Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
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 Levelland Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
A CNA provided direct care to residents without a current nurse aide certification after her credentials expired. The facility did not complete timely registry verification or ensure ongoing compliance with certification requirements, allowing the CNA to work scheduled shifts while uncertified. Staff interviews revealed gaps in the process for monitoring certification status, particularly during staff transitions.
A newly admitted resident with severe cognitive impairment and a high risk for wandering eloped from the facility within hours of admission. Despite being independently ambulatory and scoring high on a wandering risk assessment, the resident was not identified as an elopement risk in the care plan, and staff did not implement increased supervision or monitoring. The resident exited the facility unnoticed and was later found by a community member and returned by police, with staff only becoming aware of the elopement after being notified by authorities.
A resident with severe cognitive impairment and a history of wandering was able to elope from the facility and fell in the parking lot near a busy street. Staff were unaware of the elopement until the resident was found by an off-duty therapist. Documentation and communication lapses were identified regarding the use and monitoring of a wander guard device, and required assessments and supervision were not consistently implemented.
The facility did not obtain consent from responsible parties or complete required assessments before applying wander guard bracelets to three residents with severe cognitive impairment and multiple medical conditions. Documentation was lacking in care plans, and family members were not notified about the placement or removal of the devices, contrary to facility policy requiring pre-restraining assessment and consent.
Three residents with severe cognitive impairments and multiple medical conditions did not have wander guard interventions included in their care plans, despite the use or need for such devices. Staff interviews revealed a lack of awareness and training regarding care plan policies, and facility records confirmed that required care planning for wander guards was not completed.
The facility failed to maintain an effective pest control program, resulting in a fly infestation in the kitchen and dining areas. Observations showed flies on food surfaces and a resident swatting flies. Staff interviews revealed the absence of a pest control contract due to unpaid bills, with maintenance staff attempting to manage the issue themselves. The facility's pest control policy was outdated and not effectively implemented.
The facility failed to inform 6 out of 18 residents about their rights and the process for filing grievances. Residents were unaware of how to obtain or submit grievance forms, file anonymously, or receive a written decision. The DON was unsure of the grievance policy and process, and there was a lack of clear instructions or signage for residents.
The facility failed to manage respiratory care properly, as evidenced by not replacing oxygen tubing every seven days for two residents, not dating oxygen tubing for two others, and improper storage of oxygen equipment for two more. These actions were against the facility's policy and physician orders, increasing the risk of infection and inadequate oxygen therapy.
The facility failed to maintain sanitary conditions in food preparation and storage. Observations showed undated and improperly covered food in the refrigerator, and improper handling of a processor bowl during meal preparation, risking contamination. Interviews confirmed staff were trained but failed to follow procedures.
The facility failed to ensure safe storage of food in residents' personal refrigerators, as none had up-to-date temperature logs or thermometers, despite containing perishable items. Interviews revealed that housekeeping staff were responsible for monitoring, but this was not done, and the DON was unclear on procedures. This non-compliance with facility policy posed a risk of foodborne illness.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and wounds requiring dressings. Observations revealed a lack of EBP signage and PPE at room entrances, and staff did not follow proper infection control protocols. Interviews indicated a lack of training and awareness regarding EBP requirements, posing a risk of infection spread.
The facility failed to conduct criminal background, EMR, and NAR checks on two newly hired hospitality aides before they began working, leading to a deficiency in preventing abuse, neglect, and exploitation of residents. The aides were hired through an outside party, and there was an assumption that the necessary checks had been completed. However, due to a change in administration and miscommunication, the checks were not conducted until the issue was identified during a survey.
