Mi Casita Nursing: Oxygen Patient Kept Lighter - TX
The resident, identified in inspection records only as Resident #40, was admitted to Mi Casita with chronic obstructive pulmonary disease and an acute lower respiratory infection, conditions that require supplemental oxygen. He was receiving three liters per minute through a nasal cannula when inspectors first spotted the cigarette and lighter during an initial tour on the morning of March 25, 2026. They found him again two days later, on March 27, in the same condition: oxygen flowing, cigarette box in his shirt pocket, lighter inside it.
His care plan had been clear since July 2025. Smoking supplies were to be stored at the nurses' station. A safe smoking assessment completed just two weeks before inspectors arrived, on March 11, restated the same requirement. All smoking materials will be kept at the nurse's station. That line was checked off.
Nobody had told Resident #40 he wasn't allowed to carry them.
He said so himself. When inspectors spoke with him during that first morning tour, he told them staff had never informed him he couldn't keep a cigarette and lighter on his person. He said he understood he was allowed to have them. He had one in his pocket at that moment, with the oxygen running.
The nurse on duty, identified as LVN B, had signed a smoking policy in-service training record dated February 1, 2026, roughly seven weeks before the inspection. When inspectors asked her on March 27 why Resident #40 had the lighter and cigarette on him, she said she didn't know. She acknowledged that families sometimes brought cigarettes to residents without telling staff. She said Resident #40 was sometimes non-compliant with smoking policies. Then she named the risk plainly: possible burning, or combustion, if a resident on oxygen tried to light up.
Oxygen accelerates fire. A spark near supplemental oxygen can ignite clothing, bedding, or the tubing itself within seconds. It is not a theoretical concern. It is the reason the care plan existed.
The director of nursing told inspectors the staff had been trained on the smoking policy the previous month. She said residents weren't supposed to have smoking supplies on their person, but that it was sometimes difficult to manage with independent residents who smoke. Her explanation for why Resident #40 had the lighter: he probably didn't give it back to the nurses after going outside to smoke. She said staff were trained to look for smoking supplies on residents. She said a potential negative outcome was that a resident could forget and try to light a cigarette in their room.
The administrator said she expected both residents and staff to follow the smoking policies. She said all staff were responsible for monitoring residents for smoking supplies. She said she didn't know why Resident #40 had his supplies on him, unless he hadn't returned them after smoking outside. She said there was a potential risk for danger with cigarettes, lighters, and oxygen use.
Three people in positions of authority at the facility each described the same risk in nearly identical terms. Each said they didn't know how the situation had continued. None of them had caught it before federal inspectors walked through the door.
The facility's written smoking policy, last revised in October 2023, states that all smoking items, including lighters and cigarettes, shall be kept at the facility's designated area. The policy had been on the books for years. The care plan had been active for eight months. The safe smoking assessment had been completed sixteen days before the inspection.
Resident #40's cognitive assessment, completed in June 2025, gave him a BIMS score of 12, indicating intact cognition. He understood what was happening around him. When staff didn't tell him to hand over his cigarettes, he kept them. That is not non-compliance. That is a man doing what he was never told not to do.
Inspectors rated the violation at the minimal harm level, meaning no injury was documented. That rating reflects what had happened so far, not what the situation made possible. A man with diseased lungs, dependent on flowing oxygen, carrying an ignition source in his shirt pocket for at least two days that inspectors could confirm, and likely longer, had not yet been burned. The care plan meant to prevent that outcome had not been enforced by anyone on the floor.
Mi Casita Nursing and Rehabilitation Center is located at 2400 Quaker Ave in Lubbock. The inspection was completed March 27, 2026.
Resident #40 was still wearing the oxygen when inspectors left.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Mi Casita Nursing and Rehabilitation Center from 2026-03-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
MI CASITA NURSING AND REHABILITATION CENTER in LUBBOCK, TX was cited for violations during a health inspection on March 27, 2026.
They found him again two days later, on March 27, in the same condition: oxygen flowing, cigarette box in his shirt pocket, lighter inside it.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.