Inspection·September 8, 2023

F 0552 prescribed. Level of Harm - Minimal harm or potential for actual harm Findings included: Resident #8 Residents Affected - Some Record review of Resident #8's face sheet, dated 09/06/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include senile degeneration of brain (cognitive loss), diabetes (high blood sugar) and mood disorder. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #8 was usually understood (misses some part/intent of message but comprehends most conversation). The MDS revealed Resident #8 had a BIMS of 01 which indicated the resident's cognition was severely impaired . The MDS revealed Resident #8 took an antianxiety for 6 days during the last 7 days. Record review of Resident #8's order summary report dated 09/06/23 revealed the following orders: Lorazepam 0.5mg by mouth in the morning for anxiety dated 07/17/23 Lorazepam 0.5mg by mouth at bedtime for anxiety dated 07/17/23 Melatonin 3mg 3 tablets by mouth at bedtime for insomnia dated 06/15/21 Record review of a care plan for Resident #8 dated 07/28/23 revealed a focus area for anxiety medications related to anxiety. Interventions were to administered medications (Lorazepam) as ordered. There were no focus areas for insomnia or melatonin. Record review of Resident #8's medication administration records dated 09/08/23 for the month of September 2023 revealed the resident received Lorazepam 0.25mg in the morning, Lorazepam 0.5mg in the evening and Melatonin 3 mg 3 tablets at bedtime 09/01/23 through 09/07/23. Record review of Resident #9's electronic medical record under the misc. tab and the paper chart under consents revealed no consent for lorazepam or melatonin. Resident #10 Record review of Resident #10's face sheet, dated 09/06/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills), hypertension (high blood pressure), heart failure, diabetes (high blood sugar and anxiety (feeling or worry or fear). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #10 was understood. The MDS revealed Resident #10 had a BIMS of 09 which indicated the resident's cognition was moderately impaired. The MDS revealed Resident #10 took an antidepressant 7 days during the last 7 days. Record review of a care plan for Resident #10 dated 07/2723 revealed a focus care area for trazodone and to administer the medication as ordered as one of the interventions. Record review of Resident #10's order summary report dated 09/06/23 revealed the following orders: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 2 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 Trazodone 50mg by mouth at bedtime related to major depressive disorder dated 10/26/21. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #10's medication administration records dated 09/08/23 for the month of September 2023 revealed the resident received trazodone 50mg at bedtime 09/01/23 through 09/07/23. Residents Affected - Some Record review of Resident #10's electronic medical record under the misc. tab and the paper chart under consents revealed no consent for trazodone. Resident #12 Record review of Resident #12's face sheet, dated 09/07/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, psychotic disorder, anxiety and mood disorder. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #12 was usually understood. The MDS revealed Resident #12 had a BIMS of 02 which indicated the resident's cognition was severely impaired. The MDS revealed Resident #12 took an antianxiety, antidepressant and antipsychotic for 7 days during the past 7 days. Record review of Resident #12's order summary report dated 09/07/23 revealed the following orders: Seroquel 200mg at 2 times a day related to psychotic disorder dated 08/16/22. Seroquel 25mg at 2 times a day related to psychotic disorder dated 08/16/22. Sertraline 150mg in the morning related to mood disorder dated 08/19/22. Buspirone aka Buspar 10mg 3 times a day related to anxiety dated 03/31/23. Record review of a care plan dated 09/06/23 for Resident #12 revealed a focus for use of antidepressant medication (Sertraline) for depression. She had a focus for use of an antianxiety medication (buspirone) for anxiety disorder. There was no care plan for the use of the antipsychotic medication (Seroquel). Record review of Resident #12's medication administration record dated 09/07/23 revealed the following medications were given: Seroquel 200mg at 2 times a day 09/01/23 through 09/07/23. Seroquel 25mg at 2 times a day 09/01/23 through 09/07/23. Sertraline 150mg in the morning 09/01/23 through 09/07/23. Buspirone 10mg 3 times a day 09/01/23 through 09/07/23. Record review of Resident #12's electronic medical record under the misc. tab and the paper chart under consents revealed no consent for seroquel, sertraline and buspirone. Resident #15 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 3 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #15's face sheet, dated 09/06/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, dementia and anxiety disorder. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #15 was rarely/ never understood. The MDS revealed Resident #15 had a BIMS of 00 which indicated the resident's cognition was severely impaired. The MDS revealed Resident #15 took an antianxiety 3 days during the last 7 days. Record review of Resident #15's order summary report dated 09/06/23 revealed the following orders: Ativan aka lorazepam .5mg every 6 hours as needed related to Alzheimer's dated 06/21/23. Ativan .5mg 3 times a day related to Alzheimer's dated 08/22/23. Record review of a care plan dated 07/14/23 for Resident #15 revealed no focus for the use of Ativan. Record review of Resident #15's medication administration record dated 09/08/23 revealed the following medication was given: Ativan 0.5mg three times a day 09/01/23 through 09/08/23. Record review of Resident #15's electronic medical record under the misc. tab and the paper chart under consents revealed no consent for Ativan. Resident #23 Record review of Resident #23's face sheet, dated 09/06/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include major depressive disorder (mental illness), hypertension (high blood pressure), and muscle weakness. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #23 was understood. The MDS revealed Resident #23 had a BIMS of 14 which indicated the resident's cognition was not impaired . The MDS revealed Resident #23 took an antidepressant 4 days during the last 7 days. Record review of a care plan for Resident #23 dated 07/31/23 revealed a focus care area for Lexapro and administer medication as ordered as one of the interventions. Record review of Resident #23's order summary report dated 09/06/23 revealed the following orders: Lexapro 10mg by mouth for major depressive disorder dated 06/07/23 Record review of Resident #23's medication administration records dated 09/08/23 for the month of September 2023 revealed the resident received Lexapro 10mg by mouth one time a day 09/01/23 through 09/08/23. Record review of Resident #23's electronic medical record under the misc. tab and the paper chart under consents revealed no consent for trazodone. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 4 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 Resident #32 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #32's face sheet, dated 09/06/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include dementia (cognitive loss), anxiety (worry and fear), and mood disorder. Residents Affected - Some Record review of comprehensive MDS assessment dated [DATE] revealed Resident #32 was understood. The MDS revealed Resident #32 had a BIMS of 03 which indicated the resident's cognition was severely impaired. The MDS revealed Resident #32 took an antianxiety 7 days during the last 7 days. Record review of a care plan for Resident #32 dated 07/19/23 revealed a focus care area for anti-anxiety medication (Buspar) and administer medication as ordered as one of the interventions. Record review of Resident #32's order summary report dated 09/06/23 revealed the following orders: Buspar 7.5mg three times a day related to anxiety dated 03/01/22. Record review of Resident #32's medication administration records dated 09/08/23 for the month of September 2023 revealed the resident received Buspar 7.5mg by mouth three times a day 09/01/23 through 09/07/23. Record review of Resident #32's electronic medical record under the misc. tab and the paper chart under consents revealed no consent for Buspar. Resident #42 Record review of Resident #42's face sheet, dated 09/07/23, revealed an [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, depression and anxiety. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #42 was usually understood (clear comprehension). The MDS revealed Resident #42 had a BIMS of 03 which indicated the resident's cognition was severely impaired . The MDS revealed Resident #42 took an antidepressant 7 days during the last 7 days. Record review of a care plan dated 08/18/23 for Resident #42 revealed a focus for use of Lexapro related to depression. Record review of Resident #42's order summary report dated 09/07/23 revealed the following orders: Lexapro Oral Tablet 20mg at bedtime related to depression dated 08/28/23. Record review of Resident #42's medication administration record dated 09/08/23 revealed the following medication was given: Lexapro Oral Tablet 20mg 09/01/23 through 09/07/23. Record review of Resident #42's electronic medical record under the misc. tab and the paper chart under consents revealed no consent for Lexapro. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 5 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 Resident #44 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #44's face sheet, dated 09/06/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia, Alzheimer's and mood disorder. Residents Affected - Some Record review of comprehensive MDS assessment dated [DATE] revealed Resident #44 was usually understood (clear comprehension). The MDS revealed Resident #44 had a BIMS of 07 which indicated the resident's cognition was severely impaired. The MDS revealed Resident #44 took an antidepressant 7 days during the last 7 days. Record review of a care plan dated 08/10/23 for Resident #44 did not reveal a focus for use of Remeron. Record review of Resident #44's order summary report dated 09/06/23 revealed the following orders: Remeron 45mg at bedtime related to mood disorder dated 08/03/23. Record review of Resident #44's medication administration record dated 09/08/23 revealed the following medication was given: Remeron 45mg at bedtime 09/01/23 through 09/07/23. Record review of Resident #44's electronic medical record under the misc. tab and the paper chart under consents revealed no consent for Remeron. Resident #149 Record review of Resident #149's face sheet dated 09/06/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include type 2 diabetes. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #149 assessment was not complete. There was no data regarding the resident's ability to be understood or the BIMS score . Record review of Resident #149's order summary report dated 09/06/23 revealed the following orders: Melatonin 5mg at bedtime for a sleep aid dated 09/04/23. Record review of a care plan dated 09/04/23 for Resident #149 did not reveal a focus for the use of melatonin. Record review of Resident #149's medication administration record dated 09/08/23 revealed resident received the following medication: Melatonin 5mg at bedtime 09/01/23 through 09/07/23. Record review of Resident #149's electronic medical record under the misc. tab and the paper chart under consents revealed no consent for melatonin. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 6 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0552 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an interview on 09/07/23 at 12:20 PM, the ADON was asked where residents medication consent was located. She stated consent may be in the resident documents in EMR or in the Resident paper chart under consents. ADON was asked if the following resident had a completed consent. ADON stated she would look for consents. During an interview on 09/07/23 at 03:45 PM, the ADON stated she was not able to find a completed consent for the following residents: #8, #10, #12, #15, #23, #32, #42, #44 and #149. During an interview on 9/8/23 at 11:11 AM with LVN A, she stated the nurse who received the medication order was responsible for obtaining psychotropic consents. She stated that psychotropic consents should be obtained prior to giving the medication. She stated that a psychotropic medication should not be given without consent. She stated the potential negative outcome could be the resident and family not being aware of the side effects of the medication and giving the medication without consent could be going against the family or residents wishes. She stated that she had been administering psychotropic medications for the following residents, Resident #8, #10, #23, and #32, without a consent. She stated she was not aware that they did not have a consent until today (09/08/23). She stated that if she doesn't receive the order for the psychotropic medication and it's already on the MAR, she just gives the medication per the physician's order and does not check to make sure that consent was obtained. During an interview on 09/08/23 at 11:39 AM with the ADON, she stated the person responsible for obtaining consent would be the nurse who got the order. She stated that the consent should be signed before administering the medication. She stated that consents were obtained on admit if the resident comes to the facility with a psychotropic medication or when there was a new order. She stated the potential negative outcome could be possible over sedation, the family upset with administration and conflict with other medications. She stated that she had been trained on obtaining psychotropic consents. During an interview on 09/08/23 at 12:30 PM with the ADM, he stated that the DON was responsible for obtaining the psychotropic medication consents. He stated that a psychotropic consent should be obtained prior to medication administration. He stated that he was not sure why the consents were not obtained. He stated that the potential negative outcome of not obtaining consent could be administering medication against family or residence wishes. During an interview on 09/08/23 at 2:00 PM with the ADM, he stated the facility did not have a policy related to psychotropic consents. