Cascades At Port Arthur

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

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

identify what Elopement is, who to report any residents displaying exit seeking behaviors and steps for staff to take to de-escalate resident behaviors. Staff indicated they were to be aware of resident behaviors, monitor for exit seeking behaviors. Staff were able to state elopement risk factors, elopement prevention strategies, required staff response if an elopement occurs, and keys points to remember. All staff were able to identify the responsibilities for supervision and monitoring residents with any exit seeking behaviors.

During these interviews, staff stated they had received in-service training about the facility's elopement policies and procedures, including the charge nurse's responsibility and ensure they checked the elopement binder to know who's at risk for elopement. The staff stated they felt confident in identifying exit seeking behaviors. Record review of the 1:1 monitoring document dated 09/17/2025 indicated the documentation was not completed accurately. The 1:1 monitoring document reflected the following:On the time slot for 10:45 a.m. - 11:45 a.m. there was no staff initials on the line to confirm Resident #1 was being monitored.- On the time slot for 6:00 p.m.- 11:45 a.m. there was a line from 6:00 p.m. to 11:45 a.m. stating no issues. - On the time slot for 7:45 p.m. stated no issues. - On the time slot for 11:00 p.m. stated no issues. During an interview on 09/17/2025 at 2:00 p.m. the DON said it was her responsibility to ensure the 1:1 monitoring sheet was being filled out accurately. Resident #1 was transferred to another facility 09/18/2025 at 5:15 p.m. An IJ was identified on 09/14/2025. The IJ template was provided to the facility on [DATE REDACTED] at 4:10 p.m. While the IJ was removed on 09/19/2025, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because all staff had not been trained on Elopement.

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

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cascades at Port Arthur

6600 Ninth Ave Port Arthur, TX 77642

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 0755 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

orders were to be checked on the next workday. During a joint interview on 09/19/2025 at 12:55 p.m., LVN F said she had been employed at facility since April 2025. LVN F said she had been trained in admissions.

She said anytime she would be expecting admission, she would request all discharge records prior to transfer. She said she would verify the resident's name, date of birth , and medications. She said upon arrival at the facility, a verification was made by asking residents their name and date of birth , or by looking at hospital bracelets, or verify if the family was present. LVN G agreed with LVN F comments and added when notifying physician of admission and verification of medications, she would also ensure the resident orders were complete as in route, frequency, rationale, and duration. LVN F said anytime medications were questioned, the physicians were quick to respond to calls made by nursing staff. LVN G said when notifying physician to verify medications, they name every medication to the physician. Review of facility policy titled Reconciliation of Medications on Admission, with a revision date of July 2017, indicated The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Review the list carefully to determine if there are discrepancies/conflicts.The facility took the following actions to correct the noncompliance prior to the investigation:-Record review of an Employee In-service

Record dated 02/10/2025 indicated the facility in-serviced the staff on verifying all information on new admissions as correct and with the correct residents' information. The in-service was conducted by LVN F with an audience of licensed staff. Seventeen licensed staff were in-serviced. - During an interview on 09/19/2025 at 11:50 a.m., the DON said nursing administration implemented for the ADON to perform daily medication checks with orders for newly ordered medications and new admissions during the morning meetings. -Record review of an audit of new admissions indicated the facility monitored 16 new admissions from 01/21/2025 through 02/10/2025 for accuracy 5 times/week for 4 weeks with no negative outcome. -During interviews throughout the investigation from 02/16/2025 at 08:30 a.m. through 02/22/2025 at 5:15 p.m., the licensed staff were aware to verify new medications or new admission residents' medications by calling the physician to verify. (ADON, LVN A, LVN B, LVN E, LVN F, LVN G, LVN H, LVN J, and LVN K) -Record review of 19 new resident admission's clinical record from 09/21/2025 -09/22/2025, revealed the Order Summary, discharge paperwork from recent hospital visits, MAR, history and physicals, etc. indicated no errors in transcribing orders or orders being overlooked. (Resident #s 2, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18, 19, 20, and 21) The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. The facility had corrected the noncompliance before the state's investigation began.

