Health inspection·April 20, 2023

F 0727 Level of Harm - Minimal harm or potential for actual harm Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis. Based on interview and record review the facility failed ensure, except when waived, to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Residents Affected - Some -The facility failed to ensure there was RN (Registered nurse) coverage on 1/8/23, 1/14/23, 1/21/23, 1/22/23, 2/4/23, 2/5/23, 2/26/23, 3/11/23, 3/12/23, 3/18/23, 3/19/23, 3/25/23, and 03/26/23. This failure could place residents at risk of not having their nursing and medical needs met. Findings Included: During an interview with the DON on 04/06/2023 at 10:05 AM, she stated she normally worked MondayFriday, 8AM-5PM. She stated she works during the week and when available she works on the weekends. She stated the facility recently hired two RNs for the weekends. She stated for about 2 months, she was the only RN working at the facility. She stated during the times she was not physically at the facility; she was available by phone. She stated she signed a shift sign-in sheet on the days she was able to work on the weekends. She stated she did not really think there was a risk of her not being physically at the facility because she resided about 5 minutes from the facility, and she was always available to come in whenever needed. During an interview with the ED on 04/06/2023 at 10:45AM, she stated she has been employed at the facility for a few months. The ED stated there were 3 RNs (DON and 2 additional RNs) that were employed at the facility. She stated the DON works during the week and the two RNs rotate on the weekends. She stated one of the RNs will work their first shift starting on the upcoming weekend. The ED stated prior to hiring the additional RNs, the DON was the only RN employed at the facility. She stated the DON worked 7 days a week until additional RNs were hired. The ED stated the facility did not have a RN waiver. During an interview with HR on 04/06/2023 at 11:10AM, she stated the DON was the only RN working at the facility for about two months. She stated the DON work during the week and on some weekends. She stated the DON signed a shift sign on sheet on the days that she worked at the facility. She stated the facility had another RN working previously but that person quit. She stated they had been in the process of hiring additional RNs. She stated the risk of not having a RN 7 days a week was possible accidents. Record review of the facility sign-in reports revealed RN's coverage was not provided on the following dates: 1/8/23, 1/14/23, 1/21/23, 1/22/23, 2/4/23, 2/5/23, 2/26/23, 3/11/23, 3/12/23, 3/18/23, 3/19/23, 3/25/23, and 03/26/23. Page 1 of 10 676264 676264 04/20/2023 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0727 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's undated Nursing Services and Sufficient Staff policy stated, Except when waived, the facility must use services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. Residents Affected - Some 676264 Page 2 of 10 676264 04/20/2023 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 one of one kitchen reviewed for food service safety, in that: The failure could place residents at risk of foodborne illness. -Staff personal items were stored with resident's food. -Items were not dated Findings include: Observation of the kitchen on 04/05/2022 at 8:15 AM, revealed 20 oz Coca Cola bottle of soda half empty in the refrigerator, no name or date, 1 can of Monster Energy Drink and 2 can sodas of Dr. Pepper in the refrigerator. During an interview on 04/05/2023 at 10:51AM with the Dietary Manager, he stated he had been employed at the facility for about 2 weeks. He stated the staff was to place their personal items in their lockers and stated they should not have their items placed with residents' items. He stated he will let the staff put their lunch in the refrigerator with the residents food, but if it was there longer than 30 minutes, he would throw the items away. He stated all items should be labeled and dated. He stated he was responsible for ensuring that staff items and resident items were kept separate. He stated the risk of keeping the items together could cause sickness or infection if the residents were served the wrong items. Record review of the facility's Cleaning & Sanitation of Refrigerators and Freezers on Units dated October 1, 2018, stated, Only residents food will be stored in the pantry refrigerators. All food will be labeled, dated, and covered. 676264 Page 3 of 10 676264 04/20/2023 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 2 residents (Resident #27) reviewed for indwelling catheter care. 1. Resident #27's indwelling catheter bag was undated. 