Sabine Heights Nursing And Rehabilitation Center

and staff, with physician support, will address situations of suspected or identified abuse and report

675172 01/07/2026

Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642

During an interview on 01/07/26 at 1:35 p.m., MDS Nurse C said her last full-time day was 12/04/25 and she was currently PRN but had only worked a few days since then. MDS Nurse C said she was unaware Resident #34 had been admitted on hospice service and the backup; Senior Director of Reimbursement did not open a significant change MDS in the system for Resident #34.

She said it was overlooked.

She said she was educated on the completion of MDSs and was the MDS nurse for 4 years in the facility. MDS Nurse C said the resident risk was that the Resident's care plan may not be updated with the changes from the Significant change MDS due to the care plan was triggered by the MDS.

She said there was no direct resident risk.

Record review of the mds-3.0-rai-manual-v1.19.1_October_2024 indicated . An SCSA is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare-certified or State-licensed hospice provider) or changes hospice providers and remains a resident at the nursing home.

The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). An SCSA must be performed regardless of whether an assessment was recently conducted on the resident.

This is to ensure a coordinated plan of care between the hospice and nursing home is in place. A Medicare-certified hospice must conduct an assessment at the initiation of its services.

This is an appropriate time for the nursing home to evaluate the MDS information to determine if it reflects the current condition of the resident, since the nursing home remains responsible for providing necessary care and services to assist the resident in achieving their highest practicable well-being at whatever stage of the disease process the resident is experiencing.

The ARD must be less than or equal to 14 days after the IDT's determination that the criteria for an SCSA are met (determination date + 14 calendar days).

The MDS completion date . must be no later than 14 days from the ARD (ARD + 14 calendar days) and no later than 14 days after the determination that the criteria for an SCSA were met.

This date may be earlier than or the same as the CAA(s) completion date, but not later than.

675172 01/07/2026

Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642

Assessment.

675172 01/07/2026

Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642

Findings included:

Record review of Resident #11's face sheet dated 01/05/2026, reflected she was a [AGE] year-old female originally admitted on [DATE] with medical diagnoses including type 2 diabetes mellitus (high blood sugar), dementia (declining brain function related to thinking and judgement that is severe enough to impact daily life), generalized anxiety disorder (prolonged excessive worry), and hypertension (high blood pressure).

Record review of Resident #11's MDS dated [DATE] reflected her BIMS as 14 which indicated cognitive ability was intact and she required supervision or assistance for personal hygiene: The ability to maintain personal hygiene, including combing hair, shaving, applying makeup, washing/drying face and hands (excludes baths, showers, and oral hygiene).

Record review of Resident #11's care plan dated 10/01/2025 reflected ADL self-care performance deficit, with interventions including personal hygiene/oral care requiring staff participation with personal hygiene and oral care.

There was no refusal of ADLs, and personal grooming or shaving documented in Resident #11's care plan.

Record review of Resident #11's December 2025 aide flowsheet reflected Resident #11 did not refuse baths or personal hygiene.

During an observation and interview on 01/05/2026 at 1:00 p.m., Resident #11 said she did not understand why CNA P did not remove her facial hair when she bathed her this morning and said it had been a long time since she was shaved. Resident #11 said she likes her chin hair shaved with her bath.

She said she had not complained about it.

The hair under her chin was approximately 15 dark curly hairs.

During an interview on 01/06/2026 at 8:07 a.m., CNA P said she should have removed the Resident facial hair with her bath yesterday.

She said the residents must always be ready for visitors.

She said it makes the residents and families feel good about the residents' appearance.

During an interview on 01/06/2026 at 8:20 a.m., the interim DON said the residents should be kept without long facial hair unless they refuse.

She said she expected the lady residents to be without facial hair.

She said she would provide the policy on facial hair and maintaining ADLs.

She said the lack of personal hygiene could cause a decline in the resident dignity.

During an interview on 01/06/2026 at 8:30 a.m., LVN O said the facial hair should be removed during bath unless the resident refuses.

She said Resident #11 does not refuse.

During an interview on 01/06/2026 at 1:00 p.m. the Administrator said his expectation was for facial hair to be removed unless the resident refused.

Record review of the facility's policy on ADL services last revised March 2018, indicated, Residents will be provided with care, treatment, and services as appropriate to maintain or improve their ability to carry out activities of daily living.

