Jacinto Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Jacinto Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Oct 30, 2025

  Based on observation, record review, and interviews, the facility failed to ensure residents received adequate supervision for 1 of 5 residents (CR #1) reviewed for accidents. CR #1 eloped from the facility on 03/23/2025 while in the secured unit, through the window. CR #1 was found at a previous residence on 03/24/2025 and refused to return to the facility. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/23/2025 and ended on 03/24/2025. The facility corrected the non-compliance before the investigation, began on 10/14/2025. This failure could place the residents with exit seeking behaviors at risk for injury or death. […]

• Immediate jeopardy, isolatedF686Sep 7, 2023

  Based on interview, observation, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, promote healing, and to prevent new ulcers from developing for 1 (Resident #3) of 18 residents reviewed for pressure ulcers. - The facility failed to perform adequate skin assessments to identify pressure injuries for Resident #3, who was non-ambulatory and wheelchair bound. - The facility failed to identify and treat Resident #3's stage 2 (wound goes through skin and looks like a blister or ulcer but does not go through deep tissues ) and stage 3 (wound goes through deep tissue and fat but does not expose bone) pressure injuries. An Immediate Jeopardy (IJ) was identified on 9/4/2023. […]

• Immediate jeopardy, isolatedF835Sep 7, 2023

  Based on observation and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable, physical, mental, and psychosocial well-being of each resident for 1 (Resident #3) of 18 residents reviewed for Administration. - The Administrator failed to ensure nursing staff were performing weekly skin assessments on Resident #3 and other residents at the facility, causing Resident #3 to get facility acquired Stage 2 (wounds extends through skin and looks like a blister or ulcer but does not extend through deeper tissue) and Stage 3 (wound extends through deep tissue and fat but does not expose bone) pressure wounds. […]

• Actual harm, isolatedF600Aug 31, 2026

  Based on observations, interviews, and record reviews, the facility failed to ensure each resident was free from abuse for 2 of 6 residents (Residents #1 and #3) reviewed for abuse. The facility failed to ensure Resident #1, who had cognitive impairment, was free from sexual abuse when Resident #3 inserted his finger into Resident #1's vagina on 8/28/26. The facility failed to ensure Resident #3 was free from physical abuse when LVN B hit Resident #3 on the top of his head on 8/28/26. These failures placed residents, who resided in the facility, at risk of abuse, pain and emotional distress. […]

• No harm, potential for more than minimal, widespreadF727Dec 5, 2024

  Based on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 3 of 90 days (9/21/24, 9/29/24, and 10/20/24) reviewed for RN coverage. The facility failed to ensure they had RN coverage for at least 8 consecutive hours on 9/21/24, 9/29/24, and 10/20/24. This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment. Findings included: Record review of the staffing sign in sheets for 9/21/24, 9/29/24, and 10/20/24 revealed no RN signed in or on the schedule. Record review of the DON's electronic clock in sheet revealed she worked 4.6hrs on 9/21/24, she didn't work on 9/29/24, and worked 6.93hrs on 10/20/24. […]