Mi Casita Nursing And Rehabilitation Center

stated none of the staff members had told him that he was not allowed to have a cigarette and lighter

had been trained to look at the Kardex which was a simplified version of the care plan, but it had been

lighter in the front pocket of his shirt. LVN B stated sometimes Resident #40 was non-compliant with the smoking policies in the facility. LVN B stated a potential harm to the residents was their care plan not being followed.

Interview on 03/27/26 at 11:05 AM, the DON stated the staff had been trained to check the care plans for the residents.

The DON stated she did not know the last time the staff had been trained on following the care plans.

The DON stated she did not know why the smoking care plan for Resident #40 was not being followed.

The DON stated a potential negative outcome to the residents was that the residents could not get the care they needed. In an additional interview on 03/27/26 at 3:48 PM, the DON stated she did not know why Resident #7's care plan did not include oxygen therapy.

She stated the care plan should have been added when the physicians order was received.

She stated she and the MDS Coordinator were responsible for the accuracy and completeness of resident care plans.

The DON stated the care plan was used by all staff for information on how to care for a resident.

Interview on 03/27/26 at 1:41 PM, the ADM stated she expected the nursing staff to check the care plans and follow them.

The ADM stated the nursing staff was trained on care plans, but she did not know when.

The ADM stated she did not know why the nursing staff did not follow the smoking care plan for Resident #40.

The ADM stated there was a potential risk for danger with the smoking care plan not being followed.

Record review of the undated facility-provided policy titled, Policy and Procedure Comprehensive Care Planning, revealed: Purpose: Ensure every resident has a comprehensive, complete, accurate and all inclusive specific care plan written timely to [NAME] all requirements of the RAI and regulatory process to include input from all the IDT members.

Procedure.8.

Every resident will have all needs/specialized services care planned.and revised routinely.

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MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

The facility failed to ensure Resident #40's smoking items were kept at the nursing station.

This failures could place the residents at risk of inadequate supervision, accidents, and burns which could result in injury.Findings Included:

Record review of the admission record for Resident #40, dated 03/25/26, revealed a [AGE] year-old male who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: chronic atrial fibrillation (irregular heart rate), acute lower respiratory infection, and chronic obstructive pulmonary disease (lung disease).

Record review of the comprehensive MDS assessment for Resident #40, dated 06/06/25, revealed Resident #40 had a BIMS score of 12 indicating his cognition was intact.

The MDS further revealed Resident #40 currently used tobacco.

Record review of the care plan for Resident #40, last reviewed on 12/24/25, revealed, Focus: Smoker: [Resident #40] is a smoker and is safe to smoke unsupervised.

Intervention/Tasks: The resident's smoking supplies are stored at the nurses' station with an initiation date 07/01/25.

Record review of Resident #40's Safe Smoking Assessment, dated 03/11/26, revealed: .B.

Summary:4.

All smoking materials will be kept at the nurse's station was checked off.

Interview during the initial tour on 03/25/26 beginning at 9:30 AM, Resident #40 stated he was allowed to keep a cigarette and lighter on his person and he had one in his front shirt pocket at that time. Resident #40 stated none of the staff members had told him that he was not allowed to have a cigarette and lighter on him. Resident #40 was observed with oxygen on via nasal cannula at 3 liters per minute.

Observation on 03/27/26 at 9:20 AM, Resident #40 was observed to have 1 cigarette and 1 lighter in a cigarette box in his front shirt pocket. Resident #40 was observed with oxygen on via nasal cannula at 3 liters per minute.

Interview on 03/27/26 at 9:23 AM, LVN B stated she had been trained on the smoking policy at the facility recently. LVN B stated she did not know why Resident #40 had a cigarette and lighter in the front pocket of his shirt. LVN B stated sometimes Resident #40 was non-compliant with the smoking policies in the facility. LVN B stated that sometimes the families will bring cigarettes to the residents and no one will tell the staff about it. LVN B stated a potential harm to the residents was possible burning themselves or combustion if a resident was on oxygen.

Interview on 03/27/26 at 11:05 AM, the DON stated the staff had been trained on the smoking policy at the facility last month.

The DON stated the residents were not supposed to have smoking supplies on their person, but sometimes it was difficult to manage with the independent residents who smoke.

The DON stated Resident #40 probably had his smoking supplies on him because he did not give it back to the nurses.

The DON stated the staff were trained to look for smoking supplies with the residents.

The DON stated a potential negative outcome to the residents was they could forget and try to light a cigarette in their room.

Interview on 03/27/26 at 1:41 PM, the ADM stated she expected the residents and staff to follow the smoking policies and procedures.

