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 . Page 1 of 3 676264 676264 06/28/2024 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview and record review the facility failed to ensure in accordance with State and Federal laws,all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 3 nurse medication carts reviewed for medications . 1. The facility failed to ensure 2 of 3 nurses' medication carts did not contain expired oral medications. 2. The facility failed to ensure 1 of 3 nurse's medication carts did not contain expired suppository medication. These failures could place residents at risk for altered effectiveness of the medication and decreased therapeutic outcomes, requiring medical intervention. The findings include: During an observation on 06/27/24 at 1:58 p.m. of medication cart 1 of 3 with LVN A revealed the following: a blister packet of Ondansetron HCL 4mg 1 tab every 8 hours PRN and expired on 12/27/23. a blister packet of Ondansetron HCL 4mg 1 tab every 8 hours PRN and expired on 05/03/24. a blister packet of Ondansetron HCL 4mg 1 tab every 8 hours PRN and expired on 06/05/24. a blister packet of Benzonatate 100 mg 1 tab every 6 hours PRN and expired on 03/13/24. During an observation on 06/27/24 at 3:23 p.m. of medication cart 2 of 3 with LVN B revealed the following: a blister packet of Hyoscyamine 0.125 1 tab and expired on 05/18/2024. a blister packet of Clonidine .1 mg 1 tab every 6 hours PRN with a used by date of 10/31/23. During an observation on 06/27/24 at 3:38 p.m. of medication cart 3 of 3 with the ADON revealed the following: Bisacodyl 10 mg 1 suppository every 24 hours PRN and expired on 05/14/24. During an interview on 06/27/24 at 2:18 p.m., LVN A said she must have overlooked the expired medication on the medication cart. She said medications should not be left on the medication cart after the medications expired or were discontinued . She said the medication would not be effective and may not reach a therapeutic dose, which can place the resident at risk at decease therapeutic outcomes. LVN A said once a resident's medication expired , the nurse should remove the medication from the cart, which prevented the nurse from administrating the expired medicine to the resident because it 676264 Page 2 of 3 676264 06/28/2024 The Lev at Winchester 1112 Smith Dr Alvin, TX 77511

F 0761 would not be effective or may cause a negative outcome . Level of Harm - Minimal harm or potential for actual harm During an interview on 06/27/24 at 5:01 p.m. with LVN B, she said all nurses were responsible for checking their medication carts for expired medications. She said she usually checked for expired medications at the beginning of her shift but must have overlooked the PRN medications. She said once she discovered expired medications, she placed them in the discontinued box in the medication storage room. She said the risk of administering expired medications was it may decrease in potency, and the medication may not be as effective because the medication was expired. Residents Affected - Some During an interview on 06/28/24 at 2:20 p.m., the DON said the nurses and pharmacy staff/consultant were responsible for pulling expired medications from the cart to prevent the medications from being administered to residents. The DON said the strength of the drug would have been reduced and it would not be effective for the required treatment. The DON also said nurses should not administer medication past the required used by date or expired date because the medication may not be effective . She said the medications that were discontinued could place residents at risk for drug diversions or misuse of medications and should have been removed from the cart and placed immediately in the designated destruction container. During an interview on 06/29/24 at 2:15 p.m., the Administrator said she expected discontinued medications to be removed from the medication carts and put in the destruction box immediately. She said discontinued or expired medication could put the residents at risk of an adverse event. Record review of the facility's, undated, policy Medication Storage read in part, .unused medications: The pharmacy and all medication rooms are routinely inspected by the consultant pharmacist for discontinued, outdated, defective, or deteriorated medications with worn illegible, or missing labels. These medications are destroyed in accordance with our destruction of unused drugs policy. Record review of the facility's, undated, policy Destruction of Unused Drugs read in part, .all unused, contaminated, or expired prescription drugs shall be disposed in accordance with state laws and regulations . Policy Explanation and Compliance Guidelines: 2. Unused, unwanted, and non-returnable medications should be removed from their storage area and secured until destroyed 676264 Page 3 of 3