Health inspection·August 24, 2025

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial needs for 1 of 3 residents (Resident #1) reviewed for care plans as follows: The facility failed to ensure to document Resident #1 was required to wear a fire-resistant apron and receive direct supervision from staff while smoking in the care plan, which resulted in staff not being trained or made aware of how to provide the resident with proper care. Resident #1's smoking assessment reflected she required direct supervision when smoking due shaking while smoking, falling asleep while smoking, past accidents/incidents with smoking materials, having visible burn marks on her clothing and she had finger dexterity problems. An Immediate Jeopardy was identified on 8/23/25 at 4:15 PM. The IJ template was provided to the facility Administrator on 6/12/24 at 4:18 PM. While the immediate jeopardy was lifted on 8/24/24 at 6:00 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of isolated, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs which could result in serious harm and injuries. Findings included: Record Review of Resident #1's face sheet dated 8/22/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a medical history of type 2 diabetes mellitus with diabetic chronic kidney disease (damage to the kidneys caused by high blood sugar and blood pressure), unspecified visual loss (loss of eye sight), hyperlipidemia unspecified (high levels of fats in the blood), schizophrenia unspecified (mental illness that causes hallucinations, delusions, and disorganized thinking), unspecified convulsions (sudden, violent, irregular movement of a limb or the body), dorsalgia unspecified (back pain), and essential (primary) hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 7 which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's care plan dated 7/14/25 revealed focus: Resident #1 was caught smoking in her room was at risk for injury while smoking and required supervised smoking, date initiated 8/14/25, Goals: Resident #1 will be able to smoke without causing injury through the next review date, date initiated 7/14/25, revision date 8/4/25, target date 10/14/25. Interventions: Resident #1 always check to make sure she does not have her cigarettes and lighter on her, remove if found, ensure smoking in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25. Record review of Resident #1's safe smoking assessment dated [DATE], revealed under Section A Evaluation answered yes to the following questions, 7 resident shakes/has tremors while Page 1 of 15 676028 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some smoking, 8 resident falls asleep while smoking, 9 had past accidents/incidents with smoking materials, 10 are there any visible burn marks on the resident's clothing or coat, 11 does the resident have finger dexterity problems; and under Section B Summary the following options are checked, 2 This resident requires direct supervision while smoking, 3 this resident requires a fire-resistant smoking apron while smoking, 6 the evaluation has been discussed with the resident. Record review of Resident #2's care plan dated 7/17/25 revealed focus: Resident #2 vapes, date initiated 2/14/25, Goals: Resident #2 will be able to vape without causing injury, date initiated 2/14/2, revision date 2/14/24, target date 10/15/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25, the resident will be supervised by a visitor or facility staff member at all times, date initiated 2/14/25. Record review of Resident #2's safe smoking assessment dated [DATE] revealed under Section A Evaluation answered no to the following questions: 3. Can the resident independently light smoking materials safely, 4. Can the resident extinguish smoking material completely in an appropriate receptacle, 5. Can the resident dispose of ashes or other tobacco-related residue appropriately, 6. Explanation: poor coordination; and under Section B Summary the following option was checked, 2. This resident requires direct supervision while smoking. Record review of Resident #3's care plan dated 6/19/25 revealed focus: Resident #3 had oxygen via a trach collar (surgical opening in the neck to provide an airway into the trachea) secondary to respiratory failure, date initiated 8/15/21. Additionally Resident #3 smokes, dated 5/14/24, Goal: Resident #3 will be able to smoke without causing injury, date initiated 5/14/24, revision date 7/29/25, target date 9/19/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 5/14/24, the resident is safe to smoke unsupervised, at this time, date initiated 5/14/2, keep all material at nurse station, date initiated 9/21/21. Record review of Resident #3's safe smoking assessment dated [DATE] revealed under Section B Summary the following option was checked, 2. This resident is safe to smoke unsupervised at this time. Record review of Resident #3's physician orders dated 8/23/25 revealed a prescription for Respiratory care of O2 (oxygen) at night and a trach collar during the day with a start date of 9/5/23. During an observation on 8/22/25 at 11:44 AM, revealed Resident #1 was leaned forward and was asleep. Resident #1 leaned over more and more and sat up when another resident spoke to her. No staff were present in the smoking room. Resident #1 was observed not wearing a smoking apron as she held an unlit cigarette that she stated she would smoke later. During an interview on 8/22/25 at 11:45 AM, Resident #3 said he and Resident #1 often smoked together in the smoking room. He said he helped watch her because she was blind. He said he had never seen Resident #1 wear a smoking apron when she smoked. He said staff brought Resident #1 into the smoking room but they have never stayed to supervise her. During an interview on 8/22/25 at 11:50AM, Resident #1 said staff did not supervise her when she smoked but there were other residents looking out for her in the smoking room. She stated she did not have to wear an apron while smoking. She stated staff or someone with a lighter would light her cigarettes for her. She stated her cigarettes were kept at the nurse's station. She stated she had lived at the facility for about three weeks and she had not burned herself. She stated she did not fall asleep while smoking but sometimes people thought she was because her head was down. She stated she put her head down because she had bulging disks in her neck but 676028 Page 2 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some she was not asleep. She stated she was completely blind. During an interview on 8/22/25 at 3:36 PM, CNA D said she worked on hall 1. She said she took Resident #1 in the smoke room and