The ADM stated all staff were responsible to monitor for smoking supplies and should know that all smoking supplies was kept in the med room at the nurse's station.

The ADM stated she did not know why Resident #40 had his smoking supplies on his person, unless he did not give them back to the nurses after he went outside to smoke.

The ADM stated there was a potential risk for danger with cigarettes, lighters and oxygen use.

Record review of the facility in-service titled, Smoking Policy, dated 2/1/26 revealed the signature for LVN B.

Record review of the facility policy titled, Smoking Policy - Residents with a revised date of 10/23 reflected the following: Policy Statement: This facility has established and maintains safe resident smoking practices.

Policy Interpretation and Implementation:.14.

All smoking items shall be kept at the facility designated area.

This includes but not limited to lighters, cigarettes.

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MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

During an interview on 03/27/26 at 3:48 PM, the DON stated the facility policy was for oxygen tubing to be changed every week on Sunday.

She stated the night shift charge nurses were responsible for changing tubing and documenting the tubing change.

She stated nursing administration was responsible for assuring oxygen equipment was changed timely, according to orders.

The DON stated oxygen tubing and equipment was spot checked by nursing administration while on rounds in the facility.

She stated a potential negative outcome for failure to change oxygen tubing according to physicians orders was infection issues.

During an interview on 03/27/26 at 4:10 PM, the ADM she was not aware oxygen tubing changes for Residents #1 and #17 had not been completed on the scheduled date.

She stated her expectation of staff was to follow physicians orders for each resident.

The ADM stated the charge nurse was responsible for oxygen tubing changes and nursing administration was responsible for monitoring the completion of the task.

The ADM stated a potential negative outcome for failure to change oxygen tubing, according to orders, was infection.

Record review of the facility-provided policy titled Administration of Oxygen and Maintenance of Tubing and Equipment, dated 10/2017 revealed: Administration of Oxygen 1) Oxygen will be administered per physician order.

Maintenance of Tubing and Equipment. 2) Tubing will be dated, and will be changed weekly.

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MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

outcome to the residents with getting the wrong medication was that the resident could not get the

Medications will be administered in a timely manner and as prescribed by the resident's attending

administering the medication must ensure that the right medication, the right dosage.are verified before the medication is administered (e.g. review of the drug label, physician orders, etc.)

675842 03/27/2026

MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

Based on observation, interview, and record review, the facility failed to ensure all drugs and

medication carts (Med Cart A and Med Cart B) and 1 of 2 medication rooms (Med Room C) reviewed for medication storage.

The facility failed to ensure Med Cart A did not have loose pills in the drawers.

The facility failed to ensure Med Cart A, Med Cart B and Med Room C did not have expired medications and supplies.

These failure could place residents at risk of medication errors or adverse effects.

The findings included: During an observation of Med Cart A on 03/27/26 at 11:17 AM with the DON, 2 loose pills were found in the second drawer. 1 pill was oblong and was light gray in color. 1 pill was oblong and was yellow/orange in color.

During an interview on 03/27/26 at 11:26 AM, the DON stated she believed the light gray pill that was found in Med Cart A was memantine and she thought the yellow/orange pill was a different dose of memantine.

During an observation of Med Cart B on 03/27/26 at 11:23 AM with the DON, 32 sureprep pads with an expiration date of 11/15/25 were found in the bottom drawer, aloe vera hand sanitizer 2 fluid oz. with an expiration date of 08/22 and a 30 mL medicine cup with 15 mL full of a white powder, unlabeled was in the top small drawer and eucalyptus hand sanitizer 32 fluid oz. with an expiration date of 08/22 was sitting on top of the medication cart.

During an interview on 03/27/26 at 11:29 AM, LVN D stated the medicine cup of white powder in the top drawer of Med Cart B was miralax that a resident had asked for and then refused when he took it to them. LVN D stated he did not want to waste the medication, so he put it back in the medication cart.

During an observation of Med Room C on 03/27/26 at 11:35 AM with the DON revealed, 4 packs of povidone-iodine swab sticks with an expiration date of 05/25 was observed on a shelf. 4 bottles of Glucerna hunger smart shakes 10 fluid oz. with an expiration date of 07/01/25 were found in the refrigerator in Med Room C.

During an interview on 03/27/26 at 11:47 AM, the DON stated the medication aides and the nurse's were responsible for ensuring loose pills and expired items were not in the medication carts or the medication rooms.

The DON stated she did not know why expired items were found in Med Cart B or Med Room C.

