LP in Houston, TX — inspection on October 30, 2025.

Found 2 citations. 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.

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Inspection Findings

FF0689
Quality of Life and Care Deficiencies
Immediate Jeopardy

During an interview on 10/30/2025 between 9:17am and 11:13am CNA P, LVN W, CNA C, CNA V, HSK B, AA L, LVN G, LVN, M and CNA H and between 11:56am and 1:48pm CM M, CNA A, CNA W, LVN M, were able to state they were in-services on elopement.

Staff stated once it is announced that a resident has eloped from the facility they immediately begin checking all areas in the facility, to include all closed off spaces. If the resident is not found inside the facility, teams are formed to monitor the inside and a thorough search is conducted outside of the facility by a team. If the resident is not located within a perimeter of 5-10 minutes from the facility, Law Enforcement must be contacted, along with ADMN and DON to start an official investigation and file an incident report with State.

During an interview with Ombudsman R on 10/30/2025 at 11:26am he stated he was unaware of any resident eloping from the secured unit from a window and he could not provide any information regarding the elopement.

Observation of Elopement Drill on 10/30/2025 at 11:28am revealed the announcement of a missing resident over the intercom and to follow elopement procedure to locate the resident safely.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/30/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Cascades at Jacinto Rehab LP

1405 Holland Houston, TX 77029

SUMMARY STATEMENT OF DEFICIENCIES

Findings included:Record review of Resident #1's face sheet dated 10/16/25 revealed a [AGE] year old admitted to the facility on [DATE]. Resident #1's diagnoses included chronic kidney disease, and retention of urine.

Record review of Resident #1's annual MDS dated [DATE] revealed a BIMS score of 10 out of 15 indicating moderate impaired cognition. Resident #1 was dependent on staff for most ADLs and had an indwelling urinary catheter.

Record review of Resident #1's undated care plan included the following: * Resident #1 had renal insufficiency r/t acute kidney disease and acquired absence of kidney.

Goal included: The resident will be free from infection through the review date, target date was 11/29/25.

Interventions included: monitor for signs and symptoms (s/sx) of acute renal failure. *Resident#1 had a foley catheter d/t obstructive uropathy and urinary retention.

Goal: The resident will show no s/sx of urinary infection through the review date.

Interventions did not include keep urinary foley bag at a level below the resident's bladder.

Record review of Resident #1's active order summary report dated 10/16/25 revealed and order for Cefdinir 300 mg capsules by mouth two times a day for urinary tract infection (UTI) for 7 days.

Start date was 10/11/25.Observation on 10/15/25 at 1:35PM, Resident #1 was asleep in a recliner inside the resident's room.

The urine collection bag was hooked on the armrest of the recliner which was at a level above Resident #1's bladder.

In an interview and observation on 10/15/25 at 1:35 PM, LVN B stated the urine collection bag was higher than Resident #1's bladder and it should not be at or above the bladder d/t risk of infection as the urine could back up into the bladder. LVN B stated Resident #1 was being treated for a UTI. LVN B repositioned the urine collection bag below the level of the bladder.In an interview on 10/15/25 at 1:45PM, CNA A stated she and another CNA transferred Resident #1 from the bed to the recliner at 10:15 AM and said the collection bag should be below the bladder. CNA A stated the risk would be infection. CNA A asked the surveyor if she left the bag in the wrong place. CNA A stated she was rushing to get to another resident after transferring Resident #1.In an interview on 10/15/25 at 1:57 PM, the DON stated urinary collection bags should be below the level of the bladder for drainage and the risks were infection such as UTI.

The DON stated Resident #1 gets UTI's frequently due to refusals of care.

The DON stated the CNA's were responsible to ensure the urine collection bag was placed properly.

Record review of the facility policy for Urinary Catheter Care revised on August 2022 read in part: The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.Maintaining Unobstructed Urine Flow.3.

Position the drainage bag lower than the bladder at all times to prevent urine from flowing back into the urinary bladder.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Houston, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Cascades at Jacinto Rehab LP or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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