Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Mi Casita Nursing And Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to inform 9 out of 15 residents about their rights to file grievances, including access to grievance forms and the option to file anonymously. The ADM, responsible for handling grievances, did not communicate the grievance process to residents or staff, and the facility lacked postings of the grievance procedure in prominent locations.
The facility failed to meet the dietary preferences of three residents during a lunch meal service, resulting in them receiving hamburgers instead of the requested sour cream enchiladas. This occurred due to a miscalculation in the number of enchiladas prepared, leading to a shortage. The residents involved had various medical conditions, and the facility's policy to provide a diet that meets residents' nutritional and special dietary needs was not followed.
The facility failed to maintain cleanliness and proper food storage in the kitchen, with sticky substances found on appliance handles and improperly sealed food items. Staffing shortages contributed to these issues, as revealed in interviews with the DM and ADM. The facility's policies on food handling and sanitation were not adhered to, posing potential risks of food contamination.
A resident with mild cognitive impairment and several medical conditions was not provided privacy during incontinent care by a CNA, who failed to pull the privacy curtain and left the resident uncovered while sanitizing hands. Despite training, the CNA admitted to rushing and not following proper procedures. The facility's administration was unaware of these lapses until the survey.
A resident with a DNR status had an incomplete Out-of-Hospital DNR form due to a missing date on a witness's signature. Facility staff, including the social worker and administrator, acknowledged the lack of a system to monitor the accuracy of these forms, which could lead to the resident's end-of-life wishes not being honored.
A resident's motorized wheelchair was observed to be soiled with brown spots throughout the day, despite the resident's awareness and discomfort. Facility staff, including CNAs and an LVN, failed to clean the wheelchair promptly, indicating a breakdown in communication and responsibility. The facility's policy on cleaning and disinfection was not followed, impacting the resident's dignity and quality of life.
A resident's portable oxygen tank was improperly stored, left free-standing and unsecured in their room, contrary to facility policy. The resident, with multiple health conditions, relied on staff to manage the oxygen tank, which was not stored in designated holders or carts as required. This posed a potential risk for avoidable injuries.
A LTC facility failed to maintain a medication error rate below 5%, resulting in errors involving three residents. A resident did not receive his prescribed allergy medication, another was underdosed with Gabapentin, and a third was not given Methylphenidate due to staff errors. These incidents highlight failures in medication administration practices.
A Schedule IV narcotic, Lorazepam 2 MG/ML oral concentrate, was improperly stored in an unlocked lockbox within the medication storage room refrigerator. LVN A was unaware of the medication's presence, and the DON and ADON were the only ones with keys to the lockbox. The facility's policy required controlled medications to be stored in separately locked compartments, but this was not followed, leading to a potential risk of medication diversion.
A facility failed to maintain an effective infection control program, as a CNA did not perform hand hygiene between glove changes during incontinent care, and an LVN did not wear proper PPE while providing wound care to a resident on Enhanced Barrier Precautions. Both staff members had received training but admitted to lapses in protocol adherence, potentially risking infection spread.
A facility failed to implement a comprehensive care plan for a resident with dementia who became combative during care. The care plan, which included strategies for managing aggression, was not followed by a CNA, resulting in the CNA being kicked. Interviews revealed the CNA continued care despite the resident's combative behavior, contrary to the care plan's instructions. This deficiency underscores the need for consistent implementation of care plans and adherence to facility policies.
Failure to Inform Residents of Grievance Procedures
Penalty
Summary
The facility failed to provide residents and their representatives with information on their rights related to filing grievances or concerns. This deficiency was identified for 9 out of 15 confidential residents, who reported during a Resident Council meeting that they did not have access to grievance forms, were unaware of the option to file grievances anonymously, and had not been informed about the grievance procedure. Additionally, there were no postings of the grievance procedure in prominent locations within the facility, and residents did not know where to acquire a grievance form, who to submit it to, or what the process entailed once a grievance was filed. The facility's Administrator (ADM), who was responsible for handling grievances, admitted to not informing residents or the Activities Director about the location of grievance forms and was unaware of the need for residents to have access to these forms or the option to submit grievances anonymously. The ADM also stated that grievance forms were kept in her office and at each nurse's station, but residents did not request or complete them independently. The facility's grievance policy, last revised in June 2005, outlined procedures for investigating grievances and informing residents of the findings, but the ADM was not aware of the policy's requirements, including the timeframe for addressing grievances.
