Inspection·August 14, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Form 3613-A (Provider Investigation Report), dated 8/05/25, revealed the ADM was notified by LVN B on 08/04/25 at 7:12 PM, of Resident #1's elopement from the facility. Resident #1 had been picked up by a citizen and taken to the police station then escorted back to the facility by police. The resident was assessed and found to have no injuries and did not require medical treatment. A police report was not filed. Resident #1 was placed on one-to-one supervision upon return to the facility and a wander guard device was placed on Resident #1 on 08/06/25. Door alarms were checked and found to be functioning properly. Staff in-services were initiated for ANE, elopement, door alarms, and monitoring of newly admitted residents. Record review of Resident #1's Discharge MDS, dated [DATE], revealed:Section C - Cognitive Patterns - BIMS revealed a score of 0, which indicated the resident's cognition was severely impaired.Section GG - Functional Abilities revealed resident was able to stand from a sitting position and walk 150 feet independently. Record review of Discharge summary, dated [DATE], revealed Resident #1 was discharged to an alternate long term care facility with belongings on 08/08/25. During an interview on 08/13/25 at 1:30 PM, the ADM stated Resident #1 was admitted to the facility on [DATE] around 2:00 PM and eloped approximately 4 (four) hours later. She stated the resident was picked up approximately 400 meters from the facility by a citizen of the community in a private vehicle and was taken to the local police station. The facility was contacted by the police department and an officer escorted Resident #1 back into the facility. The ADM stated Resident #1 was assessed upon return to the facility and was found to have no injuries and had no recollection of leaving the facility. The ADM stated she was made aware of Resident #1's elopement by LVN B via phone on 08/04/25 at 7:12 PM. She stated upon admission, Resident #1 was cognitively impaired and was independently ambulatory. The ADM stated Resident #1 was observed ambulating with her walker around the facility shortly after admission, but Resident #1 did not exhibit exit-seeking behavior by wandering into other rooms, seeking exit doors or verbalizing desire to leave the facility. The ADM stated LVN B took Resident #1 outside to the smoking area with several other residents around 6:00 PM and the residents and staff re-entered the building approximately 15 minutes later, which was the last time Resident #1 was accounted for prior to the elopement. The ADM stated all exit doors to the facility were locked except the front door which was protected by an access code that was not posted. She stated she believed the resident followed a visitor out the front door between 6:15 PM and 6:35 PM. She stated Resident #1 did not look like a resident due to appearing younger than her age and may have been mistaken for a visitor when she exited the facility. The ADM stated one-to-one supervision was implemented for Resident #1 immediately upon return to the facility and the resident was moved to a room closer to the nurse's station for better observation of the resident. She stated in-services were initiated for staff on 08/04/25 for elopement, responding promptly to door alarms, monitoring of newly admitted residents and ANE. She stated in-services continued on 08/05/25 and were completed during a mandatory in-service on 08/08/25. The ADM stated door alarms were checked by maintenance, and all alarms were functioning. She stated the access code was changed on the door as an extra precaution. She stated elopement drills were conducted as part of the in-services. The ADM stated the tool used by the facility to determine a resident's risk for elopement was the Elopement Risk Assessment, which would be used if the resident exhibited exit-seeking behavior. She stated the Wandering Risk Assessment was part of the admission assessment, which was usually completed within 24 hours of admission. The ADM stated the Wandering Risk Assessment alone would not indicate the need for added supervision, unless the resident showed exit-seeking behavior. She stated if there was a concern of a resident being an elopement risk, her expectation of staff would be to ensure resident safety and immediately report the concern to administration. The ADM stated Resident #1 remained on one-to-one (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 2 of 7 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 08/14/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few supervision until alternate placement was obtained on 08/08/25 and the resident was transferred, with family consent, to an accepting facility with a secured unit. The ADM stated a letter was mailed to all family members on or around 08/07/25 as a reminder to ensure resident safety when exiting the facility and a notice was posted on the front door to remind visitors not to allow residents to exit the building without a staff member present. During an interview on 08/13/25 at 2:31 PM, LVN A stated she was on duty from 6 AM - 2 PM on the day Resident #1 was admitted to the facility. She stated the resident was admitted just before shift change around 1:45 PM and she completed initial vital signs and passed the admission on to the oncoming charge nurse (LVN B). LVN A stated she only had Resident #1 under her care for a brief time (approximately 15 minutes) and felt that the resident may need to be watched for wandering or exit-seeking behavior due to being self-ambulatory and appearing confused. LVN A stated during the time Resident #1 was under her care, family members were present in the room, and she did not observe the resident exhibiting exit-seeking behavior. LVN A stated she believed the Wandering Risk Assessment, which