Average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Lubbock Health Care Center during CMS and state inspections, most recent first.
Kitchen A staff left butter, rolls, and tea uncovered while not actively being served, stacked resident drink cups so the rims were exposed to the underside of serving trays, and stored 39 unlabeled and undated cups of liquid in the walk-in refrigerator. Staff also kept 17 spoiled sweet potatoes with fresh potatoes in the pantry. Interviews showed staff knew the expectations for covering food, labeling items, and discarding spoiled food, but the observed practices still occurred.
Loose Shower Room Handrail: A loose handrail was found in the South Hall shower room after residents and staff reported it had been an ongoing issue. Surveyors observed the left-side handrail in the first shower stall moving about 1 to 2 inches, and staff said the concern had been reported to maintenance multiple times. The MS stated he had repeatedly tightened the handrail and knew a proper repair would require removing tile, while the DON and ADM said they were not aware of the issue before the survey.
PRN Xanax Order Lacked Required Stop Date: A resident with anxiety and severely impaired cognition had an active PRN alprazolam order without the required 14-day stop date. The DON stated she knew PRN psychotropic meds must be limited to 14 days unless extended with documentation, and the ADM said nursing staff were responsible for checking medication orders for this requirement. The facility policy also stated PRN anti-anxiety meds are limited to 14 days unless the rationale and duration are documented.
A resident with moderately impaired cognition and a tobacco use history was care planned for smoking safety, including a smoking apron and direct supervision while smoking, after repeated noncompliance and a negotiated risk agreement. Surveyors observed the resident smoking outside without a smoking apron and at times without supervision, while the ADM, DON, and MA B acknowledged awareness of the smoking policy and the resident’s need for supervision.
Unlabeled Loose Pills Found in Medication Cart: During an observation of Medication Cart 2, a green pill and a white pill were found loose and unlabeled in the cart drawer. MA B, the DON, and the ADM stated staff were trained to check medication carts for loose pills, expired meds, cleanliness, and narcotic counts, and the DON identified the pills as amitriptyline and furosemide. The facility policy required meds and biologicals to be stored safely, securely, and properly.
A resident with asthma and an oxygen order had an oxygen concentrator observed with a red alert light on, indicating a malfunction. The resident said the light had been on for about three months and staff knew about it, but the DON, Maintenance Supervisor, Medical Supply, and ADM were unaware until surveyor intervention. Records showed ongoing oxygen use and monitoring, while facility policy required routine cleaning, filter changes, and periodic checks of concentrators in service.
A facility failed to ensure accurate accounting of a controlled substance when nursing staff did not physically count Lorazepam stored in the refrigerator during shift change, resulting in four missing syringes. The discrepancy was discovered after a review of the narcotic count sheet and interviews revealed that staff relied on paper records instead of conducting a full physical count as required by policy. The involved nurse could not account for the missing doses and refused to complete a required drug test after an initial abnormal sample.
A resident with multiple medical conditions was improperly restrained by an LVN who tied the resident's hand to the bed to prevent him from pulling out his dialysis port. The LVN did not notify the physician or obtain an order for the restraint, violating the facility's policy. The resident had a history of pulling at his port, posing a risk of severe bleeding, but the facility's policy requires a physician's order for any restraint use.
A resident in a long-term care facility was restrained without a physician's order to prevent him from pulling out his dialysis port. The LVN failed to notify the physician or the Director of Nursing about the resident's change in condition and the use of restraint, violating facility protocols. This lack of communication and adherence to procedures compromised the resident's care.
The facility failed to inform residents and their representatives about the grievance process, resulting in six residents being unaware of how to file grievances or who the grievance official was. The Activity Director and Social Worker were also unaware of the grievance procedures, leading to a lack of written documentation and confusion about roles and responsibilities.