Dietary Preferences Not Met for Residents
Penalty
Summary
The facility failed to provide a diet that met the daily nutritional and special dietary needs of three residents, taking into consideration their preferences. During a lunch meal service, sour cream enchiladas were prepared as the main entree, but there were not enough enchiladas for all residents who requested them. As a result, some residents, including Resident #16, Resident #25, and Resident #40, were served hamburgers and potato chips instead. This substitution did not align with the residents' preferences and dietary needs. Resident #25, a male with a history of contracture, major depressive disorder, and hypokalemia, expressed that he had requested enchiladas but received a hamburger instead. He noted that this was the first time such an incident occurred. Resident #40, who has major depressive disorder, anemia, and severe protein-calorie malnutrition, also requested enchiladas but was served a hamburger. He mentioned that this was not a frequent occurrence but had happened before. Resident #16, with end-stage renal disease, type 2 diabetes mellitus, and cirrhosis of the liver, also did not receive the requested enchiladas and noted that the dietary department had been running out of food lately. Interviews with staff revealed that there was a miscalculation in the number of enchiladas prepared, as 75 enchiladas were made for 39 residents, each requiring two enchiladas, resulting in a shortage. The dietary manager and other staff members acknowledged the issue, attributing it to possible last-minute changes in residents' meal preferences or incorrect marking of dietary slips. The facility's policy requires that each resident be provided with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, considering their preferences, which was not adhered to in this instance.
Deficiency in Kitchen Cleanliness and Food Storage
Penalty
Summary
The facility failed to maintain cleanliness and proper food storage in the kitchen, as observed during a kitchen tour. Specifically, the handles of three freezers, two refrigerators, and one oven were found to have dry, sticky substances on them. Additionally, a gallon-sized zip lock bag of fruit loops in the pantry was not fully sealed, and a bag of lunch meat in the refrigerator had an illegible date and was also not fully sealed. These observations indicate a failure to adhere to professional standards for food service safety. Interviews with the Dietary Manager (DM) and Assistant Dietary Manager (ADM) revealed that the facility was short-staffed due to an employee quitting, which contributed to the lack of cleanliness and improper food storage. The DM acknowledged that the dietary staff usually followed a daily cleaning schedule, but due to the staffing shortage, there was insufficient time to ensure kitchen items were cleaned. Both the DM and ADM admitted that the zip lock bags used for food storage did not always seal properly, especially when staff were in a hurry, leading to potential risks of food contamination and foodborne illness. The facility's policies on food receiving, storage, and sanitation, revised in November 2022, were not followed as required.
Failure to Maintain Resident Privacy During Incontinent Care
Penalty
Summary
The facility failed to ensure that Resident #33 was treated with respect and dignity during incontinent care, as observed during a survey. CNA D did not pull the privacy curtain before performing incontinent care, which risked exposing the resident if someone entered the room. Additionally, CNA D left Resident #33 uncovered while sanitizing his hands in the restroom, exposing the resident's lower back and buttocks. This lack of privacy was acknowledged by CNA D, who admitted to rushing and not following proper procedures despite having received training on maintaining resident privacy. Resident #33, a male with mild cognitive impairment and several medical conditions including Type 2 Diabetes Mellitus, cerebral infarction, and anxiety, was always incontinent of bowel and bladder. The facility's policies on dignity and resident rights emphasize the importance of treating residents with respect and ensuring their privacy during personal care. However, the facility's administration, including the ADM and DON, were unaware of the privacy lapses until the survey. They both acknowledged the importance of maintaining resident privacy and the potential negative outcomes of failing to do so.
