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🔎 Cascades At Senior Rehab

Inspection Results


Inspection Overview

Cascades At Senior Rehab has been cited for a total of 80 deficiencies since we began saving each survey.

In Texas, the average facility has **34.42 deficiencies** in our database. This profile shows the longer-term view.

Tip: Surveys happen throughout the year. Always check the official Medicare Care Compare site for the most recent data.



Understanding Deficiency Severity (A-L Scale)

The farther along in the alphabet (A through L) the Scope value is, the more severe the deficiency. **A through F means no actual harm has happened.**

Severity (Harm)Scope (Widespread?)Code Range
No Actual HarmIsolated to PatternA - C
No Actual HarmWidespreadD - F
**Actual Harm**IsolatedG
**Actual Harm**PatternH
**Actual Harm**WidespreadI
**Immediate Jeopardy**IsolatedJ
**Immediate Jeopardy**PatternK
**Immediate Jeopardy**WidespreadL


Detailed Deficiency List (Most Recent First)

Scope/Severity: K

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2025-02-27
Correction Date: 2025-03-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2025-02-27
Correction Date: 2025-03-21
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: C

Hire a qualified full-time social worker in a facility with more than 120 beds.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: C

Conduct mandatory training, for all staff, on the facility’s Quality Assurance and Performance Improvement Program.

Survey Date: 2024-05-15
Correction Date: 2024-06-06
Category: Administration Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident must receive and the facility must provide necessary behavioral health care and services.

Survey Date: 2024-04-16
Correction Date: 2024-04-17
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2024-04-16
Correction Date: 2024-04-17
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2024-03-18
Correction Date: 2024-01-15
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2023-11-07
Correction Date: 2023-12-04
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: J

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Survey Date: 2023-11-07
Correction Date: 2023-12-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: K

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2023-11-07
Correction Date: 2023-12-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: E

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-11-07
Correction Date: 2023-12-04
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2023-11-07
Correction Date: 2023-12-04
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Survey Date: 2023-09-21
Correction Date: 2023-09-22
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-09-21
Correction Date: 2023-09-22
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: J

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2023-06-06
Correction Date: 2023-07-10
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: G

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-06-06
Correction Date: 2023-07-10
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: J

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Survey Date: 2023-06-06
Correction Date: 2023-07-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: G

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2023-06-06
Correction Date: 2023-07-10
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

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.

Survey Date: 2023-06-06
Correction Date: 2023-07-10
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Survey Date: 2023-03-29
Correction Date: 2023-04-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2023-03-29
Correction Date: 2023-04-28
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident receives an accurate assessment.

Survey Date: 2023-03-29
Correction Date: 2023-04-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2023-03-29
Correction Date: 2023-04-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: D

Provide enough food/fluids to maintain a resident's health.

Survey Date: 2023-03-29
Correction Date: 2023-04-28
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2023-03-29
Correction Date: 2023-04-28
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: D

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Survey Date: 2023-03-29
Correction Date: 2023-04-28
Category: Nutrition and Dietary Deficiencies
From Complaint: Y

Scope/Severity: D

Have policies on smoking.

Survey Date: 2023-03-29
Correction Date: 2023-04-28
Category: Environmental Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-10-13
Correction Date: 2022-10-04
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

Survey Date: 2022-09-28
Correction Date: 2022-10-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2022-09-28
Correction Date: 2022-10-24
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: J

Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.

Survey Date: 2022-09-28
Correction Date: 2022-10-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: J

Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.

Survey Date: 2022-09-28
Correction Date: 2022-10-24
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2022-09-28
Correction Date: 2022-10-24
Category: Pharmacy Service Deficiencies
From Complaint: Y

Scope/Severity: J

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2022-01-31
Correction Date: 2022-03-11
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: K

Provide and implement an infection prevention and control program.

Survey Date: 2022-01-13
Correction Date: 2022-02-16
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

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.

Survey Date: 2021-12-29
Correction Date: 2022-01-07
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2021-12-29
Correction Date: 2022-01-28
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2021-12-29
Correction Date: 2022-01-21
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide safe and appropriate respiratory care for a resident when needed.