lit her cigarette for her. She said she had to keep an eye on her but did not have to supervise her. She said Resident #1 would be okay as long as someone was in there with her. She said she checked on her periodically. She said she had not seen Resident #1 get burned. She said she was not aware of Resident #1 if had to be supervised when she smoked or any other accommodations. During an observation on 8/22/25 at 3:45PM, Resident #1 was observed smoking a cigarette facing the corner in the smoking room. She was not wearing a smoking apron. Cigarette ashes were observed on her lap. Resident #1 was observed hunched over leaning forward and appeared to be asleep. During an interview on 8/22/25 at 3:53PM, Resident #11 said staff brought Resident #1 to the smoke room. She or other staff with lit her cigarettes. Resident #11 said Resident #1 did not wear a smoking apron; staff go back inside; they did not watch her. During an interview on 8/22/25 at 4:01PM, Resident #8 said Resident #1 had fallen asleep while smoking but she had denied it. He said he knew she was asleep because he had seen her burn her purse and he had seen her with a cigarette in her hand that was completely ash. He said he had seen staff push her to the table, give her the ashtray and cigarette, and they left. He said Resident #1 did not wear an apron when smoking. During an interview on 8/22/25 at 4:32 PM, RN A said staff helped Resident #1 to the smoking room. She was initially an independent smoker and kept her cigarettes in her room but then she accused someone of stealing them, and she lit a cigarette in her room and hallway, but said she did not know she was in the building. Resident #1 was now required to keep her cigarettes and lighter stored at the nurse station. However, she was not required to be supervised or wear protective apron when smoking. During an interview on 8/22/25 at 4:50 PM, the Regional Compliance Nurse said currently, staff were required to light the cigarette for Resident #1 but she was able to smoke by herself without supervision or devices/accommodations. During an interview on 8/23/25 at 10:57 AM, LVN B said she did not know who was responsible to update staff on updated smoking assessments. LVN B stated the facility did not have a DON and there had been a lot of changes and staffing. LVN B said changes in smoking assessment should've been updated in the care plan immediately and passed on in report. During an interview on 8/23/25 at 10:56 AM, RT M said an update to a resident's smoking assessment should have been updated on the care plan because staff used that document to refer to when they provided care to the residents. She stated the ADONs and DONs told them when there were changes in a resident's smoke assessment. During an observation and interview on 8/23/25 at 11:16AM, Resident #1 was observed smoking with no apron and sitting at table with an ashtray. No staff were present in the room. During an interview on 8/23/25 at 11:38 am, the SW said she did not think Resident #1 should smoke unsupervised. The SW said she had seen ashes in Resident #1's hair. The SW said Resident #1 would get upset and said they were trying to make her look bad when they tried to address it with her. She said the nurses completed the smoking assessments and were supposed to notify the DON or the ADM who then updated the care plan. The SW stated there was no DON currently. She said the nursing department communicated those changes through report. She was not sure of the policy on how often they updated the smoking assessments but she thought the EHR prompted staff when they were due. During an interview on 8/23/25 at 12:30PM, the MDS Coordinator said she was responsible for completing and updating MDSs and care plans. She said either she, the DON, or the ADONs updated the care plans if there were changes in a resident's smoking assessment. She said someone would let her know to update the care plan. She said she could also check the 24-hour report for changes, and they were also updated during morning meeting discussions, and also the SW would let her know of changes that needed to be updated on the MDS or care plan. She stated the EHR did not alert them of 676028 Page 3 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some changes in smoking assessments. The MDS Coordinator said she was not sure how often they were updated. She said the person who did the smoking assessment was responsible to communicate any changes to staff, the ADM, and herself. She said changes from a safe to an unsafe smoker should have been updated on the care plan as soon as the change was reported. She said she was not aware Resident #1's care plan was not updated to her being a supervised smoker. She said she was not aware Resident #1 was supposed to wear an apron while smoking. She stated a potential negative outcome of the care plan not being updated was that staff referred to the care plan to know how to provide care for the residents and they would not know Resident #1 was a supervised smoker and should've been wearing apron if the care plan was not updated. She said another potential negative outcome was that residents would not receive the right care and that could be dangerous. During an interview on 8/23/25 at 12:49PM, the ADM stated he worked at the facility since June 30, 2025, and there had been no DON for about a month, but one was starting next week. He said unsafe smokers could burn themselves or start fire if not wearing the smoking apron. He said the care plan should have been updated with the updated smoking assessment results so everyone could know what was going on with resident because that was what staff refer to when they provide care to the residents. He stated not updating care plans could cause residents to be unsafe or a resident could get injured. He said he was not aware Resident #1's care plan was not updated. The ADM said care plans were supposed to be updated immediately with changes. He said changes in care plans were communicated to the DON and the DON should review them on a regular basis. He said currently the Compliance Nurse had been trying to manage it the best she could but she worked at several different facilities. He said smoking assessments were completed monthly if that was what was documented in the care plan. He said not following care plan could result in an injury to a resident. He said the DON and ADONs were responsible to train staff. The ADM said their system to communicate changes needed or updates needed 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 checked the care plan to determine how to care for residents. He said the ADON was responsible to update care plans. Record review of the facility policy titled, Comprehensive Care Planning, undated, revealed in part the following: he facility will develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Comprehensive care plans may include but are not limited to resident Kardex records, baseline care plans, and task listings. The comprehensive care plan will describe the following - the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being; and any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASAR and the resident's representative(s)- The resident's goals for admission and desired outcomes. The resident's preference and potential for future discharge. The facility document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. Discharge plans in the comprehensive care plan, as appropriate. The comprehensive care plan will reflect interventions to enable each resident to meet his/her objectives. Interventions are the specific care and services that will be implemented. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set (MDS) to assess the resident's clinical condition, cognitive and functional status, and use of services. If a Care Area Assessment (CAA) is triggered, the facility will further assess the resident to determine whether the resident is at risk of developing, or currently has a weakness 676028 Page 4 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some or need associated with that CAA, and how the risk, weakness or need affects the resident. The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. This was determined to be an IJ on 8/23/25 at 4:15PM. The Administrator and Regional Compliance Nurse were notified on 8/23/2024 at 4:18 PM and IJ situation was identified due to the above failure and the IJ Template was provided. The following Plan of Removal submitted by the facility was accepted on 8/23/2025 at 7:50PM. Record review of the facility Plan of Removal reflected the following: [Facility Name] 8/23/20258/23/2025Plan of RemovalProblem: IJ F656 related to care planning called on 8/23/2025Interventions:1. On 8/23/2025, the Regional Compliance Nurse/ Administrator reviewed care plans for all residents who smoke and updated them with correct information related to the safe smoking assessments completed on 8/23/2025. This was to include any special safety equipment or procedures identified in those assessments.2. On 8/23/2025, off cycle QAPI with the medical director was done by the Administrator and Regional Compliance Nurse over the IJ and plan of removal.3. On 8/23/2025 Administrator and MDS case managers were in-serviced over assuring that care plans are reflective of resident conditions and preferences to include safe smoking. Monitoring:1. Beginning 8/25/2025 and 5 times weekly DON/Administrator and MDS case managers will review any changes to resident conditions or preferences to include safe smoking in the morning meeting.2. Weekly the regional compliance nurse will review 5 care plans to assure that care plans are current and reflective of resident conditions and preferences to include safe smoking.3. The Area Director of Operations and Regional MDS support staff will assure that monitoring and updating of care plans is being done according to this plan of correction. On 8/24/25 the state surveyor confirmed the facility implemented their plan of removal sufficiently to remove the IJ by: Record of facility an in-service dated 8/23/2025 revealed training on the facility will allow smoking only supervised and in designated smoking areas. There will not be any smoking or vaping devices, including cigarette lighters in resident rooms. If a resident seen with a lighter, request if from the resident and notify the Administrator immediately. Residents who wear O2 (oxygen) must leave oxygen tank inside the facility prior to enter smoking area had signatures 32 staff members. Record review of a facility in-service dated 8/23/2025 revealed training on the facility has changed today 8/23/25 to a supervised smoking facility. All smoke breaks are to be supervised, please see attachment for smoking schedule had 29 staff signatures. Record review of the off-cycle Quality Assurance Meeting document, dated 8/23/25, titled: ADHOC QAPI for identification of a system in need of immediate attention by QAPI committee. On 8/23/25 a failure was identified to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 residents) reviewed for accidents and supervision while smoking. Residents were identified on 8/23/2025 that the facility failed to ensure Resident #1 wore a fire-resistant apron and received direct supervision from staff on while smoking on 8/22/2025 and 8/23/25. Monitoring will start 8/24/2025. Regional Compliance Nurse/Area Director of Operations will monitor during weekly visits and ask DON and Administrator about status of the smoking changes and any violations identified. Monitoring will start 8/24/2025 and will continue for at least 8 weeks and prn thereafter. The administrator / DON / ADONs will monitor 5 residents' rooms daily, 5 days a week to ensure residents do not have any prohibited smoking paraphernalia in the rooms, was signed by the ADM, Regional Compliance Nurse, and physician. Record review of an in-service training dated 8/23/25 revealed, SUBJECT MATTER: Care Plans Updates. Administrator/ ADONs and MDS case managers will assure the care plans are reflective of resident conditions and preferences to include safe smoking. Once a week during the staff meeting smoking assessments and care plans will be reviewed to reflect 676028 Page 5 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some any changes, signed by the MDS Coordinator. Record review of an in-service training dated 8/23/25 revealed, SUBJECT MATTER: Care Plans Updates. Administrator/ ADONs and MDS case managers will assure the care plans are reflective of resident conditions and preferences to include safe smoking. Once a week during SOC meeting smoking assessments and care plans will be reviewed to reflect any changes, signed by the ADON. Record review of an in-service training dated 8/23/25 revealed, SUBJECT MATTER: Care Plans Updates. Care Plans Updates. Administrator/ ADONs and MDS case managers will assure the care plans are reflective of resident conditions and preferences to include safe smoking. Once a week during SOC meeting smoking assessments and care plans will be reviewed to reflect any changes, signed by the ADM. Record review of Resident #1's care plan dated 7/14/25 revealed focus: Resident #1 was often caught smoking in her room. Resident #1 was a supervised smoker and needed a smoking blanket or apron when smoking, date initiated 8/23/25, Goals: Resident #1 will