Residents who are unable to carry out activities of daily living independently will receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene .

675172 01/07/2026

Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642

During an interview on 01/07/2026 at 12:05 p.m., the DON said she expected medications to be administered by physician orders.

She said Resident #58 had physician ordered parameters regarding administration of the carvedilol 3.125 mg.

She said her expectations were for the nursing staff administering medications to be diligent in following the prescribed orders while observing parameters.

She said she had completed a Med Error report, and the physician had been notified. Resident #58 had been monitored for negative outcomes with none noted.During a phone conversation on 01/07/2026 at 12:10 p.m., the Pharmacy Consultant was interviewed re: Resident #58 having received the carvedilol 3.125 mg. when the heart rate was outside the prescribed parameters.

He said a possible negative outcome was bradycardia (when your heart beats too slowly, typically under 60 beats per minute for adults).

The pharmacy consultant said carvedilol's elimination half-life was short (usually 7-10 hours).

The pharmacy consultant added that the facility was correct in having monitored for standard side effects.

Record review of the facility's Administering Medications policy dated March 2025 indicated the following: .

Medications are administered in a safe and timely manner, and as prescribed.4.

Medications are administered in accordance with prescribers' orders. 10.

The individual administering the medication checks the label to verify the right resident, right medication, right dosage, right time and right method (route) of administration before giving the medication.

675172 01/07/2026

Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642

The facility failed to ensure Hall 400 medication cart was free of loose pills at the bottom of the medication cart drawer.These failures could place residents at risk of not receiving prescribed drugs.During an observation and interview on [DATE] at 9:00 a.m., an inspection of Hall 300 medication cart with LVN A was discovered 7 whole miscellaneous pills and 6 broken pills loose in drawer 2 of the medication cart. LVN A said she was responsible for the medication cart today.

She said the ADON double checks the medication carts weekly for scattered pills and debris.

She said they were overlooked. LVN A said she was in-serviced to check her medication cart for loose pills.

She said she usually cleans her medication cart later in the day during her shift and had not had time to clean it yet. LVN A said the resident risk of loose pills in the medication cart was that a resident may run out of their medication before they are scheduled for a refill.During an observation and interview on [DATE] at 9:33 a.m., an inspection of Hall 400 Nurse's medication cart with the ADON was discovered 3 whole pills and 1 broken pill loose in drawer 2 of the medication cart.

She said she was giving medication to Residents on Hall 400 today and was responsible for the medication cart.

The ADON said she was the backup that double checked the medication carts every Friday for cleanliness, loose medication and expired medication.

She said the loose pills were overlooked.

The ADON said she was in-serviced on cleaning the medication cart and checking for expired medication and loose pills.

She said the resident risk of loose pills on a medication cart was that a resident may be short on medication and it may need to be reordered sooner than normal.

During an interview on [DATE] at 9:54 a.m., the DON said the nurse giving medication off the medication cart was responsible for ensuring no loose pills were on the medication cart.

She said the ADON and DON were the back up to double check the medication carts weekly for loose medication.

The DON said she checked the medication room and hall 200 medication cart on Tuesday ([DATE]).

She said the loose pills were overlooked.

She said the Resident risk was that a resident could need their medication ordered too soon.

The DON said her expectation was all medication be administered per physician orders and all medication carts be checked to ensure they were up to standard.

During an interview on [DATE] at 11:00 a.m., the Administrator said all nurses giving medication off the medication cart were responsible for ensuring no loose pills were left on the medication cart. He said the ADON and DON were the back up to double check the medication carts weekly for loose medication.

The Administrator said the loose pills were overlooked. He said the Resident risk was a resident could need their medication ordered too soon.

The Administrator said his expectation was all medication be administered per physician orders and all medication carts be checked to ensure they were up to standard.

Record review of a facility policy titled Medication Labeling and Storage dated revised 02/23 indicated, .The facility stores all medication and biologicals in locked compartments under proper temperature, humidity and light controls. 1.

Medications and biologicals are stored in the packaging, containers or other dispensing systems in which they are received.

675172 01/07/2026

Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642

Review of facility's job description dated 10/06/25 for Social Worker position indicated Qualifications: Minimum of a bachelor's degree in social work or in human services fields.

Licensed per state requirements or eligible for licensure.