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 7 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Resident #6 Record review of Resident #6's face sheet, dated 09/06/23, revealed a [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include multiple sclerosis (chronic disease of the central nervous system), hypertension (high blood pressure), and psychotic disorder with delusions (unshakeable belief in something implausible, bizarre or obviously untrue). Record review of Resident #6's Comprehensive Minimum Data Set, dated [DATE], revealed Resident #6 had a BIMS score of 11 which indicated Resident #6's cognition was moderately impaired. Resident #6's mood assessment revealed the resident was feeling tired or havening little energy nearly every day. The Care Area Assessment (problem areas) revealed mood and nutritional was a care area that would be addressed in the care plan and was marked on the care area assessment to be care planned. Record review of Resident #6's care plan, dated 07/20/23, revealed no care plan for mood state or nutritional status. During an interview on 09/07/23 at 01:10 PM with Resident #6, she stated she had problems with mood, anxiety and dementia at times. She stated she does not feel she has any issues with her nutrition. She stated she does not always like what was being severed so she will just eat what she likes. She states she does not have any chewing or swallowing problems. Resident #15 Record review of Resident #15's face sheet, dated 09/06/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's dementia (cognitive loss) and anxiety disorder (worry and fear). Record review of comprehensive MDS assessment dated [DATE] revealed Resident #15 had a BIMS of 00 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 8 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some which indicated the resident's cognition was severely impaired. The medications section revealed the resident took anti-anxiety 3 days out of 7 days. The Care Area Assessment (problem areas) revealed psychotropic drug use was a care area that should be addressed in the care plan and was marked on the care area assessment to be care planned. Record review of a care plan dated 07/14/23 for Resident #15 did not reveal a care plan for psychotropic drug use. Record review of Resident #15's order summary report dated 09/06/23 revealed an order for Ativan 0.5mg every 6 hours as needed dated 06/21/23 and Ativan 0.5mg three times a day, dated 08/22/23. Record review of Resident #15's medication administration record dated 09/01/23 revealed Resident #15 received Ativan 0.5mg 09/01/23 through 09/08/23. Resident #23 Record review of Resident #23's face sheet, dated 09/06/23, revealed a [AGE] year-old-male was admitted to the facility on [DATE] with diagnoses to include major depressive disorder (mental illness), hypertension (high blood pressure), and muscle weakness. Record review of the comprehensive MDS assessment dated [DATE] revealed Resident #23 had a BIMS of 14 which indicated the resident's cognition was not impaired. The Care Area Assessment (problem areas) revealed Resident #23 skin assessment revealed he had a pressure reducing device for bed. Record review of a care plan for Resident #23 dated 07/31/23 revealed no care area for or pressure ulcer risk. Observation on 09/06/23 at 09:30 AM revealed resident had a pressure reducing device on his bed. Resident #44 Record review of Resident #44's face sheet, dated 09/06/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include dementia, Alzheimer's and mood disorder. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #44 was usually understood (clear comprehension). The MDS revealed Resident #44 had a BIMS of 07 which indicated the resident's cognition was severely impaired. The resident bladder and bowel assessment revealed the resident was occasionally incontinent. The Care Area Assessment (problem areas) revealed urinary incontinence and falls risk was a care area that will be addressed in the care plan and was marked on the care area assessment to be care planned. Record review of a care plan dated 08/10/23 for Resident #44 did not reveal a care plan for urinary incontinence or fall risk. During an interview on 09/08/23 at 11:11 AM LVN A stated a resident's care plan was used for their plan of care. She stated the care plan was used by everyone. She stated the potential negative outcome of not having care areas care planned could cause harm if you did not know how to care for the resident. She stated the examples could be how to transfer the resident, how to give their medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 9 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 (crushed or regular) and their diet. She stated she had been trained on how to use care plans. Level of Harm - Minimal harm or potential for actual harm During an interview on 09/08/23 at 11:20 AM CNA A stated she was not sure where the residents care plans were located. She stated she did have training when she first started working for the facility but has been at the facility for 8 years. She stated the care plan was used for the resident's plan of care. She stated the potential negative outcome could be harm if staff did not know how to care for the residents. She stated she got the needed information in report or from the charge nurse. Residents Affected - Some During an interview on 09/08/23 at 11:33 AM the ADON stated the MDS nurse was responsible for care planning all triggered care areas in section V of the MDS. She stated nursing care planned new falls, new injuries, and medications. She stated there was no reason a triggered care area should not be care planned. She stated the potential negative outcome could be skin breakdown or the resident not getting the proper care from staff. She stated she had been trained on care plans. During an interview on 09/08/23 at 11:24 AM the MDS nurse stated she was responsible for care planning all triggered care areas in section V of the MDS. She stated all departments complete specific sections of the care plan and she reviews the care plan once all sections of the MDS were complete. She verified missing care plans for the following residents: #6, #15, #23 and #44. She stated she does not know why the missing care areas were not care planned. She stated she does not know if there would be a potential negative outcome because staff would communicate with the charge nurse. She stated section V triggered care areas had to be care planned, no exception. She stated she had been provided training. During an interview on 09/08/23 at 12:32 PM the ADM stated the DON was responsible for care plans. He stated he had serval staff changes and that could contribute to the missing care plans. He stated the residents' care plan paints a picture of the resident and anyone should be able to care for a resident by reading the care plan. He stated the potential negative could be harm depending on what was missing on the care plan. He stated his expectations are for the care plan to be updated as it was a never-ending document. Record review of the provided facility's policy titled Care Area Assessments, revised November 2019, revealed: Policy Statement - Care area assessments (CAAs) are used to help analyze data obtained from the MSDS and to develop individualized care plans. Policy interpretation and implementation 1. Triggered care areas are evaluated by the end of disciplinary team to determine the underlying causes, potential consequences and relationships to other triggered care areas . 2b. Review the triggered CAAs by doing an in-depth, resident-specific assessment of the triggered condition 2c. Define the problems . 