Survey Date: 2021-12-29
Correction Date: 2022-01-28
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2021-12-29
Correction Date: 2022-01-28
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Provide and implement an infection prevention and control program.

Survey Date: 2021-12-10
Correction Date: 2022-01-25
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Provide care and assistance to perform activities of daily living for any resident who is unable.

Survey Date: 2021-10-18
Correction Date: 2021-10-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-10-18
Correction Date: 2021-10-19
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Survey Date: 2021-10-18
Correction Date: 2021-10-19
Category: Nursing and Physician Services Deficiencies
From Complaint: Y

Scope/Severity: D

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2021-08-06
Correction Date: 2021-09-01
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: D

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Survey Date: 2021-08-06
Correction Date: 2021-09-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Respond appropriately to all alleged violations.

Survey Date: 2021-08-06
Correction Date: 2021-09-01
Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-08-06
Correction Date: 2021-09-01
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: D

Report COVID19 data to residents and families.

Survey Date: 2021-08-06
Correction Date: 2021-09-01
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: D

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Survey Date: 2021-05-20
Correction Date: 2021-05-24
Category: Quality of Life and Care Deficiencies
From Complaint: Y

Scope/Severity: E

Reasonably accommodate the needs and preferences of each resident.

Survey Date: 2020-12-09
Correction Date: 2020-12-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: E

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Survey Date: 2020-12-09
Correction Date: 2020-12-31
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2020-12-09
Correction Date: 2020-12-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2020-12-09
Correction Date: 2020-12-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Survey Date: 2020-12-09
Correction Date: 2020-12-31
Category: Nutrition and Dietary Deficiencies
From Complaint: N

Scope/Severity: E

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2020-12-09
Correction Date: 2020-12-31
Category: Resident Rights Deficiencies
From Complaint: Y

Scope/Severity: E

Ensure services provided by the nursing facility meet professional standards of quality.

Survey Date: 2020-12-09
Correction Date: 2020-12-31
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: Y

Scope/Severity: K

Provide and implement an infection prevention and control program.

Survey Date: 2020-07-30
Correction Date: 2020-09-30
Category: Infection Control Deficiencies
From Complaint: Y

Scope/Severity: E

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Survey Date: 2019-03-06
Correction Date: 2019-03-12
Category: Resident Rights Deficiencies
From Complaint: N

Scope/Severity: D

Provide doctor's orders for the resident's immediate care at the time the resident was admitted.

Survey Date: 2019-03-06
Correction Date: 2019-03-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Assess the resident when there is a significant change in condition

Survey Date: 2019-03-06
Correction Date: 2019-03-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: E

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Survey Date: 2019-03-06
Correction Date: 2019-03-12
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Survey Date: 2019-03-06
Correction Date: 2019-03-16
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Survey Date: 2019-03-06
Correction Date: 2019-03-14
Category: Quality of Life and Care Deficiencies
From Complaint: N

Scope/Severity: D

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Survey Date: 2019-03-06
Correction Date: 2019-03-12
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure each resident’s drug regimen must be free from unnecessary drugs.

Survey Date: 2019-03-06
Correction Date: 2019-03-12
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Ensure that residents are free from significant medication errors.

Survey Date: 2019-03-06
Correction Date: 2019-03-12
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: E

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Survey Date: 2019-03-06
Correction Date: 2019-03-07
Category: Pharmacy Service Deficiencies
From Complaint: N

Scope/Severity: D

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Survey Date: 2019-03-06
Correction Date: 2019-03-29
Category: Resident Assessment and Care Planning Deficiencies
From Complaint: N

Scope/Severity: D

Provide and implement an infection prevention and control program.

Survey Date: 2019-03-06
Correction Date: 2019-03-14
Category: Infection Control Deficiencies
From Complaint: N


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All deficiency data is sourced directly from the **Centers for Medicare & Medicaid Services (CMS)**.
Data Aggregation and Review provided by **The Nursing Home Site.**