Health inspection·November 15, 2025

F 0926 Have policies on smoking. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to follow their own established smoking policy for 1 of 7 residents reviewed for smoking. (Resident #1)The facility failed to ensure Resident #1 followed the smoking policy and did not have smoking supplies (cigarettes and lighter) at his bedside. This failure could place residents at risk of injury or harm.Findings included:Record review of Resident #1's face sheet undated indicated he was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses which included Parkinsons (brain disorder), anxiety (feeling of fear and worry), hypertension (high blood pressure) and weakness.Record review of Resident #1's annual MDS assessment dated [DATE], indicated he had a BIMS score of 14, which indicated he had intact cognition. The MDS indicated Resident #1 was independent or needed set-up/clean-up assistance for most ADLs. The MDS indicated Resident #1 was using tobacco at the time of the assessment.Record review of Resident #1's Care Plan Report dated 09/12/25 indicated he enjoys smoking at times. The goal was Resident #1 will keep all cigarettes and lighters locked at the nurse's station and will only smoke during scheduled smoke times with a staff member present. Record review of Resident #1's Safe Smoking assessment dated [DATE] indicated Resident #1 had demonstrated the ability to safely smoke with other interventions - needs a staff with him to monitor him. During an observation and interview on 11/15/25 at 11:50 am with Resident #1, revealed he was lying in bed with headphones on. An observation revealed there were no smoking supplies seen on bedside table, nightstand or sink counter. Resident #1 stated that he was a current smoker. He stated he did have cigarettes and lighter in his room. He stated he kept his cigarettes and lighter in the black bag on his walker. Observation revealed the walker with black bag was in the room by the sink. He stated he walked to the smoking area to smoke. He stated there were certain smoking times during the day and staff were always present when he smoked. He stated he only went to smoke during smoking times. He stated he was not told he could not keep smoking supplies in his room. He stated he only kept them in his black bag on his walker. During an observation on 11/15/25 at 12:05 pm revealed Resident #1 went to his walker and unzipped the black bag on the walker. Observed in the black bag there was one cigarette pack and one lighter. Resident #1 zipped the bag closed and placed the walker in front of the sink area in the room. During an observation on 11/15/25 at 01:40 pm revealed residents outside in the smoking area smoking. MA A was supervising the residents. Observed a blue smoking supply box sitting on the ground beside MA A. Resident #1 was sitting in a chair smoking with his walker in front of him. During an interview on 11/15/25 at 01:42 pm with the DON, she stated per the smoking policy residents were not allowed to have smoking supplies in their room. She stated she had received training on the smoking policy, and all staff had been trained on the facility smoking policy. She stated she was not aware Resident #1 had smoking supplies in his room. She stated she had not seen any smoking supplies in residents' rooms. She stated she expected staff to follow the smoking schedule and go out with residents to smoke. She stated the purpose of the smoking policy was to keep all residents safe. She Residents Affected - Few (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675346 Printed: 05/15/2026 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 675346 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/15/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Heritage Oaks Nursing and Rehabilitation Center 5301 University Ave Lubbock, TX 79413 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)