A facility failed to maintain proper infection control practices during medication administration. An LVN did not sanitize a multi-use wrist blood pressure device between residents and neglected hand hygiene between medication administrations. Despite training, the LVN admitted to not following procedures, risking cross-contamination. Interviews with facility administration confirmed the expectation for proper sanitization, but the LVN's actions did not align with the facility's infection control policy.
A resident's Out-of-Hospital Do Not Resuscitate (OOH-DNR) form was found incomplete, missing the physician's license number and printed name. The social worker, responsible for ensuring the accuracy of these forms, acknowledged the error. The resident, a 5-year-old female with multiple health issues, was listed as DNR, but the incomplete form could lead to her end-of-life wishes not being honored.
The facility failed to ensure a safe environment as multiple toilets were found unsecured and unstable, posing a risk of injury. Two residents, both cognitively intact, reported issues with their toilets, with one noting it was loose and the other finding it too short. Maintenance and housekeeping procedures were inadequate, as regular checks for toilet stability were not conducted, and repairs were not completed in a timely manner.
A resident with a history of emphysema, CHF, and hypertension fell in the bathroom due to an unstable toilet in the facility. The toilet wobbled, causing the resident to fall and sustain a wrist laceration and bruises. The facility's investigation found that a bolt securing the toilet had stripped from the floor, leading to the instability. Despite the resident's complaints of pain, x-rays showed no fractures. The incident highlighted concerns about the toilet's condition and potential injury risks.
Uncovered food, unlabeled drinks, and spoiled items stored with fresh food
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in Kitchen A. During observations, butter was left uncovered for extended periods while it was not actively being served, and trays of rolls were left uncovered while they cooled. A large container of tea was also observed uncovered in the kitchen sink and then left uncovered on a table while smaller pitchers were filled from it. Resident drink cups were stacked directly on top of one another, exposing the rims of the cups to the underside of serving trays. Surveyors also observed 39 cups of unknown liquids in the walk-in refrigerator that were not labeled or dated. In the dry pantry, 17 spoiled sweet potatoes with visible white fuzzy substance were stored in a plastic bag dated 11/26/25 with fresh russet potatoes. The spoiled sweet potatoes remained present during repeated observations over two days and were still stored with the fresh potatoes until the investigator brought them to the attention of kitchen leadership. Interviews with the DM, dietary aides, and the ADM showed that staff were aware of expectations for covering food, labeling and dating items, and discarding spoiled food, but the observed practices still occurred. Staff stated that the butter had been left uncovered as a routine practice, that tea had been left uncovered while being prepared, that cups should not have been stacked in a way that exposed the rims, and that spoiled food should have been discarded immediately. The facility policy and the cited Food Code provisions reflected requirements for food to be protected from contamination and stored in closed containers or with protective barriers.
Loose Shower Room Handrail
Penalty
Summary
The facility failed to ensure a resident had a safe, clean, comfortable, and homelike environment when a handrail in the South Hall shower room was loose. During the survey, a confidential interview with residents identified the loose handrail as a concern, and an observation confirmed the left-side handrail in the first shower stall could be moved back and forth approximately 1 to 2 inches on the near side while the far end remained secure. Staff interviews showed the loose handrail had been known to nursing and maintenance staff for an extended period of time. A CNA stated the concern had been reported to maintenance, and another CNA stated the handrail had been loose for as long as she had worked at the facility, that it had been fixed in the past, and that it became loose again. The maintenance supervisor stated he was aware of the issue, had tightened it repeatedly, and knew the tile would need to be removed to repair it properly. He also stated the issue had been reported multiple times through the maintenance system and directly by staff. The DON and ADM stated they were not aware of the loose handrail before the survey and confirmed that maintenance requests were expected to be reported through the maintenance system or directly to the maintenance supervisor. The facility’s scheduled tasks included monthly inspection of shower rooms and shower equipment, but the facility was unable to provide a policy related to handrails.
