Cycle 1
Health 2024-12-05 · Fire 2024-12-05
9 health deficiencies
Top issue: Environmental (2 deficiencies)
3 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Houston, TX
Cascades at Jacinto Rehab LP
1-star overall rating with 2-star inspections with $51,586 in total fines with 9 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
1405 Holland, Houston, TX
(713) 455-1744
Overall
1 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
148
Certified beds
Average residents
75
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Cascades Healthcare
Operator or chain grouping
Approved since
1993-12-02
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
20 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.12
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
0.98
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.84
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
2.94
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.10
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.63
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.11
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.12
CMS adjusted RN staffing hours
Adjusted total hours
2.82
CMS adjusted total nurse staffing hours
Case-mix index
1.42
Higher values indicate more complex resident acuity
RN turnover
67%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
53%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,726
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
0
Composite VBP score used to determine payment impact.
Payment multiplier
0.9803
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
0
Baseline 57.41% · Performance 62.90% · Measure score 0 · Achievement 0 · Improvement 0
Adjusted total nurse staffing
0
Baseline 3.72 hours · Performance 2.86 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.44% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 25 · Observed rate 4% · Lower 95% interval 5.12% |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays 10 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Medicare spending per beneficiary | 0.73 |
1.02
0.3 pts better
|
|
| Drug regimen review with follow-up | 96.3% |
95.27%
1 pts better
|
Numerator 26 · Denominator 27 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 27 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 27 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 13 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 93.33% |
8.2%
85.1 pts better
|
Numerator 70 · Denominator 75 |
| Staff flu vaccination coverage | 36.84% |
42%
5.2 pts worse
|
Numerator 28 · Denominator 76 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 10 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 3 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 96.5% |
97.1%
0.6 pts worse
|
93.4%
3.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 95.7% · Q2 97.2% · Q3 97.2% · Q4 95.7% · 4Q avg 96.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 96.0% |
97.9%
1.9 pts worse
|
95.5%
0.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 96.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.5% |
3.3%
0.8 pts better
|
3.3%
0.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.4% · Q2 1.4% · Q3 4.2% · Q4 2.9% · 4Q avg 2.5% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 1.4% |
2.7%
1.3 pts better
|
11.4%
10 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 5.2% · 4Q avg 1.4% |
| Percentage of long-stay residents who lose too much weight | 7.6% |
3.3%
4.3 pts worse
|
5.4%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 1.7% · Q2 12.9% · Q3 10.9% · Q4 3.8% · 4Q avg 7.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 29.9% |
18.9%
11 pts worse
|
19.6%
10.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 31.1% · Q2 32.8% · Q3 26.6% · Q4 28.8% · 4Q avg 29.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 27.2% |
10.8%
16.4 pts worse
|
16.7%
10.5 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 28.6% · Q2 28.6% · Q3 28.2% · Q4 22.2% · 4Q avg 27.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 10.3% |
15.4%
5.1 pts better
|
16.3%
6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.6% · Q2 17.3% · Q3 6.1% · Q4 11.2% · 4Q avg 10.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 7.0% |
16.1%
9.1 pts better
|
14.9%
7.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 10.5% · Q2 8.2% · Q3 3.3% · Q4 6.1% · 4Q avg 7.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 8.4% |
15.0%
6.6 pts better
|
19.8%
11.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.4% · Q2 12.7% · Q3 1.2% · Q4 7.8% · 4Q avg 8.4% |
| Percentage of long-stay residents with pressure ulcers | 2.6% |
4.2%
1.6 pts better
|
5.1%
2.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 2.7% · Q3 1.3% · Q4 3.1% · 4Q avg 2.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 53.6% |
89.7%
36.1 pts worse
|
81.7%
28.1 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 69.7% · Q2 65.6% · Q3 50.0% · Q4 34.9% · 4Q avg 53.6% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 16.1% |
12.0%
4.1 pts worse
|
12.0%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 16.1% · Observed 20.0% · Expected 13.8% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 74.2% |
88.0%
13.8 pts worse
|
79.7%
5.5 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 74.2% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 28.0% |
25.9%
2.1 pts worse
|
23.9%
4.1 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 28.0% · Observed 25.0% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-09-07 · Fire 2023-09-07
20 health deficiencies
Top issue: Quality of Life and Care (6 deficiencies)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Cycle 3
Health 2022-06-30 · Fire 2022-06-30
3 health deficiencies
Top issue: Environmental (1 deficiency)
6 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-12-05
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-12-05
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-12-05
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-12-20
F · Potential for more than minimal harm
2023-09-07
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-07
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-07
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-07
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-07
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-10-06
F · Potential for more than minimal harm
2023-09-07
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-10-06
E · Potential for more than minimal harm
2023-09-07
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2023-10-06
C · Minimal harm
2023-09-07
E39 · Emergency Preparedness Deficiencies
Fire Safety
Conduct testing and exercise requirements.