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

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cascades at Port Arthur

6600 Ninth Ave Port Arthur, TX 77642

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 0760 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

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

p.m., LVN F said she had been employed at facility since April 2025. LVN F said she had been trained in admissions. She said anytime she would be expecting admission, she would request all discharge records prior to transfer. She said she would verify the resident's name, date of birth , and medications. She said upon arrival at the facility, a verification was made by asking residents their name and date of birth , or by looking at hospital bracelets, or verify if the family was present. LVN G agreed with LVN F comments and added when notifying physician of admission and verification of medications, she would also ensure the resident orders were complete as in route, frequency, rationale, and duration. LVN F said anytime medications were questioned, the physicians were quick to respond to calls made by nursing staff. LVN G said when notifying physician to verify medications, they name every medication to the physician.Review of facility policy titled Reconciliation of Medications on Admission, with a revision date of July 2017, indicated

The purpose of this procedure is to ensure medication safety by accurately accounting for the resident's medications, routes, and dosages upon admission or readmission to the facility. Medication reconciliation helps to ensure that medications, routes and dosages have been accurately communicated to the Attending Physician and care team. Review the list carefully to determine if there are discrepancies/conflicts.The facility took the following actions to correct the noncompliance prior to the

investigation

-Record review of an Employee In-service Record dated 02/10/2025 indicated the facility in-serviced the staff on verifying all information on new admissions as correct and with the correct residents' information. The in-service was conducted by LVN F with an audience of licensed staff.

Seventeen licensed staff were in-serviced. - During an interview on 09/19/2025 at 11:50 a.m., the DON said nursing administration implemented for the ADON to perform daily medication checks with orders for newly ordered medications and new admissions during the morning meetings. -Record review of an audit of new admissions indicated the facility monitored 16 new admissions from 01/21/2025 through 02/10/2025 for accuracy 5 times/week for 4 weeks with no negative outcome. -During interviews throughout the investigation from 02/16/2025 at 08:30 a.m. through 02/22/2025 at 5:15 p.m., the licensed staff were aware to verify new medications or new admission residents' medications by calling the physician to verify. (ADON, LVN A, LVN B, LVN E, LVN F, LVN G, LVN H, LVN J, and LVN K) -Record review of 19 new resident admission's clinical record from 09/21/2025 -09/22/2025, revealed the Order Summary, discharge paperwork from recent hospital visits, MAR, history and physicals, etc. indicated no errors in transcribing orders or orders being overlooked. (Resident #s 2, 4, 5, 6, 7, 8, 9,10,11,12,13,14,15,16,17,18, 19, 20, and 21) The noncompliance was identified as past noncompliance (PNC). The IJ began on 02/07/2025 and ended on 02/10/2025. The facility had corrected the noncompliance before the state's investigation began.

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

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cascades at Port Arthur

6600 Ninth Ave Port Arthur, TX 77642

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 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Based on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in accordance with currently accepted professional principles for 1 of 3 medication carts (300 hall) reviewed for storage of medication and biologicals.The facility failed to ensure 4 tablets of Ondansetron 8mg (medication used for nausea and vomiting) expired 10/31/24, had been expired for 322 days, were removed from use. The facility failed to ensure 5 tablets of Clonidine 0.1mg (medication used for high blood pressure) expired 07/31/24, had been expired for 414 days, were removed from use.These failures could place residents at risk of adverse reactions to medications, misappropriation of medications, and not receiving therapeutic effects of medication.Findings included:Observation on 09/18/25 at 10:45 a.m. of the facility 300 Hall medication storage cart indicated in the second draw the following:- an individual medication card with 4 untouched tablets of Ondansetron 8mg with an expiration date of 10/31/24 and fill date of 11/06/23, the medication had been expired for 322 days and had not been removed from use in the medication cart. - an individual medication card with 5 tablets of Clonidine 0.1mg (medication used for high blood pressure) expired 07/31/24 and fill date 08/11/23, had been expired for 414 days, were removed from use.During an interview on 09/18/25 at 10:45 a.m. LVN A said the Ondansetron 8mg medication had been expired since 10/31/24 and she said 4 out of 10 tablets were left and 5 out of 30 tablets of Clonidine 0.1mg were left and had expired 07/31/24. LVN A said she was new and had started working with the facility about 3-4 days ago and this was her first day working by herself. LVN A said she was responsible for administering medication out of the 300-hall medication cart but had not given any of the expired Ondansetron or Clonidine. LVN A said she had been trained by the facility on medication storage, making sure meds are not expired before giving medication and keeping the cart stocked, free of expired medications and spills. LVN A said if residents were administered expired medications it could lead to medication poisoning or sickness. LVN A said she would remove the expired medications from the cart.During an interview on 09/18/25 at 1:10 p.m., the DON said there should be no expired medications inside the medication room or inside the medication carts. The DON said the Nurse working on the medication cart checked the medication cart every time they work on the medication cart. The DON said nurses are to check for expired medications and discharged residents' medication to be removed for disposal. The DON said she was responsible in ensuring that the nurses were checking the medication carts for removal and disposal of expired medications and she said was not sure how it got over looked.