PRN Xanax Order Lacked Required 14-Day Stop Date
Penalty
Summary
The facility failed to ensure that a PRN psychotropic medication order for Resident #11, a female admitted with diagnoses including anxiety and with severely impaired cognition on the MDS, was limited to 14 days unless the attending physician or prescribing practitioner documented that an extension beyond 14 days was appropriate. Resident #11 had an active PRN order for alprazolam (Xanax) 0.26 mg by mouth every 8 hours as needed for anxiety, and the order did not include a documented 14-day stop date. Record review showed that Resident #11 had a psychotropic medication consent on file acknowledging the risks and side effects of Xanax. The MAR showed one PRN dose was administered on one date and no doses were given on another date reviewed. The care plan identified behavioral concerns related to anxiety and depression and included interventions for administering medications as ordered and monitoring for side effects and effectiveness. During interviews, the DON stated she was familiar with the requirement that PRN psychotropic medications have a 14-day stop date and that after 14 days the medication should be discontinued or a new order created. She stated nursing staff were responsible for ensuring the stop date was included when the order was entered, including hospice orders. The ADM also stated that PRN psychotropic medications required a 14-day stop date and that nursing staff were responsible for reviewing medication orders for this requirement. The facility’s psychotropic medication policy stated that PRN orders for anti-anxiety drugs are limited to 14 days unless the rationale and duration are documented in the resident’s medical record.
Failure to Supervise a Resident During Smoking
Penalty
Summary
The facility failed to ensure adequate supervision and assistance devices to prevent accidents for one resident who smoked. Resident #4 had diagnoses including a cognitive communication deficit, a Brief Interview for Mental Status score of 09 indicating moderately impaired cognition, and a documented tobacco use history. Her care plan stated that she smoked, was frequently noncompliant with scheduled smoking times, and included interventions to redirect her to scheduled smoking times and require a smoking apron while smoking, but it did not include supervision while smoking. Record review showed that the resident had repeated issues with smoking safety. Progress notes documented that she was outside smoking outside of supervised smoking hours, was resistant to education regarding smoking safety, and later had a negotiated risk agreement completed after being observed falling asleep while smoking. That agreement stated she would be supervised while smoking. A subsequent negotiated risk agreement again stated that she agreed to wear a smoking apron and be supervised while smoking. A smoking assessment also identified that she required direct supervision while smoking and a fire-resistant smoking apron. Survey observations showed the resident smoking without the smoking apron and without supervision. On one occasion she was observed returning from smoking with an unknown staff member present outside with her and other residents. On another occasion she was observed outside smoking without a smoking apron, and later the same morning she was again observed outside smoking unsupervised and without a smoking apron. During interview, the resident stated she could smoke independently and did not need supervision or a smoking apron. Staff interviews showed the ADM, DON, and MA B were aware of the smoking policy, the resident's need for supervision, and the requirement for a smoking apron, but the resident was still observed smoking without those protections in place.
Unlabeled Loose Pills Found in Medication Cart
Penalty
Summary
The facility failed to ensure drugs and biologicals used in the facility were stored and maintained in accordance with currently accepted professional standards for 1 of 2 medication carts reviewed, specifically Medication Cart 2. During an observation with MA B, 1 green pill and 1 white pill were found loose and unlabeled in the second drawer of the cart. MA B stated she had been trained to check medication carts monthly through in-services and to check them weekly and as needed for expired medication, loose pills, cleanliness, and correct narcotic counts, and she said she had checked Medication Cart 2 earlier and was surprised to find the two loose pills. During interviews, the DON identified the loose pills as amitriptyline and furosemide. The DON stated nursing staff were trained to check medication carts at least weekly and to look for expired medication, loose pills, and overall cleanliness. The ADM also stated staff were trained to check the carts monthly and that administration performed sweeps to ensure the carts were kept clean and updated. Record review of the facility policy on Medication Storage in the Facility stated medications and biologicals are to be stored safely, securely, and properly, and that outdated, contaminated, or deteriorated medications and those in containers that are cracked, soiled, or without secure closures are to be immediately removed from stock.