was included in the admission assessment, was to be completed within 24 hours of admission, but she was unsure of the exact timeframe. LVN A stated when she returned to duty the next day (08/05/25), Resident #1 was on one-to-one supervision and remained under continuous supervision for the duration of the week until being discharged . LVN A stated she did not observe Resident #1 exhibit exit-seeking behavior at any time during her stay at the facility. LVN A stated she was in-serviced on ANE, elopement, door alarms and monitoring of newly admitted residents upon her return to duty on 08/05/25. During an interview on 08/13/25 at 2:50 PM, LVN B stated she worked weekdays from 2 PM - 10 PM and was on duty the day Resident #1 was admitted to the facility. She stated LVN A obtained Resident #1's vital signs and passed the admission process on to LVN B, due to it being shift change. LVN B stated she entered Resident #1's room at approximately 2:45 PM and observed the resident sitting in the room holding a baby doll with family member present in the room. She stated she completed the physical assessment of Resident #1 before beginning medication pass. She stated Resident #1 was observed ambulating in the hallway during the medication pass. LVN B stated the resident looked younger and had good mobility and did not have the appearance of a resident. She stated she spoke with the ADM in the hallway and discussed that Resident #1 looked like a visitor and was ambulating throughout the facility but had not exhibited exit-seeking behavior. She stated Resident #1's tray went to her room and her family member left just prior to the meal being served but did not inform staff he was leaving. She stated after the evening meal, around 6 PM, Resident #1 was still ambulating in the facility, so she took Resident #1 outside with her and another resident to smoke. She stated the residents, and staff re-entered the building approximately 10 - 15 minutes later and Resident #1 was seen ambulating near the nurse's station. LVN B stated she had another admission and went into a room to check on another resident. She stated CNA C was down the hall and had just started her shift (6pm-6am) and should have been told in report by CNA D to check on Resident #1, but she could not say if the information was passed on or not. LVN B stated sometime after 6:30 PM she received a phone call from the local police department that Resident #1 had been brought to the police station and that the resident would be escorted back to the facility by an officer. LVN B stated she immediately notified the ADM, the physician and Resident #1's family member. No new orders were received. Resident #1 was returned to the facility, accompanied by a police officer. LVN B stated she assessed Resident #1, and she was found to have no injuries, and her vital signs were stable. She stated Resident #1 did not recall leaving the facility. Resident #1 was immediately placed on one-to-one supervision and did not show signs of exit-seeking following the elopement. LVN B stated she did not believe that Resident #1 knew where the exit doors were located in the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 3 of 7 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 08/14/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few facility, and she did not observe the resident to go to a door or verbalize the desire to leave the facility. LVN B stated she completed an Elopement Risk Assessment when the resident returned to the facility and she completed the admission assessment the following day, which was within 24 hours of admission. LVN B stated Resident #1 was on continuous one-to-one supervision during the duration of her stay and a wander guard device was added once the order and consent were obtained. LVN B stated she was in-serviced on ANE, elopement, door alarms and monitoring of newly admitted residents on 08/04/25. During an interview on 08/13/25 at 5:14 PM, the ADON stated Resident #1 was admitted in the afternoon on 08/04/25. She stated the facility got three admissions that day and she and the DON assisted to enter Resident #1's medications and diagnoses into the computer but she did not personally observe or assess Resident #1 on the day of admission. The ADON stated she was made aware of Resident #1's elopement by the DON via phone call at approximately 7:30 PM on 08/04/25. She stated she was not aware of any staff member having concerns about Resident #1 wandering or being a flight risk. She stated she did not direct staff to implement added supervision of Resident #1 and, to her knowledge, no one else in administration directed staff to add extra supervision, because the resident was not trying to leave the facility. The ADON stated she was responsible for conducting staff in-service training following the elopement and she began in-services immediately with direct care staff on 08/04/25 and continued on 08/05/25. She stated a mandatory in-service was held on 08/08/25 at approximately 2:30 PM to in-service the remainder of staff on the following: ANE, elopement, responding to door alarms promptly, and monitoring newly admitted residents. During an interview on 08/13/25 at 5:27 PM, the DON stated Resident #1 was admitted from home on [DATE] around 2:00 PM. She stated LVN A was on duty when the resident admitted to the facility, but she only got the resident's vital signs then passed the care of the resident on to LVN B due to shift change. She stated she observed Resident #1 in her room later that same day but did not personally observe Resident #1 ambulating outside the room. The DON stated she was not made aware of any staff concerns for Resident #1 wandering or exit-seeking and she did not direct staff to implement checks that were more frequent than the standard two-hour checks, per facility policy. She stated she was