Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Lakes At Texas City during CMS and state inspections, most recent first.
Inaccurate PASRR Level 1 screenings were completed for two residents with documented psychiatric diagnoses, including schizoaffective disorder, schizophrenia, bipolar disorder, depression, and anxiety. Both residents’ screenings indicated no mental illness, and neither record contained evidence of a PASRR Level 2 evaluation. One resident had moderate cognitive impairment on MDS, and the other had significant cognitive impairment.
A resident with severe neurologic injury, tracheostomy, feeding tube, and total ADL dependence had physician-ordered BUE hand rolls for contracture management, but repeated observations found contracted hands with no hand rolls in place. Staff interviews showed therapy had been placing the hand rolls while services were active, and after therapy ended the hand rolls were not being consistently provided by nursing as ordered.
A resident with severe neurologic injury, total ADL dependence, and contracted hands did not receive ordered BUE hand rolls for contracture management after OT services ended. Observations showed the resident in bed with contracted hands and no hand rolls present, while staff reported therapy had been placing the hand rolls during rehab and nursing was supposed to continue them afterward.
Expired medication was found in a medication refrigerator in 1 of 1 med rooms when an open bottle of Acetylcysteine for a resident was observed long after its labeled 96-hour use period. The resident had Muscular Dystrophy, intact cognition, and no active order for the medication, while the ADON, DON, and Consultant Pharmacist described routine checks of med fridges and carts for outdated meds.
Insulin products on a medication cart were found without resident names or open dates, including multiple pens and vials for several residents with diabetes. An LVN, DON, ADON, and consultant pharmacist all stated insulin should be labeled with the resident name and dated when opened, and the facility policy required insulin pens to be assigned to one patient and labeled appropriately.
Incomplete privacy curtains were found in 4 of 7 rooms reviewed, including rooms with 2 residents where the curtain rail or curtain placement did not fully cover both beds. Staff stated they had not noticed the curtains, often relied on closing the door during care, and the Administrator said residents should have privacy curtains for dignity; the facility also stated it did not have a policy specific to privacy curtains.
Inaccurate MDS Assessments for Oral/Dental Status: The facility failed to ensure MDS assessments accurately reflected the condition and status of 3 residents. Two residents were coded as having no oral/dental problems and all natural teeth intact, but observations and care plans showed missing teeth or edentulous status, and one resident was also served a mechanically altered diet. A third resident’s MDS was also inaccurate, while the care plan addressed unplanned weight gain. The MDS Coordinator and DON stated assessments should reflect the resident’s condition and status.
Care Plan Did Not Reflect Weight Loss: A resident with DM, heart disease, anxiety, hepatitis C, chronic pain, and cancer-related chemo effects had a care plan that still addressed weight gain instead of his current weight loss and inconsistent intake. The record and RD assessment noted altered taste, poor appetite around chemo, mechanically altered diet, missing partial dentures, and a history of significant wt loss, while observations showed he was weak, skipped lunch, and relied on supplements and snacks.
A resident with a history of traumatic brain injury and craniectomy, who was totally dependent on two staff for ADL care, experienced a fall and injury when only one CNA remained at the bedside during a bed bath while the other left to retrieve linens. The resident slid off the bed and sustained a head injury, with no helmet in use and no physician order for one, despite family requests. Staff interviews confirmed the requirement for two-person assistance was not followed, leading to the incident.
The facility failed to provide scheduled showers to two residents who were dependent on staff for personal hygiene, due to staffing issues on the 2pm-10pm shift. Despite documentation indicating showers were given, resident interviews revealed that they often went weeks without proper bathing. The DON and Administrator were unaware of these issues, highlighting discrepancies in record-keeping and adherence to the facility's Quality-of-Life Policy.
The facility's kitchen failed to store and label food items according to professional standards, with several items in the walk-in cooler found unlabeled and undated. The Dietary Manager and facility administrator acknowledged the importance of labeling and dating food to prevent foodborne illness, as per the facility's policy.
A facility failed to respect the rights and dignity of three residents by not providing adequate privacy and accommodation for a consensual relationship between two residents. Despite their requests, the facility did not allow them to share a room or have private time, impacting their quality of life. Another resident was inconvenienced by being asked to leave her room to provide privacy for the couple. The facility's actions were inconsistent with its policy on resident rights.