Oxygen concentrator alert not addressed
Penalty
Summary
The facility failed to ensure that Resident #7’s oxygen concentrator was maintained in safe and proper operating condition. Resident #7 was a female resident with diagnoses including cognitive communication deficit and mild persistent asthma, and her records showed she was ordered oxygen at 2 to 5 liters per minute via nasal cannula every shift. Her care plan identified oxygen therapy as an ongoing intervention, and her MAR showed oxygen was administered daily with oxygen saturation monitoring documented. During observation on 12/08/25, Resident #7’s oxygen concentrator was seen with a red alert light illuminated. The key under the light indicated that the red light meant oxygen flow rate less than 0.5 liters per minute or oxygen concentration less than 73%. At the time of observation, the oxygen flow was measured at 3.5 liters per minute. Resident #7 stated that the red light had been on for approximately three months and that the airflow did not seem as strong, although she felt she could breathe. She also stated that staff were aware the red light was on. Interviews with the DON, Maintenance Supervisor, Medical Supply, and ADM showed that the issue had not been reported to them before surveyor intervention. The DON stated that essential equipment should be working properly and that a red light or alert should have been addressed even if the machine did not sound an alarm. The Maintenance Supervisor stated he had not been told that Resident #7 had an oxygen concentrator needing maintenance and did not know which residents had oxygen concentrators. The ADM stated she relied on staff to report equipment issues and was unaware the concentrator was not working properly until the surveyor identified it. The facility policy required oxygen concentrators to be cleaned and filters changed according to manufacturer recommendations, and the respiratory policy required periodic purity checks and maintenance documentation for each unit in service.
Failure to Accurately Account for Controlled Substance Due to Incomplete Narcotic Count
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate accounting of a resident's narcotic medication, specifically Lorazepam Intensol Oral Concentrate. The resident, a male with diagnoses including depression, anxiety, acute systolic heart failure, and respiratory failure, had an active physician order for Lorazepam to be administered four times daily. On a specific date, the narcotic count sheet for this medication showed a discrepancy: four syringes were missing from the count, and the count was subsequently corrected by administrative staff after the discrepancy was discovered. Interviews with nursing staff revealed that at the shift change, the outgoing and incoming nurses did not physically count the Lorazepam stored in the refrigerator, instead relying on the paper record. Both nurses admitted to not counting the medication in the refrigerator, which led to the failure to account for the missing syringes. One nurse stated she had taken all four syringes at the start of her shift and kept two in her pocket for later administration, but could not account for the missing doses. The facility's policy required all controlled substances, including those in the refrigerator, to be counted at each shift change by two staff members, but this procedure was not followed. The incident was further complicated when one of the nurses involved refused to complete a required drug test after providing a urine sample with an abnormal temperature, as per facility protocol for missing narcotics. The missing medication was not located despite a search of all medication carts and interviews with involved staff. The resident did not miss any doses of Lorazepam as the medication was replaced, but the failure to properly account for and secure controlled substances constituted a deficiency in pharmaceutical services.
Improper Use of Physical Restraint on Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, as required by regulations, unless needed for medical treatment. A Licensed Vocational Nurse (LVN) tied a resident's hand to the bed without notifying the physician, Director of Nurses (DON), or the resident's responsible party. The LVN took this action to prevent the resident from pulling out his dialysis port, which could have led to severe bleeding. However, there was no physician's order for this restraint, and the facility's policy requires such an order before applying any restraint. The resident involved was an elderly male with multiple medical conditions, including metabolic encephalopathy, sepsis, acute posthemorrhagic anemia, myocardial infarction, atrial fibrillation, heart failure, and acute kidney failure. He had a history of pulling at his dialysis port, which was a significant concern due to the risk of bleeding. Despite these challenges, the facility's records did not document any order for restraint, nor did they reflect any communication with the physician regarding the use of restraints. Interviews with staff revealed that the LVN believed he was acting in the resident's best interest to prevent a life-threatening situation. However, he did not follow the facility's policy and procedure for restraints, which requires physician notification and an order. The facility's policy emphasizes maintaining a restraint-free environment and only using restraints when medically necessary and with proper authorization. The incident was discovered by the DON, who found the resident's hand tied to the bed and confirmed that no proper procedures had been followed.