Failure to Verify and Maintain Nurse Aide Certification
Penalty
Summary
The facility failed to ensure that a nurse aide (CNA A) had a current and valid nurse aide certification while actively providing care to residents. Record review showed that CNA A's certification had expired, yet she continued to work scheduled shifts and provide direct care. The facility did not obtain timely registry verification prior to allowing CNA A to serve as a nurse aide, and there was no documentation in her personnel file indicating any disciplinary actions or concerns with her resident care during the period her certification was expired. Interviews with facility staff revealed that the Director of Nursing (DON) became aware of the expired certification after CNA A brought in documentation showing her certificate had lapsed. The DON confirmed that CNA A had worked a night shift after her certification had expired and before the issue was identified. The Administrator (ADM) and Human Resources (HR) Manager both acknowledged that there was a lapse in the process for monitoring and verifying CNA certifications, especially during a period of staff turnover in the DON and ADON positions. The HR Manager stated she was not aware that the responsibility for checking renewals had not been transferred to the new DON and ADON. CNA A reported she was unaware her certification had expired and believed that previous management would handle the renewal process. She continued to work her scheduled shifts until she was notified of the expiration. The facility's policy required verification of licensure or certification prior to employment and prohibited staff from providing direct care without current credentials, but this policy was not followed in CNA A's case.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a newly admitted resident with severe cognitive impairment. The resident, who had diagnoses including dementia, cerebral infarction, chronic kidney disease, major depressive disorder, hypertension, and atrial fibrillation, was admitted in the afternoon and was noted to be alert but disoriented, with both short-term and long-term memory problems. The resident was independently ambulatory and used a walker, but did not verbally express a desire to leave the facility. Despite a high score on the facility's Wandering Risk Scale, indicating a high risk for wandering, the resident's baseline care plan did not identify them as an elopement risk. Approximately four hours after admission, the resident eloped from the facility without staff awareness. The last known observation of the resident was after returning from the smoking area with staff and other residents. The resident was not accounted for between 6:15 PM and 6:35 PM, during which time they exited the facility, likely by following a visitor out the front door, which was protected by an access code. Staff did not observe any exit-seeking behavior prior to the incident, and there was no implementation of increased supervision or monitoring, despite the resident's high wandering risk score and cognitive impairment. The resident was found by a community member walking down the street, who then transported the resident to the local police department. The facility was notified of the elopement by the police department. Interviews with staff revealed that although some staff felt the resident needed to be watched for wandering due to confusion and independent mobility, there was no clear communication or directive to increase monitoring or implement more frequent checks. The facility's policy required care planning for residents at risk of wandering or elopement, but the assessment and care plan did not result in additional supervision or interventions prior to the incident. The deficiency was identified as placing residents at risk of harm, serious injury, or death.
Failure to Prevent Resident Elopement and Ensure Adequate Supervision
Penalty
Summary
A deficiency occurred when the facility failed to provide adequate supervision and assistance devices to prevent accidents for a resident with a history of cognitive impairment, repeated falls, and exit-seeking behavior. The resident, who had diagnoses including dementia, metabolic encephalopathy, and muscle weakness, was not consistently care planned for a wander guard despite documented exit-seeking and wandering behaviors. On the day of the incident, the resident was able to elope from the facility and was found in the parking lot near a busy street by an off-duty occupational therapist, after having fallen. Staff were not aware of the resident's elopement until after the incident occurred. Documentation and interviews revealed inconsistencies in the application and monitoring of the wander guard device. Although a nurse reported placing a wander guard on the resident after observing exit-seeking behavior, there was confusion among staff regarding whether the device had been previously used or removed, and documentation was lacking. The alarm system for the wander guard was reported to be working intermittently, and staff did not always respond promptly to alarms. Additionally, the required assessments and consents for the use of the wander guard were not consistently completed prior to its application, and there was no clear documentation of increased supervision or 1:1 observation as required for residents at risk of elopement. Interviews with staff, family members, and the nurse practitioner indicated a lack of communication regarding the resident's risk status, the use and removal of the wander guard, and the need for increased supervision. The resident's care plan did not reflect the interventions necessary to address his exit-seeking behavior, and staff were not uniformly trained or informed about the resident's needs. The failure to ensure adequate supervision and the proper use of assistive devices resulted in the resident's unsupervised exit and fall outside the facility.
Failure to Obtain Consent and Complete Assessment Prior to Wander Guard Placement
Penalty
Summary
The facility failed to inform residents and their responsible parties in advance about the risks and benefits of proposed care and treatment, specifically regarding the placement of wander guard bracelets. For three residents with significant cognitive impairments and multiple medical diagnoses, there was no evidence that consent was obtained from responsible parties prior to the application of these devices. Record reviews showed that care plans did not include documentation of wander guard use, and interviews with staff and family members confirmed that notifications and consents were not consistently obtained or documented before or after the devices were applied or removed. In one case, a resident with severe cognitive impairment and a history of elopement was found outside the facility after an elopement incident. The nurse placed a wander guard on the resident after the incident, but the assessment to determine the need for the device was completed after its application. The family was not notified about the placement or removal of the wander guard, and the responsible party stated they would have declined removal if they had been informed. The physician and nurse practitioner were also not consistently notified about the use or removal of the device, and there was no documented order for its removal. Facility policy required that a pre-restraining assessment and consent from the resident or responsible party be obtained before applying any restraint, including wander guards. The policy also specified that restraints should only be used for medical symptoms and not for staff convenience or fall prevention. Despite these requirements, the facility did not follow its own procedures, as assessments and consents were not completed prior to the use of wander guards, and documentation was lacking in the residents' records.