Incomplete DNR Form Puts Resident's Wishes at Risk
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate advance directives, specifically for one resident who was listed as Do Not Resuscitate (DNR). The resident, an elderly female with a history of cerebral infarction, dementia, and type 2 diabetes, had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form that was incomplete due to a missing date accompanying one of the witness's signatures. This oversight was identified during a review of the resident's records, which included a physician order summary and care plan indicating a DNR status. Interviews with facility staff, including the social worker (SW) and the administrator (ADM), revealed that there was no system in place to monitor the accuracy of OOH-DNR forms. Both the SW and ADM acknowledged that the OOH-DNR form was not valid if not filled out correctly, and they confirmed the missing information on the form. The SW admitted that human error was the reason for the incomplete form and stated that she was responsible for ensuring the forms were completed correctly. The ADM also confirmed the lack of a monitoring system and stated that the Director of Nursing (DON) should be responsible for reviewing the forms for accuracy.
Failure to Maintain Cleanliness of Resident's Wheelchair
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment for a resident, specifically in maintaining the cleanliness of the resident's wheelchair. The resident, who was cognitively intact and had multiple medical conditions including paraplegia and incontinence, was observed using a motorized wheelchair that was visibly soiled with brown spots on the backrest and seat. Despite the resident's awareness and discomfort with the soiled condition of the wheelchair, it remained uncleaned throughout the day. Interviews with the facility staff, including CNAs and the LVN, revealed a lack of awareness and responsibility in addressing the cleanliness of the resident's wheelchair. The CNAs were responsible for cleaning the wheelchair when soiled, but the assigned CNA did not notice or clean the wheelchair during her shift. The LVN was also unaware of the soiled condition until later in the day, indicating a communication breakdown among the staff regarding the resident's needs. The facility's policy on cleaning and disinfection of resident-care items was not adhered to, as the wheelchair was not cleaned promptly despite being visibly soiled. The Director of Nursing and the Administrator acknowledged the importance of maintaining a sanitary environment and the potential for embarrassment to the resident. However, the failure to clean the wheelchair in a timely manner demonstrated a deficiency in the facility's care practices, impacting the resident's dignity and quality of life.
Improper Storage of Portable Oxygen Tank
Penalty
Summary
The facility failed to ensure the proper storage of a portable oxygen tank for a resident, which posed a potential risk for avoidable injuries. During an observation, the oxygen tank was found free-standing and resting against a wall in the resident's room, unsecured and not stored in a designated holder or cart. Interviews with the Director of Nursing (DON) and the Administrator (ADM) confirmed that staff had been verbally trained on securing oxygen tanks, yet the tank was left unsecured, contrary to the facility's policy. The resident involved was a male with end-stage renal disease, heart failure, and chronic respiratory failure, who used a wheelchair independently. The resident reported that staff were responsible for handling the oxygen tank, including placing it on and off his wheelchair for dialysis trips. Despite the facility's policy requiring oxygen tanks to be stored in racks with chains, sturdy carts, or approved stands, the tank was left in the resident's room, creating a potential hazard. The facility's policy also prohibited storing oxygen cylinders in resident rooms or living areas, highlighting a lapse in adherence to safety protocols.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 6.52% based on 3 out of 46 opportunities. This involved three residents who experienced medication administration errors. The errors were observed during medication administration observations and involved two medication aides, MA A and MA B, who failed to administer medications as per the physician's orders. Resident #43, a male with a history of dementia, anemia, malnutrition, major depressive disorder, and allergic rhinitis, did not receive his prescribed Fluticasone Propionate Nasal Suspension for allergies. MA A documented the administration of the medication in the MAR but later admitted during an interview that she did not administer the medication and was unsure why she marked it as given. This oversight could potentially lead to the resident not receiving the necessary therapeutic treatment for his allergies. Resident #44, a male with multiple diagnoses including diabetes, peripheral vascular disease, and respiratory issues, was underdosed with Gabapentin, a medication for nerve pain. MA B administered only one capsule instead of the prescribed two, failing to verify the medication with the order prior to administration. Additionally, Resident #23, a male with vascular dementia and other neurological conditions, was not given his prescribed Methylphenidate due to MA B's distraction during the medication pass. MA B failed to verify the medications in the cup with the physician's orders, leading to the omission of the controlled medication. These errors highlight the facility's failure to ensure proper medication administration practices, as outlined in their policy.
