Cascades At Jacinto Rehab Lp

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

attempt to ascertain why the resident is choosing that location;b. document that other, more suitable, options of locations that are equipped to meet the needs of the resident were presented and discussed;c. document that despite being offered other options that could meet the resident's needs, the resident refused those other more appropriate settings; andd. determine if a referral to Adult Protective Services or other state entity charged with investigating abuse and neglect is necessary. The referral should be made at

the time of discharge. Record review on 10/15/2025 of policy for Wandering and Elopements (Revised March 2019).The facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents.If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safetyIf an employee observes a resident leaving the premises, he/she should:Attempt to prevent the resident from leaving in a courteous manner;- Get help from other staff members in

the immediate vicinity, if necessary; and- Instruct another staff member to inform the Charge Nurse or Director of Nursing Services that a resident is attempting to leave or has left the premises.If a resident is missing, initiate the elopement/missing resident emergency procedure:1. Determine if the resident is out on

an authorized leave or pass;- If the resident was not authorized to leave, initiate a search of the building(s) and premises; and- If the resident is not located, notify the Administrator and the Director of Nursing Services, the resident's legal representative, the Attending Physician, law enforcement officials, and (as necessary) volunteer agencies (i.e., Emergency Management, Rescue Squads, etc.).When the resident returns to the facility, the Director of Nursing Services or Charge Nurse shall:1. Examine the resident for injuries;2. Contact the Attending Physician and report findings and conditions of the resident;3. Notify the resident's legal representative (sponsor);4. Notify search teams that the resident has been located;5.

Complete and file an incident report; and6. Document relevant information in the resident's medical record

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.

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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

10/30/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cascades at Jacinto Rehab LP

1405 Holland Houston, TX 77029

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observation, interview, and record review the facility failed to ensure Residents who are incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extend possible for 1 of 5 residents (Resident #1) reviewed for incontinent care.

CNA A failed to place the urine collection bag of the indwelling urinary catheter below Resident #1's bladder after transferring from bed to chair.The failure could place residents with indwelling urinary catheters at risk for infection from potential backflow of urine into the bladder. 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 REDACTED]. Resident #1's diagnoses included chronic kidney disease, and retention of urine.Record review of Resident #1's annual MDS dated [DATE REDACTED] 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.

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