Health inspection·November 24, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few revealed no orders for a helmet. Record review of facility incident and accident report log with a date range of 09/01/2025 through 11/20/2025 revealed CR #1 had a witnessed fall on 11/4/2025 at 4:00pm. Record review of CR #1's incident and accident report dated 11/4/25 at 4:00 pm revealed the following documentation by LVN A: .called to the resident room by CNA. Nurse entered the room observed the resident on the floor laying supine (lying on one's back with face upward), between the bed and wall, trach (tracheostomy) remained in place. The CNA states the resident was overturned and (sic)begin to slide off the bed with forehead leaned against the wall. Another CNA entered the resident room and observed the resident sliding off the bed and assisting the resident to the floor. Head-to-toe assessment complete. Red area noted to right side of forehead. Record review of CR #1's ER hospital A record dated 11/4/25 revealed CT of the head concerning for a right frontoparietal convexity [Refers to the outer convex having an outline or curved surface like the exterior of a circle] surface of the brain located where the frontal and parietal [top of the brain] lobes meet] collection suspicious for seroma [collection of clear fluid] or hygroma [fluid-filled sac or cyst that develops in soft tissue, often over a bony prominence due to repeated trauma or pressure] as well as moderate mass effect with an 8mm right to left midline shift and a large left frontoparietal craniectomy .unclear if seroma/hygroma is new or unchanged in size. Therefore, will initiate discussion/transfer to site of patient's previous care at [Hospital B]. Record review of CR #1's Hospital B CT Scan results dated 11/6/2025 revealed the following: Impression: Increased size of right convexity [Refers to the outer convex having an outline or curved surface like the exterior of a circle] subdural [situated or occurring under the tough outer membrane that covers the brain] collection containing only gas with increased right to left midline shift . Record review of CR#1's neurologist progress notes from Hospital B dated 11/7/25 revealed, [CR#1] is being evaluated for neurosurgery after falling from his bed. s/p craniectomy. It appears point of contact was right forehead. No bone flap left side. Observation of CR #1 at Hospital B on 11/19/2025 at 1:22pm which included bedside interview with Hospital RN who said 11/19/2025 was her first day working with the resident. She said CR#1 was non-verbal and non-communicative so far, and he readmitted to the hospital after sustaining a fall at a nursing home. Upon entering the resident's room, there was sign posted on his door that read NPO, Central Line and L NO Bone Flap. Hospital RN said he originally admitted to that facility after an MVA 8/22/25 and had a craniotomy where the left side of his head was left open with no skull bone and remains that way, hence the sign on the door. She said the left side of his head is just skin and no bone, so they are very careful when turning and repositioning him and they use 2 people. CR #1 was observed in a specialized electric bed with at least 3 large pillows surrounding his head and he was not wearing a helmet. Hospital RN said S/P surgery CR#1 went to a SNF and readmitted because of a fall at the SNF but she was not aware of any additional injuries as a result of the fall. CR #1 opened his eyes but did not respond to any commands and the right side of his head and forehead had no visible external injury, bump, or bruising. CR #1 had a full head of dark curly hair, with no visible scars or markings apparent on the sides and front of his face or skull. The Hospital RN said she had just been to the bedside within the last 15 minutes and performed trach care and was reluctant to move the resident again at that time. She said in the hospital, any helmet used would only be worn while a patient was out of bed and they did not use it while a patient was in the bed for just turning and repositioning. She said he did not have an order for a helmet at that time and had a diagnosis of sepsis upon admission and respiratory cultures were pending. Interview with family member on 11/19/25 at 11:40 am who said they advised the facility that CR #1 was to wear a helmet on his head whenever turning or repositioning even in bed due to his bone flap, craniectomy, and brain surgery history. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 2 of 6 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 11/24/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Interview on 11/20/25 at 12:58 pm with Administrator and DON. DON said that CR #1 had fallen, but it was a change in plane because he was assisted to the floor. The DON said CNA A and CNA B were giving CR #1 a bed bath and while CR #1 was rolled to one side facing the wall CNA A was at the bedside and had rolled CR #1 to the side while CNA B went to the room door to get clean linens and CR #1 began to slide into the wall and between the bed and the wall. CNA B ran back and was able to assist CR #1 to the floor. LVN A was called to assess the resident, and it was reported that CR #1 had a reddened area to the right side of his head with no swelling just redness. LVN A then notified CR#1's NP who advised to monitor CR #1 hourly and report any additional changes. LVN A then notified RP who wanted CR #1 sent to the hospital for scans and diagnostic studies, so LVN A called NP back who advised to send CR #1 to ED. The DON said she completed in-service training with all staff after the incident on 11/5/25 and completed 1:1 in-service training with CNA B after the incident on 11/5/25, but CNA A self-terminated because she never returned to work at the facility but had completed training prior to the incident. DON said she spoke with hospital staff who advised CR #1 had no injury but CR#1's family wanted him sent back to hospital B where he had his original brain surgery. DON said CR #1 was a 2 person assist with all care. The DON said there was a helmet with CR #1's belongings but there was no discussion with family or NP/MD about use of the helmet and no MD order for use of the helmet. Interview with Administrator on 11/20/25 at 1:10pm she said they did a PIP/QAPI after the incident on 11/5/25 with CR #1 and staff had been retrained and in-serviced on 2-person ADL care, Hoyer lifts and they audited the witnessed falls and all residents that required 2-person ADL care with no adverse findings. The Administrator said CNA A never returned to work and had been removed as an employee at the facility. Interview with LVN A on 11/20/25 at 5:25pm she said she had been alerted by CNA B that CR #1 was assisted to the floor after they provided a bed bath for CR #1 and CNA B stepped away to get linens and CNA A rolled CR #1 to his side and CR #1 kept rolling into the wall and slid between the bed and the wall bumping or rubbing the right side of his forehead on the wall. LVN A said CR #1 had a helmet but did not wear it and there were no MD orders for the helmet that she could recall. LVN A said she notified NP who gave orders to monitor CR #1 but after speaking with CR #1's family they wanted CR #1 to have a CT scan and or X-rays, so she called NP back and was given the order to send CR #1 to the ER. LVN A said she was never provided with any update on CR #1 ‘s status and if he had sustained any additional injuries from the fall. LVN A said they and all the nurses and CNAs were trained again by the DON after CR #1 had the fall, on 11/5/25. LVN A said they were all in-serviced on 2-person ADL care on 11/5/25 and how 2 staff are to remain at the bedside at all times during care on 11/5/25 and if items are needed or forgotten, to use the call light or they can leave the resident in a safe position and return to perform care with 2 people present on 11/5/25. Interview with LVN B on 11/20/2025 at 12:05pm who said she worked with CR #1 but was not working at the time of the incident. LVN B said the day after the incident they were all trained and clarified it was all the CNAs and nurses regarding 2-person ADL care and bed mobility and bed baths, as well as following the resident care plan and Kardex [a specific type of care plan for CNA and direct care staff to review what type of care a resident required] for resident care and following MD orders, abuse, neglect, exploitation, and 2-person transfers. LVN B said CR #1 was totally dependent for care and required 2 people for ADL care. She said there had been additional training the day after the incident on bringing all supplies to the bedside and calling for assistance rather than leaving the bedside if needed. LVN B said it was unfortunate that CR#1 bumped his head and said it would not have happened if both CNAs had remained at the bedside. Interview with CNA B on 11/22/25 at 11:56 am who said that CR #1 had a known head injury and was a 2 person assist with his care. CNA B said that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 3 of 6 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 11/24/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few they were the one who left the bedside to retrieve the linens and CR #1 was lying flat on his back on the bed while CNA A remained at the bedside. CNA B said she did not know why CNA A rolled CR #1 to his side but believed CNA A was probably just trying to take soiled linens out from underneath CR #1 in preparation to change the linens and may have thought it safe to just roll CR #1 to his side. CNA B said that CR #1's forehead was the only spot that was pressed against the wall when she came back, and she positioned herself between CR #1 and the wall and assisted CR#1 to the floor. CNA B said that CR#1 never actually hit his head, but it was pressed against the wall and that CR #1 had a red mark towards the right side of his forehead after the incident, but no bump or swelling at that time. CNA B said they were in-serviced specifically by DON after the incident on 11/5/25 and had been trained prior to and after the incident, to stop care if items were needed and make sure the resident was always safe and had 2 people present at the bedside at all times during ADL care on 11/5/25. CNA B also said they could use the call light and ask for additional assistance instead of leaving the bedside on 11/5/25. Attempts to reach CNA A via telephone on 11/20/25 at 3:48pm, and 11/22/25 at 10:47am and again at 1:08pm were unsuccessful. Interview with NP on 11/24/25 at 10:10am who said that CR#1 had no hospital discharge orders or instructions for a helmet. NP said helmets were usually used on residents with out of bed activities or when a resident would be up and out of bed. NP said helmets were not usually used while a resident was in bed and would not be something that a resident would keep wearing 24 hours a day because it could lead to skin breakdown and other issues. NP also said there was not an indication the use of a helmet while CR #1 was at the facility because he was immobile during his admission. NP said it was unfortunate that the two CNAs did not remain at the bedside at all times during the bed bath of CR #1 so as to avoid or prevent an accident like what happened to CR #1, but said she would be surprised if CR #1 had any significant injury after the incident and thought the results from Hospital A actually only reported the same injury CR #1 already admitted to the facility with. NP said that CR #1 was immobile and would have most likely required 2 staff for ADL care. In a telephone interview with Medical Director and CR #1's attending physician on 11/24/2025 at 2:53 pm he said that he had been made aware of CR #1's fall back on 11/4/2025 and actively participated in the Ad Hoc QAPI and direct care staff training on 11/5/2025, the day after the incident. He said CR #1 had no orders from the hospital or neurosurgeon for a helmet to be used and there was no indication for the use of a helmet while the resident was in bed because he was immobile and helmets were used mostly for activity out of the bed to prevent any potential injury. He said CR #1 was dependent and immobile so