be able to smoke without causing injury through the next review date, date initiated 7/14/25, revision date 8/4/25, target date 10/14/25. Interventions: Resident #1 always check to make sure she does not have her cigarettes and lighter on her, if smoking materials are found on her, remove from her and continue to redirect her not to smoke in room, ensure smoking in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, resident was notified via negotiated risk agreement (NRA) on 8/23/25 that smoking is only allowed supervised at designated times in designated areas, she may not store smoking materials in her room and must check these in at the nurse station, this resident requires a fire-resistant smoking apron while smoking, dates initiated 7/14/25, 8/14/25, and 8/23/25. Record review of Resident #1's safe smoking assessment dated [DATE], revealed under Section A Evaluation answered yes to the following questions, 7. Resident shakes/has tremors while smoking, 8. Resident falls asleep while smoking, 9. Had past accidents/incidents with smoking materials, 10. Are there any visible burn marks on the resident's clothing or coat, 11. Does the resident have finger dexterity problems; and under Section B Summary the following options are checked, 2. This resident requires direct supervision while smoking, 3. this resident requires a fire-resistant smoking apron while smoking, 6. The evaluation has been discussed with the resident. Record review of care plans for Residents #2,#3, $4, #5, #6, #7, #8, #9, #10, #11, #12, #13 revealed they were updated with current smoking information on 8/23/25. During an interview on 8/24/25 at 9:55AM, the ADM said they completed in-services to ensure care plans were updated timely and were updated with residents most current information. They would discuss smoking assessments weekly and review care plans. He said they would document their monitoring on logs to ensure they were monitoring according to the plan of removal. During an interview on 8/24/25 at 1:10 PM, with Resident #3, stated he messed up when he took his oxygen tank in the smoking room, he owned it. He stated he was upset about the changes of the supervised smoking schedule and how the code to the front door was changed so they have to be let out by staff. He stated he was upset about the changes and felt like it was prison. During an observation and interview on 8/24/25 at 1:24PM, with HK O, stated staff were in-serviced about having a smoking schedule and the different departments would take turns and monitor the residents when smoking and all of the new smoking procedures and rules. Resident #1 was observed smoking and was wearing an apron. Three HK staff were watching her. Resident #1 was observed to be leaning over. A HK staff asked Resident #1 if she was falling asleep. Resident #1 said she was told she could not smoke when she wanted, it would be a schedule. Resident #1 stated staff come get her for smoke breaks. She said she felt claustrophobic with the apron but she would wear it. Resident #1 was observed dropping ash on herself. During an 676028 Page 6 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0656 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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. 676028 Page 7 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 wore a fire-resistant apron and received direct supervision from staff on while smoking on 8/22/2025 and 8/23/25. Resident #1's smoking assessment reflected she required direct supervision when smoking due shaking while smoking, falling asleep while smoking, past accidents/incidents with smoking materials, having visible burn marks on her clothing and she had finger dexterity problems. 2. The facility failed to ensure Resident #2 received direct supervision per his smoking assessment from staff while smoking a vape on 8/23/25. 3. The facility failed to ensure Resident #3 did not have his oxygen tank with him while smoking on 8/22/25 and 8/23/25. An Immediate Jeopardy was identified on 8/23/25 at 4:15 PM. The IJ template was provided to the facility Administrator on 8/23/24 at 4:18 PM. While the immediate jeopardy was removed on 8/24/24 at 6:00 PM, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm and a scope of pattern, due to the facility's need to evaluate the effectiveness of their plan of correction to prevent future concerns. The failures could place residents at risk for serious injury, serious harm, burns, and death. Findings included: Resident #1 Record Review of Resident #1's face sheet dated 8/22/25 revealed a [AGE] year-old female admitted to the facility on [DATE] and readmitted on [DATE]. Resident #1 had a medical history of type 2 diabetes mellitus with diabetic chronic kidney disease (damage to the kidneys caused by high blood sugar and blood pressure), unspecified visual loss (loss of eye sight), hyperlipidemia unspecified (high levels of fats in the blood), schizophrenia unspecified (mental illness that causes hallucinations, delusions, and disorganized thinking), unspecified convulsions (sudden, violent, irregular movement of a limb or the body), dorsalgia unspecified (back pain), and essential (primary) hypertension (high blood pressure). Record review of Resident #1's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 7 which indicated Resident #1 had severe cognitive impairment. Record review of Resident #1's care plan dated 7/14/25 revealed focus: Resident #1 was caught smoking in her room, was at risk for injury while smoking and required supervised smoking, date initiated 8/14/25, Goals: Resident #1 will be able to smoke without causing injury through the next review date, date initiated 7/14/25, revision date 8/4/25, target date 10/14/25. Interventions: Resident #1 always check to make sure she does not have her cigarettes and lighter on her, remove if found, ensure smoking in designated smoking areas, ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25. Record review of Resident #1's safe smoking assessments dated 8/1/25, revealed under Section A Evaluation answered yes to the following questions, 7. resident shakes/has tremors while smoking, 8. resident falls asleep while smoking, 9. had past accidents/incidents with smoking materials, 10. are there any visible burn marks on the resident's clothing or coat, 11. does the resident have finger dexterity problems; and under Section B Summary the following options were checked, 2. This resident requires direct supervision while smoking, 3. This resident requires a fire-resistant smoking apron while smoking, and 6. The evaluation has been discussed with the resident. Record review of progress notes written by SW for