2. Resident #27's electronic data chart had not record of indwelling catheter's last change or placement date. This deficient practice placed 2 residents who require indwelling catheter care and 86 residents who require electronic data charting at risk for errors in care and treatment. Findings include: Record Review Face Sheet dated 04/06/23 revealed Resident #27 is a [AGE] year-old male admitted to the facility on [DATE]'s diagnosis was Sepsis, Unspecified Organism, Personal History of Urinary Calculi, Neuromuscular Dysfunction of Bladder, Unspecified, and Benign Prostatic Hyperplasia without Lower Urinary Tract Symptoms. Record Review Resident #27's Care Plan last updated 04/03/23 revealed Resident had a supra-pubic catheter related to neurogenic bladder and benign prostatic hyperplasia, a urinary tract infection related to chronic super-public catheter, had bowel incontinence, an ADL self-care performance deficit relating to limited mobility, limited physical mobility relation to generalized weakness and activity intolerance, and a cognitive communication deficit related to cognitive decline. Record Review of Order Summary Report dated 04/06/23 for Resident #27 revealed: Suprapubic foley catheter 16fr, 10ml change every 30-days and PRN when needed. Order date: 02/10/23 Foley output every shift, may flush foley catheter as needed, Record Review of Matrix Dated 4/4/23 revealed Resident #27: Indwelling Catheter, Intravenous Therapy, and UTI. Interview on 04/05/23 at LVN D stated he is Resident #27's nurse. He looked in PCC and seen that an ADON put in an order for the resident's foley to be changed every 30-days today. He does not know who changed the bag or what day it was changed. Interview on 04/05/23 at 03:55 PM, Interview DON stated Resident #27's catheter was changed last week after two aids brought to her attention that the resident had pulled out his catheter. She stated she will locate in notes and provided the exact date and time. Interview on 04/05/23 at 03:59 PM Interview ADON stated she updated Resident #27's order today to 676264 Page 4 of 10 676264 04/20/2023 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0842 Level of Harm - Minimal harm or potential for actual harm change the foley bag every 30-days, during a routine audit. She stated that the catheter was not changed today. Interview on 04/05/23 at 04:13 PM DON stated that there is no nursing notes for when Resident #27's catheter was changed last. Residents Affected - Few Interview on 04/05/23 at 04:27 PM DON stated that the physician order to change the catheter every 30-days and PRN was received and entered today. She stated she spoke to LVN E who looked in her handwritten notes and found that she performed Resident #27's standard pubic catheter change 3/24/23. She stated that LVN E should have logged the catheter change notes into PCC and dated the actual catheter bag. She stated that LVN D is a new LVN and a new LVN with the facility. She stated that the risk of not charting the resident's catheter change could result in the catheter being in too long and causing increased risk of infection for the resident. She stated LVN D just came out of orientation training and will be in-serviced on documentation. DON apologized for the omission and stated that LVN D will change out the resident's bag only today and date it. Interview on 04/06/23 at 10:11 AM LVN E stated she has worked with the facility since 01/15/23. She stated this is her first LVN position and she has only been a LVN 3-months. She stated she completed orientation and was asked to look at Resident #27's catheter care after the catheter tubing had been pulled out. She stated she performed the catheter changed but did not complete the electronic charting. She stated she is new to documentation and just learned today that she was supposed to do the documentation after performing the care. She stated that the importance of documenting the catheter changes in the resident's electronic data chart and on the physical foley bag ensures that the catheter is not in longer than needs to be, know when the 30-days is up to change it, and other staff know when the foley is due to for change. She stated in addition if the catheter is not changed timely, it puts the resident at risk for infection, and internal infection even greater than lesser. Record Review of Catheterization of a Male Policy: 9. Documentation of the procedure shall include: The type of catheter inserted, including French size and balloon size. B. Amount of fluid used of inflation, C. Ease of insertion or any problems, such as resistance, bleeding, or pain. D. Amount and description of the urine return. E. Resident's response to the procedure. Record Review Catheter Care dated 2021 Both: 24. Document care and report any concerns noted to the nurse on duty. 676264 Page 5 of 10 676264 04/20/2023 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0880 Provide and implement an infection prevention and control program. 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 an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 1 resident observed for blood glucose monitor for (Resident #42) and 1 of 1 resident observed for feeding assistance (Resident #28). Residents Affected - Some 1. LVN D failed to properly change gloves and wash or sanitize hands after providing blood glucose monitor to Resident #42. 