F 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited
to receiving treatment and supports for daily living safely.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide housekeeping and the maintenance
services necessary to maintain a clean, sanitary, safe, and comfortable environment for 7 of 10 resident
rooms (Rooms #215, #216, #309, #311, #312, #313, and #314) reviewed for the environment. This failure
could affect the health, safety and the dignity of the residents and other residents in the facility. Findings
include: On 1/22/2026 at 9:05 a.m., an observation of resident room [ROOM NUMBER] was conducted.
The bed was observed to be positioned close to a torn window blind. The floor of the room was observed to
have thick, dark, dirty stains along the edges and corners. The walls were observed to be in poor condition
with paint visibly peeling off in multiple areas. On 1/22/2026 at 9:08 a.m., an observation of resident room
[ROOM NUMBER] was conducted. The floor of the room was observed to be dirty and sticky, dirty stains
along the edges and corners. The walls were observed to be in poor condition with paint visibly peeling off
in multiple areas. On 1/22/2026 at 9:10 a.m., an observation of resident room [ROOM NUMBER] was
conducted. There was multiple dirty resident clothing on the floor near a full dirty trashcan. The floor of the
room was observed to be sticky and have dark, dirty stains along the edges and corners. The window blind
was observed to be torn and damaged. On 1/22/2026 at 9:29 a.m., an observation of resident room [ROOM
NUMBER] was conducted. The observation reflected the room floor had thick dark dirt stains along the
edges and corners of the floor. On 1/22/2026 at 9:32 a.m., an observation of resident room [ROOM
NUMBER] was conducted. The observation reflected the room floor had thick dark dirt stains along the
edges and corners of the floor. On 1/22/2026 at 9:35 a.m., an observation of resident room [ROOM
NUMBER] was conducted. There was no window blind and no privacy curtain in the room. The floor of the
room was dirty and sticky. The wall by the window had brown stains on the bottom. The room floor had
thick, dark, dirty stains along the edges and corners of the floor. A part of the ceiling had holes and opens,
the air vent had thick black dirt on the vents. The bathroom floor had dark stains along the corners of the
floor and behind the toilet. On 1/22/2026 at 9:40 a.m., an observation of resident room [ROOM NUMBER]
was conducted. The observation reflected the floor was filthy, sticky, and thick dark dirty stains along the
edges near the bed. The base of the wall toward the right entrance of the room has peeled off and has
brown liquid around it. In an interview with the Maintenance Director on 01/22/26 at 9:48 a.m. resident room
[ROOM NUMBER], the Maintenance Director said there was black stuff on the vent and it should not look
like that. The gap (hole) in the ceiling needed to be covered to prevent roaches and rats from entering the
room. The facility was in the process of painting the walls and repairing the baseboards. The resident rooms
and environment should be homelike, clean, nice, and organized. The resident rooms (#215, #216, #309,
#311, #312, #313, and #314) did not feel like a homelike environment. She checked each room daily for
hazards, but any staff could check for environmental hazards/concerns, and if reported, she would address
it.
(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 4
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
01/22/2026
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
When resident rooms are not free from hazards, and not cleaned, it will be unsanitary for the residents. She
stated that maintaining clean resident rooms is important for resident health and safety. In an interview with
LVN J on 1/22/2026 at 10:50 a.m., LVN J stated that the housekeeping staff make daily rounds and provide
cleaning services daily and as needed. She noted that there is only one housekeeping staff member
assigned to the memory care unit. She conducts room rounds daily and as needed. If any hazardous
conditions are identified, she documents them in the maintenance log and notifies the administrator.
