Levelland Nursing and Rehabilitation: Elopement Jeopardy - TX
Federal inspectors who arrived at the facility on August 14 found that the lapse had already been classified as Immediate Jeopardy, the most serious level of harm CMS assigns, one that signals a situation likely to cause serious injury or death. The finding covered the period from August 4 through August 8, when the facility completed corrective training.
The elopement itself is the event that set everything in motion. A resident left the building. The inspection report does not describe how far they got, what condition they were in when they returned, or whether they were injured. What it does describe is the gap that made the elopement possible and the four days that followed before anyone addressed it.
The facility's own policy, last revised in March 2019, laid out exactly what was supposed to happen. Staff were to identify residents at risk for wandering before problems developed. Care plans were to include specific strategies for those residents. When a resident returned after an elopement, a nurse was supposed to examine them for injuries, the attending physician was to be contacted, and the resident's legal representative was to be notified. Everything was to be documented.
Whether those steps were followed after the August 4 incident, the inspection report does not say. What it does say is that the staff on the floor had not been trained on elopement prevention, on monitoring new admissions for exit-seeking behavior, or on responding promptly when door alarms sounded.
The training happened on August 8. CNA G, a day-shift nursing assistant, told inspectors during an interview on the afternoon of August 14 that the assistant director of nursing had pulled staff together four days after the elopement and gone through all of it: elopement, exit-seeking behavior, door alarms, and abuse, neglect, and exploitation. That in-service, the report indicates, is what ended the Immediate Jeopardy period.
The inspectors arrived six days after that training. By then, the facility had corrected the noncompliance, and the IJ designation had been lifted before the survey even began. That timing matters under federal inspection rules. A facility that resolves an Immediate Jeopardy finding before surveyors arrive still receives the citation, but the correction is noted in the record.
What the record does not resolve is the question of the resident who left on August 4. The inspection report is silent on their identity, their diagnosis, whether they had a history of exit-seeking behavior, and whether they were a new admission being monitored under the facility's own protocols. It is silent on where they were found and how long they were outside. It notes only that the IJ began the day they left.
Door alarms at nursing facilities are a last line of defense. They are loud by design, meant to give staff seconds to respond before a resident reaches a parking lot, a street, or weather that can kill a person who is confused and underdressed. An alarm that goes unanswered because the person nearest the door was never told to treat it as urgent is not a functioning safety system. It is a noise.
Levelland Nursing and Rehabilitation sits in a West Texas city of roughly 13,000 people. August in that part of the state means temperatures that regularly exceed 100 degrees. The inspection report does not say whether the resident who eloped on August 4 was outside in that heat, or for how long, or what the temperature was that day. It does not say whether they were found quickly or not.
The facility's policy language, written in the careful passive voice of institutional documents, describes a system that works when everyone knows their role. The charge nurse examines. The physician is contacted. The family is called. The record is updated. What the August 4 elopement revealed is that the people closest to the doors, the CNAs on the floor, had not been told clearly enough what their role was.
Four days later, they were.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Levelland Nursing and Rehabilitation Center from 2025-08-14 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 18, 2026 · Our methodology
Levelland Nursing and Rehabilitation Center in Levelland, TX was cited for violations during a health inspection on August 14, 2025.
The finding covered the period from August 4 through August 8, when the facility completed corrective training.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.