Levelland Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Resident #1, Resident #17 and Resident #43) reviewed for infection control. -CNA B did not perform hand hygiene between all glove changes when providing incontinence care and catheter care to Resident #1.- CNA D did not perform hand hygiene between all glove changes when providing incontinence care to Resident #17.- CNA E did not perform hand hygiene between all glove changes when providing incontinence care to Resident #43. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 4 of 6 shared bathrooms (rooms [ROOM NUMBERS] shared bathroom, rooms [ROOM NUMBERS] shared bathroom, rooms [ROOM NUMBERS] shared bathroom and rooms [ROOM NUMBERS] shared bathroom); in that: The facility failed to ensure the hot water in the shared bathroom sinks in rooms [ROOM NUMBERS], rooms [ROOM NUMBERS], rooms [ROOM NUMBERS] and rooms [ROOM NUMBERS] were at a safe and comfortable temperature. This failure could place residents at risk for injuries to include scalding and burns.

Inspectors wroteBased on interview and record review, the facility failed to conduct a comprehensive assessment of a resident in accordance with the timeframes, 14 calendar days after admission, excluding readmission in which there is no significant change in the resident's physical or mental condition and not less than once every 12 months for 2 of 24 residents (Resident #8 and Resident #34) reviewed for comprehensive assessments. The facility failed to ensure Resident #8's and Resident #34's annual MDS Assessments were completed within 12 months of the previous MDS Assessments. This failure could place residents at risk of not having their medical needs met and assessments completed timely, which could result in denial of services and/or payment for services.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all PASARR Level I residents with mental illness were provided with an accurate PASRR Level I for 1 of 24 residents (Resident #7) reviewed for PASARR screening, in that: Resident #7 did not have an accurate and updated PASARR Level 1 assessment, reflecting a diagnosis of mental illness. This failure could place residents, with an inaccurate PASARR Level 1 and no PASARR Level 2 Evaluation, at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable for 2 of 2 meals reviewed for palatability. The facility failed to provide food that was palatable for 1 of 3 food forms served (puree) at 2 of 2 meals observed (01/14/26 lunch and 01/15/26 lunch). This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed on 01/14/26 to seal and date food stored in the refrigerator. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA A) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide. The facility failed to ensure CNA A had a current nurse aide certification while employed at the facility, while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure adequate supervision of Resident #1 who was newly admitted to the facility on [DATE] around 2:00 PM and exhibiting signs of confusion. Resident #1 then eloped from the facility approximately 4 (four) hours later between 6:15 PM and 6:35 PM and was picked up by a Community Member and transported to the local police department. Staff were unaware of Resident #1's elopement when the facility was notified by the police department via telephone on 08/04/25 at approximately 6:50 PM that the resident had been brought to the police station. The noncompliance was identified as PNC. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, supervision. The facility failed to ensure Resident #1 received supervision and assistive devices to prevent accidents. Resident #1 was exit seeking and was able to elope and had fallen in the parking lot by the street. Staff were not aware of Resident #1's elopement and was found by Occupational Therapist that was off the clock. An Immediate Jeopardy (IJ) was identified on 03/21/25 at 3:32 PM. The IJ template was provided to the facility on [DATE] at 3:32 PM. While the IJ was removed on 03/22/25 at 5:36 PM; [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 3 of 3 resident reviewed for resident rights. (Resident #1, Resident #2, and Resident #3) The facility failed to ensure consents from responsible parties were given to place wander guard bracelets on Resident #1, Resident #2, and Resident #3. This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs, as well as describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for care plans in that: The facility failed to care plan for wander guards for Resident #1, Resident #2, and Resident #3. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and not having personalized or individualized plans developed to address specific needs or concerns.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests in the kitchen and dining room reviewed for physical environment, in that: The facility failed to provide an effective pest control program for flies and insects in the facility. These failures could place residents at risk for vector-borne diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 6 of 18 confidential residents. The facility failed to ensure 6 of 18 confidential residents were provided, through postings in prominent locations, the Grievance Procedure, access to the Grievance forms, information of who the facility's grievance official was and their contact information, how to file an anonymous grievance, and their right to obtain a written decision related to their grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care, were provided such care, consistent with professional standards of practice for 6 (Residents #16, #17, #24, #26, #30 and #42) of 8 residents reviewed for respiratory care. 1. The facility failed to ensure that Resident #24 and Resident #42's oxygen tubing was replaced every seven (7) days. 2. The facility failed to ensure that oxygen tubing was dated for Resident #26 and Resident #30. 3. The facility failed to ensure that oxygen tubing was properly stored for Resident #16 and Resident #17. These failures could place residents at risk for respiratory compromise and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1. The facility failed to ensure foods were prepared under sanitary conditions. 2. The facility failed to store and date foods stored in the refrigerator. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 5 of 5 refrigerators reviewed for food safety (room [ROOM NUMBER], 208, 216, 217, and 220) in that: The refrigerator located in room [ROOM NUMBER] did not have an up-to-date temperature log present nor did it have a thermometer inside of the refrigerator. The refrigerator contained perishable food items such as deli lunch meats, protein shakes and pickles. The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer inside of the refrigerator. The refrigerator contained perishable food items such as canned sodas and cottage cheese. The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer inside the refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #20, #42 and #45) of 3 residents and 3 of 3 staff (LVN A, LVN B, CNA A) reviewed for infection control. 1. The facility failed to implement EBP (Enhanced Barrier Precautions) for Resident #20 and Resident #42 who each required indwelling urinary catheters. 2. The facility failed to implement EBP (Enhanced Barrier Precautions) for Resident #20 and Resident #45 who had wounds which required a dressing. These failures could place residents at risk for cross contamination, spread of infection and sepsis.