Resident #1 dated 7/28/25, revealed staff spoke with the resident regarding the smoking policy and smoking in the hallways. Resident #1 stated she was confused and believed the CNA 676028 Page 8 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some wheeled her into the smoking room. Reminded her that it was unsafe for her and the other residents to smoke inside. She understood and stated it won't happen again. Nurse and I (SW) asked her if we could hold the cigarettes and lighter at the nurses' station. Resident #1 said no, I'm not a child. Spoke with family member in person. Updated her and asked her if she would be willing to speak with the resident about the situation. The family member said yes and was understandable of situation. Record review of nursing progress notes, author unknown, for Resident # 1 dated 8/14/25, revealed Resident #1 was noted to be found smoking in the room. The resident stated she did not know she was in the building and said she thought she was in the smoking area. The resident was educated about fire hazards and a no smoking tolerance in the building. The family member was notified about the incident. Resident #2 Record Review of Resident #2's face sheet dated 8/23/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #2 had a medical history of paraplegia unspecified (paralysis of the legs or lower body), quadriplegia, 5-C7 complete (paralysis of all four limbs, torso, and some organs), unspecified asthma uncomplicated (lung condition that causes trouble breathing), epilepsy unspecified not intractable without status epilepticus (brain disorder causing seizures), unspecified lack of coordination, muscle weakness (generalized), muscle wasting atrophy (loss of muscle tissue), cognitive communication deficit (difficulty with communication due to cognitive impairment), and dysphagia unspecified (difficulty swallowing). Record review of Resident #2's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 12 which indicated Resident #2 had moderate cognitive impairment. Record review of Resident #2's care plan dated 7/17/25 revealed focus: Resident #2 vapes, date initiated 2/14/25, Goals: Resident #2 will be able to vape without causing injury, date initiated 2/14/2, revision date 2/14/24, target date 10/15/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 7/14/25 and 8/14/25, the resident will be supervised by a visitor or facility staff member at all times, date initiated 2/14/25. Record review of Resident #2's safe smoking assessment dated [DATE] revealed under Section A Evaluation answered no to the following questions: 3. Can the resident independently light smoking materials safely, 4. Can the resident extinguish smoking material completely in an appropriate receptacle, 5. Can the resident dispose of ashes or other tobacco-related residue appropriately, 6. Explanation: poor coordination; and under Section B Summary the following option was checked, 2. This resident requires direct supervision while smoking. Resident #3 Record Review of Resident #3's face sheet dated 8/23/25 revealed a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. Resident #3 had a medical history of acute and chronic respiratory failure with hypercapnia (build-up of carbon dioxide in the lungs), type 2 diabetes mellitus with diabetic polyneuropathy (high blood sugar levels that cause nerve damage), obstructive sleep apnea (temporary pauses in breathing during sleep), acute diastolic (congestive ) heart failure with hypoxia (blood backed up in the lungs and insufficient oxygen delivery to the body), unspecified lack of coordination (difficulty controlling muscle movements), muscle weakness (generalized), tracheostomy status (surgical opening in the neck to provide an airway into the trachea), and cognitive communication deficit (difficulty with communication due to cognitive impairment). Record review of Resident #3's MDS dated [DATE] revealed, Section C - Cognitive patterns revealed a BIMS score of 9 which indicated Resident #3 had moderate cognitive impairment. Record review of Resident #3's care plan dated 6/19/25 revealed focus: Resident #3 had oxygen via a trach collar (surgical opening in the neck to provide an airway into the trachea) secondary to 676028 Page 9 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some respiratory failure, date initiated 8/15/21. Additionally Resident #3 smokes, dated 5/14/24, Goal: Resident #3 will be able to smoke without causing injury, date initiated 5/14/24, revision date 7/29/25, target date 9/19/25. Interventions: Ensure smoking occurs in smoking areas, ensure that ensure that no oxygen is located in the smoking area while the resident is smoking, ensure the resident is made aware of the facility smoking policy, no smoking materials or igniters will be stored in resident's rooms, safe smoking assessment every month, date initiated 5/14/24, the resident is safe to smoke unsupervised, at this time, date initiated 5/14/2, keep all material at nurse station, date initiated 9/21/21. Record review of Resident #3's safe smoking assessment dated [DATE] revealed under Section B Summary the following option was checked, 2. This resident is safe to smoke unsupervised at this time. Record review of Resident #3's physician orders dated 8/23/25 revealed a prescription for Respiratory care of O2 (oxygen) at night and a trach collar during the day with a start date of 9/5/23. Record review of the facility's smokers list dated 8/21/25 revealed Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12, and #13 smoked. During an observation on 8/22/25 at 8:54 AM, revealed a sign was observed next to the front door on the outside front porch area that indicated it was a no smoking area. During an observation and interview on 8/22/25 at 11:44 AM revealed there was sign posted on the wall outside of smoking room, that reflected, No oxygen beyond this point. Observed Residents #1 and #3 in the smoking room. Resident #3 was observed smoking a cigarette while sitting in his scooter with an oxygen tank in between his legs. Resident #3 was observed wearing a trach collar on his neck. Resident #1 was within arm's reach distance from Resident #3. Resident #1 was leaned forward and was asleep. Resident #1 leaned over more and more and sat up when someone spoke to her. No staff were present in the smoking room. Resident #1 was observed not wearing a smoking apron while holding an unlit cigarette that she stated she was holding for later. During an interview on 8/22/25 at 11:45 AM, Resident #3 said he used oxygen as needed during the day. He said he and Resident #1 often smoked together in the smoking room. He said he helped watch her because she was blind. He