Failure to Follow Restraint Protocols and Notify Physician
Penalty
Summary
The facility failed to provide appropriate treatment and care for a resident in accordance with professional standards and the resident's comprehensive person-centered care plan. The Licensed Vocational Nurse (LVN D) did not notify the resident's physician or responsible party about a change in the resident's condition, specifically the resident's behavior of attempting to remove his dialysis port. This lack of communication prevented the physician from exploring alternative interventions to manage the resident's behavior. Additionally, LVN D applied a restraint to the resident's arm without obtaining a physician's order. The restraint was used to prevent the resident from pulling out his dialysis port, which could have led to severe bleeding. However, this action was taken without following the facility's policy and procedure for restraints, which requires notification and approval from the physician, the Director of Nursing (DON), and the resident's responsible party. The incident was discovered when the DON found the resident's hand tied to the bed frame. Interviews with staff revealed that LVN D was aware of the facility's no-restraint policy but chose to restrain the resident temporarily for safety reasons. The failure to follow proper procedures and communicate effectively with the healthcare team and the resident's family compromised the quality of care provided to the resident.
Failure to Inform Residents of Grievance Process
Penalty
Summary
The facility failed to provide residents and their representatives with information on their rights related to filing grievances. This deficiency was identified for six confidential residents who were unaware of the grievance process, including how to file a grievance, who the grievance official was, and their right to obtain a written decision. During a Resident Council meeting, all six residents expressed their lack of knowledge about the grievance process, indicating that they did not know where to obtain or submit a grievance form. The Activity Director (AD) confirmed that she had never discussed grievances in Resident Council meetings and was unaware that residents could file grievances independently or anonymously. The AD, who had been employed for 18 months, stated she had not been trained on the grievance procedure and was unaware of the facility's grievance policy. The AD documented grievances in the facility's electronic records but did not maintain written documentation. The Social Worker also lacked awareness of the requirement to keep grievance documentation for three years and stated that no written grievances were completed by staff, residents, or their representatives. The facility's grievance policy outlines that residents have the right to voice grievances without fear of reprisal and that the facility must make prompt efforts to resolve them. However, the policy was not effectively communicated or implemented, as evidenced by the lack of awareness among residents and staff. The facility's grievance process involved the Social Worker and the Administrator, but there was confusion about the roles and responsibilities, and the grievance forms were not easily accessible to residents.
Inadequate Infection Control Practices During Medication Administration
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of LVN A during medication administration. LVN A did not properly clean a multi-use wrist blood pressure device between residents, which was observed during multiple medication passes. Specifically, the device was used on several residents without being sanitized before or after each use, potentially leading to cross-contamination and the spread of infections among residents. Additionally, LVN A did not sanitize her hands between administering medications to different residents. This was observed during several medication passes, where LVN A prepared and administered medications to multiple residents without performing hand hygiene before or after each interaction. This lack of hand sanitization was acknowledged by LVN A, who admitted to not following proper procedures due to being in a routine and not being trained to sanitize medical devices between residents. Interviews with facility administration, including the ADM and DON, revealed that staff training on infection control practices, including hand hygiene and sanitizing medical devices, was conducted quarterly or monthly. However, LVN A's actions during the medication pass indicated a failure to adhere to these training protocols, as confirmed by the facility's policy on infection control, which mandates hand washing after each direct resident contact.