he would most likely require 2-staff for ADL care. The Medical Director said he had no privileges at Hospital B and had not received any updated reports on CR #1's condition directly but the facility DON had followed up with Hospital A after the fall and was given a report by Hospital A staff that CR #1 was being sent back to Hospital B because he had his original brain surgery there and CR #1's family had requested he be sent back to the original hospital. The Medical Director said he believed CR #1 had no new injury and would be surprised if there had been any significant change in CR#1's status or prognosis post incident. The Medical Director said he felt like the facility handled the incident post fall appropriately and put appropriate interventions and training in place to prevent any type of similar accident from occurring. In an interview with CNA C on 11/20/2025 at 4:00pm, she said she had been trained on 2-person Hoyer lift transfers, 2-person ADL care including bed mobility and bed baths and following the resident Kardex and care plan. She said she had been trained upon hire and again at the beginning of November. In an interview with CNA D on 11/20/2025 at 4:05 pm, she said they had ANE training upon hire and had a 2-person Hoyer lift competency upon hire. She said about 2-3 weeks ago they did a more detailed training on 2-person (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 4 of 6 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 11/24/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Hoyer lift transfers, 2-person ADL care including bed mobility and bed baths and following the resident Kardex and care plan after a witnessed fall incident. She said that she had also been trained on not leaving the bedside during care and making sure all necessary supplies were at the bedside and calling for additional help as needed. In an interview with CNA E on 11/24/2025 at 12:05 pm, she said they had ANE training upon hire and had a 2-person Hoyer lift competence upon hire. She said about 2-3 weeks ago they did a more detailed training on 2-person Hoyer lift transfers, 2-person ADL care including bed mobility and bed baths and following the resident Kardex and care plan after a witnessed fall incident. She said that she had also been trained on not leaving the bedside during care and making sure all necessary supplies were at the bedside and calling for additional help as needed. In an interview with CNA F on 11/24/2025 at 2:05 pm, she said they had ANE training upon hire and had a 2-person Hoyer lift competency upon hire. She said about 2-3 weeks ago they did a more detailed training on 2-person Hoyer lift transfers, 2-person ADL care including bed mobility and bed baths and following the resident Kardex and care plan after a witnessed fall incident. She said that she had also been trained on not leaving the bedside during care and making sure all necessary supplies were at the bedside and calling for additional help as needed. In an interview with CNA G on 11/24/2025 at 2:15 pm, she said they had ANE training upon hire and had a 2-person Hoyer lift competency upon hire. She said about 2-3 weeks ago they did a more detailed training on 2-person Hoyer lift transfers, 2-person ADL care including bed mobility and bed baths and following the resident Kardex and care plan after a witnessed fall incident. She said that she had also been trained on not leaving the bedside during care and making sure all necessary supplies were at the bedside and calling for additional help as needed. Interview with LVN C on 11/24/2025 at 3:05pm who said she never worked with CR #1 but was trained and in-serviced after the incident. LVN C said the day after the incident all direct care staff had been trained on 2-person ADL care and bed mobility and bed baths, as well as following the resident care plan and Kardex for resident care and following MD orders, ANE and 2-person transfers. She said there was also training on bringing all supplies to the bedside and calling for assistance rather than leaving the bedside if needed. LVN C said if a resident required the assistance of 2 staff for ADL care that should be followed so accidents did not happen, and residents did not get hurt. Interview with LVN D on 11/24/2025 at 4:18pm she said she was not familiar with and had never worked with CR #1 but had been trained on 2-person ADL care and bed mobility and bed baths, as well as following the resident care plan and Kardex for resident care and following MD orders, ANE and 2-person transfers. She said there was also training on bringing all supplies to the bedside and calling for assistance rather than leaving the bedside if needed. LVN D said that CNA staff can find out what type of care a resident requires from the Kardex/care plan including mobility, transfers and bathing and if the order and Kardex said they required the assistance of 2 staff, then 2 people need to perform the care together at all times. The DON was provided the PNC IJ template on 11/22/2025 at 2:44 pm. A Plan of Removal was not requested. The non-compliance began on 11/4/2025 and ended on 11/5/2025. The facility had corrected the non-compliance before the investigation began. Observations on 11/19/2025, 11/22/2025 and 11/24/25 of facility direct care staff providing incontinent care which required side-to-side rolling of residents, and bed baths on 3 separate residents who required 2 staff assistance with ADL care including bed mobility and bed baths. The following interventions were implemented prior to surveyor entrance and surveyor confirmed Past Noncompliance. 1. CR # 1 was immediately assessed and sent to ED as ordered.2. 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. 3. Facility notified RP, MD, Administrator, DON, (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 455490 If continuation sheet Page 5 of 6 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 11/24/2025 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 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. Event ID: Facility ID: 455490 If continuation sheet Page 6 of 6