said he had never seen Resident #1 wear a smoking apron when she smoked. He said staff brought Resident #1 into the smoking room, but they never stayed to supervise her. He said staff or himself or other residents would light Resident #1's cigarettes for her. He said he had not seen Resident #1 burn herself while smoking. During an interview on 8/22/25 at 11:50AM, Resident #1 said staff did not supervise her when she smoked but there were other residents looking out for her in the smoking room. She stated she did not have to wear an apron while smoking. She stated staff or someone with a lighter would light her cigarettes for her. She stated her cigarettes were kept at the nurse's station. She stated she had lived at the facility for about three weeks and she had not burned herself. She stated she did not fall asleep while smoking but sometimes people thought she was because her head was down. She stated she put her head down because she had bulging disks in her neck but she was not asleep. During an interview on 8/22/25 at 2:46PM, Resident #9 said she smoked in the smoke room regularly. She had seen Resident #1 in the smoke room and had never seen staff supervise Resident #1 when she smoked. She said she had never seen Resident #1 wear an apron when she smoked. She said Resident #1 had fallen asleep while smoking. She said she had not seen Resident #1 get burned while smoking. During an interview on 8/22/25 at 2:48PM, Resident #12 said he occasionally saw staff bring Resident #1 outside but staff did not stay to supervise her. He said Resident #1 did not wear a smoking apron. During an interview on 8/22/25 at 3:25 PM Resident #4 said he saw Resident #4 smoke, staff brought her in the smoking room, staff did stay to watch her. He said he had never seen her wear a smoking apron. He said he was not aware of her burning herself. He said staff lit her cigarettes or other smokers would. During an observation on 8/22/25 at 3:31 PM, revealed staff CNA D rolled Resident 676028 Page 10 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some #1 in the smoke room and exited at 3:33PM. Resident #1 stayed in the smoking room. During an interview on 8/22/25 at 3:36 PM, CNA D said she had worked at the facility for 2 weeks and worked 6am to 6pm. She said she worked on hall 1. She said she took Resident #1 in the smoke room and lit her cigarette for her. She said she had to keep an eye on her but did not have to be in the room to supervise her. She said Resident #1 would be okay as long as someone was in there with her. She said she checked on her periodically. She said she had not seen Resident #1 get burned. She said she was not aware if Resident #1 had to be supervised when she smoked or any other accommodations. She said she was not aware of any resident on her hall that had to be supervised while smoking. During an observation on 8/22/25 at 3:45PM, Resident #1 was observed smoking a cigarette facing the corner in the smoking room. She was not wearing a smoking apron. Cigarette ashes were observed on her lap. Resident #1 was observed hunched over leaning forward and appeared to be asleep. CNA D entered the smoking room and asked Resident #1 why she was in the corner. Resident #1 said she did not know where she was in the smoking room. Resident #1 said she was still trying to learn her way around the facility. CNA D moved her to the table and gave her an ashtray. She was observed to use the ashtray properly. Smoking aprons were observed to be hanging in the smoke room and a red container labeled fire blankets was hung up on the wall in the smoke room. During an interview on 8/22/25 at 3:53PM, Resident #11 said staff brought Resident #1 to the smoke room. She or other staff lit her cigarettes. Resident #11 said Resident #1 did not wear a smoking apron; staff went back inside, they did not watch her. She had not seen Resident #1 burn herself. During an interview on 8/22/25 at 4:01PM, Resident #8 said Resident #1 had fallen asleep while smoking but she had denied it. He said he knew she was asleep because he had seen her burn her purse and he had seen her with a cigarette in her hand that was completely ash. He said he had seen staff push her to the table, give her the ashtray and cigarette, and they left. He said Resident #1 did not wear an apron when smoking. During an interview on 8/22/25 at 4:32 PM, RN A said staff helped Resident #1 to the smoking room. She was initially an independent smoker and kept her cigarettes in her room but then she accused someone of stealing them, and she lit a cigarette in her room and hallway, but said she did not know she was in in the building. He said staff were supposed to put Resident #1 in front of the table in the smoking room, she was still able to light her own cigarette, or he would light it for her. Resident #1 was now required to keep her cigarettes and lighter stored at the nurse station. However, she was not required to be supervised or wear a protective apron when smoking. He was not aware of any residents on halls 1 and 2 that were required to be supervised while smoking or wear an apron. They tried to promote independence. He had no concerns of her smoking independently. He said he did not know if she had burned herself at the facility but had seen burn marks on almost all of her clothing. He was not aware if it happened before she moved to the facility. He said the only other cigarettes he kept at the nurse station was for Resident #13 who needed help rationing them. During an interview on 8/22/25 at 4:47PM, Resident #2 said he only smoked a vape in the front, he did not smoke in the smoking room because could not stand the smell. He said staff were not with him when he smoked, and he did not need a smoking apron to smoke a vape. During an interview on 8/22/25 at 4:50 PM, the Regional Compliance Nurse said currently, staff were required to light the cigarette for Resident #1 but she was able to smoke by herself without supervision or devices/accommodations. During an interview on 8/23/25 at 9:13 AM, RN A sated there were no vapes being held at the nurse station for any residents. He said they only held Resident #1's cigarettes due to her smoking in her room and she accused people of stealing her cigarettes. He said he had not been told to supervise any residents while they smoked. He said residents were not supposed to take oxygen tanks in the smoking room. He said there were no residents in the facility 676028 Page 11 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some they supervised when smoking. He said residents who vaped must still vape in the smoking room. During an observation on 8/23/25 at 9:23 AM, a sign was observed