The Lakes At Texas City
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
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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The Lakes at Texas City in Texas City, TX inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Texas City, TX, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Lakes at Texas City or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.