The DON stated the staff were trained on medication storage but she did not have an exact date on when the last training was.

The DON stated a potential negative outcome to the residents was the expired supplies could not work as well.

The DON stated a potential negative outcome to the residents with improperly labeled medications was medication errors.

During an interview on 03/27/26 at 1:41 pm, the ADM stated the DON was responsible for medication storage and labeling.

The ADM stated she expected for expired items to be pulled off the shelf before the expiration date.

The ADM stated she did not know why some medications were not labeled properly or why some items were expired, maybe was an oversight.

The ADM stated a potential negative outcome to the residents was the expired items may not be as effective.

The ADM stated a potential negative outcome to the residents with unlabeled medications was the residents could be short pills.

Record review of the facility policy titled, Storage of Medications with a revised date of November 2020 reflected the following: Policy heading: The facility stores all drugs and biologicals in a safe, secure, and orderly manner.Policy Interpretation and Implementation:.2.

Drugs and biologicals are stored in packaging, containers or other dispensing system in which they are received.

Only the issuing pharmacy is authorized to transfer medication between containers.4.Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

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MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

serve food in accordance with professional standards.

serve food in accordance with professional standards for food service safety in 1 of 1 kitchen

removed from the dry pantry.These failures could place residents at risk for foodborne illness. On 3/25/26 an initial kitchen observation tour from 9:47 AM to10:30 AM revealed the following:The dry pantry had a plastic bin dated 2/24/26 with red onions in it.

There were 6 red onions found to have green sprouted shoots and were soft to touch.

There were 4 red onions with dark black and grey molded areas and were soft to touch.

During an interview on 3/25/26 at 10:05 AM the DS stated that staff were to check the red onions every day.

She stated, it was likely the red onions had not been checked in the past couple of days.

She stated that the date on the plastic bin, 2/24/26, was when the red onions were received.

She stated the kitchen was very hot and the dry pantry was hot and the temperature could cause the red onions to go bad faster.

She stated the red onions should have lasted 2 weeks in the dry pantry with the heat.

She stated she would have a staff member sort the red onions in the bin and throw away the spoiled red onions.

During an interview on 3/25/26 at 11:46 AM the DS stated all the red onions were thrown away and new red onions were ordered.During an interview on 3/27/26 at 3:55 PM Corporate Account Manager stated that the red onions should have been checked daily and dietary staff should discard any that were spoiled.

She stated that the heat could cause the red onions to ruin faster as well as moisture.

She stated additional education would be provided to dietary staff.

During an interview on 3/27/26 at 5:00 PM the ADM stated the company had the ADM do a walk through in the kitchen every week.

She had completed the walk through on Monday and did not see the spoiled red onions in the dry pantry.

Record review of the facility's Use by date Guide used to determine a use by date when labeling opened and unopened food that must be used within a certain time frame.Item/Category - produce, fresh fruits and vegetables, Use By- Check daily for freshness.

Record review of the facility's policy titled Food receiving and storage dated, 2001 and revised date November 2022, revealed in part:Policy Statement: Food shall be received and stored in a manner that complies with safe food handling practices.Policy Interpretation and Implementation:4.

Food services, or other designated staff, maintain clean and temperature/humidity-appropriate food storage areas at all times.Dry Food Storage:4.

Dry foods and goods in storage must be checked weekly for perishable or changes to the integrity of the food product.

Food products in which the integrity of the food has changed since arrival must be disposed of properly.5.

Dry foods that are stored in bins are removed from original packaging, labeled and dated ( use by date).

Such foods are rotated using a first in - first out system

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MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

During an interview on 03/27/26 at 3:48 PM, the DON stated she was not aware oxygen tubing changes for Residents #1 and #17 had been inaccurately documented.

She stated documentation should be accurate for all residents at all times.

She stated a task should be signed for only after being completed or should have a strikeout by staff if a task was not completed.

She stated documentation was monitored by nursing administration and by the regional nurse during onsite visits.

The DON stated a potential negative outcome for inaccurate documentation was care that was ordered for a resident could be missed if signed for and not completed.

During an interview on 03/27/26 at 4:10 PM, the ADM stated she was not aware oxygen tubing changes for Residents #1 and #17 had been inaccurately documented.

She stated her expectation of staff was to accurately document all care in a timely manner.

The ADM stated the system for monitoring the accuracy of documentation was through random checks of the health record by nursing administration and the regional nurse.

She stated a potential negative outcome for inaccurate documentation was that the resident may not get care tasks completed according to orders.