The DON said if the medication were not given for months then they could expire and be overlooked on the medication cart. She said the effects of expired medications could range from reduced effectiveness to unfavorable side effects.Record Review of the facility pharmacy monthly medication review for storage dates 7/2025 to 9/2025 indicated no evidence of expired medications on the medication carts needing removal.Record review of the facility undated policy titled Medication Storage reflected in part:. Policy: It is

the policy of this facility to ensure all medications housed on our premises will be stored in the pharmacy and or medication rooms according to the manufacturer's recommendations and sufficient to ensure proper sanitation, temperature, light, ventilation, moisture control, segregation and security.5. Staff should observe proper storage and labeling requirements for all medications and vaccines during the performance of their daily task and should demonstrate safety in regards to the medication's integrity such duties should include but are not limited to: c. Remove any expired medications from active stock and discard medications according to facility policy.

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

09/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Cascades at Port Arthur

6600 Ninth Ave Port Arthur, TX 77642

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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

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

staff know to disinfect equipment. The Director of Rehabilitation said all equipment including the parallel bars should be disinfected after each use to prevent the spread of germs. She said the DON told her PT#1 should have had his index finger covered to prevent cross contamination. The Director of Rehab said she has not been in-serviced by the facility on infection control but has completed infection control computer modules. She said her expectation was for her staff to disinfect equipment after each use, wash hands

before and after working with the residents. During interview 09/22/2025 at 3:38 p.m. indicated the Administrator said his expectation was for therapy to be in-serviced by the DON on infection control before working with Residents. He said he expected therapy to wash their hands before and after working with the residents and clean equipment between usage. Record review of [company] (online education) Certificate of Course Completion dated 04/25/2025 indicated The Director of Rehabilitation completed Infection Control Microlearning: Standard Precautions for Clinical and Nonclinical Staff. The brief course was an annual refresher training course on infection control. Record review of [company] (online education) Certificate of Course Completion dated 04/04/2025 indicated OT#1 completed Infection Control Microlearning: Standard Precautions for Clinical and Nonclinical Staff. The brief course was an annual refresher training course on infection control. Record review of [company] Certificate of Course Completion dated 9/22/2025 indicated PT#1 completed Personalized Learning: Understanding Infection Control. The brief course was an annual refresher training course on infection control. Record review of Infection Control policy dated: July 2019 indicated: Policy Statement: This facility's infection control policies and practices are intended to facilitate maintaining a safe, sanitary, and comfortable environment and to prevent and manage transmission of diseases and infections.1. This facility's infection control policies and practices apply equally to all personnel, consultants, contractors, residents, visitors, volunteer workers, and the general public alike, regardless of race, color, creed, national origin, religion, age, sex, handicap, marital or veteran status, or payor source.2. The objectives of our infection control policies and practices are tob. Maintain a safe, sanitary, and comfortable, environment for personnel, residents, visitors, and the general public.f. Provide guidelines for the safe cleaning and reprocessing of reusable resident- care equipment. 3. The Quality Assurance and Performance Improvement Committee, through the Infection Control Committee, shall oversee implementation of infection control policies and practices, and help department heads and managers ensure that they are implemented and followed. 4. All personnel will be trained on infection control policies and practices upon hire and periodically thereafter, including where and how to find and use pertinent procedures and equipment related to infection control. The depth of employee training shall be appropriate to the degree of direct resident contact and job responsibilities. 6. Inquiries concerning our infection control policies and facility practices should be referred to the Infection Preventionist of Director of Nursing Services.

Event ID:

Facility ID:

If continuation sheet