The facility failed to transmit MDS assessments within the required 14-day period for several residents, with delays ranging from 15 to 42 days. This issue arose after the death of the former MDS nurse, leading to staffing challenges and a backlog in assessments. The new MDS nurse and the administrator acknowledged the delays, which could impact residents' care plans and services.
The facility failed to provide routine and emergency dental care for three residents, leading to a deficiency. Despite being cognitively intact and having care plans indicating dental issues, the residents reported pain and unmet requests for dental services. Interviews revealed systemic issues, including the absence of a visiting dentist and unaddressed referrals by the social worker.
A facility failed to update the PASRR Level 1 forms for a resident with an active diagnosis of Bipolar Disorder, resulting in the resident being deemed ineligible for PASRR specialized services. The Social Worker responsible for PASRR completion was unaware of the need to update the forms and lacked training on the process, potentially placing residents at risk of not having their special needs assessed and met.
The facility's kitchen was found to be unsanitary, with a dirty floor, unchanged mop water, and unclean deep fryer. The handwashing sink was cluttered, and the hand sanitizer dispenser was non-functional. Serving trays and bowls were not properly labeled, and there was no cleaning schedule. The Dietary Manager, recently promoted and uncertified, acknowledged the lack of sanitation, while the Administrator failed to notice the issues despite frequent visits.
The facility failed to maintain an effective pest control program, with rat and mice droppings found in the kitchen and a live roach in the dry food storage room. The Dietary Manager noted a hole in the kitchen allowing rats to enter, and despite regular pest control treatments, roaches persisted. The Administrator confirmed awareness of these issues, with pest control services conducted monthly and as needed.
A resident with a history of behavioral issues and multiple medical conditions was discharged from the facility without proper documentation or a formal discharge plan. The discharge was initiated due to the resident's behavior, but the facility failed to provide a written discharge summary or ensure continuity of care, violating federal regulations and facility policy.
Inaccurate PASRR Level 1 Screenings for Two Residents
Penalty
Summary
PASRR Level 1 screenings for two residents did not accurately reflect their mental health status. One resident had diagnoses including schizoaffective disorder, depression, generalized anxiety disorder, and restlessness and agitation, but the PASRR Level 1 screening completed for her indicated no mental illness. Her annual MDS showed a BIMS score of 11 out of 15, indicating moderate cognitive impairment, and there was no evidence of a PASRR Level 2 evaluation in the record. A second resident had diagnoses including undifferentiated schizophrenia, bipolar disorder, major depression, hemiplegia, hemiparesis following cerebral infarction, bradycardia, and cognitive communication impairment. Her annual MDS showed a BIMS score of 6 out of 15, indicating significant cognitive impairment, but her PASRR Level 1 screening also indicated no mental illness. The clinical record contained no evidence of a PASRR Level 2 evaluation. The DON stated MDS staff were responsible for PASRR-related evaluations, and the MDS Coordinator stated she would review diagnoses and admitting paperwork to ensure the assessment accurately reflected the resident's condition.
Failure to Follow Hand Roll Orders for Contracture Management
Penalty
Summary
The facility failed to ensure that services provided for Resident #10 met professional standards of quality by not following physician orders for hand rolls used for contracture management. Resident #10 was admitted with diagnoses including hypoxic ischemic encephalopathy, tracheostomy, hypertension, respiratory failure, tachycardia, stiffness of joint, anoxic brain damage, cardiac arrest, and dysphagia. Her care plan and MDS showed total dependence for ADLs, bilateral impairment, incontinence, feeding tube use, oxygen therapy, suctioning, tracheostomy care, and no splint/brace assistance documented. A physician order dated 11/4/25 directed OT to address BUE hand rolls for contracture management 6 hours or as tolerated 5 days a week, and OT documentation stated the resident would tolerate BUE hand roll splints for 3 to 5 hours for contracture management. During observations on 12/1/25, 12/2/25, and 12/3/25, Resident #10 was found in bed sleeping with a tracheostomy, feeding tube infusing Jevity 1.5, oxygen at bedside, and suction equipment on the bedside table; her hands were contracted and no hand rolls were present. Staff interviews indicated the restorative aide and OT had been placing and removing the hand rolls while therapy was active, and the Rehab Director stated that after therapy ended on 11/12/25, nurses were supposed to place the hand rolls for at least 6 hours daily. The ADON searched the room and did not find hand rolls, then obtained washcloths from laundry to use as hand rolls. The DON stated she was aware of the issue and explained that the prior order had been tied to therapy placement, but nurses were now expected to place the hand rolls and assess for skin breakdown.
