Health inspection·January 22, 2026

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. Page 1 of 4 675231 675231 01/22/2026 Cascades at Jacinto Rehab LP 1405 Holland Houston, TX 77029

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 675231 Page 2 of 4 675231 01/22/2026 Cascades at Jacinto Rehab LP 1405 Holland Houston, TX 77029

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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. 675231 Page 3 of 4 675231 01/22/2026 Cascades at Jacinto Rehab LP 1405 Holland Houston, TX 77029

F 0912 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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. 675231 Page 4 of 4