Failure to Develop Comprehensive Care Plans for Residents with Wander Guards
Penalty
Summary
The facility failed to develop comprehensive care plans that included measurable objectives and timeframes for three residents who required wander guards. Record reviews for all three residents showed significant cognitive impairments, including severely impaired decision-making abilities and memory loss, as well as multiple medical diagnoses such as dementia, metabolic encephalopathy, and intellectual disability. Despite these conditions and the use or need for wander guards, none of the residents had this intervention included in their care plans. Interviews with facility staff, including the ADON, Administrator, and DON, revealed a lack of familiarity with care plan policies and insufficient training on care plan development. The ADON admitted to not being aware of missing wander guard care plans and stated that care plans are monitored quarterly, but also acknowledged that she had not been trained on care plans. The Administrator and DON both confirmed that care plans should be accurate, up to date, and tailored to each resident, and that the absence of care planning for wander guards was not known until brought to their attention during the survey. The DON further stated that she assumed care plans were completed for long-term residents and only discovered the omission upon review. Facility policy requires a baseline care plan within 48 hours of admission and a comprehensive, interdisciplinary care plan within 21 days, including all necessary interventions and services. However, the care plans for these residents did not address the use of wander guards, despite their cognitive impairments and behavioral risks. The lack of care planning for this intervention was confirmed through record review and staff interviews, indicating a systemic failure to ensure that all resident needs were addressed in their care plans.
Ineffective Pest Control Program Leads to Fly Infestation
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of flies in the kitchen and dining areas. Observations over several days revealed flies crawling on the steam table, refrigerator, and food carts, as well as a resident swatting flies with a napkin in the dining room. Interviews with staff, including the dietary manager, maintenance personnel, and the assistant director of nursing, confirmed the ongoing issue with flies and the lack of a current pest control contract. The dietary manager acknowledged the problem and mentioned attempts to keep kitchen doors closed and food covered, but noted that the pest control company had not visited due to unpaid bills. The maintenance staff admitted to sporadically spraying the facility themselves, but without a formal contract in place. The business office manager indicated that all bills were paid through corporate, yet the pest control company had not been to the facility since the previous year. The facility's pest control policy, last revised in 2008, stated the need for an ongoing program to keep the building free of pests, but the lack of a current contract and effective measures left the facility vulnerable to pest-related issues.
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 6 out of 18 confidential residents who were unaware of the grievance process, including how to obtain or submit a grievance form, the ability to file anonymously, and their right to receive a written decision once a grievance was resolved. During a Resident Council meeting, these residents expressed that the grievance procedure had never been discussed, and they had not observed any postings of the procedure in prominent locations within the facility. Observations revealed that blank grievance forms were available outside the social services office, but there were no instructions or signage indicating their presence or how to submit a grievance. The Director of Nursing (DON) was interviewed and admitted to being unaware of the grievance policy, unsure of where grievance forms were kept, and uncertain about the timeframe for resolving grievances. The DON believed the social worker was responsible for handling grievances, but the social worker was unavailable for an interview. The facility's policy on residents' rights mentioned grievances but did not provide specific guidance on the grievance process.
Deficiency in Respiratory Care Management
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for several residents, as evidenced by the improper management of oxygen tubing. Specifically, the facility did not replace the oxygen tubing for two residents, Resident #24 and Resident #42, every seven days as required by their physician orders. Observations revealed that both residents had oxygen tubing dated over a week old, which was not in compliance with the facility's policy and physician orders. Additionally, the facility did not ensure that oxygen tubing was dated for Resident #26 and Resident #30. During observations, it was noted that the oxygen tubing and humidifier water for these residents were not dated, which is a deviation from the standard practice of marking the date on such equipment to ensure timely replacement and prevent infection. Furthermore, the facility failed to properly store oxygen tubing for Resident #16 and Resident #17. Observations showed that the nasal cannula and oxygen tubing for these residents were found on the floor, which is against the facility's policy of storing unused oxygen equipment in plastic bags. Interviews with staff confirmed that the improper storage of oxygen tubing could lead to infection, and it was everyone's responsibility to ensure proper storage. The Director of Nursing acknowledged that the failure to change, date, and store oxygen tubing according to orders and policy increased the risk of infection and inadequate oxygen therapy.