Incomplete OOH-DNR Form for Resident
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advance directive, specifically for one resident who was listed as Do Not Resuscitate (DNR). The Out-of-Hospital Do Not Resuscitate (OOH-DNR) form for this resident was incomplete, missing the physician's license number and printed name associated with the physician's signature. This oversight was identified during a record review and confirmed through interviews with the facility's social worker and administrator. Both acknowledged that the OOH-DNR form was not valid if not filled out correctly, and the social worker admitted to being responsible for ensuring the accuracy of these forms. The resident in question was a 5-year-old female with multiple diagnoses, including cerebral infarction, muscle weakness, hypertension, major depressive disorder, and type 2 diabetes. The deficiency was attributed to human error, as stated by the social worker, who was responsible for monitoring the accuracy of OOH-DNR forms. The facility's policy required that all validly executed DNR orders be honored, and the social worker was tasked with assisting residents and family members with the execution of these forms. However, the missing information on the OOH-DNR form could potentially lead to the resident's end-of-life wishes not being honored.
Unsecured Toilets Pose Safety Risk
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as evidenced by unsecured and unstable toilets in multiple rooms. On June 25, 2024, it was observed that toilets in rooms #3, #8, #13, #16, #32, #50, #51, #52, #56, and the rooms of Residents #2 and #3 were not properly secured to the floor, posing a risk of injury and falls. This issue was identified during observations and interviews with staff and residents, revealing that the toilets were loose and unstable. Resident #2, a cognitively intact female with a history of hypoxia, hypertension, anxiety, and seizures, required assistance for toilet use. She reported that her toilet was loose and had not been fixed despite being informed of the issue. Similarly, Resident #3, a cognitively intact male with a history of morbid obesity, lack of coordination, hypertension, and seizures, noted that his toilet was too short but did not comment on its stability. Interviews with staff, including the ADM and maintenance personnel, indicated that the issue had been identified but not adequately addressed, with maintenance staff noting that some toilets could not be tightened further without risking damage. The facility's maintenance and housekeeping procedures were found lacking, as regular checks for toilet stability were not part of the routine maintenance schedule. The maintenance staff had been informed of the issue but had not completed the necessary repairs before leaving the facility. Housekeeping staff were instructed to report any issues, but the process for ensuring repairs was not effectively implemented. The ADM acknowledged the potential for injury due to unsecured toilets and indicated that safety and environmental rounds would be conducted, but these actions were not part of the initial response to the deficiency.
Resident Falls Due to Unstable Toilet
Penalty
Summary
The facility failed to ensure that the resident environment was free from accident hazards, leading to an incident involving a resident. The resident, a cognitively intact female with a history of emphysema, CHF, and hypertension, experienced a fall in the bathroom due to an unstable and loose toilet. The incident occurred when the resident attempted to use the toilet, which wobbled and caused her to fall, resulting in a laceration on her wrist and bruises on her arm and neck. The facility's investigation revealed that one of the bolts securing the toilet had stripped from the floor, causing the toilet to be unstable. The resident was found on the floor by a CNA, with the toilet leaning over but not on top of her. Despite the resident's complaints of aches and pains, x-rays showed no acute fractures. The resident was admitted to the facility on the same day of the incident and was discharged two days later, unrelated to the fall. Interviews with facility staff and the resident's family highlighted concerns about the toilet's condition and the potential for injury. The facility's policy on event reporting requires a thorough investigation of incidents, including documentation of actions taken to prevent recurrence. However, the report does not mention any corrective actions taken by the facility to address the deficiency after the incident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lakeside Rehabilitation And Care Center | 0.1 mi | ★★★★★ | 7 | 0 |
| Southern Specialty Rehab & Nursing | 0.3 mi | ★★★★★ | 13 | 2 |
| Mi Casita Nursing And Rehabilitation Center | 0.6 mi | ★★★★★ | 15 | 0 |
| Mesquite Post Acute Care | 0.7 mi | ★★★★★ | 11 | 0 |
| The Mildred & Shirley L. Garrison Geriatric Educat | 1.3 mi | ★★★★★ | 14 | 5 |
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