2d. Make decisions about the care plan 2e. Document interventions on the care plan FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 10 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: Record review of Resident #15's face sheet, dated 09/06/23, revealed an [AGE] year-old-female was admitted to the facility on [DATE] with diagnoses to include Alzheimer's, dementia and anxiety disorder. Record review of comprehensive MDS assessment dated [DATE] revealed Resident #15 was rarely/ never understood. The MDS revealed Resident #15 had a BIMS of 00 which indicated the resident's cognition was severely impaired. Section N Medications Received: During the last 7 days or since admission/entry or reentry if less than 7 days: 3 days of antianxiety Record review of Resident #15's order summary report dated 09/06/23 revealed the following orders: Ativan .5mg every 6 hours as needed related to Alzheimer's dated 06/21/23. Ativan .5mg 3 times a day related to Alzheimer's dated 08/22/23. Record review of Resident #15's medication administration record dated 09/01/23-09/08/23 revealed the following medication was given: Ativan .5mg PRN was not given during the above mentioned time period. Ativan .5mg from the 1st-8th at 8:00 AM, the 6th & the 7that 2:00 PM, 1st-5th at 5:00 PM and the 1st-7th at 8:00 PM. Record review of a care plan dated 07/14/23 for Resident #15 did not reveal a focus for use of Ativan. During an interview on 09/08/23 at 11:21 AM, the ADM said the DON and the pharmacist was responsible for ensuring the residents medications have the appropriate diagnosis. He said he was unaware that (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 11 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few any residents in the facility were receiving antipsychotics to treat the diagnosis of Alzheimer's or dementia. He said he had not received any training regarding antipsychotics and improper diagnosis but understood that they have to be reviewed and go through a gradual dose reduction. He said a potential negative outcome for a resident taking an antipsychotic for the wrong diagnosis was that the diagnosis would not be treated. He said he could not think of any other outcome. He said he expected that when this was identified, there should be a conversation between the facility staff, pharmacy, and the doctor for the proper recommendation. Still, he would ultimately leave it up to the physician. He said he was aware that the diagnosis of Alzheimer's and dementia cannot get better but progressively worsen. He said he was unfamiliar with the black box warnings and was unaware if there was an increase in deaths associated with antipsychotics and the elderly population. During an interview on 09/08/23 at 12:08 PM, the ADON said she knew Resident #15 was taking Ativan but was unaware that the medication diagnosis was for Alzheimer's. She said Resident #15 was on hospice. She said all nurses are responsible for ensuring the proper diagnosis was paired with the appropriate medication. She said the nurse entering the information should catch if there was a discrepancy. She said it was important because if residents were taking a medication that was not appropriate, it could have a contraindication. She said Ativan could not treat the diagnosis of Alzheimer's or dementia. She said she had training regarding antipsychotics, but it had been general training about long-term care. She said that they monitor side effects every shift. She said that she had not brought the inappropriate diagnosis to the doctor's attention. She said they had a system where they monitor and conduct chart reviews monthly. She said they had not conducted a chart review in a couple of months. She said a potential negative outcome could have been over-sedation. She said she does expect the diagnosis and the medication to match. During an interview on 09/08/23 at 12:09 PM, the DON said she was aware that Resident #15 was taking Ativan for the diagnosis of Alzheimer's. She said she was unsure about Resident #15 as she had been at the facility as the DON for a short time, but certain medications are not paid for through hospice without the proper diagnosis. She said the nurses are responsible for identifying discrepancies once they receive the orders. She said that Ativan cannot make Alzheimer's better, but it can treat anxiety. She said she has received training in long-term care in general. She said the potential negative outcome was that residents in the elderly population and with the diagnosis of Alzheimer's are more at risk of having an opposite effect of the medication intention. She had not brought it to the doctor's attention that the diagnosis was inappropriate for the Ativan. She said her system to monitor was mainly on monitoring side effects. She said she expected the diagnosis to match the medication. Record review of the facility's policy titled Use of Antipsychotic Medication Use, dated July 2022, revealed: Policy Statement Residents will not receive medications that are not clinically indicated to treat a specific condition. Policy Interpretation and Implementation Residents will only receive antipsychotics medications when necessary to treat specific conditions for which they are indicated and effective. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 12 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. The findings include: Record review of the facility's menu, dated Spring/Summer 2023, revealed the following: Week 4 Wednesday: Turkey [NAME], Herbed Rice, wheat Roll, Margarine, Tropical Fruit, Coffee or Tea and Milk An observation on 09/06/23 at 11:35 AM revealed staff serving the following: meatballs, brown gravy, green beans and mash potatoes. During an interview on 09/06/23 at 12:15 PM, the D said the Regional Consulting Manager has trained her. She said they cook the same breakfast every day. She said she was trained to ensure she followed breakfast when state came. She said this was a challenge because she did not know when state would enter the facility. She said that they do not ever follow the menu. She said they cook what they have in the fridges. She said that she has an $8,000.00 a month budget that she has to follow, and she cannot get what was on the menu. She said the Regional Consultant told her it was okay to change the menu. She said that she and the Regional Consultant met with the residents to see what they would like, and they changed the menu. She said that she was trained that it was okay to change the menu to things that the residents may like better. During an interview on 09/07/23 at 01:37 PM, Dietary [NAME] A said they normally do not follow the menu. She said they prepare the meals based on the available food in the kitchen. She said the DM chose the meal on 09/06/23, and they wanted something simple to make because they were receiving their weekly truck. She said they did not know how much time they would have to prepare and interact with the vendor delivering the truck. She said the DM decided what they would have the day before on 09/05/23. She said as long as the DM did not have to work the floor, then she was the person who prepared the menus each week. She said she did not know a potential negative outcome of following the menu. She said she was not sure why that would be important. During an interview on 09/07/23 at 01:57 PM, Dietary Aide A said he could not give any information regarding the menu process because he had not been trained and does not deal with the menus. He said he received what was on the menu from the DM or the cook. During an interview on 09/08/23 at 11:21 AM, the ADM said the DM and the Dietician ensured the menus were followed. He said he was not aware that they were not following the menus. He said he has not been formally trained in this area. He said that a potential negative outcome of not following the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 13 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many menu was the residents would not receive their dietary needs and could experience weight loss or nutritional value would not be there. He said the residents require a certain amount of nutrition, and following the menu helped the residents receive their nutrients. He said he expected the dietary staff to follow the