Southern Specialty Rehab & Nursing

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

interview on 8/24/25, at 1:39PM, Resident #2 said he was told about the new rules for smoking. He said his vape was at the nurse station and he would be supervised while vaping. He said he was told about the new smoke schedule and that the front door code was changed. He said he was told staff would let him out after

he signed out. He said he had no concerns to report. During an interview on 8/24/25 at 3:45PM, the Regional Compliance stated she provided in-services to staff on care plans. She said the ADON was trained to review care plans in service the ADON, MDS Coordinator, and ADM would review them once a week. She would train the new DON on those updates after they start. She said she would continue to in-service staff of changes in care plans. She said care plans should've been updated immediately because

it could cause harm to residents. She said she would come once a week and review care plans to ensure

they were updated. She would also train the new DON to check weekly to ensure care plans are updated.

On 8/24/2025 between the 3:00 to 5:31PM interviews were conducted with the following staff members: CNAs D, K, L, RN A, LVNs B, C, E, I, MAs F, G, H, SW, DOR, RTs M, N, DS, HKs O, P, Q, AIT, and LS J. All staff members stated they were in-serviced on 8/23/25 and 8/24/25 on smoking policies including scheduled smoking and smoking schedule, and residents were supervised, all cigarettes, vapes, and lighters must stay at the nurse station, no oxygen was allowed in the smoking room, Resident #1 must wear

a smoking apron, Resident #2 must be supervised, staff must light the cigarettes and residents were not allowed to share cigarettes were supervised, all cigarettes, vapes, and lighters must stay at the nurse station, no oxygen was allowed in the smoking room, Resident #1 must wear a smoking apron, Resident #2 must be supervised, staff must light the cigarettes and residents were not allowed to share cigarettes.On 8/24/25 at 6:00PM, the ADM was informed the IJ was removed however the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that was not immediate jeopardy and a scope of isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems.

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Printed: 04/13/2026 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

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/24/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Southern Specialty Rehab & Nursing

4320 W 19th Street Lubbock, TX 79407

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 - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

said he was aware there was a resident that should be wearing an apron and should be supervised but he was not aware that was not occurring. He said regardless of the age of documentation it should be followed until otherwise updated. He said care plans should have been updated with the updated smoking assessment results so everyone could know what was going on with residents because that was what staff referred to when they provided care to the residents. He said the DON and ADONs were responsible to train staff. The ADM said their system to communicate changes needed or updates need to the MDS and care plan were to discuss them during morning meetings to ensure care plans were being followed. During

an interview on 8/23/25 at 7:12 PM, LVN C said he completed the smoking assessment on Resident #1 because he observed her two or three times and observed her to be asleep with a cigarette in her hand, on her lap, in the smoking room. He said it was not a scheduled assessment. He said Resident #1 got mad and denied falling asleep. He said some of her clothes had burn marks on them and he did not believe her clothes had burn marks on them when she moved in. He said Resident #1 wanted to smoke as soon as she woke up. He said he did not believe she was fully awake but they could not tell her anything because she would holler and curse people out. He said she smoked every 30 minutes. He said last night she called her family member at 4:00AM to bring her cigarettes because she ran out. LVN C said Resident #1 accused him of stealing her cigarettes. He said he forwarded the smoking assessment to the ADON and he went and told the ADON that night he did it, as well. He said he did not know what the ADON was supposed to do with the assessment next. He said he would tell his aides of the changes and he would verbally pass it

on to the nurse on the next shift. He said the aides he told no longer worked at the facility, but he told the new aide last night. He said he told RN A about it as well. He said RN A told him last night that the SW told him Resident #1 was to b

Event ID:

Facility ID:

If continuation sheet