Lubbock Health Care Center

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen (Kitchen A) reviewed for dietary services. [NAME] D failed to ensure food was stored, prepared, and served under sanitary conditions. Food items-including butter and rolls were left uncovered for extended periods while in the kitchen. Resident drink cups were stored on 12/7/25 by DA A and DA E: Trays were stacked directly on top of uncovered cups, exposing the rims of the cups to the unsanitary underside of serving trays. DM failed to discard spoiled sweet potatoes that were visibly rotten and stored with fresh food items. DA A and DA E failed to label and date beverages stored in the walk-in refrigerator. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident has a right to a safe, clean, comfortable and homelike environment for 1 of 20 residents reviewed for physical environment. A handrail in the shower room on South Hall was loose. This deficient practice has the potential to place residents at risk for injuries related to falls that could result in bruising, skin tears, wounds, fractures, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days for 1 of 20 resident (Resident #11) reviewed for PRN psychotropic medications, in that: Resident #11 had an active PRN order for alprazolam (Xanax) without a documented 14-day stop date, despite facility policy and regulatory requirements. This failure could place residents at risk for receiving unnecessary medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 (Resident #4) of 20 reviewed for accidents and supervision. The facility failed to consistently supervise Resident #4 while smoking and failed to ensure the use of a smoking apron, despite assessments and negotiated risk agreements identifying the need for direct supervision due to the risk of injury. These failures had the potential to result in resident harm, including burns or other smoking-related injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 2 medication carts (Medication Cart 2) reviewed. The facility failed to ensure 2 loose pills in Medication Cart 2 were properly labeled or stored. This failure could place residents at risk for medication errors and drug diversion.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure resident essential equipment was maintained in safe and proper operating condition for 1 (Resident #7) of 20 residents. Resident #7's oxygen concentrator was observed with a red alert light illuminated, indicating a potential malfunction, and staff were unaware or failed to report and address the issue in a timely manner. This failure had the potential to result in inadequate oxygen delivery and respiratory distress, placing the resident at risk for harm.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 5 residents (Resident #1) reviewed for narcotic medication being accounted for. The facility failed to prevent Resident #1's Lorazepam Medication from being accounted for. This failure could place residents at risk for not receiving prescribed medication.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident was free from any physical or chemical restraints imposed for purposes of discipline or convenience for 1 (Resident #1) of 3 residents reviewed for physical restraint. The facility failed to ensure the Licensed Vocational Nurse (LVN D) notified the physician (P J), Director of Nurses (DON), and Member F prior to tying Resident #1's hand to his bed on 02/18/25, and as of 03/04/25 the physician confirmed he had not written an order for this restraint. This LVN said he tied Resident #1's hand to prevent him from pulling out his dialysis port, while he administered the residents' medications. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure a resident received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 3 residents (Resident #1) reviewed for quality of care. 1. The LVN D failed to notify Resident #1's physician and Member F of Resident #1's change of condition. 2. LVN D failed to obtain an order from the physician to restrain Resident #1's arm to prevent him from pulling out his dialysis port (a medical device used to provide access to a patient's bloodstream for hemodialysis treatment, which is a procedure that removes waste products and excess fluid from the blood when the kidneys are unable to do so). 3. LVN D failed to notify the DON or LVN A, who was the oncoming charge nurse, of the restraint left on Resident #1's arm prior to leaving his shift. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 6 of 6 confidential residents. 1. The facility failed to make information known to Resident's and their Representatives either individually or through postings in prominent locations throughout the facility on who the facility grievance official was, their contact information, how to file an anonymous grievance and their right to obtain a written decision related to their grievance. 2. The facility failed to ensure 6 of 6 confidential residents had information known to them on how to file a grievance or concern, who the grievance official was, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 10 of 18 residents (Resident #3, #39, #40, #41, #43, #44, #49, #53, #56, #60) and 1 of 1 staff (LVN A) reviewed for infection control. 1. LVN A failed to properly clean multi-use equipment between each resident during medication administration for Resident # 39, #40, #56, and #60. 2. LVN A failed to sanitize hands between residents during medication administration for Resident #3, #39, #40, #41, #43, #44, #49, #53, #56 and #60. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 18 residents (Residents #42) reviewed for advanced directives, in that: Residents #42 were listed as DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was missing required information. These failures could place residents at risk for not having their end of life wishes honored and incomplete records.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 11 of 16 toilets reviewed for safe environment, in that: - On June 25, 2024, the toilets in rooms #3, #8, #13, #16, #32, #50, #51, #52, #56, and Resident #2's and #3's rooms were unsecured to the floor and unstable. These failures could place the residents and public at risk for injury and falls.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remained free of accident hazards for 1 of 1 resident (resident #1) reviewed for accidents in that: - On June 15, 2024, Resident #1 ambulated to the bathroom and sat on the toilet, the toilet was unstable and loose causing Resident #1 to fall. These failures could place residents at risk for injury.

Inspectors wroteBased on record review, interviews, and facility policy review, the facility failed to ensure a quarterly trust fund statement was provided for 3 (Resident #1, Resident # 2 and Resident #3) of 6 residents reviewed for resident rights. The facility failed to provide quarterly statements for Residents #1, #2, and #3 for the 3rd quarter (June 2023-September 2023). This failure could place the residents at risk for not having access to their personal funds and not having their personal needs met.

Inspectors wroteBased on interview and record review, the facility failed to notify each resident that receives Medicaid benefits when the amount in the resident's account reaches $200 less than the SSI resource limit for one person, and that if that amount reaches the SSI resource limit for one person, the resident may lose eligibility for Medicaid or SSI for 2 (Resident #1 and 2) of 6 residents reviewed resident rights. 1. The facility failed to communicate with Resident #1 and his preferred family contact that his trust fund account was over the resource limit and he could lose his eligibility. 2. The facility failed to provide Resident #1 and his preferred family contact with a written notice per the facility's trust fund policy that his trust fund account was over the resource limit and he could lose his eligibility. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly labeled and dated. 2. The facility failed to ensure expired foods were discarded. These failures could place residents who ate the food from the kitchen at risk for food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 5 resident (Resident #28, #35, #44, and #48) reviewed for infection control. The facility failed to ensure that facility staff perform hand hygiene appropriately during medication pass, incontinent care, and the delivery of food trays. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene.

Inspectors wroteResident #35 FTag Initiation 07/27/23 10:10 AM Per interview with [NAME] MDS Manager who reviewed the chart for Resident #35 and reported that they review the 7 day look back period per his record for the nurses summary and weekly notes which had no documentation of the resident having behaviors, the medication administration record which will track resident behaviors which had no documentation of the resident having behaviors in the 7-day look back period, the progress notes which had no documentation of behaviors in the 7-day look back period, and the treatment record which had no documentation in the 7-day look back period from the 7-9-2023 Quarterly MDS. [...]

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASARR) for 2 (Resident #35 and Resident #62) of 19 Residents reviewed for PASRR. The facility failed to conduct a PASRR Level II for Resident #35 after the PASRR Level I was found to be positive for Mental Illness. The facility failed to ensure that Resident #62's PASRR Level I was coded to match the diagnosis of Schizophrenia and therefore did not conduct a PASRR Level II for Resident #62. This failure could place residents at risk of the facility not meeting the resident's medical, functional, and psychosocial needs.

Inspectors wroteBased on observation, interview, and record review; it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 1 of 3 medication carts. 1 bottle of Cetirizine was found in medication cart with no expiration dated noted on bottle. This medication is a over the counter medication and does not belong to any specific resident. The facility's failure to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable could place all residents receiving medication at risk for receiving medication that will not meet a therapeutic level.