menus. He said he had no system to monitor and ensure the menus were followed. He said the menu was a guide for staff that they should follow. He said the menu will show staff how to prepare the food and should ensure the residents receives the appropriate nutritional value. He said he did not know who approved the menu. He said he would sometimes look to see what they were eating and typically focus on lunch and dinner. He said he understood if the residents did not like what was on the menu, they could go through a process that involved the DM and the Dietician. He said he told the DM in the past that she could purchase what she needed, and he would worry about the cost. He said he was not aware of how much her monthly budget was. He said he was unsure about the facility policy related to changing the menu, but from his experience, the Dietician had to review it and sign off on it. He said the Dietician was the only person that could change the menu. During an interview on 09/08/23 at 12:32 PM, the DM said she said the purpose of the menu was so that they would not get in trouble by state. She said the potential negative outcome of not following the menu was that you could get in trouble. She said she was trained to follow the menu when state was in the facility. She said she was trained and needed to especially ensure breakfast was followed. She said she would not change what she normally did for the three days that state was in the facility She said the residents at the facility were picky. She said the Dietician was aware that they were not following the menu. She said the Dietician was not concerned because they gave the residents food they liked. She said they chose between a meal and an alternative when looking at the menu approved by the dietitian. She said they do not follow breakfast or the alternative option. They keep the same meal for their alternative and breakfast. She said only 4 residents attended the meeting. When asked about 4 residents making the choices for the entire facility, she said they chose the pickiest residents. She said no other attempts were made to include other residents outside the attendees. During an interview on 09/08/23 at 04:47 PM, the Dietician said she was aware that there were some items on the menu that staff crossed out because residents did not like some of the food. She said a meeting was held where the residents chose what they wanted on the menu. She said she believed this meeting was held in April 2023. She said this was when she approved the menu change. She said when there was a change or a substitution, the DM should log it on the substitution log. She said her understanding was that there was always an alternative. She said she could not name the exact alternative, but she thought the facility had an alternative available. She said she did not attend the meeting in April. She said she did not review the minutes. (Please note the surveyor requested the substitution log and it was not provided.) During an interview on 09/08/23 at 05:04 PM, the Regional Consultant said she had been helping the DM because she was new. She said regarding the menus, she explained to the DM that she needed to follow the menu with no exception. She said they had a committee meeting and went over the menus. She said the residents in the meeting decided that they wanted one choice. She said it was decided to have the same breakfast daily. She said she told the DM to change the breakfast so that they would have different things daily. She said she, the DM, and the residents from the meeting decided to have a standing alternate menu. She said all foods do not have the same nutritional value. When asked about allowing 4 residents to make the decisions for the entire facility, she said that they spoke with everyone and invited the residents to the meeting, but the 4 who showed up were the ones who wanted to attend. She said the menu was supposed to be followed daily to ensure residents get the nutrition they need. She said she had encouraged the DM to read the policies (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 14 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0803 Level of Harm - Minimal harm or potential for actual harm and procedures because if she did not, the experiences she was going through (experience with the state surveyors) could happen. Record review of the facility's policy titled Operational Policy and Procedure Manual for Long Term Care, undated revealed: Residents Affected - Many Menu (Revised October 2017) Policy Statement Menus are developed and prepared to meet resident choices including religious, cultural and ethnic needs while following established national guidelines for nutritional adequacy, Policy Interpretation and Implementation 1. Menus meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board (National Research Council and National Academy of Sciences), 2, Menus for regular and therapeutic diets are written at least two (2) weeks in advance, and are dated and posted in the kitchen at least one (1) week in advance, 4. The dietitian reviews and approves all menus. 6. Deviations from posted menus are recorded (including the reason for the substitution and/or deviation) and archived. 9. If a food group is missing from a resident's daily diet (e.g., dairy products), the resident is provided an alternate means of meeting his or her nutritional needs (e.g., calcium supplementation or fortified nondairy alternatives). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 15 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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). These failures could place residents at risk for food contamination and foodborne illness. The findings include: On 09/06/23 at 9:50 AM revealed the following: -At 10:06 AM, Dietary [NAME] A entered the food preparation area without a hair restraint. She walked past the steam stable, where the brown gravy was uncovered. At 10:10 AM, she retrieved a hair restraint and placed it on. Dietary [NAME] A did not wash her hands upon entering the food preparation area. -At 10:09 AM, an observation revealed a partially eaten plate of food was directly to the left of the steam table next to an open bag of unlabeled tortillas, a bag of potato chips, and an unlabeled half a loaf of bread. -At 10:10 AM, leftover scrambled eggs were observed in a bag to the left of the steam table labeled prepared 09/06/23 and used by 09/08/23. The Surveyor touched the bag and it was cool to the touch. Uncovered bread was observed next to the bag of scrambled eggs. Observed three leftover sausage patties in a bag on the food preparation table. The Surveyor touched the bag and it was cool to touch. -At 10:11 AM, an observation was made of the area below the steam table which revealed torn foil and dried food on the foil paper. -At 10:12 AM, an observation of staff's personal food (unknown sauce and fried dumplings) next to unused, clean dessert bowls in the food preparation area. The fried dumpling package was on the food preparation table unlabeled and undated in the food preparation area. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 16 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm -At 10:13 AM, observed a pair of used gloves on the food preparation table. They were folded inside of one another with an unknown greasy substance on them. -At 10:14 AM, a broken ice scoop was observed on the cart next to the steam table without a barrier between the scoop and the cart. Residents Affected - Many -At 10:15 AM, an observation was made that the scoops used to dip out the thickener powder, brown sugar, and powdered bread were placed on top of the containers without a barrier between the scoops and the exposed lid tops. -At 10:15 AM, an observation was made of lemon juice dated 01/02/23 placed next to the seasonings. The lemon juice bottle reflected, refrigerate after opening. The lemon juice bottle was partially gone. A bottle of hot sauce was also on the seasoning rack, undated. An observation was made of a cup of brown sugar in a cup uncovered and unlabeled. -At 10:20 AM, an observation revealed 17 cans were dented on the bottom shelf in the dry pantry. One of the 17 cans did not have a label to indicate what was inside the can. There was no sign indicating that the cans were not for resident consumption. Also observed in the dry pantry a measuring cup with a leftover brown dry substance. -At 10:22 AM, an observation of a personal blanket in the dry food storage area on the shelf next to clean plasticware. -At 10:23 AM, an observation revealed 11 bags of cauliflower and a bag of diced celery that were undated in the freezer. There was an observation of 65 loaves of bread undated located on multiple bread racks located in the back of the kitchen. There were three rows with a sticker that reflected use first along the side. An observation of partially used bread revealed they were on rows that did not have the use first sticker on it. -At 10:27 AM, 6 cups of uncovered, undated milk was observed in Refrigerator #2. Milk was spilled on the tray. -At 10:34 AM, the scrambled eggs and the sausage were still out. The brown gravy was uncovered on the steam table. -At 10:40 AM, observed three scoops on the lid of the thickener without a barrier between the scoops and the exposed lid. -At 12:07 PM, an observation of the same scrambled eggs and sausage in the bags from breakfast on a cart in the food preparation area. -At 12:09 PM, an observation of Dietary Aide A preparing food with his beard exposed and not properly restrained. He was standing over 6 uncovered trays of food. -At 12:17 PM, an observation of Dietary Aide A over 10 uncovered plates of food and no hair restraint on his beard. -At 12:21 PM, an observation of two vents in the food preparation area revealed they were dirty. An observation of one stove vent in the back was visibly dirty. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 17 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many -At 3:20 PM, an observation revealed that the eggs and sausage from breakfast had been placed in Refrigerator #1. -At 4:00 PM, an observation of 40 cups revealed they were stained dark brown. The cups were prepared for resident use for dinner. Observed the DM use her finger to point inside one of the cups. The DM then used her ballpoint pen to touch the inside of the cup. The DM did not remove the two cups from the tray after that was done. Dietary Aide A filled the cups with tea for dinner. -On 09/08/23 at 12:32 PM, an observation of the DM in the kitchen without a hair restraint while serving fish from the food service line. During an interview on 09/06/23 at 10:18 AM, Dietary [NAME] A said the brown sugar uncovered on the seasoning rack was used for the residents' oatmeal in the morning. She said everything on the seasoning rack was used for resident consumption. She said they had served breakfast that morning and finished it at 7:45 AM. During an interview on 09/06/23 at 3:22 PM, the Dietary [NAME] A said that they keep their dented cans in the dry pantry with the rest of the resident food for consumption. She said that if they need a particular can of food and they do not have it in regular stock, and they do have it in their dented or damaged cans, they will use the dented or damaged cans. She said the driver from the vendor said they could not take the cans back. She said the eggs and sausage from breakfast were placed in the refrigerator and would be served for breakfast the next morning. She said the cauliflower and the diced celery were not labeled because she did not have the labels that stick to the frozen items. She said she knows that she received the items as of 08/28/23. She said anyone else may not know that because it was not labeled. She said they try cleaning the stoves and large kitchen appliances every two weeks. She said they clean the top of the stove but never think to clean the back, where all the lint builds up. She said that the personal food in the food preparation area belonged to the Dietary [NAME] A and Dietary Aide A. She said they do not label their bread because they use it daily. She said that they also have a system with the use first stickers. She said she was unaware that the staff was not following the system. She said the Regional Consulting Manager has trained her. She said the lemon juice stored with the seasonings was for cleaning the stove. She said she had new cups that she used but was waiting on the bleach that she ordered to clean them. She said that the vendor that she used was out of the bleach. She said the bleach normally would get the glasses clean. During an interview on 09/07/23 at 01:37 PM, Dietary [NAME] A said that on the first day (09/06/23), the personal food items in the food preparation area were hers and Dietary Aide A. She said they do not normally eat in the food preparation area, but they were eating there because they were receiving a truck that day. She said the tortilla, chips, and mashed potatoes with meatballs were hers, and the fried dumplings belonged to Dietary Aide A. She said all of them are responsible for ensuring that personal food items are not in the food preparation area. She said they were all responsible for cleaning and ensuring all the food was properly labeled. She said she was not sure why the food was not labeled. She said that all items should be labeled. She said if it was in a box, label the box, but if the food was wrapped individually out of the box, then the food should be labeled individually. She said the dented cans are considered damaged, but they only use those if they are out of the item in regular stock. She said she would only use them in case of an emergency. She said she did not have a hair net and did not wash her hands when she first entered the food preparation area on 09/06/23 because she came in to see who was in the kitchen because sometimes the residents would go in the kitchen. She said she did not think about it because she began talking to the surveyor about the food on the steam table. She said walking into the kitchen without a hair net was not normal. She (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 18 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many said she did not have a reason why she did not wash her hands when she came into the kitchen, and she should have washed her hands immediately when she came into the kitchen. She said she was aware of the food being in the food preparation area, her failure to wear a hairnet, and her failure to wash her hands. She said she was not aware of the unlabeled cauliflower in the refrigerator. She said the potential negative outcome of not wearing a hair net was hair could get in the food or get where it was not supposed to be. She said failure to wash her hands could cause cross-contamination. She said if the food was not stored and labeled correctly, then they, as staff, would not know how long the food had been in the refrigerator. She said she did place the eggs and the sausage in the refrigerator. She said she did not know that she was only supposed to leave the items out for two hours. She said she did leave the eggs and sausage out all day and placed them in the refrigerator for resident consumption. She said a potential