The Lakes at Texas City

Scope/severity J — IMMEDIATE JEOPARDY

Survey 2025-11-24 · Tag F0689 · Complaint investigation · Past Non-Compliance

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

What this scope/severity letter means: CMS found the facility's failure caused, or was likely to cause, serious injury, harm, impairment, or death to a resident. This is the most serious finding a surveyor can make. Affected one resident or instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-12-04 · Tag F0641 · Routine survey · Deficient, Provider has date of correction · Correction reported 2026-01-04

Ensure each resident receives an accurate assessment.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-12-04 · Tag F0645 · Routine survey · Deficient, Provider has date of correction · Correction reported 2026-01-04

PASARR screening for Mental disorders or Intellectual Disabilities

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2025-12-04 · Tag F0656 · Routine survey · Deficient, Provider has date of correction · Correction reported 2026-01-04

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-12-04 · Tag F0658 · Routine survey · Deficient, Provider has date of correction · Correction reported 2026-01-04

Ensure services provided by the nursing facility meet professional standards of quality.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-12-04 · Tag F0688 · Routine survey · Deficient, Provider has date of correction · Correction reported 2026-01-04

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-12-04 · Tag F0755 · Routine survey · Deficient, Provider has date of correction · Correction reported 2026-01-04

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-12-04 · Tag F0761 · Routine survey · Deficient, Provider has date of correction · Correction reported 2026-01-04

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.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2025-12-04 · Tag F0914 · Routine survey · Deficient, Provider has date of correction · Correction reported 2026-01-04

Provide bedrooms that don't allow residents to see each other when privacy is needed.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2024-11-26 · Tag F0677 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-12-10

Provide care and assistance to perform activities of daily living for any resident who is unable.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2024-09-11 · Tag F0550 · Routine survey · Deficient, Provider has date of correction · Correction reported 2024-10-04

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2024-09-11 · Tag F0640 · Routine survey · Deficient, Provider has date of correction · Correction reported 2024-10-04

Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2024-09-11 · Tag F0644 · Routine survey · Deficient, Provider has date of correction · Correction reported 2024-10-04

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2024-09-11 · Tag F0791 · Routine survey · Deficient, Provider has date of correction · Correction reported 2024-10-04

Provide or obtain dental services for each resident.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity F — Potential for harm

Survey 2024-09-11 · Tag F0812 · Routine survey · Deficient, Provider has date of correction · Correction reported 2024-10-04

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it affected the facility broadly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2024-06-05 · Tag F0622 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-06-07

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.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity F — Potential for harm

Survey 2024-06-05 · Tag F0812 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-06-07

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it affected the facility broadly. How the A–L grid works

Scope/severity F — Potential for harm

Survey 2024-06-05 · Tag F0925 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2024-06-07

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it affected the facility broadly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2023-08-04 · Tag F0636 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-09-03

Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2023-08-04 · Tag F0644 · Complaint investigation · Deficient, Provider has date of correction · Correction reported 2023-09-03

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2023-08-04 · Tag F0645 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-09-03

PASARR screening for Mental disorders or Intellectual Disabilities

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2023-08-04 · Tag F0655 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-09-03

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2023-08-04 · Tag F0656 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-09-03

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works

Scope/severity E — Potential for harm

Survey 2023-08-04 · Tag F0657 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-09-03

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm, and it happened repeatedly. How the A–L grid works

Scope/severity D — Potential for harm

Survey 2023-08-04 · Tag F0755 · Routine survey · Deficient, Provider has date of correction · Correction reported 2023-09-03

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

What this scope/severity letter means: No resident was harmed, but the failure could have caused more than minimal harm. Affected one resident or one instance. How the A–L grid works