Health inspection·November 25, 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 3 residents reviewed for smoking. (Resident #1)The facility failed to ensure staff followed the smoking policy and took residents out to smoke in designated smoking area. This failure could place residents at risk of injury or harm.Findings included:Record review of Resident #1's face sheet undated revealed she was [AGE] years old and admitted to the facility on [DATE]. Resident #1 had diagnoses which included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breathe), emphysema (lung condition that causes shortness of breath), hypertension (high blood pressure), shortness of breath, anxiety (feeling of fear and worry), and tobacco use.Record review of Resident #1's quarterly MDS assessment dated [DATE], revealed she had a BIMS score of 12, which indicated she had moderate cognitive impairment. The MDS indicated Resident #1 needed supervision or touching assistance for most ADLs. The MDS did not indicate Resident #1 was using tobacco at the time of the assessment.Record review of Resident #1's Care Plan Report revealed she had a problem attempting to smoke and asking others to take her to smoke. Resident #1 had been educated by ADON and DON that this was a nonsmoking facility dated 10/14/25. Interventions included caregivers to provide opportunities for positive interaction, attention, to stop and talk with him/her as passing by, explain all procedures to the resident before starting, intervene as necessary to protect the rights and safety of others, approach/speak in a calm manner, divert attention, and remove from situation and take to alternate location as needed. The care plan further revealed observe and report behavior episodes and attempt to determine underlying causes, consider location, time of day, persons involved, and situations and document behavior and potential causes.Record review of Resident #1's Safe Smoking assessment dated [DATE] revealed Resident #1 was determined to be a safe smoker.Record review the facility's provided undated Smoker List revealed two resident names and Resident #1 was not listed. Smoke schedule 0900, 1400, 1900 and smoke area outside of the dining room.During an interview on 10/14/25 at 09:30 am with the ADM, she stated during her investigation of the fire, CNA A admitted to taking Resident #1 out on the patio at the end of Hall 300 to smoke between 12:00 pm and 1:00 pm. She stated Resident #1 was not a smoker and when admitted was told the facility was a nonsmoking facility. She stated the facility had two residents that were still allowed to smoke in the designated smoking area outside the dinner room.An observation on 10/14/25 at 09:33 am of the patio at the end of Hall 300 revealed the door to patio was keypad locked on inside and outside. The gazebo was located at back right side of patio approximately 25ft. from facility door. The patio railing at the back on the right side and the support post are burnt. A flower planter box located on the back right corner was burnt. There was no observation of ash trays, a fire extinguisher, or red trash can.During an interview on 10/14/25 at 09:35 am with LVN B, she stated they occasionally took residents out on the patio to help with their behaviors. She stated the designated smoking area was located by the dining room. She stated they would occasionally take Residents Affected - Few Page 1 of 3 676318 676318 11/25/2025 Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few residents out on the patio at the end of Hall 300 to smoke at night because the lighting was better. She stated they always took the cigarette butts to the red can located in the designated smoking area outside of the dining room.During an interview on 10/14/25 at 01:20 pm with the ADM, she stated CNA A took Resident #1 outside to smoke. She stated CNA A was not aware that Resident #1 was not on the list of smokers. She stated the facility had two residents that were allowed to smoke. She stated when she interviewed Resident #1, Resident #1 stated she had put her cigarette out in the planter box on the patio at the end of Hall 300. She stated CNA B was making rounds and seen flames out at the patio. CNA B got the fire extinguisher, put the fire out and 911 was called. She stated the designated smoking area was located outside of the dining room. She stated the smoking area was for resident-use only.During an observation on 10/14/25 at 01:30 pm, the smoking area outside dining room had an ash tray, red can, and fire extinguisher.During an interview on 10/14/25 at 02:13 pm with CNA A, she stated on Tuesday 10/07/25 Resident #1 asked to go outside on the patio to warm up because she was cold. She stated she went back inside to get another resident and when she returned to the patio Resident #1 was down at the gazebo smoking. She stated she did not think anything about it because they occasionally took residents outside on patio to smoke. She stated Resident #1 put the cigarette out in pot inside of planter box and had the top part of cigarette in her hand when she went back inside facility. She stated she was not sure where Resident #1 got the cigarette and lighter. She stated she told the receptionist that Resident #1 went outside and smoked. She stated the receptionist told her Resident #1 was not supposed to smoke and the receptionist notified the ADON and DON. She stated she was not aware Resident #1 was not supposed to smoke.During an interview on 10/14/25 at 02:26 pm with the DON, she stated CNA A worked Hall 300. She stated the receptionist reported to her Resident #1 went out on the patio at the end of Hall 300 and smoked with CNA A. She stated CNA A stated she did not know Resident #1 was going to smoke. She stated she did not know where Resident #1 got cigarettes and lighter. She stated someone had to bring them to her. She stated the only designated smoking area was outside by the dining room. She stated the facility was non-smoking and currently had two residents who were grandfathered in, and once those residents were no longer at the facility, they will be 100% non-smoking. She stated all staff were aware of the designated smoking area. She stated Resident #1 told her she did not have any more cigarettes in her room. She stated Resident #1 did not allow staff to look through her belongings. She stated the purpose of the designated smoking area was so the residents had everything they needed, and a safe place to smoke to prevent fires and be monitored. She stated all staff have been trained where the location of the designated smoking area was and the smoking policy. She stated the potential negative outcome could be a fire.During an interview on 10/14/25 at 02:35 pm with the ADON, she stated it was reported to her and the DON that Resident #1 went outside on the patio at the end of Hall 300 and smoked. She stated when they went to Hall 300 Resident #1 was back in her room. She stated CNA A stated she took her outside on the patio at the end of Hall 300 to smoke. She stated CNA A did not know Resident #1 was not supposed to smoke or the location of designated smoking area. She stated she was trained on the smoking policy and designated smoking area. She stated Resident #1 stated she had cigarettes in her room, but no one ever took her outside to smoke. She stated Resident #1 did not have a lighter and would not tell them who lit her cigarette. She stated the policy was for residents to only smoke in designated smoking areas. She stated the designated smoking area was located outside the dining room. She stated all staff had been in-serviced on the smoking policy and designated area. She stated the potential negative outcome could be a fire.During an interview on 10/14/25 at 02:45 pm with Resident #1, she stated she asked the staff to take her outside to smoke. She stated CNA A took her outside to smoke 676318 Page 2 of 3 676318 11/25/2025 Windmill Village Rehabilitation & Care Center 507 Martin Luther King Blvd Lubbock, TX 79403

F 0926 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few and lit her cigarette. She stated she did not know the code to get out on the patio or get back into facility. She stated she was not aware she could not smoke outside on the patio at the end of Hall 300. She stated when she was on Hall 100, she would see people smoking outside her window. She stated she had no cigarettes or lighter in her room.During an interview on 10/14/25 at 03:15 pm with the ADM, she stated the purpose of the designated smoking area was to take the residents there, so they were monitored and safe. She stated she was not aware the staff were taking residents out on the patio at the end of Hall 300 to smoke. She stated all staff have been in-serviced on the smoking policy and the location of the designated smoking area. She stated her expectation was for all staff to follow the smoking policy. She stated the charge nurse was responsible for monitoring staff who took residents out to smoke. She stated the potential negative outcome could be a fire.Review of the facility's policy titled Smoking Policy - Residents revised 03/08/23 revealed the following:Policy Statement - This facility should establish and maintain safe resident smoking practices .2. Smoking is only permitted in designated smoking areas, which are located outside of the building.4. Ensure that fireproof or compatible containers are available in smoking areas. 676318 Page 3 of 3