Record review of the facility-provided policy titled Charting and Documentation, revised July 2017, revealed: Policy Statement .The medical record should facilitate communication between the interdisciplinary team regarding the resident's condition and response to care.

Policy Interpretation and Implementation. 3.

Documentation in the medical record will be objective (not opinionated or speculative), complete, and accurate. 7.

Documentation of procedures and treatments will include care specific details, including: a.

The date and time the procedure/treatment was provided.

675842 03/27/2026

MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

The facility failed to ensure LVN B washed her hands after entering the room to provide wound care to Resident #32.

This failure could place residents at risk for cross contamination and infection.

The findings included:

Record review of the face sheet for Resident #32, dated 03/25/26 revealed an [AGE] year-old male who was admitted to the facility on [DATE] with the following diagnoses: chronic obstructive pulmonary disease (lung disease), pressure ulcer of right heel stage 3, and peripheral vascular disease (poor blood circulation).

Record review of the comprehensive MDS assessment for Resident #32, dated 01/17/26 revealed Resident #32 had a BIMS score of 09 which indicates his cognition was moderately impaired.

The MDS further revealed Resident #32 had a Stage 3 Pressure ulcer.

Record review of the order summary report for Resident #32, dated 03/25/26, revealed an order: Tx [treatment] to right outer heel stage 3 pressure ulcer: Cleanse, pat dry, apply iodosorb and calcium alginate, clover and secure with bordered gauze.

Every dayshift with a start date of 01/09/26.

Record review of the care plan for Resident #32, last care plan review completed 03/05/26 revealed: Focus: The resident has actual pressure injury development to his right heel.

During an observation of wound care on 03/26/27 at 10:02 AM, LVN B gathered her supplies on a tray at the wound care cart and entered Resident #32's room for wound care. LVN B set her supplies down, put on a clean gown and gloves and began performing wound care for Resident #32's Right heel wound. LVN B did not wash her hands after entering the room and before putting on clean gloves.

During an interview on 03/26/27 at 10:12 AM, LVN B stated she had been trained to wash her hands before providing care to the residents. LVN B stated she was last trained a few months ago on infection control. LVN B stated she washed her hands at the sink before the surveyor began watching the wound care observation. LVN B stated it had slipped her mind to wash her hands after entering the room. LVN B stated a potential negative outcome for the residents was an increased risk for infection.

During an interview on 03/27/26 at 11:05 AM, the DON stated she expected the staff to wash their hands before starting any care.

The DON stated she did not know why LVN B did not wash her hands after going in the room to provide care for Resident #32.

The DON stated LVN B was last trained on infection control in February of 2026.

The DON stated a potential negative outcome to the residents was an infection control risks to the residents.

During an interview on 03/27/26 at 1:41 PM, the ADM stated she expected the staff to wash their hands before providing care to the residents.

The ADM stated the DON manages infection control concerns in the facility.

The ADM stated she knows LVN B had been trained on infection control at the facility, but the DON would have that information.

The ADM stated a potential negative outcome to the residents was a possible infection.

Record review of the facility's in-service document titled, Handwashing/Gloves, dated 02/16/26 revealed LVN B's signature.

Record review of the facility's policy titled, Policies and Practices - Infection Control with a revised date of 10/18 reflected the following: Policy Statement: This infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment and to help prevent and manage the transmission of disease and infections.

Record review of the facility's policy titled, Handwashing/Hand Hygiene with a revised date of 10/23 reflected the following: Policy Statement: This facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Policy Interpretation and Implementation:.2.

All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents, and visitors.Indications for Hand Hygiene:1.

Hand hygiene is indicated:a. immediately before touching a resident.5.

The use of gloves does not replace hand washing/hand hygiene.

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MI Casita Nursing and Rehabilitation Center 2400 Quaker Ave Lubbock, TX 79410

During an interview on 03/27/26 at 10:15am with the Administrator, she was asked if she wanted to apply for the room size waiver she stated, Yes, I want to apply for the waiver.

She stated rooms #1, 3, 5, 8, 27, 29, 30, 31, 32, and 33 had a waiver for years and there has been no change to the floor plan.

During a general observation tour on 03/27/26 between 2:30pm and 3:00pm, it was noted that 10 of 40 semi-private rooms had 154 square feet instead of the required 160 square feet for 2 residents: (Rooms) #1, 3, 5, 8, 27, 29, 30, 31, 32, and 33.

During an interview on 03/27/26 at 3:33pm with the Administrator, regarding the risk of residents not having the appropriate space, she stated there have been no issues with the room size in the past 34 plus years.

She stated there was no facility policy for room size waiver.