Average — CMS composite of the measures below.
The next survey window likely opens around December 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 Levelland Nursing & Rehabilitation Center during CMS and state inspections, most recent first.
Hand Hygiene Not Performed Between Glove Changes During Resident Care: CNAs failed to perform hand hygiene between glove changes while providing incontinence care and catheter care to three residents. One resident had an indwelling catheter and was dependent for toileting hygiene, while the other two residents also required assistance with toileting hygiene. During observation, staff removed gloves and put on clean gloves without washing or sanitizing their hands, despite stating they had been trained to do so and despite the DON’s expectation that hand hygiene be performed between glove changes.
Hot water at hand sinks in 4 shared bathrooms measured 117.5 to 125.6 degrees Fahrenheit, above the facility’s expected 100 to 110 degree range. The MS stated the water heater mixing valve had failed, water temperatures had not been checked for 2 weeks, and no temperature logs were kept. The ADM stated she expected sink water to remain between 100 and 110 degrees Fahrenheit.
A facility failed to complete annual MDS assessments within the required timeframe for two residents with cognitive impairment and other diagnoses, including dementia, Bipolar II disorder, Alzheimer’s disease, and hypertension. Their MDS records were still in progress, with blank sections and no RN Assessment Coordinator signature verifying completion. The ADM said the MDS nurse was responsible for all assessments but the facility did not have one, and the CN was trying to catch up on late assessments.
A resident with schizoaffective disorder and major depressive disorder did not have an accurate or updated PASRR Level I screening reflecting those mental illness diagnoses. Surveyors found an old PASRR record with no qualifying diagnosis and an uncompleted PASRR form, while the resident’s MDS, care plan, and physician orders documented the psychiatric diagnoses and related medications. The ADM and SW stated they were unaware the PASRR was inaccurate and acknowledged the diagnoses should have been reflected.
Puree Diets Served With Chunks and Runny Consistency: The facility failed to provide palatable puree food for two meals reviewed. A staff member prepared puree items that were runny and contained pea-sized chunks, and the surveyor’s taste tests of chicken, broccoli, Salisbury steak, and vegetable blend found pieces that had to be chewed. The DM and ADM stated puree should be smooth like baby food with no chunks, and the facility policy stated blenderized food should have no lumps and should not be runny.
Improper Food Storage in Kitchen Refrigerator: Surveyors observed a bag of tortillas with no label or date and a bowl of chili with an unsealed lid in the kitchen refrigerator. The A, DM, and ADM stated all food in the refrigerator should be sealed, labeled, and dated, and the facility policy required refrigerated foods to be covered, labeled, and dated.
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.
Hand Hygiene Not Performed Between Glove Changes During Resident Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for 3 of 4 residents reviewed for infection control when CNAs did not perform hand hygiene between glove changes during incontinence care and catheter care. Resident #1 was a male with diagnoses including encounter for surgical aftercare following surgery on the digestive system, neuromuscular dysfunction of the bladder, and urinary tract infection, and he had an indwelling catheter and was dependent for toileting hygiene. During observation, CNA B provided incontinence care and catheter care, removed gloves multiple times, and stated she should wash her hands and put on clean gloves, but did not perform hand hygiene between glove changes. Resident #17 was a female with diagnoses including displaced trimalleolar fracture of the right lower leg, type 2 diabetes mellitus, and unspecified dementia, and she was dependent for toileting hygiene. During observation, CNA D provided incontinence care, removed gloves, and put on clean gloves without performing hand hygiene between glove changes while cleansing the resident’s groin and buttocks and placing a clean brief. Resident #43 was a female with diagnoses including unspecified dementia, essential hypertension, and dependence on wheelchair, and she required partial/moderate assistance for toileting hygiene. During observation, CNA E provided incontinence care, removed gloves, and put on clean gloves without performing hand hygiene between glove changes while cleansing the resident’s groin and buttocks and placing a new brief. During interviews, CNA B, CNA D, and CNA E stated they had been trained to perform hand hygiene after every glove change, but they did not do so during the observed care. CNA B stated she was not sure if she had to actually wash her hands in front of the surveyor, and CNA D and CNA E stated they were nervous in front of the surveyor. The DON stated she expected staff to actually perform hand hygiene between all glove changes and that the residents had an increased risk for passing on bacteria, sickness, or illness to the next resident. The facility’s hand hygiene policy stated that hand hygiene is the primary means to prevent the spread of infections, that staff are expected to adhere to hand hygiene practices, and that gloves do not replace hand washing or hand hygiene.
Hot Water Temperatures Exceeded Safe Range in Shared Bathrooms
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 4 of 6 shared bathrooms. During observations, the hot water at the hand sinks in the shared bathrooms for the identified room groups measured 122 degrees Fahrenheit, 124.6 degrees Fahrenheit, 125.6 degrees Fahrenheit, and 117.5 degrees Fahrenheit. These temperatures were above the facility’s stated expected range of 100 to 110 degrees Fahrenheit and above the limit described in the facility policy for water heaters serving resident areas. During interview, the MS stated plumbers had recently worked on the water heater and it was supposed to be set, and later stated the mixing valve had gone out, causing the water temperatures to be too high. The MS stated the water temperatures in the facility were last checked two weeks earlier, that he was trained to check water temperatures in random rooms weekly, and that he did not know why he had not checked them in two weeks. He also stated he did not keep logs of the water temperature checks and did not know he needed to. The ADM stated she expected sink water temperatures to be between 100 and 110 degrees Fahrenheit and stated the plumbers had recently made repairs because the water had been too cold.