negative outcome for leaving those items was that bacteria could have grown inside the eggs. She said she had been trained in food safety, labeling, and storage. During an interview on 09/07/23 at 01:57 PM, Dietary Aide A said he had been trained on food safety, storage, and labeling. He said he was aware that he did not have a hair restraint on his beard. He said he normally does not have a beard and that the facility did not have hair restraints for the beard. He said the potential negative outcome of not restraining hair was the food could get in the food, drinks, and silverware and make the resident sick. He said he was aware of the dented cans in the food pantry and that they are trained to use them if needed. He said, for example, if the recipe calls for peaches and they do not have them in regular stock, they will use the dented cans. He said he could not think of a potential negative outcome related to using dented cans because he had not been trained that this was unacceptable. He said he was one of the staff with his personal food in the food preparation area. He said the fried dumplings were his and knew he shouldn't have had them in the food preparation area. He said the delivery truck was coming and this was why he was eating in the food preparation area and shouldn't have left them there. He said they clean the kitchen and appliances every two to three months. She said the DM would call everyone for a deep clean. He said they were supposed to do a deep clean before the state came. He said the potential negative outcome would be that dust could fall in the resident's food. He said he was responsible for the milk uncovered in the refrigerator. He said he had not been trained to cover up the drink in the refrigerator. He said something could have fallen in the drinks, making the residents sick. He said he did not have any information about the eggs and sausage that were left out because he was responsible for drinks, desserts, and wrapping the silverware. Although he was not responsible, he said leaving food out could make the residents sick. During an interview on 09/08/23 at 11:21 AM, the ADM said the DM was responsible for all activity in the kitchen but that she had been receiving training from the Regional Consultant. He said the DM was responsible for the storage and labeling in the kitchen. He said he was aware and had observed some things in the kitchen, such as food not being labeled, but none of the deficient practices discussed (hair restraints, dirty vents). He said he goes into the kitchen periodically, which was his monitoring system. He said in the past, he was in the kitchen 2-3 times a week, but more recently, not so much. He said he had no documentation to support his visits and observations in the kitchen. He said his expectation was for his kitchen staff to have good sanitation, dented cans should not be used for resident consumption, all food should be dated and labeled, and employees should not eat in the food preparation area. He said he would have to check with his upper management regarding the expectation for the resident refrigerators. During an interview on 09/08/23 at 12:32 PM, the DM said that she was going to the kitchen to hand the cook her timesheet, but then the staff asked her for two pieces of fish. She said she should have had on a hair (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 19 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm net. She said a potential negative outcome would have been hair could get in the food. She said the Dietician visits the facility once a month. She said the Dietician walked through and would tell her anything that she saw wrong in the kitchen area and areas that she needed to fix. She said she received training from the Regional Consultant but that it is difficult sometimes to understand her due to language barrier. She said she wanted additional training but was told she did not need it. Residents Affected - Many During an interview on 09/08/23 at 04:47 PM, the Dietician said she goes to the facility once a month. She said while she was at the facility, she would conduct a walk-through, visit with residents, conduct resident assessments, and make any necessary recommendations and interventions for the residents. She said doing some of her walk-throughs, she did have some of the same concerns about labeling food. She said she discussed this with the DM. She said that she discussed that all food needed to be labeled, even if it was for lunch the same day. She said she had no issues with hair restraints or staff eating their food in the food preparation area. She said she was unaware that the staff was using the dented cans for the residents. She said using dented cans was not good because it was difficult to tell if the can had been compromised. She said the potential negative outcome could have been exposure to botulism (poisoning caused by bacteria). During an interview on 09/08/23 at 05:04 PM, the Regional Consultant said she had been helping the DM because she was new. She said the DM had been doing well and had no issues besides staffing. She said she had conversations with her about cleaning and needed to clean regularly. She said she trained the DM that everything was to be labeled. She said with the new vendor, they received bread weekly, but it should have been labeled. She said she was not aware that they were using the dented cans. She said using the dented cans was bad because the particles from the can could get in the can and make the residents sick. She said she had encouraged the DM to read the policies and procedures because if she did not, the experiences she was going through (experience with the state surveyors) could happen. Record review of the following certifications listed below: Dietary Manager Serv Safe Certification #23870054 completed 04/17/23 with an expiration date of 04/17/28. Dietary Manager successfully completed the standards set forth for the ServSafe Food protection Manager Certification Examination, which is accredited by the American National Standards Institute Dietary Manager 99 cent food handler certification #3FUYJNW completed 07/21/22 with an expiration date of 07/21/24. Dietary Aide A 99 cent food handler certification #G3Y9U completed 01/20/23 with an expiration date of 01/20/25. Dietary [NAME] A 99 cent food handler certification #3GXCV2P completed 09/11//23 with an expiration date of 09/11/25. (Note the completion of this course was after survey exit) Record review of 2022 Food Code U.S. Food and Drug Administration revealed: Chapter 3. Food Condition 3-101.11 Safe, Unadulterated, and Honestly Presented. Sources 3-201.11 Compliance with Food Law. FDA considers food in hermetically sealed containers that are swelled or leaking to be adulterated (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 20 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many and actionable under the Federal Food, Drug, and Cosmetic Act. Depending on the circumstances, rusted and pitted or dented cans may also present a serious potential hazard. 