A list of the most recent deficiencies for Cascades at Jacinto Rehab LP. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure each resident receives an accurate assessment. | Health | 2023-09-07 | 2023-10-10 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-07 | 2023-10-10 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-09-07 | 2023-10-10 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2023-09-07 | 2023-10-10 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-07 | 2023-10-10 | N |
| 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. | Health | 2023-09-07 | 2023-10-10 | N |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2023-09-07 | 2023-10-10 | N |
| 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. | Health | 2023-09-07 | 2023-10-10 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-07 | 2023-10-10 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2023-09-07 | 2023-10-10 | N |
| Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse. | Health | 2023-09-07 | 2023-10-10 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-07 | 2023-10-10 | N |
| Provide bedrooms that don't allow residents to see each other when privacy is needed. | Health | 2023-09-07 | 2023-10-10 | N |
| Make sure that a working call system is available in each resident's bathroom and bathing area. | Health | 2023-09-07 | 2023-10-10 | N |
| 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. | Health | 2023-09-07 | 2023-10-10 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-07 | 2023-10-10 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| 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. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-08-31 | 2023-10-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-06-23 | 2023-07-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-06-23 | 2023-07-14 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-02-22 | 2023-03-18 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-06-30 | 2022-07-19 | N |
| 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. | Fire Safety | 2022-06-30 | 2022-07-02 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-06-30 | 2022-07-02 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-30 | 2022-07-02 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-06-30 | 2022-07-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-30 | 2022-07-01 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-06-30 | 2022-07-01 | N |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-05-23 | 2022-06-13 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-02-02 | 2022-02-09 | Y |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2021-03-25 | 2021-04-23 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2021-03-25 | 2021-04-23 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-03-25 | 2021-04-23 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-03-25 | 2021-04-23 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-03-25 | 2021-04-23 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-03-25 | 2021-04-23 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-03-25 | 2021-04-23 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-03-25 | 2021-04-23 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-03-25 | 2021-04-23 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-03-25 | 2021-04-23 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-03-25 | 2021-04-23 | N |
