Inspection·November 21, 2025

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 3 hallways, (Hall 200), conference room, and Resident #1 and #2's shared room. The facility had live flies in the room of Resident #1 and #2 located on Hall 200. The facility had live gnats in and outside the conference room located on Hall 200. This failure has the potential to place residents at risk for disease and a decline in their physical health. Findings included: Record review of Resident #1's Electronic Health Record revealed a [AGE] year-old male admitted to the facility on [DATE] with a principal diagnosis of Unspecified Psychosis not due to a substance or known psychological condition (when an individual exhibits psychotic symptoms such as hallucinations, delusions, or disorganized thinking, but the underlying cause is not attributable to substance use or a known physiological condition). Record review of Resident #1's Quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicates a severe cognitive impairment. Record review of Resident #2's Electronic Health Record revealed an [AGE] year-old male admitted to the facility on [DATE] with a principal diagnosis of Chronic Obstructive Pulmonary Disease (a term for lung and airway diseases that restrict breathing). Record review of Resident #2's Quarterly MDS dated [DATE] revealed a BIMS score of 3, which indicates a severe cognitive impairment. In an observation on 11/18/2025 at 8:45 am, 2 gnats were observed in the conference room located on the 200 hall. In an observation on 11/18/2025 at 8:50am, 1 gnat was observed in the hallway of 200 hall outside of the conference room. In an observation on 11/18/2025 at 1:46pm of room [ROOM NUMBER] shared by Resident#1 and #2 located on the 200 hall there were 2 flies flying in the room. One fly was observed to fly above both residents and to land on Resident#2's linen, and the second fly was observed on the bedside table of Resident#2. In an effort to interview on 11/18/2025 at 1:46pm, Resident#1 decline to be interviewed. In an interview and observation on 11/18/2025 at 1:50pm, Resident #2 said he saw one fly in his room. Resident#2 pointed to his bedside table where a fly was located. He said that he saw flies all the time but had not told anyone about the flies. In an interview on 11/18/2025 at 1:55pm, the ADON said that she saw a fly on the bedside table of Resident#2. She said that a pest control company came to the facility monthly, and she thought the facility's pest control was effective. She said that she would report the fly she observed in the room of Resident#1 and #2 to the Administrator. In an interview on 11/18/2025 at 3:15pm with the Administrator and DON, both were made aware of observation of flies in room [ROOM NUMBER] and gnats in the conference room. The Administrator said that the facility's pest control company was scheduled to service the facility each month, and the pest control company was scheduled to return to the facility on [DATE] for targeted concerns. In an observation on 11/20/2025 at 1:17pm, 1 gnat was seen to fly in the conference room. In an interview on 11/20/2025 at 1:17pm with the Maintenance Director, she said that when there is a sighting for a pest control problem it should be reported to her. She said she then goes to assess the area of concerns, Residents Affected - Some (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675231 Printed: 05/15/2026 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 675231 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 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)