Improper Storage of Schedule IV Narcotic in Medication Room
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments, specifically in the medication storage room refrigerator. During an observation, it was found that a Schedule IV narcotic, Lorazepam 2 MG/ML oral concentrate, was stored in an unlocked lockbox within the refrigerator. The padlock for the lockbox was unsecured and open, which was confirmed by LVN A, who was unaware of the medication's presence in the lockbox and did not have a key to it. The Director of Nursing (DON) and the Assistant Director of Nursing (ADON) were the only ones with keys to the lockbox, and the DON was also unaware of the medication being stored there. Interviews with the DON and the Administrator (ADM) revealed that the medication storage room was supposed to remain locked at all times, and narcotics required a double locking process. The DON stated that nursing staff were responsible for ensuring proper storage and reconciliation of medications at the end of each shift. However, the oversight occurred possibly due to the medication being brought by Hospice and overlooked during staff reconciliation. The facility's policy required Schedule II-V controlled medications to be stored in separately locked compartments, but this was not adhered to, leading to the potential risk of medication diversion.
Infection Control Lapses in Hand Hygiene and PPE Use
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by two specific incidents involving staff and residents. In the first incident, a Certified Nursing Assistant (CNA) did not perform hand hygiene between glove changes while providing incontinent care to a resident with multiple health conditions, including sacral spina bifida, paraplegia, and end-stage renal disease. The CNA admitted to not sanitizing her hands between glove changes, attributing it to an oversight when the resident requested care unexpectedly. Despite having received training on proper hand hygiene, the CNA acknowledged the risk of spreading bacteria and germs due to this lapse. In the second incident, a Licensed Vocational Nurse (LVN) failed to wear the appropriate personal protective equipment (PPE) while providing wound care to a resident on Enhanced Barrier Precautions (EBP) due to multiple pressure ulcers. Although the LVN initially donned a gown and gloves, she neglected to put on a gown upon re-entering the room to continue wound care after retrieving additional supplies. The LVN, who had been trained on EBP, recognized the importance of wearing proper PPE to prevent infection spread but admitted to forgetting to wear a gown during the procedure. Interviews with the facility's administration and nursing staff revealed that they were unaware of these lapses in infection control practices prior to the survey. Both the Administrator and Director of Nursing (DON) emphasized the importance of adhering to hand hygiene and EBP protocols to prevent infection spread. The facility's policies on hand hygiene and EBP were reviewed, highlighting the expectations for staff to follow these guidelines to minimize the risk of healthcare-associated infections.
Failure to Implement Comprehensive Care Plan for Combative Resident
Penalty
Summary
The facility failed to implement a comprehensive person-centered care plan for a resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3). The care plan did not include measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment. Specifically, the facility did not ensure staff implemented the care plan for a resident who became combative during incontinent care, placing the resident at risk of not having their individual care needs met. The resident, a male with a history of dementia, cerebral infarction, psychotic disorder, major depressive disorder, and other conditions, was admitted to the facility with severe cognitive impairment. The resident's care plan indicated he required assistance for toileting and transfers and had behaviors of resisting care due to dementia. The care plan outlined strategies for managing aggression, such as allowing the resident to make decisions about treatment, providing clear explanations, and returning later if the resident resisted care. However, during an incident, a CNA continued to provide care despite the resident becoming combative, resulting in the CNA being kicked in the mouth. Interviews with staff revealed that the CNA did not follow the care plan's instructions to stop care and report the incident to a nurse. Instead, the CNA continued care due to being short-staffed. The facility's policy and procedure for comprehensive care planning and behavioral assessment were not effectively implemented, as evidenced by the failure to adhere to the care plan and manage the resident's behavior appropriately. This deficiency highlights the need for consistent implementation of care plans and adherence to facility policies to ensure residents' needs are met safely and effectively.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 74 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Lubbock
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Mesquite Post Acute Care | 0.2 mi | — | 1 | 0 |
| Lakeside Rehabilitation And Care Center | 0.6 mi | — | 4 | 0 |
| Lubbock Health Care Center | 0.6 mi | — | 6 | 0 |
| Southern Specialty Rehab & Nursing | 0.7 mi | — | 2 | 0 |
| The Mildred & Shirley L. Garrison Geriatric Educat | 1.5 mi | — | 3 | 2 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Mi Casita Nursing And Rehabilitation Center.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.