Failure to Provide Hand Rolls for Contracture Management
Penalty
Summary
The facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion. Resident #10 was admitted with diagnoses including hypoxic ischemic encephalopathy, tracheostomy, hypertension, respiratory failure, tachycardia, stiffness of joint, anoxic brain damage, cardiac arrest, and dysphagia. The annual MDS showed the resident was dependent on staff for all ADLs, had impairment on both sides, and had no splint/brace assistance days. The baseline care plan documented total dependence on staff for all ADLs, and the care plan included therapy to screen, evaluate, and treat as needed. The physician's order dated 11/4/25 directed OT to address bilateral upper extremity hand rolls for contracture management 6 hours or as tolerated 5 days a week, and the OT evaluation recommended bilateral hand roll splints for 3 to 5 hours for contracture management. However, observations on 12/1/25, 12/2/25, and 12/3/25 showed the resident in bed sleeping with contracted hands and no hand rolls present. Staff interviews indicated therapy had been placing and removing the hand rolls while the resident was on therapy services, but after therapy was discontinued on 11/12/25, the nurses were supposed to place the hand rolls. The ADON could not find any hand rolls in the room and used washcloths temporarily, and the DON stated the prior order had gone away when therapy ended.
Expired Medication Left in Medication Refrigerator
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring expired medications were removed from the medication refrigerator in 1 of 1 medication rooms. During observation on 12/2/25 at 10:23 a.m., the Station 1 Medication Room contained one Acetylcysteine 20% Solution 30 ml bottle for Resident #46 with an open date of 1/31/25 written on the label, and the label stated it was good for 96 hours. Record review showed Resident #46 was a male admitted with diagnoses including Muscular Dystrophy, and his quarterly MDS indicated a BIMS score of 15, showing intact cognition. His order summary had no active Acetylcysteine order as of 12/2/25, and his April 2025 MAR showed the last documented Acetylcysteine administration was on 4/21/2025 at 6 p.m. During interview, the ADON stated Resident #46 was not taking Acetylcysteine anymore, that he had always refused it and took it only as needed, and that she would dispose of it. The ADON stated nurses were supposed to check the medication refrigerator every day and that she also checked the medication fridge. The DON stated expired medication would not give the full effect because it may not have been as potent, and said the charge nurse and medication aides checked the medication fridges for medications they were giving, while the ADON oversaw that they had done so. The Consultant Pharmacist stated she visited the facility once a month, checked one medication room, and did spot checks of the refrigerator, but did not notice the Acetylcysteine; she also stated Acetylcysteine is only good for 96 hours once opened. The facility policy stated medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications.
Insulin Pens and Vials Were Left Unlabeled or Undated on a Medication Cart
Penalty
Summary
Medication storage and labeling were not maintained in accordance with accepted professional principles on the Station 2 nurse medication cart. During observation on 12/2/25, one Insulin Aspart Flex Pen had an open date of 10/30/25 but no resident name, and multiple insulin products had no open date documented, including a vial of Lantus 100 u/ml and two Humalog KwikPens for one resident, a vial of Insulin Glargine 100 u/ml and two Insulin Aspart FlexPens for another resident, an Insulin Degludec FlexTouch pen for a third resident, and an Insulin Aspart Protamine and Insulin Aspart 70/30 mix FlexTouch pen for a fourth resident. The report identified residents with diabetes diagnoses and active insulin orders, including one resident with intact cognition, one resident with severe cognitive impairment, and others receiving scheduled or sliding-scale insulin. During interview, the LVN stated insulin should be documented with an open date as soon as it was opened and said the unlabeled and undated insulins should have been checked by the night nurse as well. The LVN also stated that insulin without an open date could be old if it had been out too long and said she would have to get new insulin and discard the unlabeled and undated insulin. The DON stated that if no name was on the medication it could be given to the wrong person, and if the medication was expired it could be less effective for treating diabetes. The ADON stated the nurse who removed insulin from the refrigerator was responsible for ensuring it was labeled with the resident's name and open date, and that insulin was good for 28 days once removed from refrigeration. The consultant pharmacist stated insulin should be stored in the refrigerator until opened and dated when removed from the refrigerator, and that all insulins should have a resident's name. The pharmacist also stated she checked two medication carts at random during visits for expired medications, open dates, and labeling. Facility policy stated insulin pens should be assigned to one patient and labeled appropriately, and medication carts were to be routinely inspected for discontinued, outdated, defective, or deteriorated medications.