2. CNA B failed to properly wash or sanitize her hands after scratching her head while providing feeding assistance to Resident #28. This deficient practice placed 1 of 1 resident who received frequent blood glucose monitoring and 1 of 1 resident require feeding assistance at risk for cross contamination and/or spread of infection. Findings include: Review of the Facesheet dated 04/06/23 revealed Resident #42 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Diabetes Mellitus with Diabetic Neuropathy, Bipolar Disorder, Combined Systolic (Congestive) and Diastolic (Congestive) heart Failure, Chronic Obstructive Pulmonary Disorder, Hypothyroidism, and Alzheimer's Disease. Record Review of the most recent MDS dated [DATE] revealed Resident #42's cognitive skills for daily decision making were intact. Resident #42 primary medical condition was Medically Complex Condition: Diabetes Mellitus. Record review of the Care Plan dated 12/14/22 revealed Resident #42 had a history of chronic pain related to diabetic neuropathy. Record review of the Physician Order dated 06/22/22 revealed Resident #42 had blood sugar checks twice daily for lab monitoring. During an observation on 04/5/23 at 09:00 AM, LVN D who performed an accucheck (test to obtain blood sugar level for diabetic residents) on Resident #42. LVN D performed hand hygiene before donning gloves and entered the room to perform procedure, he wiped residents' finger with alcohol, pricked the finger, performed the accucheck and wiped the blood off the finger after the procedure. He then walked out of the room with the gloves still on and started touching many areas of the medication cart including drawers and top of cart prior to taking gloves off. During an interview on 04/05/23 at 10:00 AM, LVN D stated when doing an accucheck complete wash hands, get accucheck ready, clean it, go in room, put on my gloves, would have dry gauze alcohol pad, wipe finger, prick finger wipe first blood, do check, after done with reading, wipe finger with gauze, then remove gloves when complete and do hand hygiene before leaving room. During an interview on 04/05/23 at 02:17 PM , LVN D stated he has worked PRN with the facility for a month and as a LVN for 8 years. He stated that after performing Resident #42's glucose blood check 676264 Page 6 of 10 676264 04/20/2023 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some he walked out of the resident's room before doffing and performing hand sanitation because the shot disposal box is attached it his cart located outside the resident's room. He stated looking back, he realized that once he disposed of the shot, he did not donn and doff nor perform hand sanitation and began entering the resident's electronic data on his computer. He stated he spoke with the DON after performing resident's blood check and learned that he is not to come out of the resident's room gloved, that donning, and doffing is to be performed before exiting the resident's room. He stated the risks of coming out of the room with gloves increased the chance of contamination and the spread of infection. He stated he had been in serviced on hand washing while working at the facility in the past, (date unknown). During an interview on 04/05/23 at 02:17 PM, DON stated she had been the infection control preventionist for 3 years. She stated that the facilities corporate office had the in- service logs. She stated that corporate also had provided infection control training online when they took over in October 2022. She stated the Reliance training also provides infection control, and PPE training. She stated that she last performed an in-service with nursing staff and different departments outside of nursing on handwashing protocols, PPE use and provided a handwashing demonstration on random dates and times in December of 2022. Record review Infection Prevention and Control Program dated 2022 revealed Record review of the Face Sheet dated 04/13/23 revealed Resident #28 was a [AGE] year-old female admitted to the facility on [DATE] with diagnosis COVID-19, Dementia, Unspecified Protein-Calorie Malnutrition, and Nontraumatic Intracerebral Hemorrhage. During an observation on 04/06/23 at 12:42 PM, CNA B assisted Resident #28 with feeding. While feeding, CNA was observed scratching her head multiple times and rubbing her eye. CNA B continued to assist the resident with feeding and did not perform hand hygiene. During an interview on 04/06/23 at 01:16 PM, CNA B She stated she has been employed at the facility for almost a year. She stated she was on the job CNA training at this facility and got her CNA certificate September 2022. She stated when assisting residents with feeding, she used hand hygiene prior to assisting the resident and in between assisting multiple residents. The CNA B acknowledged that she should have completed hand hygiene after scratching her head and rubbing her eye, she stated she was nervous, and she was not thinking about it. She stated the risk of not