Jacinto Nursing And Rehabilitation Center
Jacinto Nursing and Rehabilitation Center 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.
Inspection Findings
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:
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.