Incomplete Privacy Curtains in Multiple Resident Rooms
Penalty
Summary
The facility failed to ensure that each bed had ceiling-suspended privacy curtains that extended around the bed to provide total visual privacy in combination with adjacent walls and curtains in 4 of 7 rooms reviewed for privacy: Room D1, Room D5, Room D6, and Room D9. Observations and attempted interviews on 12/01/25 found that Room D1 was occupied by 2 residents and did not have full visual privacy curtains; the curtain was on the rail between the A and B beds and did not cover both residents. In Room D5, 2 residents were observed with the privacy curtain by the A bed, and an attempt to pull it ended halfway at the A bed, exposing that bed. In Room D6, 2 residents were observed and the curtain could only go halfway on the rail and was at the foot of the bed. In Room D9, 2 residents were observed and the curtain between the A and B beds could only cover part of the B bed. During interviews, CNA S and CNA T stated they did not notice the curtain in Room D9, and CNA T said she usually closed the door during patient care and did not pay attention to the curtains because people always knocked and would not come in. LVN H stated residents needed privacy for dignity reasons and that the curtain provided a sense of having their own space, but she had not paid attention to the privacy curtains. CNA I also stated she had not noticed the privacy curtains and usually closed the door. The Administrator stated all residents should have privacy curtains for dignity and said she would have asked Maintenance to inspect all rooms for full visual privacy curtains; she also stated staff needed education on residents' privacy and ensuring curtains go around the bed to provide privacy and dignity. The facility later stated it did not have a policy specific to privacy curtains.
Inaccurate MDS Assessments for Oral/Dental Status
Penalty
Summary
The facility failed to ensure that assessments accurately reflected the residents’ status for 3 of 18 residents reviewed for accurate assessments. Resident #7’s Annual MDS assessment coded oral/dental status as having no problem and all natural teeth intact, and the nutritional approaches section indicated a mechanically altered diet. However, the care plan identified the resident as edentulous, and during observation the resident had no teeth in the oral cavity and stated he had full dentures that did not fit and were kept in his nightstand. The resident also reported that he ate what he could and left what he could not eat. Resident #20’s Annual MDS assessment also coded oral/dental status as no problem with all natural teeth intact and indicated a mechanically altered diet, while the care plan documented likely carious and missing teeth. During observation, the resident was served a mechanically altered diet and stated she had no natural teeth and no dentures. Resident #22’s Annual MDS assessment similarly coded oral/dental status as no problem with all natural teeth intact and indicated a mechanically altered diet, while the care plan addressed unplanned/unexpected weight gain and related complications. The MDS Coordinator stated that assessments should reflect the resident’s condition and status, and the DON stated that an inaccurate assessment may delay services and that residents should be assessed accurately.
Care Plan Did Not Reflect Resident’s Weight Loss
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #22 that included measurable objectives and timeframes to meet his identified medical, nursing, mental, and psychosocial needs. The resident’s care plan, dated 04/01/22 and revised 09/25/24 with a target date of 10/20/25, continued to address weight gain, stating that he had unplanned/unexpected weight gain and listing interventions such as RD evaluation, diet counseling, monitoring food intake, and notifying the MD for signs related to increased weight. The plan did not accurately reflect the resident’s current weight-related condition. Resident #22’s record showed diagnoses including Type 2 diabetes mellitus without complications, heart disease, generalized anxiety disorder, hepatitis C, and chronic pain. His annual MDS indicated a BIMS score of 14, showing he was cognitively intact, and he was coded as receiving a mechanically altered diet. The RD assessment documented a history of inadequate oral intake that had improved, inconsistent intake at some meals, altered taste related to cancer and chemotherapy, and a history of significant weight loss over 90 to 180 days with stabilized weight over 30 to 45 days, with risk for malnutrition, further unplanned weight loss, and/or hydration deficit due to cancer and chemotherapy effects. During observations and interviews, Resident #22 was seen in bed, alert and oriented, stating he was not doing well, felt weak, and wanted to sleep. Later he said he did not eat lunch because he was not hungry and planned to drink his liquid protein and eat snacks. The next morning he ate 80% of breakfast, had only two teeth in his oral cavity, and stated he no longer had his partial dentures, ate what he could when hungry, and was aware of his weight loss, which he attributed to monthly chemotherapy that reduced his appetite until the next treatment. The DON stated that care plan revisions and updates were the responsibility of the interdisciplinary team and that the care plan should be updated to reflect the resident’s condition.
