Health inspection·June 28, 2024

F 0727 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 to ensure the services of a registered nurse were used for at least eight consecutive hours a day, seven days a week for 1 out of 30 days reviewed June 2024. The facility failed to ensure RN coverage for Sunday, 06/02/2024 . This failure could place residents at risk for not having adequate qualified personnel in case of a health crisis. Findings include: Record review of CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 2, 2024, run date 06/02/2024, reflected Low Weekend Staffing was triggered (Submitted Weekend Staffing data is excessively low). Record review of the monthly staffing schedule dated June 2024, reflected no RN coverage on 06/02/2024 . During an interview on 6/28/2024 at 1:17 PM, the DON said when she filled in for staff, she would usually sign the bottom of the Staffing Daily Posting. She said the Staff Daily Posting did not show her signature dated 06/02/2024. She said without coverage the facility would have more issues of resident's satisfaction. She said no one would be available to respond to family issues, complaints or concerns upon request . During an interview on 6/28/2024 at 1:39 PM, the ADON said she was not able to verbalize the risk. During an interview on 6/28/2024 at 1:55 PM, the Administrator said she had been working in the facility for one year and one month. She said it was state guidelines to have an RN in the facility for coverage. She said the risk was no guidance of proper care being provided to the residents if no RN coverage was available in the facility. She said she knew the date in particular, Sunday, 06/02/2024, showing no RN coverage . 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 3 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 06/28/2024 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)