on the wall hanging next to the smoking-room entrance doors that reflected, No oxygen beyond this point. During an interview on 8/23/25 at 10:27 AM, a Family Member said Resident #1 had been blind for 7 years and smoked since she was 7 years old. The family member said Resident #1 caught a pillowcase and blanket on fire in the past, she had burned her fingers, ankle, knee, thighs, and clothing. No medical treatment was needed for any of the burns. The family member said the facility no longer allowed Resident #1 to keep her cigarettes or a lighter in her room. She had to get them from staff now. The staff would light the cigarette for Resident #1. She thought staff watched Resident #1 smoke but was not sure. She said she did not know if Resident #1 was required to wear an apron when smoking. The Family Member said when Resident #1 lived with her, she often fell asleep and the cigarette had fallen out of her hand before. The Family Member said Resident #1 denied being asleep and she would tell Resident #1 to wake up and Resident #1 would not know the cigarette had fallen out of her hand. She said the ADM told her they caught Resident #1 smoking in her room. She told them she would ask Resident #1 to let them hold her cigarettes at the nurse station for safety purposes. She now gave the cigarettes to nurse for them to hold and Resident #1 was okay with it. The Family Member said Resident #1 smoked 12 to 15 cigarettes a day. The Family Member said Resident #1 did not have neck muscles and held her neck down. She's had several falls over the years, she was never trained to walk with a walking stick, and she did not know how to do anything while being blind. During an observation and interview on 8/23/25 at 10:53AM, Resident #2 was observed sitting on the front porch smoking his vape. No staff were observed to be present. Resident #2 said he kept his vape in his room. During an interview on 8/23/25 at 10:57 AM, LVN B said she was the charge nurse on hall 2. She said Resident #3 was the only smoker on this hall and he was an independent smoker. LVN B said Resident #2 used an oxygen concentrator at night and used a portable oxygen tank as needed during the day. She said Resident #3 was not supposed to take the oxygen tank into the smoke room because it could start a fire and burn himself or others. She said the oxygen tank could ignite. LVN B said everyone was responsible to make sure he did not take it in there. LVN B said she had been asking for scheduled smoke breaks so they could check everyone on their way to the smoke room. She said no one vaped on hall 2. She said she was not sure if Resident #3 kept his cigarettes in his room because they held cigarettes for everyone at the nurse station on hall 1. She said she was not aware if residents were allowed to keep cigarettes and lighters in their rooms. She said there was no system in place to track when residents smoked. She said she did not know who was responsible to update staff on updated smoking assessments. LVN B stated the facility did not have a DON and there had been a lot of changes and staffing. LVN B said changes in smoking assessment should've been updated in the care plan immediately and hopefully passed on in report. During an interview on 8/23/25 at 10:56 AM, RT M said Resident #3 went to dialysis on Tuesday, Thursday, Saturday, and took a portable oxygen tank with him. RT M said Resident #3 used the concentrator at night and as needed during the day and during the day he used room air and could use oxygen as needed when out of breath. RT M said Resident #3 knew he was not supposed to take the oxygen tank into the smoking room. RT M said the oxygen tank was flammable and could ignite and burn a resident or start a fire. She said no one on hall 2 vaped. She stated there was no system in place to track when Resident #3 went to smoke because there was no smoking schedule. RT M said an update to a resident's smoking assessment should have been updated on the care plan because staff used that document to refer to when they provided care to the residents. She stated the ADONs and DONs told them when there were changes on a resident's smoke assessment. During an observation and interview on 8/23/25 at 676028 Page 12 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 11:16AM, Resident #1 was observed at the nurse station and asked for a cigarette. RN A was observed getting a cigarette out of a lock box and he gave it to Resident #1. RN A then rolled Resident #1 into smoking room, lit the cigarette, and exited room at 11:19AM. Resident #1 was observed smoking with no apron and sitting at table with an ashtray. She was observed to use the ashtray. She said she had never burned herself but had burned her clothes when she lived with her one of her family members. She said she had never started a fire with a cigarette. During an observation on 8/23/25 at 11:31 AM, Residents #3 and #8 were observed smoking outside on the front porch within arm's reach of each other. Resident #3 had a portable oxygen tank in between his legs on his scooter. During an interview on 8/23/25 at 11:38 am, the SW said she did not think Resident #1 should smoke unsupervised. The SW said she had seen ashes in Resident #1's hair. SW said Resident #1 got upset and said they were trying to make her look bad when they tried to address it with her. The SW stated staff held Resident #1's cigarettes at the nurse station because she was an unsafe smoker, she had ashes in her hair, and she missed the ashtray. The SW stated Resident #1 had not burned herself while at the facility, but all of her clothing had burn holes, but Resident #1 reported they were from before she lived at the facility The SW said Resident #1 was lethargic and was hunched over and she looked like she fell asleep when she was smoking, but there was no confirmation of that. She said the nurses completed the smoking assessments and were supposed to notify the DON or the ADM who then updated the care plan. The SW stated there was no DON currently. She said the nursing department communicated those changes through report. She was not sure of the policy on how often they updated the smoking assessments, but she thought the EHR prompted staff when they were due. The SW said per policy, residents were not supposed to keep cigarettes in their room, nurses were supposed to keep them. The SW said Resident #1 went on a pass with her family member and could bring cigarettes in without them knowing. The SW said she was not aware of residents that kept cigarettes in their rooms. She said she did not think residents were supposed to take oxygen tanks in the smoking room because residents could get burned