Failure to Provide Adequate Supervision During ADL Care Resulting in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the environment was free from accident hazards and that a resident received adequate supervision and assistance devices to prevent accidents. The incident involved a male resident with a history of traumatic brain injury, craniectomy with no bone flap on the left side of his skull, tracheostomy, and a persistent vegetative state. The resident was totally dependent on at least two staff members for activities of daily living (ADL) care, including bed mobility and bathing, and was assessed as being at moderate risk for falls. On the day of the incident, two CNAs were providing a bed bath to the resident. One CNA left the bedside to retrieve clean linens, leaving the other CNA alone with the resident. During this time, the remaining CNA rolled the resident to his side, at which point the resident began to slide off the bed, with his forehead pressed against the wall. The second CNA returned and assisted the resident to the floor. The resident was found with a reddened area on the right side of his forehead. There was no helmet in use, and there were no physician orders for a helmet at the time, despite the family’s request for helmet use during repositioning due to the resident’s craniectomy. Interviews with staff confirmed that the resident required two-person assistance for all ADL care and that both staff members should have remained at the bedside during care. The failure to maintain two-person supervision during ADL care directly led to the resident’s fall and subsequent injury, which resulted in rehospitalization. The facility’s policy required staff to remain with residents during ADL care and to provide the necessary level of assistance based on the resident’s needs.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to perform activities of daily living (ADL) were provided with necessary services to maintain good personal hygiene. Specifically, two residents, identified as Resident #3 and Resident #5, did not receive their scheduled showers. Both residents were cognitively intact, with BIMS scores of 15, and were dependent on staff for showering and personal hygiene. Resident #3, a male with multiple health conditions including paraplegia and osteomyelitis, required assistance during bathing. Resident #5, a female with cardiorespiratory conditions and non-Alzheimer's dementia, was also dependent on staff for bathing and personal hygiene. Interviews with residents and staff revealed that there were significant issues with staffing on the 2pm-10pm shift, which was responsible for providing showers to certain residents. Residents reported that they were often told there were not enough staff to assist with showers, and some residents had gone weeks without a shower or bed bath. Staff interviews corroborated these claims, with CNAs acknowledging complaints from residents about not receiving showers and admitting that they sometimes marked showers as completed even when they were not. The Director of Nursing (DON) and the Administrator were unaware of the ongoing issues with shower schedules and staffing shortages. The facility's documentation indicated that showers were provided, but resident interviews contradicted this, suggesting discrepancies in record-keeping. The facility's Quality-of-Life Policy emphasized the importance of maintaining residents' well-being and self-esteem, but the failure to provide scheduled showers compromised these standards.
Improper Food Storage and Labeling in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food storage, preparation, distribution, and service in its kitchen, as observed during a survey. Specifically, the facility's walk-in cooler contained several food items that were not properly labeled or dated. These items included leftover cake, a can of sliced apples in a partially covered container, food items in a grocery bag, an unidentified food product, leftover salad in a Ziplock bag, flour tortillas, and gallons of chocolate milk with expired use-by dates. The Dietary Manager acknowledged these issues, stating that all leftover food items and products removed from their original containers should be labeled and dated to prevent foodborne illness. During interviews, the Dietary Manager confirmed that serving expired milk could lead to foodborne illness and expressed that she would not use it. The facility administrator also stated that she expected all food items in the walk-in cooler to be labeled and dated. The facility's policy on frozen and refrigerated food storage requires items to be dated upon receipt unless they have a manufacturer use-by date. The failure to comply with these standards could potentially affect residents receiving meals from the kitchen, placing them at risk for foodborne illness.