completing hand hygiene increases the risk of spreading infections. During an interview on 04/06/23 at 01:57 PM, DON stated staff are in-serviced on PPE/Hand Hygiene monthly. She stated there is no specific hand hygiene use policy for feeding residents. She stated the hand hygiene and infection control policies and procedures apply to all patient care areas including feeding. She stated if staff touch any part of their face or hair while feeding residents, staff should immediately perform hand hygiene before returning to feeding the resident. She stated failure to perform hand hygiene increases the risk of germ cross contamination and the spread of infection. She stated this risk places residents at risk of infection. Record review of the facilities undated Hand Hygiene Table, Hand hygiene is indicated and will be performed under the conditions listed in, but not limited to, the attached hand hygiene table. Record review of the facilities undated Hand Hygiene Table, Between resident contacts and before performing resident care procedures, either soap and water or alcohol-based hand rub (ABHR is 676264 Page 7 of 10 676264 04/20/2023 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0880 Level of Harm - Minimal harm or potential for actual harm preferred) should be applied. After handling items potentially contaminated with blood, body fluids, secretions, or excretions. 6. The use of gloves does not replace hand hygiene. If your task requires gloves, perform hand hygiene prior to donning gloves and immediately after removing glove. Residents Affected - Some 676264 Page 8 of 10 676264 04/20/2023 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews the facility failed to document if the resident received the pneumococcal immunization, Covid-19 vaccination, or the Mantoux tuberculin skin test due to medical contraindication or refusal for 1 of 9 residents (#83) whose medical records were reviewed for immunizations: Residents Affected - Few 1. Resident #83's medical record had no immunization records being administered or refused. This deficient practice could affect 86 residents who were admitted since April 2021 and put them at risk for infection. The findings were: Record review of Resident #83's Face Sheet revealed an admission date of 01/23/2023 with diagnoses of Spondylosis, Wedge Compression Fracture of First Thoracic Vertebra, Initial Encounter for Closed Fracture, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris and Obesity. Record review of Resident #83's most recent Care Plan revealed resident was at risk for infection related to Covid-19, will be offered flu/pneumonia vaccine per protocol. Review of the most recent Minimum Data Set Assessment (MDS) dated [DATE] revealed Resident #83's cognitive skills for daily decision making were intact. Resident #83 did not receive the influenza vaccine in the facility during this year's influenza vaccination period as it was not offered. Resident's Pneumococcal vaccination is not up to date, as it was not offered during this influenza vaccination period. Record review Resident #83's Updated Immunization dated 04/06/23 revealed, Per resident she has tested positive on TB skin test multiple times and declines testing at this time. Record review Resident #83's undated Immunization record revealed, Resident states she had taken all 3 Covid-19 vaccines when she was in jail, but is not sure the dates. Record review of Resident #83's electronic medical record and hard chart reviewed for pneumonia vaccine did not have any documentation indicating if pneumococcal immunization, Covid-19 vaccination, or the Mantoux tuberculin skin test was administered or refused. During interview on 04/06/23 at 02:52 PM, with Corporate Nurse stated that Resident #83 had not had any immunizations. She stated the resident received her TB and Covid-19 vaccination today (04/06/23). She stated residents without immunizations could spread infection to other residents, placing them and other residents at risk of infection. Record Review Infection Prevention and Control Policy dated: Copyright 2022 pages 1 of 4. 8. Covid-19 immunization offer vaccinations to staff and residents. Screened prior to administering vaccination, educated on risks and benefits of vaccination prior to administering, inform resident representatives, documentation to reflect education provided and details regarding whether staff received 676264 Page 9 of 10 676264 04/20/2023 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0883 vaccination. Level of Harm - Minimal harm or potential for actual harm Record review of facility's policy on Pneumococcal Vaccination revision date 11/28/17 revealed 2. Based upon the patient's pneumococcal vaccination history, offer the appropriate vaccination following the recommended schedule. 3. Document the patient either received the pneumococcal immunization on patient's MAR and/or electronic record or did not receive the pneumococcal immunization due to medical complications or refusal. Residents Affected - Few 676264 Page 10 of 10