Health inspection·April 6, 2024

F 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 (Resident #8) of 2 resident reviewed for respiratory care, in that: Residents Affected - Some -The facility failed to set the oxygen flow rate at 3 liters of oxygen per minute as ordered on 11/27/2023 for Resident #8. This deficient practice could place residents at risk of inadequate respiratory support or respiratory infections resulting in a decline in health. Findings included: Record review of Resident #8's Face Sheet (undated) revealed she was a [AGE] year-old female who was admitted to the facility on [DATE] and re-admitted on [DATE]. Resident #8's diagnoses included chronic obstructive pulmonary disease (A group of lung diseases that block airflow and make it difficult to breathe) and dementia (A group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #8's Comprehensive MDS assessment dated [DATE] revealed she was assessed as having a BIMS of 03 out of 15 indicting severely impaired cognitively. Further review of Section O- C1. Oxygen therapy revealed: Oxygen in use while a Resident. Record review of Resident #8's care plan dated 12/14/2023 and revised on 04/05/2024 revealed the following: Focus: I use oxygen therapy r/t COPD Goal: The resident will have no s/sx of poor oxygen absorption through the review date. Target Date: 06/04/2024 Interventions/Tasks: OXYGEN SETTINGS: O2 via NC @ 3lpm as needed Record review of Resident #8's Physician's Order Summary Report for the month of April 2024 revealed an order for O2 @ 3L via NC for SOB as needed (delivery of oxygen directly into the nose) Order dated 11/27/2023. Observation and interview on 04/05/2024 at 9:22a.m., revealed Resident#8 was sitting on the side of (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: 676264 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 676264 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/06/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE The Lev at Winchester 1112 Smith Dr Alvin, TX 77511 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)