Additional cleaning should be done as needed in all the rooms. For room [ROOM NUMBER], she had not
noticed any damage to the base of the wall or brown liquid around it. She would address the issue
immediately. She confirmed that it is her responsibility to ensure residents are safe within their rooms and
environment. CNAs are responsible for monitoring and cleaning after housekeeping has already made their
round for the day, and they are also responsible for picking up dirty laundry. The resident rooms should be
safe, clean, and homelike environment. She confirmed that if resident rooms are not cleaned properly, the
environment will be unsanitary for the residents and could affect their health condition. In an interview with
Administrator on 1/22/2026 at 12:35 p.m., she stated that one of her roles is to ensure resident safety within
the facility. She conducts daily observations to ensure residents have a safe environment. Safety concerns
are identified and addressed as promptly as possible. The resident environment should be homelike, clean
and safe. The environmental issues remain due to the age of the building and competing priorities, but
efforts are ongoing to address outstanding concerns. The resident rooms (#215, #216, #309, #311, #312,
#313, and #314) did not feel like a homelike environment. The facility had two housekeeping staff members
per day to provide housekeeping services throughout the facility. The housekeeping and maintenance staff
are responsible for cleaning and room maintenance for resident safety and well-health being. She
acknowledged that there have been instances where cleaning duties were not completed as expected. If
the resident rooms are not cleaned, it will be unsanitary for the residents. She stated that maintaining clean
resident rooms is important for resident well-being and safety. In an interview with CNA H on 1/22/26 at
2:55 p.m., she stated that housekeeping and maintenance staff are responsible for ensuring resident rooms
are clean and maintained in a home-like environment. She reported that if she enters a resident room and
identifies housekeeping concerns, she reports them to housekeeping staff for cleaning. If maintenance
concerns are identified she documents the issue in the maintenance log for follow-up. The resident rooms
are expected to be maintained in safe condition. She reported that she had not observed any environmental
concerns in the units or resident rooms. She acknowledged that some window blinds in the resident rooms
needed replacement. Most of the resident rooms need to be painted, due to the paint peeling off. Additional
cleaning needs to be done in the residents' rooms. If the resident rooms are not cleaned, it will be
unsanitary for the residents. She stated that maintaining clean resident rooms is important for resident
well-being and safety. In an interview on 01/22/2026 at 2:58 p.m., the DON stated housekeeping is
responsible for cleaning the resident rooms. The facility had 2 housekeeping staff, and the resident rooms
are cleaned once daily. Resident rooms need more frequent cleaning, and additional cleaning should be
done as needed. The resident rooms are expected to be cleaned daily and as needed by housekeeping,
however she was unsure why some resident rooms were observed to be unclean and unsanitary. CNAs are
responsible for monitoring and cleaning after housekeeping has already made their round for the day, and
they are also responsible for picking up dirty laundry. She confirmed that if resident rooms are not cleaned
adequately, the environment will be unsanitary for the residents and could affect their health. In an interview
with LVN O on 01/22/2026 at 4:12 p.m., LVN O stated that the resident rooms require attention from
housekeeping
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675231
If continuation sheet
Page 2 of 4
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
01/22/2026
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 0584
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Some
FORM CMS-2567 (02/99)
Previous Versions Obsolete
and maintenance. Many resident rooms have window blinds that are torn and need replacement. The base
of the wall in some resident rooms is peeling off, and wall paints are peeling off in some areas. The facility
management is aware of the issue but was unsure why the repairs have not been completed. The resident
rooms are expected to be maintained in a clean, safe and homelike manner. LVN O confirmed that if
resident rooms are not cleaned adequately, the environment will be unsanitary and can affect the health of
the residents. Record review of the facility's policy revised on February 2021 on Homelike environment
Residents are Provided with a safe, clean, comfortable, and home like environment and encouraged to use
their personal belongings to the extent possible. Staff provide person - centered care that emphasizes the
residents comfort, independence, and the personal needs and preferences. The facility staff and
management maximize, to the extent possible, the characteristics of the facility that reflects a personalized,
homelike setting. These characteristics include a) clean, sanitary, and orderly environment.
Event ID:
Facility ID:
675231
If continuation sheet
Page 3 of 4
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
01/22/2026
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 0912
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single
resident rooms.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the facility failed to provide a minimum of 80 square feet per
resident for 2 of 6 multiple occupancy resident rooms (Rooms #311 and #314) reviewed for room
size.Rooms #311 and #314 did not have the required 80 square feet per resident.These failures could
place residents at risk of reduced living space and could affect their activities of daily living (ADLs).The
findings were:Record review of Form 3740 Bed Classifications, signed by the Administrator on 1/15/26,
revealed rooms #311, #312, #313, #314, #315, and #316 was classified to have 3 resident beds in each
room.In an interview on 1/21/26 at 1:02 p.m., the Administrator said she did not have documentation to
show that 3 beds were allowed in the room. She said the corporate office informed her in the past that they
did not need a waiver. In an observation on 1/21/26 at 2:12 p.m., the Maintenance Director measured
rooms #311 and #314 in the secure unit. Room size measurements were as follows:1. room [ROOM
NUMBER] (3-person room - 3 residents in room) 20 ft x 11 ft = 220 sq ft / 3 residents = 73.3 sq. ft per
resident2. room [ROOM NUMBER] (3-person room - 3 residents in room) 20 ft x 10.25 ft = 221.3 sq ft / 3
residents = 73.77 sq. ft/residentIn an interview on 1/21/26 at 2:18 p.m., the Maintenance Director said she
was unsure of the amount of space needed per resident and needed to verify. She said there was no
concerns brought to her about the size of the room and the number of beds but risks for the inappropriate
amount of space could include falls, trips, clutter, and not enough space for evacuation.In an interview on
1/21/26 at 2:56 p.m., the Administrator said each resident needed 80 square feet. She said she would make
the rooms a two-person room to ensure enough space. She said she could not find a waiver but would
continue to look.
Event ID:
Facility ID:
675231
If continuation sheet
Page 4 of 4