Record review of the ASWB licensure examinations website process indicated the following:To become a licensed social worker in Texas, you must earn a CSWE-accredited degree in social work, complete a Texas specific jurisprudence exam, pass the relevant Association of Social work boards (ASWB) exam, undergo a fingerprint background check, and fulfill supervised practice hours for clinical licenses, all while applying through the Texas Board of Social Worker Examiners (part of the Texas Behavioral Health Executive Council) to maintain your license.

During an interview on 01/07/26 at 12:00 p.m., the Administrator said the SW had been employed at the facility since 10/06/25.

The Administrator said the SW had a Bachelor of Science degree in Psychology and had been preparing to take the licensure exam. He said currently, the SW was not licensed.

The Administrator said he wanted her to obtain certification for Texas but did not feel it would change anything except she would receive a pay increase.

During an interview on 01/07/26 at 1:00 p.m., the SW said she had researched the application process for certification requirement for the state of Texas, however she had not applied yet.

Review of CMS Form 3740, Bed Classification dated 01/07/26 indicated the facility was certified for 150 beds.

675172 01/07/2026

Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642

equipment (PPE) is changed before caring for another resident.3.

Face protection may be used if there

hygiene;5. changing linens;6. changing briefs or assisting with toileting;7. device care or use (central

opening requiring a dressing).4. EBPs are indicated (when contact precautions do not otherwise apply) for residents infected or colonized with the following:1.

Pan-resistant organisms;2.

Carbapenemase-producing carbapenem-resistant Enterobacterales;3.

Carbapenemase-producing carbapenem-resistant Pseudomonas spp;4.

Carbapenemase-producing carbapenem-resistant Acinetobacter baumannii;5.

Candida auris;6.

Methicillin-resistant Staphylococcus aureus (MRSA);7.

ESBL-producing Enterobacterales;8.

Vancomycin-resistant Enterococci (VRE);9.

Multidrug-resistant Pseudomonas aeruginosa; and10.

Drug-resistant Streptococcus pneumonia.5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.6. EBPs remain in place for the duration of the resident's stay or until resolution of the wound or discontinuation of the indwelling medical device that places them at increased risk.7.

The use of EBPs does not impose limitations on group activities or room restrictions for residents.8.

Standard precautions apply to the care of all residents regardless of suspected or confirmed infection or colonization status.9.

Staff are trained prior to caring for residents on EBPs.10.

Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.11. PPE is available outside of the resident rooms.12.

Residents, families and visitors are notified of the implementation of EBPs throughout the facility.

The facility failed to ensure that LVN E, LVN F, LVN G, LVN H, CNA J, CNA K, CNA L, CNA M, and CNA N had completed their mandatory QAPI training.

This failure could place residents at risk of being care for by untrained staff.The findings included:

Review of the facility's training log, undated, showed no evidence of training for QAPI for LVN E, LVN F, LVN G, LVN H, CNA J, CNA K, CNA L, CNA M, and CNA N.

Record review of employee files indicated the following staff had not completed QAPI training during orientation or annually:* LVN E, hire date 12/12/25;* LVN F, hire date 05/12/25;* LVN G, hire date 07/16/25;* LVN H, hire date 12/04/25;* CNA J, hire date 07/03/25; * CNA K, hire date 10/28/25;* CNA L, hire date 12/30/23; and* CNA M, hire date 10/30/23;* CNA N, hire date 10/29/25.

During an interview on 01/07/26 at 11:00 a.m., HR said she was not aware of the new requirement for QAPI training.

She said she would check with the interim DON and the Administrator.

During an interview on 01/07/26 at 11:30 a.m., the interim DON said she thought the last DON should have completed the QAPI training on the staff however she said she was unable to locate any documentation.

During an interview on 01/07/26 at 1:10 p.m., the Administrator said his expectation for the QAPI training was it would have been included in their computerized training system. He said if they do not receive the mandatory training the staff might not be fully trained.

Record review of the undated Quality Assurance and Performance Improvement (QAPI) Program Plan indicated .

Facility employees are provided the necessary training to enable them to perform their jobs effectively.

Topics covered in the training program include but are not limited to: .

Regulatory requirements .

The QAPI Coordinator is responsible for: Leading the QAPI committee.Facilitating staff education on QAPI principles and practices.

675172 01/07/2026

Cascades at Port Arthur 6600 Ninth Ave Port Arthur, TX 77642