The Lakes At Texas City
The Lakes at Texas City in Texas City, TX — inspection on November 24, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
jeopardy to resident health or safety
Ombudsman, and facility Medical Director4. An Ad Hoc QAPI was conducted to review CR #1's fall and facility 2 person ADL care and fall prevention protocols.5. In-serviced all direct care staff on ANE, 2 person ADL care including bed mobility and bed baths as well as 2 person Hoyer lift transfers and following resident care plans/Kardex at all times.
Ensuring all supplies at bedside and what to do if additional assistance is required during care to ensure 2 people remain at bedside. An ad-Hoc QAPI meeting was held on 11/5/2025 with the following addressed:1.
Incident/accidents-falls reviewed; specifically, CR #1's incident.2.
Staff in-servicing continued for all direct care staff on providing 2-person ADL care, fall prevention, following resident care plans and Kardex. 3.
Completed an audit of all residents with witnessed falls on 11/5/2025 with no findings of injuries or need for 2-person assistance. 4.
The facility completed an audit of residents that required 2-person assistance with ADL's on 11/5/2025 with no adverse findings. 5.
CNA A no longer works at the facility.
Record review on 11/19/2025 at 6:40 pm of 1:1 in-service training given to CNA B 11/4/2025 on 2 person ADL care including bed mobility, bed baths and bathing and following resident Kardex/care plan at all times while providing care.
Record review on 11/19/2025 at 6:52 pm of all direct care staff in-serviced on ANE, 2 person ADL care including bed mobility and bed baths as well as 2 person Hoyer lift transfers and following resident care plans/Kardex at all times.
Ensuring all supplies at bedside and what to do if additional assistance is required during care to ensure 2 people remain at bedside.
Record review on 11/19/2025 at 6:58 pm of facility audits of all residents with witnessed falls who required 2-person assistance on 11/5/2025 which revealed a total of 3 residents including CR #1 with other findings for the other 2 residents who had no findings of injuries or any adverse outcomes.
Record review on 11/19/2025 at 7:03 pm of facility completed audit of residents that required 2-person assistance with ADL's on 11/5/2025 with no adverse findings related to the residents that required 2-person staff assistance with ADLs.
Record review of personnel file for CNA A revealed she had been terminated after not returning to work, No call, No show on 11/5/2025.
Continued record review of time report for CNA A revealed the last date she worked was 11/4/2025.
Record review of facility incident and accident report log with a date range of 09/01/2025 through 11/20/2025 revealed there had been no witnessed falls since CR #1's incident in 11/4/2025.
Record review of the facility policy and procedure titled Clinical Practice Guideline Activities of Daily Living dated 11/23/2016 read in part: Residents will receive essential services for activities of daily living to maintain good nutrition, grooming, and personal and oral hygiene.based on residents needs provide the amount of staff assistance/support and remain with resident during ADL care.
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.