Health inspection·August 7, 2024

F 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few her to work. She stated she signed the paperwork at the facility today to have her background checked and to show that she had been trained regarding ANE. She said her training included shadowing another CNA. She said she believed the ADM and the DON were responsible for completing her background before working. During an interview on 08/07/24 at 1:59 PM, Hospitality Aide B stated she signed the ANE contract and was told on 08/07/24 that her background would be completed. She said that her background had not been completed, nor had she signed the ANE checklist before 08/07/24. She stated she did not know why it was important to have her background checked prior to working with residents. She stated that she did not have a criminal background. During an interview on 08/07/24 at 2:04 PM, the DON stated the potential negative outcome of not checking the two hospitality aides' backgrounds before they worked at the facility was that they could be felons and potentially hurt the residents. She stated she would have to look at the facility policy. Still, she assumed it stated that anyone working at the facility had to have their background checked before working with the residents. She also stated it included hospitality aides. She stated she was unaware that the two hospitality aides' criminal backgrounds had not been completed before they worked. She stated she had observed the two aides working around residents but not providing personal care. She stated they don't provide actual care to the residents but have access to the residents. She stated the ADM was usually responsible for completing the criminal background, EMR, and NAR on all staff at the NF. She stated the Former ADM left on 08/02/24, and the ADM came on 08/05/24. She stated that the outside party did not complete a criminal background, EMR, and NAR because she asked the Career Consultant about it and said she had not. The DON stated she did not know how long the two aides had been working at the facility because ADON usually handled the workers that came from the outside party. She said the purpose of completing criminal backgrounds, EMR, and NAR was to keep residents safe. She stated they did not complete the criminal background because they thought the outside party ran them. She said the system to monitor criminal backgrounds, EMR, and NAR checks was the ADM conducted them all. She stated no one outside of the Former ADM ran the checks. She said she had been trained to ensure that all workers' backgrounds were checked. During an interview on 08/07/24 at 2:13 PM, the ADM said the potential negative outcome of not completing criminal backgrounds, EMR and NAR was potential harm to the residents at the facility. She said the purpose of completing the checks on staff before they worked at the facility was to hire good employees. She said they didn't want someone with a history of violence, people with assault records, or criminal records. She said she was unaware that the two hospitality aides' backgrounds had not been completed and that they had hospitality aides at the facility. She stated that she was unaware of the program with the outside party and how it worked. She said she had been at the facility for only three days. She said the system to monitor criminal background checks was the Former ADM who ran the checks. She said she had been trained to have all workers' criminal backgrounds checked before working around residents. She said this included hospitality aides and volunteers. She said she had not observed the hospitality working with residents but had observed them making beds. She initially said the reason the system failed was because of the change in administrators but later stated that this may not have been the reason since the hospitality aides had been working before the transitions of administrators, so she did not have a reason why the criminal background, EMR, and NAR were not completed. She stated that the criminal backgrounds of hospitality aides should have been checked before they worked, and this was her expectation. In her experience as an administrator, she said the human resources department was responsible for ensuring the criminal background checks were done. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 2 of 4 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 08/07/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 08/07/24 at 3:55 PM, the ADON stated the two hospitality aides had been working at the facility for a month. She said she gave the information to complete the criminal background, EMR, and NAR to the Former ADM. She stated she was unaware that the criminal background had not been completed. She stated that she signed a timecard for the hospitality aides every Friday and did not keep a copy of it. She said the potential negative outcome was they would not know if the staff had been convicted or arrested for anything that could result in the staff not providing adequate care to the residents. She stated that the system to monitor criminal background checks was once a person was hired, and the staff identification cards, and social security cards were provided to the administrator. She stated that the Former ADM would then tell them that the staff was clear about proceeding with the hiring process. She stated the two hospitality aides were hired through an outside party. She said that she observed the hospitality aides working, and they do not provide direct patient care. She said they pass ice, make beds, pick up linen and trash. She said they could answer call lights. She said the hospitality aides worked Monday through Friday, 7- 3 AM when she worked so