informed of Resident #1's elopement via phone call from LVN B in the evening of 08/04/25. The DON stated Resident #1 was immediately placed on one-to-one supervision upon return to the facility and a CNA was called in to assist with supervision that evening. The DON stated Resident #1 did not exhibit exit-seeking behavior following the elopement and remained on continuous supervision until her discharge on [DATE]. During an interview on 08/13/25 at 6:06 PM, CNA C stated she worked the evening shift on the day Resident #1 was admitted . She stated she was told in report by CNA D to watch the new resident and she observed the resident walking in the hallway sometime after 6 PM, when the resident came in from the smoking area with LVN B. CNA C stated she informed LVN B she was going to shower a resident. She stated she did not see Resident #1 again until she returned to the facility with the police, and she was not told by LVN B to conduct more frequent checks on Resident #1. CNA C stated she did not know whether LVN B told CNA D to conduct more frequent checks on Resident #1. She stated she did not observe Resident #1 wandering into other rooms and did not observe any exit-seeking behavior by the resident. She stated she would have informed her charge nurse if she had seen Resident #1 trying to get out. CNA C stated she observed Resident #1 on one-to-one monitoring with another CNA when she returned to the facility and she had been in-serviced on elopement, door alarms, ANE and monitoring new residents on 08/05/25. During an interview on 08/13/25 at 7:40 PM, CNA D stated she was on duty on the day shift on 08/04/25 when Resident #1 was admitted . She stated she was on break when the resident first came in and initially saw her in her room. CNA D stated she observed Resident #1 ambulating in the hallways with (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 4 of 7 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 08/14/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few her walker, carrying a baby doll. She stated the Resident #1 interacted with others who spoke to her when she was walking in the hallways, but she did not observe the resident enter other resident's rooms or look for the exit door. CNA D stated she did not hear Resident #1 verbalize the desire to leave the facility and she observed LVN B checking on Resident #1 frequently. She stated she was told by LVN B to look out for the resident and make sure she is OK, but she was not instructed by LVN B to do more frequent checks on the resident. She stated there was no extra documentation or extra checks implemented on Resident #1 until after the elopement. CNA D stated she told CNA C in report to keep an eye on the new resident but did not state that the resident needed to be monitored at set times. She stated Resident #1 was confused but did not exhibit exit-seeking behavior and stated she was surprised when she was informed Resident #1 had left the facility. CNA D stated in order for her to do more frequent checks on a resident and document the checks, she would need to be instructed by her charge nurse or the DON or ADON to initiate the checks. CNA D stated she observed Resident #1 on one-to-one supervision when she returned to work the following day. She stated she was in-serviced on ANE, door alarms, elopement and monitoring of new residents upon reporting to work on 08/05/25. During a phone interview on 08/14/25 at 10:18 AM, the Community Member stated she was driving at approximately 6:35 PM on 08/04/25 about a block or two from the nursing facility when she saw Resident #1 walking with her walker down the street and carrying a blanket and a baby doll. She stated she turned around and asked the resident if she needed a ride and the resident stated, I need to go home. The Community Member stated Resident #1 got into the back seat of her car and she put her walker in the trunk and drove the resident around the block looking for her house. The Community Member stated Resident #1 had no idea where her home was, so she called the police department and was told to bring the resident to the station. She stated an officer met them in the parking lot and had placed a call to the nursing facility prior to their arrival at the station. She stated the officer followed her to the facility and escorted the resident back into the facility. The Community member stated the resident did not appear to be in distress or overheated when she picked her up and the resident remained in the air-conditioned vehicle from the time she picked her up until she was escorted back into the facility by the officer. During a follow-up interview on 08/14/25 at 11:28 AM, the DON stated the Wandering Risk Assessment was initiated for Resident #1 on 08/04/25 and was completed on 08/05/25, which was within the expected 24-hour time frame. She stated a high score on the wandering assessment would not indicate the automatic need for extra supervision of a resident. She stated she did not feel that Resident #1 would have required more than q 2-hour checks, even if her Wandering Assessment score was high, because the resident was not actively seeking to exit. She stated each resident was assessed on an individual basis and her expectation of staff would be to assure resident safety and report to nursing administration if there was a concern for any resident to be a flight risk and to complete an Elopement Risk Assessment if the resident was exhibiting exit-seeking behavior. The facility implemented the following interventions from 08/04/25 - 08/08/25: Record review of Resident #1's Comprehensive Care Plan, dated 08/05/25, revealed:Focus: Resident #1 is an elopement risk/wanderer related to history of attempts to leave facility unattended, impaired safety awareness; resident wanders aimlesslyGoal: The resident's safety will be maintained through the