Deficiencies in Food Storage and Preparation Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a survey of the kitchen. Specifically, the facility did not ensure that foods were prepared under sanitary conditions and failed to store and date foods in the refrigerator properly. Observations revealed that individual desserts and cheese slices in the refrigerator were not dated, and the cheese was not adequately covered. During the preparation of pureed meals, a staff member did not allow the processor bowl to air dry properly, potentially leading to chemical contamination. The staff member also improperly added water directly to the processor bowl at the 3-compartment sink, which could lead to cross-contamination. Interviews with the Dietary Manager (DM) and Assistant Director of Nursing (ADON) confirmed that all food items in the refrigerator should be dated and stored in sealed containers, and that staff had been trained to follow these procedures. The DM acknowledged that the staff's failure to date and wrap food items was due to laziness, and that improper drying of the processor bowl could result in chemical contamination. The ADON reiterated that all kitchen staff had been in-serviced on proper food storage practices and that taking food from the prep area to the 3-compartment sink could cause cross-contamination. The facility's policies on food preparation and storage emphasize the importance of preventing cross-contamination and ensuring that all refrigerated foods are labeled, dated, and monitored.
Failure to Maintain Safe Storage of Residents' Food Items
Penalty
Summary
The facility failed to maintain and ensure safe and sanitary storage of residents' food items in personal refrigerators across five rooms. Observations during the survey revealed that none of the refrigerators had up-to-date temperature logs or thermometers, despite containing perishable food items such as deli lunch meats, protein shakes, pickles, canned sodas, cottage cheese, ice cream, yogurt, and perishable snack items. This lack of monitoring and equipment could potentially lead to foodborne illnesses among residents. Interviews with the Assistant Director of Nursing (ADON) and the Director of Nursing (DON) highlighted a lack of clarity and adherence to the facility's policies regarding the monitoring of personal refrigerators. The ADON stated that housekeeping staff were responsible for checking and logging refrigerator temperatures daily, but this was not being done. The DON was unsure of the frequency of checks and the last training provided to staff on this matter. The facility's policy required residents or their families to provide thermometers for personal refrigerators, and for facility staff to monitor temperatures daily, discarding any unsafe items. However, these procedures were not being followed, posing a risk to resident safety.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the lack of Enhanced Barrier Precautions (EBP) for residents with indwelling urinary catheters and wounds requiring dressings. Specifically, Resident #20 and Resident #42, both with indwelling urinary catheters, did not have EBP signage or personal protective equipment (PPE) available at their room entrances. Additionally, Resident #20 and Resident #45, who had wounds requiring dressings, also lacked EBP signage and PPE at their room entrances. These oversights were observed during facility rounds, indicating a systemic issue in implementing EBP. The report highlights specific instances where staff failed to adhere to infection control protocols. For example, CNA A entered Resident #42's room without sanitizing her hands and did not don a gown before performing catheter care. Similarly, LVN B entered Resident #45's room without sanitizing her hands and failed to wear a gown while performing wound care. These actions demonstrate a lack of compliance with EBP guidelines, which are crucial for preventing the spread of infections in residents with chronic wounds or indwelling medical devices. Interviews with staff, including LVN A, LVN B, and CNA A, revealed a lack of training and awareness regarding EBP requirements. The Director of Nursing (DON), who also serves as the Infection Preventionist, admitted to not being familiar with EBP requirements and acknowledged that nursing administration had not implemented the necessary precautions despite being aware of the pending requirements. This lack of training and implementation of EBP poses a risk of cross-contamination and infection spread among residents.
Failure to Conduct Background Checks on New Hires
Penalty
Summary
The facility failed to develop and implement written policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents, and misappropriation of resident property. This deficiency was identified through the review of employment files for two newly hired hospitality aides, Aide A and Aide B, who began working without completed criminal background checks, EMR, and NAR checks. The lack of these checks was discovered during interviews and record reviews, revealing that the aides had been working at the facility for several weeks without the necessary clearances. Interviews with the hospitality aides and various staff members, including the DON, ADM, ADON, BOM, and the Former ADM, highlighted a breakdown in the facility's system for conducting background checks. The aides were hired through an outside party, and there was an assumption that the outside party had completed the necessary checks. However, this was not the case, and the aides began working without the facility verifying their backgrounds. The DON and ADM acknowledged the potential risk to residents due to this oversight, as the aides had access to residents, although they did not provide direct care. The facility's policy required that all staff, including hospitality aides, have their criminal backgrounds checked before working with residents. However, due to a change in administration and miscommunication regarding responsibilities, this policy was not followed. The Former ADM assumed the outside party handled the checks, while the new ADM and other staff were unaware of the aides' employment status and the lack of completed checks. This oversight was only rectified after the issue was identified during the survey, with the BOM completing the necessary checks on the day of the interviews.
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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 Levelland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lynwood Nursing And Rehabilitation | 13 mi | — | 12 | 0 |
| Arbor Grace Wellness Center | 22 mi | — | 15 | 0 |
| Crown Point Health Suites | 25.7 mi | — | 7 | 0 |
| Whisperwood Nursing & Rehabilitation Center | 26.5 mi | — | 2 | 0 |
| Carillon Inc | 26.5 mi | — | 0 | 0 |
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