A list of the most recent deficiencies for The Lakes at Texas City. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
---|---|---|---|---|
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-08-04 | 2023-09-03 | N |
PASARR screening for Mental disorders or Intellectual Disabilities | Health | 2023-08-04 | 2023-09-03 | N |
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-08-04 | 2023-09-03 | N |
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-08-04 | 2023-09-03 | N |
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-08-04 | 2023-09-03 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-04 | 2023-09-03 | N |
Ensure medication error rates are not 5 percent or greater. | Health | 2023-08-04 | 2023-09-03 | N |
Ensure that residents are free from significant medication errors. | Health | 2023-08-04 | 2023-09-03 | N |
Provide or get specialized rehabilitative services as required for a resident. | Health | 2023-08-04 | 2023-09-03 | N |
Provide and implement an infection prevention and control program. | Health | 2023-08-04 | 2023-09-03 | N |
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2023-08-04 | 2023-09-03 | Y |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-08-01 | 2023-08-31 | N |
Ensure precautions for handling oxygen cylinders and equipment are correctly followed. | Fire Safety | 2023-08-01 | 2023-08-31 | N |
Respond appropriately to all alleged violations. | Health | 2023-05-25 | 2023-06-23 | Y |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-01-26 | 2023-02-04 | Y |
Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2023-01-26 | 2023-02-04 | Y |
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-01-26 | 2023-02-04 | Y |
Provide and implement an infection prevention and control program. | Health | 2023-01-12 | 2023-02-03 | Y |
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-12-27 | 2023-02-03 | Y |
Provide and implement an infection prevention and control program. | Health | 2022-12-27 | 2023-02-03 | Y |
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-06-20 | 2022-07-19 | N |
Provide activities to meet all resident's needs. | Health | 2022-06-20 | 2022-07-19 | N |
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2022-06-20 | 2022-07-19 | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2022-06-20 | 2022-07-19 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-06-20 | 2022-07-19 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-06-20 | 2022-07-19 | Y |
Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-06-16 | 2022-07-19 | N |
Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-06-16 | 2022-07-19 | N |
Have simulated fire drills held at unexpected times. | Fire Safety | 2022-06-16 | 2022-07-19 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2022-04-01 | 2022-05-20 | Y |
Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-01 | 2022-04-11 | Y |
Provide safe, appropriate pain management for a resident who requires such services. | Health | 2022-04-01 | 2022-04-11 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-01 | 2022-04-11 | Y |
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-13 | 2022-02-14 | Y |
Have policies on smoking. | Health | 2022-02-13 | 2022-02-14 | Y |
Respond appropriately to all alleged violations. | Health | 2021-10-06 | 2021-10-20 | Y |
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2021-09-23 | 2021-10-18 | Y |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-09-23 | 2021-10-18 | Y |
Provide and implement an infection prevention and control program. | Health | 2021-08-20 | 2021-09-24 | Y |
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-08-20 | 2021-09-19 | Y |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-20 | 2021-09-19 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-08-20 | 2021-09-19 | Y |
Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-03-04 | 2021-04-03 | Y |
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-04 | 2021-04-03 | Y |
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-01-22 | 2021-02-21 | N |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2021-01-22 | 2021-02-21 | N |
Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-01-22 | 2021-02-21 | N |
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-01-22 | 2021-02-21 | N |
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2021-01-22 | 2021-02-21 | N |
Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2021-01-22 | 2021-02-21 | N |
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2021-01-22 | 2021-02-21 | N |
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-01-22 | 2021-02-21 | N |
Provide and implement an infection prevention and control program. | Health | 2021-01-22 | 2021-02-21 | N |
Implement a program that monitors antibiotic use. | Health | 2021-01-22 | 2021-02-21 | N |
Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2021-01-22 | 2021-02-21 | N |
Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2021-01-21 | 2021-01-22 | N |
Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2021-01-21 | 2021-01-22 | N |
Assess the resident when there is a significant change in condition | Health | 2023-08-04 | Not Fixed | N |
Ensure each resident receives an accurate assessment. | Health | 2023-08-04 | Not Fixed | N |
Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge. | Health | 2023-08-04 | Not Fixed | N |
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-08-04 | Not Fixed | N |