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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