Inspection·November 5, 2025

F 0729 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure it received registry verification for 1 (CNA A) of 5 employees reviewed for registry verification prior to allowing an applicant to serve as a nurse aide. The facility failed to ensure CNA A had a current nurse aide certification while employed at the facility, while actively providing care for residents. This failure could result in residents being provided care by staff who have not provided documentation of training and competency in providing care. Findings included:Record review of CNA A's personnel file reflected a date of hire of [DATE]. The last Employability Stats Check Search that was completed on [DATE] reflected CNA A's NAR status would expire on [DATE]. There were not any disciplinary action forms in the personnel file reflecting any concerns with resident care. Record review of CNA A's time punch detail dated [DATE] reflected CNA A clocked in and worked from 9:57 PM until 6:07 AM. During an interview on [DATE] at 2:35 PM the DON stated that there was a concern with CNA A's nurse aide certificate. She stated that CNA A came to the facility or called her on Friday [DATE] that she needed help with her certificate. The DON stated she explained to CNA A she would need to go to the facility, and she would help her. She stated on Monday [DATE] CNA A went to the facility and handed her a paper that showed her certification expired on [DATE]. She stated she told the ADM that CNA A's certificate expired [DATE] and she would remove her from the schedule. She stated the ADM told her she would speak to the HR Manager to see about HR running the checks yearly. She stated the last day CNA A worked was Thursday [DATE]. She stated there were not any complaints or written warnings pertaining to resident care for CNA A during the time she worked at the facility after the certification expired. During an interview on [DATE] at 3:10 PM the ADM stated on Friday [DATE] it was brought to her attention by HR Manager that CNA A's certification had expired. She stated the HR Manager should have been doing the checks. She stated once it was brought to her attention on [DATE] she put a PIP in place and held an off-cycle QAPI Meeting. She stated that the plan of correction was for the HR Manager to complete a full audit of license by [DATE]. The DON would keep a binder of all nursing licensure and will review monthly for compliance. The DON/ADON will provide notification to nursing staff 60 days prior to the licensure expiration. The DON/ADON will provide any assistance needed to renew the licenses or certification. That she will monitor and make any changes as needed. She stated CNA A had not worked since they found out her certificate expired. During an interview on [DATE] at 3:20 PM the HR Manager stated the previous ADON and DON were the ones that were keeping up with checking for renewals for the CNAs. She did the annual reviews for Criminal History EMR and Licensing and the initial check for hiring staff. She stated in the last 5 months the facility had a new DON and ADON. She stated she was not aware that the new DON and ADON did not take over the job of checking the renewals. She stated the CNA A told her something about going on Tulip and her CNA certificate. She stated she went in Tulip and pulled up the certificate and saw it had expired, and she immediately notified the DON. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675329 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 11/05/2025 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)