Cascades at Galveston

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2026-04-22 · Tag F0580 · Complaint investigation · Deficient, Provider has no plan of correction

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

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2026-04-22 · Tag F0692 · Complaint investigation · Deficient, Provider has no plan of correction

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

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2024-03-29 · Tag F0580 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-05-01

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

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2024-03-29 · Tag F0693 · Routine survey · Deficient, Provider has date of correction · Correction reported 2024-05-01

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity J — IMMEDIATE JEOPARDY

Survey 2024-03-08 · Tag F0695 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-03-13

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

What this scope/severity letter means: CMS found the facility's failure caused, or was likely to cause, serious injury, harm, impairment, or death to a resident. This is the most serious finding a surveyor can make. Affected one resident or instance. How the A–L grid works

Scope/severity J — IMMEDIATE JEOPARDY

Survey 2023-10-28 · Tag F0580 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2023-11-27

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

What this scope/severity letter means: CMS found the facility's failure caused, or was likely to cause, serious injury, harm, impairment, or death to a resident. This is the most serious finding a surveyor can make. Affected one resident or instance. How the A–L grid works

Scope/severity J — IMMEDIATE JEOPARDY

Survey 2023-10-28 · Tag F0695 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2023-11-27

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

What this scope/severity letter means: CMS found the facility's failure caused, or was likely to cause, serious injury, harm, impairment, or death to a resident. This is the most serious finding a surveyor can make. Affected one resident or instance. How the A–L grid works

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2023-09-28 · Tag F0684 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2023-10-30

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

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity K — IMMEDIATE JEOPARDY

Survey 2023-09-28 · Tag F0686 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2023-10-30

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

What this scope/severity letter means: CMS found a pattern of failures that caused, or were likely to cause, serious injury, harm, impairment, or death. This is the most serious finding a surveyor can make. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2026-04-22 · Tag F0641 · Complaint investigation · Deficient, Provider has no plan of correction

Ensure each resident receives an accurate assessment.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2026-04-22 · Tag F0656 · Complaint investigation · Deficient, Provider has no plan of correction

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

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2026-04-02 · Tag F0609 · Complaint investigation · Deficient, Provider has no plan of correction

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

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2026-03-18 · Tag F0656 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2026-04-13

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

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2026-03-18 · Tag F0726 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2026-04-13

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.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2026-03-18 · Tag F0755 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2026-04-13

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

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2026-03-18 · Tag F0880 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2026-04-13

Provide and implement an infection prevention and control program.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-11-25 · Tag F0725 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-11-26

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

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity F — Potential for harm

Survey 2025-11-25 · Tag F0838 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-11-26

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it affected the facility broadly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-11-19 · Tag F0761 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-12-09

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.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-09-05 · Tag F0656 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2026-01-12

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

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-09-05 · Tag F0925 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2026-01-12

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-05-29 · Tag F0641 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-05-30

Ensure each resident receives an accurate assessment.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-05-29 · Tag F0656 · Routine survey · Deficient, Provider has date of correction · Correction reported 2025-05-30

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

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-05-16 · Tag F0580 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-05-17

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

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-05-16 · Tag F0657 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2025-05-17

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works