Inspection visit
Health inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0622
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Not transfer or discharge a resident without an adequate reason; and must provide documentation and
convey specific information when a resident is transferred or discharged.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
interviews and record review, the facility failed to permit each resident to remain in the facility, and not
transfer or discharge the resident from the facility unless the discharge was necessary for 1 (CR #1) of 4
residents reviewed for discharge requirements.
1. The facility failed to ensure CR #1 was provided a discharge in writing.
2. The facility failed to document a discharge summary in resident clinical record.
This failure placed residents at risk of not receiving necessary care and services.
Findings included:
Record review of CR #1 electronic face sheet revealed a [AGE] year-old male admitted on [DATE] and
readmitted on [DATE]. His diagnoses included Cerebral infraction (stroke- reduce blood supply to part of the
brain), mood disorder, Schizoaffective disorder, Bipolar, and communicative deficit (lack of communication).
Record review of CR #1 annual MDS assessment dated [DATE] revealed: Section on cognitive Patterns
with a BIMS Score of 15 indicated his cognition was intact. Section GG Functional Abilities and Goals
CR#1 required supervision with and assistant in Toileting and Dressing.
Record review of CR#1's progress notes dated 10/23/23 at 1:43 p.m. read in part Discharge
Planning/Discharge resident was discharged to a local group home , he was escorted out by the CNA via
wheelchair. Resident was A&Ox3, stable, no concerns at time of discharge, medications, and personal
belongings left with resident at time of discharge. Nursing.
Record review of Social Services Note Text: dated 10/23/2023 at 12:15 p.m. CR #1will be discharging today
to a local group home in . He will discharge with his personal belongings and a new wheelchair .he will use
the group home's pharmacy of choice. CR #1 and his mother, are satisfied with the choice of group home .
Record review of Social Services Note Text: dated 10/20/2023 at 4:54 p.m. Social Services has informed
CR #1's RP about a facility or group home that may take CR #1. She has given the company's email and
phone number in hopes they will connect to discuss payment, name, phone number, and address of the
facility or group home. RP said CR #1 can only pay so much and that she was not able to assist him. She is
aware that if he is unable to afford the place, he will be discharging Monday to her
(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 7
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
06/05/2024
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)
F 0622
residence. Social Services.
Level of Harm - Minimal harm
or potential for actual harm
Record review of physician orders dated 10/20/23 revealed okay to discharge to home with personal
belonging, current medication, home health for nursing, CNA' PT, OT, and high strength light weight
wheelchair to assist in ADLs .
Residents Affected - Few
Record review of Physician's assessment dated [DATE] read in part History of present Illness:
[AGE] year-old male who is an LTC resident with a past medical history of significant for hyperlipidemia,
schizophrenia, tobacco abuse, alcohol use disorder, with residual left hemiparesis, functional paraplegia,
and behavior disorder, falls and recent, left wrist fracture, and recent lumbar osteomyelitis/diskitis L1-L2
completed antibiotics.
Patient is seen today due to report that he was in an altercation and punched another resident twice in the
chest. The other resident is doing and denies any pain or injury. Patient is reported to have been having
more behavioral issues, yelling, and throwing things in his room. He is also seen today for discharge
planning. Patient will be going home to be with his mom who is the responsable party. He will need home
health SN/PT, OT and HHA. He will also need a wheelchair and bedside commode. Patient was
uncooperative during this visit and will not provide any explanation for his behaviors.
During an interview with the facility DON on 06/03/24 at 1100AM, she said discharge planning of the
residents had to do with the Social Worker and the Social Worker would answer any question regarding
discharges.
During an interview with the facility's Social Worker on 06/03/23 at 2:00pm, she said she was told by the
Administrator that CR # 1 needed to be discharged due to CR #1's behavior. She said in the past CR #1's
behavior was managed by a reward system. She said CR #1 continued to hit other residents and throw
things when he did not get his way. She said CR#1 was receiving psychiatric services from a local psych
company. She said all she had for discharge planning was her notes and phone communication with the
receiving facility. She said there was no formal discharge planning with the resident and the resident's RP.
She said the resident's RP was from out of town and she wanted CR #1 to be discharged close to her
home. She said CR #1 was discharged home with a wheelchair that she had ordered for CR #1 that he was
using at the facility. She said she called the facility to follow up and the facility and CR # 1 said he was
doing well. She said they did not provide the home health company that was contacted for continuity of
care.
During an interview with the Administrator on 06/04/24 at 2:00PM, she said she was not the Administrator
at the facility at that time.
Record review of facility's policy on admission, transfer, and discharge rights dated, 10/10/17 updated
02/20/2020 read in part:
This facility complies with federal regulations to permit each resident to remain in the facility, and not
transfer or· discharge unless the following criteria is met.
Fundamental Information
I. The transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met
in the
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455490
If continuation sheet
Page 2 of 7
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
06/05/2024
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)
F 0622
facility.