that she could monitor them. She confirmed that they worked on 08/07/24 and that she was off on 08/07/24. She said the Former ADM was responsible for completing the criminal background, EMR, and NAR checks. She stated she had no reason why the check was not completed. During an interview on 08/07/24 at 4:00 PM, the BOM stated that she ran the two hospitality aides' criminal history, EMR, and NAR on 08/07/24. She was unaware that the criminal backgrounds had not been completed for the two hospitality aides. She stated the Former ADM was responsible for completing the checks on all staff, and when he left, that duty had been passed to her. She stated she was not told this until 08/07/24. She stated the ADM told her to complete the background checks on the hospitality aides. She said the potential negative outcome was that the staff could have had a criminal background or penal code that barred them from working with residents. She said this could have affected the residents because the staff could have had a history of harming residents. She stated that it was not done because the hospitality aides came from an outside party that pays their wages, and it was thought that it was done. She said she had been trained that all staff, including hospitality aides, should have their criminal history completed. She stated there were no exceptions to this rule. She said working with the Former ADM was the first time the administrator ran the criminal history checks. She stated that there were no issues when she ran the background check. During an interview on 08/07/24 at 4:07 PM, the Human Resource Representative stated she was unaware that two hospitality aides who had not had their criminal history checked were working at the facility. She said she was not physically housed at the facility and worked from home. She stated she does not complete background checks for the facility but was responsible for corporate duties such as training the business office manager and payroll. She stated that the human resource person at the facility was the Former ADM. She said she was unsure who was completing the background checks at the facility. She stated that the potential negative outcome was that the facility could hire someone who should not be there, which could be detrimental to the residents. She said this expectation had no exceptions, and all staff's criminal background should be completed. During an interview on 08/07/24 at 4:14 PM, the Former ADM stated he did not complete their background because he was not officially theirs and had been hired through an outside party. He stated that he treated the hospitality aides like agency staff. He stated all he did was interview them. He stated the hospitality aides have been working since the end of May 2024 or the beginning of June 2024. He stated it was entirely his fault because he assumed the outside party did all the paperwork and ran background checks on the hospitality aides. He stated the potential negative outcome was the staff could have had allegations of abuse and convictions, and this (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 3 of 4 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 08/07/2024 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 0607 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few could affect the residents because they could potentially be abused. He said he thought the criminal background checks had been done and expected all staff, with no exceptions, to have their criminal history checked. He stated the ADM and business office completed the checks before the residents worked. The Former ADM stated he did not feel that their system failed but that he treated the hospitality aides as if they were agency staff, and they were not. He stated he would have completed them once they were certified and hired as official staff at the nursing facility. During an interview on 08/07/24 at 4:23 PM, the Career Consultant stated she was a career consultant for the outside party. She said the only thing they did was pay the wages for the staff, but it was up to the employer to complete the additional checks, such as criminal background, if that was a requirement for employment. She stated she did not remember if she had a specific conversation with the Former ADM but said if he brought it up, she would have told him they did not complete criminal background checks. She said the application process asked them if they had been convicted of a crime. She said that the staff could be dishonest and there was no way to confirm. Record review of the facility policy, Credentialing of Nursing Services Personnel, revised May 2019 revealed: Policy A copy of all documents obtained during the verification and background check are filed in the employee's personnel file. Such records are filed accordance with current federal and state laws and facility policy to protect the confidentiality of information. Record review of Hospitality Aide A's EMR report revealed that it was completed on 08/07/24 at 1:20 PM and no results found. Record review of Hospitality Aide A's NAR report revealed that it was completed on 08/07/24 at 2:10 PM and no results found. Record review of Hospitality Aide A's EMR report revealed that it was completed on 08/07/24 at 1:04 PM and no results found. Record review of Hospitality Aide B's EMR report revealed that it was completed on 08/07/24 at 1:19 PM and no results found. Record review of Hospitality Aide B's NAR report revealed that it was completed on 08/07/24 at 2:11 PM and no results found. Record review of Hospitality Aide B's EMR report revealed that it was completed on 08/07/24 at 1:03 PM and no results found. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 4 of 4