Failure to Uphold Resident Rights and Privacy
Penalty
Summary
The facility failed to uphold the rights of three residents, leading to a deficiency in maintaining their dignity and quality of life. Resident #42, a male with intact cognition and several medical conditions, was involved in a consensual relationship with Resident #66, a female also with intact cognition and multiple diagnoses. Both residents were their own responsible parties and had expressed a desire to be together, yet the facility did not provide them with the opportunity to share a room or have private time together. This lack of accommodation was despite the residents' requests and the facility's acknowledgment of their relationship in their care plans. Resident #44, who shared a room with Resident #66, was affected by the facility's failure to provide privacy for Residents #42 and #66. She was asked to leave her room to allow the couple private time, which she and Resident #42 found uncomfortable. The facility's administrator acknowledged the issue but cited a lack of available rooms that could accommodate a male and female together due to shared bathroom arrangements. The facility had suggested discharging the couple to an assisted living facility, but they refused. The facility's admission policy emphasizes the residents' rights to a dignified existence, self-determination, and reasonable accommodation of individual needs and preferences. However, the facility's actions did not align with these policies, as they failed to provide the necessary accommodations for the residents' relationships and privacy needs. This oversight resulted in a deficiency related to the residents' rights and quality of life.
Delayed MDS Assessment Transmissions
Penalty
Summary
The facility failed to electronically transmit Minimum Data Set (MDS) assessments within the required 14-day period after the Assessment Reference Date (ARD) for eight residents. This deficiency was identified through record reviews and interviews, revealing that the assessments for these residents were significantly delayed. For instance, Resident #9's annual MDS assessment was transmitted 27 days after the ARD, while Resident #33's admission MDS was transmitted 37 days late. Other residents, including Residents #44, #50, #66, #75, CR #79, and #382, also experienced delays ranging from 15 to 42 days past the ARD. The delays in transmitting MDS assessments were attributed to staffing challenges following the death of the former MDS nurse in February. The facility relied on corporate nurses temporarily until a new MDS nurse was hired in March. The newly appointed MDS nurse, who began working with MDS assessments in April, acknowledged the backlog and was in the process of catching up on the assessments. The MDS nurse and the facility administrator both recognized that these delays could impact the residents' care plans and the provision of appropriate care. The CMS Resident Assessment Instrument (RAI) manual specifies that admission assessments must be completed within 14 days of admission, and other comprehensive MDS assessments must be completed within 14 days of the ARD. The facility's failure to adhere to these timelines for multiple residents indicates a systemic issue in managing MDS assessments, potentially affecting the residents' care and Medicaid payments.
Failure to Provide Dental Care
Penalty
Summary
The facility failed to assist residents in obtaining routine and 24-hour emergency dental care for three residents, leading to a deficiency in dental services. Resident #9, a cognitively intact female with multiple diagnoses including anxiety disorder and major depressive disorder, was found to have obvious or likely cavities or broken teeth. Despite being care planned for dental issues, she reported experiencing dental pain and had not seen a dentist since her admission. Her care plan included monitoring for oral problems and referring to a dentist, but these interventions were not effectively implemented. Resident #42, a cognitively intact male with conditions such as hypertension and diabetes, also had obvious or likely cavities or broken teeth. His care plan included daily oral care and monitoring for dental issues, but he reported that his requests to see a dentist were ignored. He had informed the social worker multiple times without receiving a response. Similarly, Resident #66, a female with PTSD and diabetes, was assessed with dental issues but lacked a care plan for dental care. She reported pain and loose teeth, yet her complaints to the social worker went unaddressed. Interviews with facility staff revealed systemic issues in addressing dental care needs. The social worker admitted to not assessing residents for dental issues and noted difficulties in securing a visiting dentist. The MDS coordinator confirmed that dental referrals were the social worker's responsibility, while the facility administrator acknowledged the absence of a regular visiting dentist. The facility's policy on dental care services was requested but not provided, indicating a lack of structured procedures to ensure residents receive necessary dental care.