2-402 Hair Restraints 2-402.11 Effectiveness. (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from FDA Food Code 2022 Chapter 2. Management and Personnel Chapter 2 - 22 contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES. 3-602 Labeling 3-602.11 Food Labels. (A) FOOD PACKAGED in a FOOD ESTABLISHMENT, shall be labeled as specified in LAW, including 21 CFR 101 - Food labeling, and 9 CFR 317 Labeling, marking devices, and containers. (B) Label information shall include: (1) The common name of the FOOD, or absent a common name, an adequately descriptive identity statement; (H) EMPLOYEES are using proper methods to rapidly cool TIME/TEMPERATURE CONTROL FOR SAFETY FOODS that are not held hot or are not for consumption within 4 hours, through daily oversight of the EMPLOYEES' routine monitoring of FOOD temperatures during cooling; Record review of the facility's policy titled Operational Policy and Procedure Manual for Long Term Care, undated revealed: Food Receiving and Storage (November 2022) Policy Statement Foods shall be received and stored in a manner that complies with safe food handling practices. Policy Interpretation and Implementation .2. Dry storage may be in a room or area designated for the storage of dry goods, such as single service items, canned goods, and packaged or containerized bulk food that is not PHF/TCS. 3. Dry foods and goods are handled and stored in a manner that maintains the integrity of the packaging until they are ready to use. 4. Dry foods that are stored in bins are removed from original packaging, labeled and dated (use by date). Such foods are rotated using a first in - first out system. Refrigerated/Frozen Storage 1. All foods stored in the refrigerator or freezer are covered, labeled and dated (use by date). .7. Refrigerated foods are labeled, dated and monitored so they are used by their use-by date, frozen, or discarded. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 21 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many .9. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. Preventing Foodborne Illness-Employee Hygiene and Sanitary Practices (Revised November 2022) .9. Soaps, detergents, cleaning compounds or similar substances will be stored in separate storage areas from food storage and labeled clearly. Policy Interpretation and Implementation 1. All employees who handle, prepare or serve food are trained in the practices of safe food handling and preventing foodborne illness. Employees will demonstrate knowledge and competency in these practices prior to working with food or serving food to residents. Hand Washing/Hand Hygiene .6. Employees must wash their hands: c. whenever entering or re-entering the kitchen Hair Nets .15. Hair nets or caps and/or beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens. Sanitization (Revised November 2022) Policy Statement The food service area is maintained in a clean and sanitary manner. .2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. Substitutions (Revised April 2007) .2. All utensils, counters, shelves and equipment are kept clean, maintained in good repair and are free from breaks, corrosions, open seams, cracks and chipped areas that may affect their use or proper cleaning. Seals, hinges and fasteners are kept in good repair. .4. All substitutions are noted on the menu and filed in accordance with established dietary policies. Notations of substitutions must include the reason for the substitution. 5. The food services manager will review the substitutions regularly to avoid recurrences when (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 22 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 possible. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 23 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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: Residents Affected - Some 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. 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 an open coke, leftover takeout, and a bowl of sealed queso cheese. All food was undated. 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. This failure could place resident at risk for food borne illnesses. Findings include: An observation during the duration of the survey (09/06/23-09/08/23) revealed the following: room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. room [ROOM NUMBER] Observed a refrigerator. There was no log present. There was no thermometer present. I observed a bag of nuts and licorice candy that were unlabeled. room [ROOM NUMBER] Observed a refrigerator. There was no log present. There was no thermometer present. room [ROOM NUMBER] Observed a refrigerator. There was no log present. There was no thermometer present. Inside was an open coke, leftover takeout, and a bowl of sealed queso cheese. All food was undated. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 24 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 Level of Harm - Minimal harm or potential for actual harm room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. Residents Affected - Some room [ROOM NUMBER]: Observed a refrigerator. There was no log present. There was no thermometer present. An observation of a parfait, two cokes, an uncovered cookie, and an undated cupcake. During an interview on 09/08/23 at 11:21 AM, the ADM said that family and residents are responsible for cleaning their fridges and monitoring the temperatures. He said although housekeeping would clean the outside, the contents were the residents and their family's responsibility. When asked who would be responsible for resident fridges if the resident was unable to and did not have family, he said the staff would have to. He said the previous company had the staff clean the outside of the fridge, including wiping it down, but not monitoring the temperature. He said he was not sure if this was covered in the policy. He said he was unsure if the residents were told during admission and that this information was not part of the admission packet. He said if the resident's refrigerators were not monitored, the potential negative outcome could be foodborne illness. He said he would have to check with his upper management regarding the expectation for the resident refrigerators. During an interview on 09/08/23 at 12:32 PM, the DM said regarding the residents' refrigerators, the housekeepers are responsible for cleaning the refrigerator inside and out. She said the kitchen staff are not allowed in the residents' room. Record review of the facility's policy titled Operational Policy and Procedure Manual for Long Term Care, undated revealed: Food brought by Family/ Visitors (Revised March 2022) Policy Statement Food brought to the facility by visitors and family is permitted. Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. 4. Safe food handling practices are explained to family/visitors in a language and format they understand. 5. Food brought by family/visitors that is left with the resident to consume later is labeled and stored in a manner that it is clearly distinguishable from facility-prepared food. a. Non-perishable foods are stored in re-sealable containers with tight-fitting lids. Intact fresh fruit may be stored without a lid. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 25 of 26 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675329 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/08/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Levelland Nursing & Rehabilitation Center 210 West Ave Levelland, TX 79336 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0813 b. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Level of Harm - Minimal harm or potential for actual harm Containers are labeled with the resident's name, the item and the use by date. 6. The nursing staff will discard perishable foods on or before the use by date. Residents Affected - Some 7. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger (for example, mold growth, foul odor, past due package expiration dates). 8. Potentially hazardous foods that are left out for the resident without a source of heat or refrigeration longer than 2 hours are discarded. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 26 of 26