Inspection·May 25, 2023

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to have evidence that an alleged violation of abuse was thoroughly investigated and the results reported to the State Survey agency within 5 working days of the incident when CR#1 alleged abuse. Residents Affected - Few ---The facility failed to complete an investigation, provide an investigation report, and report an incident when CR#1 became upset and charged at a staff member. This failure could affect any resident and could result in allegations not being investigated timely. Findings include: Record review of CR#1's face sheet revealed admission date 1/31/23, with diagnoses including respiratory failure with hypoxia (lack of oxygen in the tissues), non-ST elevation myocardial infarction (heart attack when the heart's need for oxygen can't be met), endocarditis (infection of the heart's inner lining), asthma (inflammation of the airway), Schizoaffective disorder (mental health condition that could exhibit symptoms of delusions, hallucinations, depressed episodes, feeling of superiority and/or manic periods of high energy), heart failure, muscle wasting and lack of coordination. Record review of CR#1's care plan (undated) revealed he was independent with ADL's (transfer, hygiene, toileting, feeding, bathing). Record review of CR#1's admission MDS dated [DATE] revealed a BIMS score of 15, indicating independence in cognitive skills for daily decision making, and no supervision required for ADL's. Record review was completed on 5/25/23 for the self-report in state database and documentation there was no report found. Record reviews and interviews on 5/25/23 showed CR#1 alleged abuse after the incident occurred, when CNA B went with him to his room to calm him down. CNA B denied any abuse happened. Record review of CR#1's facility skilled nursing progress note written by LVN A, dated 4/9/23 read, in part: .around 7 A.M. this morning, the resident was standing in the doorway of the room across the hall from his room. the CNA asked why he was in that room. the resident proceeded to exit the room, walking hastily toward the nursing station, where myself and a CNA were standing. The resident was talking out loud, I couldn't make clear what he was saying until he came into my personal space and accused me of writing him up in a threatening gesture. I backed away and raised my hands to guard (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 455490 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 455490 B. Wing A. Building (X3) DATE SURVEY COMPLETED 05/25/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lakes at Texas City 424 N Tarpey Rd Texas City, TX 77591 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)