Level of Harm - Minimal harm
or potential for actual harm
2. The transfer or discharge is appropriate because the president's health has improved sufficiently so the
resident
Residents Affected - Few
no longer needs the service provided by the facility.
3. The safety of the individuals in the facility is endangered due to the clinical or behavioral status of the
resident.
4. The health of individuals in the facility would otherwise be endangered.
5. Respite residents are discharged based upon the agreed length of stay and plan of care
6. The resident has foiled, after reasonable and appropriate notice, to pay for (or to have paid under
Medicare or
Medicaid) a stay at the facility or
7. The facility ceases to operate.
Non-emergency discharge:
7
Non-Emergency Transfers or Discharges - initiated by the facility, return not anticipated.
a.
Document the reasons for the transfer or discharge in the resident's medical record, and in the case of
necessity for the resident's welfare and the resident's needs cannot be met in the facility, document the
specific resident needs that cannot be met, facility attempts to meet the resident needs, and the service
available at the receiving facility to meet the needs. Document any danger to the health or safety of the
resident or other individuals.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455490
If continuation sheet
Page 3 of 7
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
06/05/2024
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observations, interviews, and record review, the facility failed to store, prepare, distribute, and
serve food under sanitary conditions in the only facility kitchen.
Residents Affected - Many
The facility failed to clean the floor in the kitchen.
The facility failed to maintain clean mop water in the kitchen.
The facility failed to date and label covered bowls of food on serving tray.
The facility failed to clean the serving trays used to serve and store covered bowls of food.
The facility failed to change the grease in the deep fryer or keep the exterior sides of the deep fryer clean.
The facility failed to ensure the only sink in the kitchen for employee handwashing was free from clutter and
obstacles to ease staff use.
The facility failed to ensure the only alcohol-based hand sanitizer dispenser was clean and functional for
staff use.
These failures could place the residents who ate meals prepared in the kitchen at risk for food borne
illness.
Findings:
During an observation and interview on 6/4/24 at 11:40 am, the entire kitchen floor was stained and
splattered with material and crumb like substances. There was a large black build up on the floor directly in
front of the kitchen door. Continued observations of the entire kitchen floor revealed skid marks, footprints,
crumbs, and residue all over the floor. Dietary Aide A was observed mopping the floor in the dishwashing
room, who then quickly tried to remove a yellow bucket of dark blackish gray, turbid water. The yellow
bucket had dark black streaks dripping along its sides and had black material crusted into the corners and
crevices of the bucket. There was a mop sitting upright inside the water in the bucket. Dietary Aide A said
that he was going to dump the water because they were about to serve lunch. He did not answer when
asked when the mop water had been changed last. The grease in the deep fryer was opaque dark brown
with food debris floating inside. The sides of the deep fryer were dirty with tan and white streaks down the
sides. The wall on the left side of the deep fryer had globules of brown grease hanging from it. The wall
directly behind the deep fryer had stained streaks of dried grey material streaming down the wall. There
was one sink with an attached eye wash station, which was surrounded by clutter and difficult to access.
There was a foot pedal operated wastebin directly underneath the sink that was covered by a food box with
food debris inside the box. The paper towel dispenser located directly above the sink was hanging open
with the roll of paper towel exposed. There was one wall mounted hand sanitizer dispenser that was
hanging open with the inside covered in small black and brown particles and specks of unknown debris.
There was no sanitizing solution inside the dispenser. There was a light-colored tray located at the bottom
of a shelf that had oatmeal like crumbs on it and a large black speck of unknown origin. There were three
black bowls with plastic covers on them that were undated or labeled that were still on the tray .
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455490
If continuation sheet
Page 4 of 7
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
06/05/2024
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)
F 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
In an interview with the Administrator on 6/4/24 at 12:08pm he said that they were physically in the kitchen
2-3 times per week but had not taken notice of anything wrong. The Administrator said that the dietary staff
were contracted, and the contracting entity was responsible for training dietary staff. She said she believed
the Dietary Manager had been trained .
In an interview with the Dietary Manager on 6/4/24 at 12:20 pm she said she was just promoted from cook
about a week ago after the previous Dietary Manager abruptly left.
Follow up interview with the Dietary Manager on 6/4/24 at 1:05pm she said she was certified but not
licensed as a Dietary Manager and had been in the position for the last 3 months. She was unable to
provide kitchen cleaning schedules. When asked if she thought the kitchen was clean, she said yes. When
asked if she thought the kitchen was sanitary, she said no. The Dietary Manager would not say how she
thought the lack of sanitation in the kitchen could impact the residents, she repeated that she was new to
her role.
Interview with the Dietary Manager on 6/5/24 at 3:01 pm she said the kitchen was cleaned on 6/4/24 and
they will continue to clean and that it looked better than when she first started. She said the kitchen was
supposed to be cleaned daily. She said she had been trained by someone out of state through Company A
for about 2 weeks. The Dietary Manager said she was not sure if she had discussed any cleanliness or
santitation issues in the kitchen directly with the Administrator.