Inspectors wroteBased on Interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property for 2 of 5 (Hospitality Aide A and B) new hired employee's files reviewed background checks. A. The facility failed to complete criminal background, EMR and NAR checks on Hospitality Aide A before her employment date of 06/12/24. B. The facility failed to complete criminal background, EMR and NAR checks on Hospitality Aide B before her employment date of 06/12/24. This failure could place residents as risk for abuse, neglect and exploitation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed and reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy for residents, for 1 out of 1 lunch served on 09/06/23 in that: 1. The facility failed to follow the approved dietary menu on 09/06/23 during the lunch period. These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: 1) The facility failed label all food items within the kitchen. 2) Dietary staff failed to store foods in a manner to prevent contamination. 3) Dietary staff failed to perform sanitary handwashing when entering the kitchen (Dietary [NAME] A) 4) Dietary staff failed to wear proper hair restrains while in the food preparation area (the DM, Dietary [NAME] A & Dietary Aide A). 5)Dietary Staff failed to use dishware that was in serving condition (broken ice scoop and stained glasses)(DM). 6) Staff failed to clean exposed vents and large kitchen appliances within the kitchen ( DM, Dietary Aide A and Dietary [NAME] A). [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 9 of 16 residents (Residents #8, #10, #12, #15, #23, #32, #42, #44 and #149) reviewed for resident rights . 1. The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #8 and #149 prior to administering melatonin (sleep aid). 2. [...]

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 4 of 16 residents (Residents #6, #15, #23 and #44) reviewed for care plans as follows: Resident #6 did not have a care plan for mood state and nutritional status. Resident #15 did not have a care plan for psychotropic drug use. Resident #23 did not have a care plan for dehydration and pressure ulcer risk. Resident #44 did not have a care plan for urinary incontinence and fall risk. These failures could place residents at risk of not receiving the care required to meet their individualized needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 7 of 8 refrigerators reviewed for food safety (room [ROOM NUMBER],209 211, 212,214, 216, and 218) in that: The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator. The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator. Inside of the refrigerator was a parfait, two cokes, an uncovered cookie, and an undated cupcake. The refrigerator located in room [ROOM NUMBER] did not have a temperature log present nor did it have a thermometer in side the refrigerator. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a condition as diagnosed and documented in the clinical record in an effort to discontinue these drugs for 1 of 16 residents reviewed for unnecessary medication (Resident #15). The facility did not ensure that Resident #15 medications had adequate indications for its use in that she was receiving Ativan for the diagnosis of Alzheimer's. This failure could place the residents at risk for adverse consequences of medication.