Annual MDS Assessments Not Completed on Time
Penalty
Summary
The facility failed to complete comprehensive annual MDS assessments within 12 months of the previous assessments for 2 of 24 residents reviewed, Resident #8 and Resident #34. For Resident #8, the electronic face sheet showed diagnoses including an unspecified open wound of the right hip, unspecified dementia, and Bipolar II disorder. The annual MDS record showed a BIMS score of 11, indicating moderate cognitive impairment, but Section A and Section B were blank and the RN Assessment Coordinator signature verifying assessment completion was not present. A screenshot of the assessment information showed the annual MDS was in progress with an ARD/target date of 11/25/2025 and a complete-by date of 12/12/2025. For Resident #34, the electronic face sheet showed diagnoses including Alzheimer’s disease with late onset and essential primary hypertension. The annual MDS record showed a BIMS score of 11, indicating moderate cognitive impairment, but Section A and Section B were blank and the RN Assessment Coordinator signature verifying assessment completion was not present. A screenshot of the assessment information showed the annual MDS was in progress with an ARD/target date of 12/7/2025 and a complete-by date of 12/7/2025. During interview, the ADM stated the MDS nurse was responsible for completing all MDS assessments, but the facility did not currently have an MDS nurse and the CN was assisting with completion. The ADM stated she was not aware the annual MDS assessments for Resident #8 and Resident #34 were not completed, and stated that if the RN Assessment Coordinator's signature was not completed, the document was not completed. The CN stated she was trying to bring late assessments current and had not yet completed all of them. The facility policy stated all MDS assessments are to be completed and electronically transmitted in accordance with OBRA regulations.
Inaccurate PASRR Screening for Resident with Mental Illness Diagnoses
Penalty
Summary
The facility failed to ensure that Resident #7 had an accurate and updated PASRR Level I screening that reflected the resident’s mental illness diagnoses. Record review showed the resident had diagnoses including schizoaffective disorder, bipolar type, and major depressive disorder, single episode, severe without psychotic features, along with altered mental status and a BIMS score of 11 on the annual MDS, indicating moderate cognitive impairment. The resident’s care plan also listed major depressive disorder and schizoaffective disorder, and the physician’s order summary included olanzapine and paroxetine related to those diagnoses. The resident’s PASRR documentation reviewed by surveyors included a PASRR Evaluation Report dated 10/09/2020 stating no qualifying diagnosis was found, and a PASRR Evaluation Short Form dated 10/21/2020 that was uncompleted. No additional PASRR Level I screenings or current updated PASRR evaluation documents were provided to show that the resident’s mental illness diagnoses had been reflected in the PASRR record. A diagnosis report dated 01/15/2025 listed major depressive disorder and schizoaffective disorder with onset dates in 2021 and 2022. During interviews, the ADM stated the MDS nurse was responsible for ensuring PASRR screenings were accurate and for requesting updated screenings when a resident received a new mental illness diagnosis, but the facility did not currently have an MDS nurse. The ADM and SW both stated they were not aware the resident’s PASRR screening did not reflect the mental illness diagnoses, and both acknowledged that schizoaffective disorder and major depressive disorder qualified as mental illnesses and should have been reflected on the PASRR screening. The facility policy stated that new onset or changes in behavior indicating a newly evident or possible serious mental disorder would be referred for a PASARR Level II evaluation.
Puree Diets Served With Chunks and Runny Consistency
Penalty
Summary
The facility failed to provide palatable food for 2 of 2 meals reviewed for palatability, involving 1 of 3 food forms served: puree. During an observation on 01/14/26 at 11:26 a.m., a staff member was preparing a puree meal. The pureed chicken and broccoli were observed to be runny with pea-sized chunks, and the surveyor’s taste test found chunks that had to be chewed in both items. During an observation of a puree diet test tray on 01/15/26 at 12:35 p.m., the pureed Salisbury steak and Prince vegetable blend were also observed to be runny with visible pea-sized chunks, and the surveyor’s taste test again found chunks that had to be chewed. During interviews, the staff member stated pureed food should be smooth, like baby food, and that puree diets are for residents who have difficulty chewing or swallowing regular textured food. The DM stated all staff were trained to prepare puree diets and that pureed food should be smooth like baby food, with residents on puree diets due to trouble chewing, swallowing, or teeth problems. The ADM also stated puree should be smooth with no chunks and that residents are on puree diets because they cannot chew food. Record review of the facility policy titled Nutrition Policies and Procedures stated blenderized food should have no small pieces or lumps and the final product should not be runny, but should have a fluffy, moist consistency with no lumps.
Improper Food Storage in Kitchen Refrigerator
Penalty
Summary
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. During the initial kitchen tour on 01/14/26 at 09:27 a.m., surveyors observed a bag of tortillas with no label and no date, and a bowl of chili with a lid that was not sealed. These observations showed food items in the refrigerator were not being stored in the manner described by the facility's food storage policy. During interviews, the A stated that all food in the refrigerator should be sealed, labeled, and dated, and that it was everyone's responsibility to do so. The DM and ADM also stated that all staff were responsible for ensuring food placed in the refrigerator was properly sealed, labeled, and dated, and that staff had received training on proper food storage. Record review of the facility policy, Food Receiving and Storage, dated revised November 2022, stated that all foods stored in the refrigerator or freezer are to be covered, labeled, and dated, and that refrigerated foods are to be labeled, dated, and monitored so they are used by their use-by date, frozen, or discarded.
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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Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — including the 1 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 14 | 1 |
| Arbor Grace Wellness Center | 22 mi | ★★★★★ | 15 | 0 |
| Crown Point Health Suites | 25.7 mi | ★★★★★ | 7 | 0 |
| Whisperwood Nursing & Rehabilitation Center | 26.5 mi | ★★★★★ | 7 | 4 |
| Carillon Inc | 26.5 mi | ★★★★★ | 7 | 0 |
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