review date.Interventions: Distract resident from wandering by offering pleasant diversions, structured activities, food, conversation, television, books. Identify pattern of wandering. Intervene as appropriate. Record review of the facility document for Missing Resident/Elopement Monitoring revealed daily monitoring of door locking mechanism and alarm functioning on exit doors from 08/04/25 through 08/13/25. Record review of the facility in-service training on 08/04/25 for Verbal/Exploitation/ Neglect/ Abuse (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 5 of 7 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 08/14/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few Policy and Protocol/Resident Rights reviewed ANE definitions and reporting and was signed by 23 staff members. Record review of the facility in-service training on 08/05/25 reviewed reporting any potential ANE to the ADM or DON immediately and was signed by 23 staff members. Record review of the facility in-service training on 08/05/25 reviewed Elopement and Exit Seeking Protocol and was signed by 30 staff members. Record review of the facility in-service training on 08/05/25 reviewed Door Alarm Protocol and was signed by 26 staff members. Record review of the facility in-service training on 08/05/25 reviewed Monitoring New Admits and was signed by 31 staff members. An observation on 08/13/25 at 1:26 PM revealed the front door required a keypad access code for entrance or exit to and from the facility. The access code was not visibly posted and required a staff member to enter code. During an observation on 08/13/25 at approximately 4:30 PM, the ADM tested staff response to the front door alarm sounding. Surveyor observed several staff members respond to the front door area within one minute of alarm sounding and check to see if any residents were in the area near the door. Record review of an undated letter which was sent on 08/07/25 via USPS mail to all family members revealed a reminder when visiting the facility, to be aware of residents near the doors who may be attempting to exit the facility unsupervised. The letter further reminded family members not to share the door access code, and to ensure the door closes securely when exiting. Record review of documentation of one-to-one monitoring for Resident #1 from 08/04/25 - 08/08/25 revealed staff signed for whereabouts of Resident #1 every 15 minutes beginning on 08/04/25 at 7:30 PM through 08/08/25 at approximately 5:00 PM, when Resident #1 was transferred out of the facility. During an interview on 08/13/25 at 1:30 PM, the ADM stated on 08/05/25, all residents who were known to have exit-seeking behavior were reviewed and monitored through elopement assessments and wander guard system checks. She stated wander guard drills were conducted as part of the in-services for elopement. During an interview on 08/13/25 at 5:14 PM, the ADON stated she was responsible for conducting staff in-service training following the elopement and she began in-services immediately with direct care staff on 08/04/25 and continued on 08/05/25. She stated a mandatory in-service was held on 08/08/25 at approximately 2:30 PM to in-service the remainder of staff on the following: ANE, elopement, responding to door alarms promptly, and monitoring newly admitted residents. The ADON stated all disciplines of staff were in-serviced and any staff on leave would be in-serviced prior to returning to work. During an interview on 08/13/25 at 2:31 PM, LVN A - day shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/13/25 at 2:50 PM, LVN B - evening shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/13/25 at 6:06 PM, CNA C - evening shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/13/25 at 7:40 PM, CNA D - day shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/14/25 at 3:05 PM, the Director of Rehabilitation stated he had been in-serviced by the ADON on 08/08/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/14/25 at 3:39 PM, CNA E - day shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/14/25 at 3:48 PM, CNA F - day shift, stated she had been in-serviced by the ADON on 08/05/25 regarding elopement, monitoring new admissions for (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675329 If continuation sheet Page 6 of 7 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 08/14/2025 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 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete exit seeking behavior, responding promptly to door alarms, and ANE. During an interview on 08/14/25 at 3:54 PM, CNA G - day shift, stated she had been in-serviced by the ADON on 08/08/25 regarding elopement, monitoring new admissions for exit seeking behavior, responding promptly to door alarms, and ANE. Record review of the facility's policy titled Wandering and Elopements, Revised March 2019 revealed: Policy StatementThe facility will identify residents who are at risk of unsafe wandering and strive to prevent harm while maintaining the least restrictive environment for residents. Policy Interpretation and Implementation1. If identified as at risk for wandering, elopement, or other safety issues, the resident's care plan will include strategies and interventions to maintain the resident's safety.4. When the resident returns to the facility the director or nursing services or charge nurse shall: a. examine the resident for injuries; b. contact the attending physician and report findings and conditions of the resident; c. notify the resident's legal representative (sponsor); . f. document relevant information in the resident's medical record. The noncompliance was identified as PNC. The IJ began on 08/04/25 and ended on 08/08/25. The facility had corrected the noncompliance before the survey began. Event ID: Facility ID: 675329 If continuation sheet Page 7 of 7