Failure to Update PASRR Level 1 Forms for Resident with Bipolar Disorder
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for a resident who was reviewed for PASRR. Specifically, the facility did not update the PASRR Level 1 forms for a resident to indicate a mental health illness, despite the resident having an active diagnosis of Bipolar Disorder. The resident's face sheet indicated that she was a 69-year-old female with a documented onset of Bipolar Disorder as of April 2024. However, the PASRR Level 1 Screening conducted in March 2024 did not reflect this mental health condition, leading to the resident being deemed ineligible for PASRR specialized services. The deficiency was further highlighted during an interview with the facility's Social Worker, who was responsible for completing the PASRR. The Social Worker confirmed that the PASRR Level 1 on admission was negative for mental illness and admitted to not knowing the requirement to submit an updated PASRR Level 1 form. The Social Worker also revealed a lack of training regarding PASRR and did not have a system in place to ensure timely and accurate completion of PASRR Level 1 assessments. This oversight could potentially place residents requiring PASRR services at risk of not having their special needs assessed and met by the facility.
Sanitation Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its only kitchen, as observed during a survey. The kitchen floor was stained and covered with crumbs and residue, and the mop water used for cleaning was dirty and unchanged. The deep fryer contained opaque, dark brown grease with food debris, and its exterior was unclean. The handwashing sink was cluttered and difficult to access, with a non-functional hand sanitizer dispenser nearby. Additionally, serving trays and bowls of food were not properly dated or labeled, and the kitchen lacked a documented cleaning schedule. Interviews revealed that the dietary staff were contracted, and the Dietary Manager was recently promoted and uncertified. The Dietary Manager admitted to not having a cleaning schedule and acknowledged the kitchen was not sanitary. The Administrator, who was in the kitchen multiple times a week, did not notice any issues. The facility's Sanitation Standard Operating Procedures were undated, and the FDA Codes require that equipment and surfaces be clean to sight and touch, which was not adhered to in this case.
Pest Control Deficiency in Kitchen and Food Storage Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, as evidenced by observations of rat and mice droppings in the kitchen area between the deep fryer and the stove, as well as in the mop closet. The Dietary Manager acknowledged the presence of a hole in the kitchen that allowed rats to enter at night, although she had not personally seen them. The facility had multiple glue rat traps placed around the kitchen, and the exterminator had visited the facility the day before the survey to spray for rodents. Additionally, a live roach was observed in the dry food storage room, and a dead roach was found in the freezer identified as the activity's freezer. The Dietary Manager reported that despite regular pest control treatments, the exterminator was unable to eliminate the roaches. The facility's Administrator confirmed awareness of the pest control issues and stated that the pest control company treats the facility monthly and as needed. Record reviews of pest control invoices indicated ongoing issues with German cockroaches and small flies in various areas of the facility.
Failure to Document and Plan Resident Discharge
Penalty
Summary
The facility failed to comply with discharge requirements for a resident, identified as CR #1, who was discharged without proper documentation and planning. The resident, a male with a history of cerebral infarction, mood disorder, schizoaffective disorder, and other medical conditions, was discharged to a local group home. However, the facility did not provide a written discharge summary or ensure that the discharge was documented in the resident's clinical record. This oversight placed the resident at risk of not receiving necessary care and services post-discharge. Interviews and record reviews revealed that the discharge was prompted by the resident's behavioral issues, including altercations with other residents. The facility's social worker indicated that the discharge was directed by the administrator due to these behaviors. Despite the resident's history of managed behavior through a reward system and ongoing psychiatric services, the facility did not conduct formal discharge planning with the resident or his responsible party. The social worker's notes and phone communications with the receiving facility were the only records of discharge planning. The facility's policy on admission, transfer, and discharge rights requires documentation of the reasons for discharge, especially when the resident's needs cannot be met in the facility. However, in this case, there was no documentation of the specific needs that could not be met, attempts to meet those needs, or the services available at the receiving facility. The lack of a formal discharge plan and documentation contravened the facility's policy and federal regulations, leading to the deficiency noted in the report.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Texas City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Bayou Pines Care Center | 0.8 mi | ★★★★★ | 4 | 1 |
| The Shoal | 1.1 mi | ★★★★★ | 5 | 0 |
| Seabreeze Nursing And Rehabilitation | 1.3 mi | ★★★★★ | 8 | 0 |
| Harbor Point Skilled Nursing | 4.6 mi | ★★★★★ | 9 | 0 |
| The Phoenix Post-acute | 6.3 mi | ★★★★★ | 4 | 0 |
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