Record review of undated Sanitation Standard Operating Procedures read as follows: The establishment
must maintain daily records sufficient to document the implementation and monitoring of the Sanitation
SOP's and any corrective action taken. Cleaning of facilities including floors, walls, and ceilings .Cleaning
procedures .1. Debris is swept up and discarded. 2. Facilities are rinsed with potable water. 3. Facilities are
cleaned with approved cleaner. 4. Facilities are rinsed with potable water. Cleaning of floors, ceilings, and
walls is done at the end of each production day and when needed to maintain sanitary conditions.
Establishment monitoring .The Team Captain performs daily organoleptic examination before operations
begin 2. All equipment tables and other product contact surfaces are cleaned and sanitized throughout the
day as needed to maintain sanitary conditions and protect the product.
Record review of The Food and Drug Administration Codes August 2021, 4-601.11 Equipment,
Food-Contact Surfaces, Nonfood-Contact Surfaces, and Utensils indicated:
. (A) Equipment food-contact surfaces and utensils shall be clean to sight and touch.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455490
If continuation sheet
Page 5 of 7
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
06/05/2024
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)
F 0925
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
Level of Harm - Minimal harm
or potential for actual harm
Based on observations, interviews, and record review, the facility failed to maintain an effective pest control
program for 1 of 1 kitchen, and 1 of 1 food storage area reviewed for pests.
Residents Affected - Many
1.
Rat\mice droppings were observed in the kitchen area between the deep fryer and the stove on 06/04/24.
2.
A live roach was observed in the dry food storage room on 06/04/24.
This deficient practice could place residents at risk of residing in an environment with pests and at risk for
food borne illness.
Findings included:
Kitchen observation and interview on 06/04/24 at 12:00PM, revealed rat\mice droppings in the kitchen
between the deep -fryer and the stove and mice\rat dropping in the closet identified by the dietary manage
as the mop closet. Observation revealed multiple glue rat traps all around the kitchen. In an interview the
Dietary Manager said there was a hole in the kitchen leading outside where rats were coming from at night.
She said she did not see any, but some kitchen staff had reported seeing rats. She said the exterminator
was present at the facility on 06/03/24 to spray the facility for rodents.
Observation and interview of the dry goods storage room away from the main kitchen on 06/04/24 at
1:20PM, revealed a live roach under one of the two racks. Observation of the freezer identified as the
activity's freezer revealed a dead roach in the freezer. In an interview the Dietary Manager said the
exterminator does spray the facility and cannot get rid of the roaches.
During an interview on 06/4/24 at 1:00 PM, the facility Administrator said the exterminator was called in on
06/03/24 to treat the facility because some of the staff reported seeing roaches, flies, and gnats around.
She stated I am aware of pest control issues, and we have a pest control company that treat the facility
once a month and at any time as needed.
Record review of Facility's pest control invoice dated 06/03/24 revealed the facility was treated for German
roaches target dish pit, electrical outlet, and wall void. Invoice dated 05/16/24 revealed the laundry room
noted seeing German cockroaches, during my inspection of the laundry room, harborage was seen near
the doorway. The kitchen had noted issue of German cockroaches, and small flies.
Record review of facility's policy on pest control dated 01/10/2020 read in part It is the policy of this facility
to maintain an effective pest control program that eradicates and contains common household pests and
rodents.
Policy Explanation and Compliance Guidelines:
1. Facility will maintain a written agreement with a qualified outside pest service to provide
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455490
If continuation sheet
Page 6 of 7
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
06/05/2024
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)
F 0925
comprehensive pest control services on a regular and scheduled basis.
Level of Harm - Minimal harm
or potential for actual harm
2. Facility will ensure that appropriate chemicals are used to control pests but can be used safely inside the
building without compromising resident health.
Residents Affected - Many
3. Facility will obtain services as indicated related to issue that may arise in between scheduled visits with
the outside pest service and treat as indicated.
4. Facility will utilize a variety of methods in controlling certain seasonal pests, i.e. flies. These will involve
indoor and outdoor methods that are deemed appropriate by the outside pest service and state and federal
regulations.
5. Facility will ensure that the outside pest service also treats the exterior perimeter of the facility and any
outlying buildings or structures as indicated i.e. dumpster area, etc.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
455490
If continuation sheet
Page 7 of 7
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F622 - Transfer and discharge-
Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F925 - Maintain an effective pest control program so that the facility is free of
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.
FAQ · About this visit
Common questions about this visit
What happened during the June 5, 2024 survey of The Lakes at Texas City?
This was a inspection survey of The Lakes at Texas City on June 5, 2024. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at The Lakes at Texas City on June 5, 2024?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific info..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.