or catch on fire, the oxygen tanks could explode, and it was a safety concerns. The SW said there was a fire blanket in the smoking room. She said they had not had anyone report burning themselves or their clothing. The SW said it wouldn't hurt for Resident #1 to wear an apron even if she denied getting the burn holes while at the facility, but she did not think Resident #1 would agree. Resident #1 said she did not want to be treated like a child. The SW said a potential negative outcome of not supervising resident were that they could get burned, ashes in their clothing, cigarettes may not be put out properly, and there would be cigarette butts everywhere. During an interview on 8/23/25 at 12:30PM, the MDS Coordinator said she was responsible for completing and updating MDSs and care plans, she helped with therapies, PASRR, and helped on the floor if needed. She said either she, the DON, or the ADONs updated the care plans if there were changes in a resident's smoking assessment. She said someone would let her know to update the care plan. She said she could also check the 24-hour report for changes, and they were also updated during morning meeting discussions, and also the SW would let her know of changes that needed to be updated on the MDS or care plan. She stated the EHR did not alert them of changes in smoking assessments. The MDS Coordinator said she was not sure how often they were updated. She said the person who did the smoking assessment was responsible to communicate any changes to staff, the ADM, and herself. She said there had been meetings with staff, resident council meetings, and with the ombudsman about smoking issues at the facility. The MDS Coordinator said residents go to the grocery store and could bring smoking materials in without them knowing. She said residents were not supposed to keep cigarettes or lighters in their rooms, they were kept at the nurse desk. She said she was not sure about vapes but she thought they would be treated 676028 Page 13 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some like cigarettes. She said resident were not supposed to vape in their room or keep vapes in their rooms. She said there was a sign outside the smoking room that reflected, no oxygen beyond this point. She said she did not think residents could take oxygen tanks in the smoking room. She said residents were not allowed to smoke on the front porch and were not supposed to smoke outside next to someone with an oxygen tank. The MDS Coordinator said she saw Resident #3 smoking with another resident on the front porch this morning and she told them they were not allowed to smoke there; however, she did not notice Resident #3 had an oxygen tank between his legs. The MDS Coordinator said she was not sure if a person that vaped had to be supervised since there was no fire involved. She said she was not sure if there was a system in place to ensure staff were communicating changes in smoking restrictions. She said staff monitored the facility to see if they saw residents with cigarettes in their hands, but they could not do anything about the ones that hid them and took them into their rooms. She said all residents who smoked and used oxygen knew they could not take oxygen in the smoking room. She said there was no system to check resident's with oxygen before they enter the smoking room, there was not smoking schedule as resident's smoked whenever they wanted. The MDS Coordinator said a potential negative outcome could be that the oxygen tank could explode and cause a fire, that happened at the facility about 14 years ago. She said that was even possible even if they were smoking outside in close proximity to an oxygen tank. She said residents could burn themselves and they could catch themselves on fire if not supervised and not wearing an apron. She said changes from a safe to an unsafe smoker should have been updated on the care plan as soon as the change was reported. She said she was not aware Resident #1's care plan was not updated to her being a supervised smoker. She said she was not aware Resident #1 was supposed to wear an apron while smoking. She stated a potential negative outcome of the care plan not being updated was that staff referred to the care plan to know how to provide care for the residents and they would not know Resident #1 was a supervised smoker and should've been wearing apron if the care plan was not updated. She said another potential negative outcome was that residents would not receive the right care and that could be dangerous. She said she was not aware Resident #3 took his oxygen tank into the smoke room and outside while sitting with other people smoking. During an interview on 8/23/25 at 12:49PM, the ADM stated he worked at the facility since June 30, 2025, and there had been no DON for about a month, but one was starting next . He said residents who used oxygen should've left the oxygen in their room or somewhere safe, they were not allowed to take oxygen in the smoke room. He said the system to monitor that was the residents should tell staff they wanted to smoke and staff were supposed to remove the oxygen tank from their chairs. He said residents were not supposed to keep cigarettes and lighters in their rooms. He said residents were not supposed to smoke vapes or keep vapes in their room. They must vape in the designated smoking areas. He said the SW was responsible for completing smoking assessments. He said there was no policy on how often smoking assessments were completed and updated. He said an initial smoking assessment was completed during admission, and they would go from there to determine when to complete the next one. He stated himself and the DON were responsible to communicate changes in smoking assessments to staff. He said changes were currently communicated during morning meetings. The ADM said he believed a person that was an unsafe smoker and vaped should be supervised as well. He said unsafe smokers could burn themselves or start fire if not wearing the smoking apron. The ADM said oxygen was combustible and could start a fire and burn residents. He said he was not aware a resident took an oxygen tank in the smoking room or that a resident was outside with an oxygen tank smoking with other resident. He said he was not aware of a resident that vaped that was not being supervised that should be supervised. He said he did not know any of the residents that vaped. He 676028 Page 14 of 15 676028 08/24/2025 Southern Specialty Rehab & Nursing 4320 W 19th Street Lubbock, TX 79407

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 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 676028 Page 15 of 15