Corrected 2023-10-06
C · Minimal harm
2023-09-07
K324 · Smoke Deficiencies
Fire Safety
Provide properly protected cooking facilities.
Corrected 2023-10-06
C · Minimal harm
2023-09-07
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2023-10-06
F · Potential for more than minimal harm
2022-06-30
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Corrected 2022-07-19
F · Potential for more than minimal harm
2022-06-30
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2022-07-01
E · Potential for more than minimal harm
2022-06-30
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2022-07-02
E · Potential for more than minimal harm
2022-06-30
K293 · Egress Deficiencies
Fire Safety
Have properly located and lighted "Exit" signs.
Corrected 2022-07-02
E · Potential for more than minimal harm
2022-06-30
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2022-07-02
E · Potential for more than minimal harm
2022-06-30
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2022-07-01
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-22
F584 · Resident Rights Deficiencies
Health
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.
Not marked corrected
D · Potential for more than minimal harm
2026-01-22
F912 · Environmental Deficiencies
Health
Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.
Not marked corrected
E · Potential for more than minimal harm
2025-11-21
F925 · Environmental Deficiencies
Health
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Corrected 2025-12-01
J · Immediate jeopardy
2025-10-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
D · Potential for more than minimal harm
2025-10-30
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Not marked corrected
D · Potential for more than minimal harm
2024-12-27
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2025-02-10
D · Potential for more than minimal harm
2024-12-27
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-02-10
F · Potential for more than minimal harm
2024-12-05
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-12-20
E · Potential for more than minimal harm
2024-12-05
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-12-05
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-12-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-20
D · Potential for more than minimal harm
2024-11-15
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2024-12-05
D · Potential for more than minimal harm
2024-11-15
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-12-05
J · Immediate jeopardy
2023-09-07
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-10-10
J · Immediate jeopardy
2023-09-07
F835 · Administration Deficiencies
Health
Administer the facility in a manner that enables it to use its resources effectively and efficiently.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-07
F584 · Resident Rights Deficiencies
Health
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.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-07
F676 · Quality of Life and Care Deficiencies
Health
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-07
F677 · Quality of Life and Care Deficiencies
Health
Provide care and assistance to perform activities of daily living for any resident who is unable.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-07
F745 · Quality of Life and Care Deficiencies
Health
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-07
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-07
F914 · Environmental Deficiencies
Health
Provide bedrooms that don't allow residents to see each other when privacy is needed.
Corrected 2023-10-10
E · Potential for more than minimal harm
2023-09-07
F919 · Environmental Deficiencies
Health
Make sure that a working call system is available in each resident's bathroom and bathing area.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-07
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-07
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-07
F688 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-09-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-10-10
C · Minimal harm
2023-09-07
F847 · Administration Deficiencies
Health
Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.
Corrected 2023-10-10
D · Potential for more than minimal harm
2023-06-23
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-07-14
D · Potential for more than minimal harm
2023-06-23
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-07-14
E · Potential for more than minimal harm
2022-06-30
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2022-07-01
Penalties and ownership
What sits behind the stars
$4,194
2023-11-06
Fine
Fine · fine $4,194
Fine
$47,392
2023-09-07
Fine
Fine · fine $47,392
Fine
$0
2023-09-07
Payment Denial
Payment Denial · denial start 2023-10-07 · 3 days
3 day denial
Ownership
Cascades At Jacinto Rehab, LP
5% Or Greater Direct Ownership Interest · Organization
Cascades At Jacinto Rehab, LP
Operational/Managerial Control · Organization
Cascades Healthcare Of Texas, LLC
General Partnership Interest · Organization
Crump, Jason
Operational/Managerial Control · Individual
Crump, Jason
Corporate Director · Individual
Fullmer, Chad
Operational/Managerial Control · Individual
Fullmer, Chad
Corporate Director · Individual
Lone Star Assets, Flp
Limited Partnership Interest · Organization
Mcspadden, Darin
Operational/Managerial Control · Individual
Mcspadden, Darin
Corporate Director · Individual
Nodyah, Flp
Limited Partnership Interest · Organization
Saimaa, Flp
Limited Partnership Interest · Organization
Taki, Flp
Limited Partnership Interest · Organization
White, Derek
Operational/Managerial Control · Individual
White, Derek
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
East View Healthcare
Houston, TX
4-star overall rating with 5-star inspections with 4 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Bridgecrest Rehabilitation Suites
Houston, TX
3-star overall rating with 3-star inspections with $48,802 in total fines with 2 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
#3
Paradigm at Faith Memorial
Pasadena, TX
2-star overall rating with 2-star inspections with $98,417 in total fines with 10 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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