Cycle 1
Health 2025-08-08 · Fire 2025-08-08
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
2 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (2 deficiencies)
Alvin, TX
The Lev at Winchester
3-star overall rating with 4-star inspections with $3,174 in total fines with 6 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
1112 Smith Dr, Alvin, TX
(281) 331-6125
Overall
3 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
94
Certified beds
Average residents
80
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
Oakbend Medical Center
Operator or chain grouping
Approved since
2010-11-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Staffing
Hours and turnover
RN hours / resident day
0.12
Registered nurse staffing
LPN hours / resident day
1.16
Licensed practical nurse staffing
Aide hours / resident day
1.83
Nurse aide staffing
Weekend hours
2.86
Weekend nurse staffing
RN turnover
0%
Annual RN turnover
Total nurse turnover
47%
Annual nurse turnover
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 2.5 |
2.1
0.4 pts worse
|
1.8
0.7 pts worse
|
Long Stay · 20240701-20250630 |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.4% |
3.3%
2.9 pts better
|
3.3%
2.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who have depressive symptoms | 1.3% |
2.7%
1.4 pts better
|
11.4%
10.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who lose too much weight | 8.0% |
3.3%
4.7 pts worse
|
5.4%
2.6 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 18.7% |
18.9%
0.2 pts better
|
19.6%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who received an antipsychotic medication | 13.4% |
10.8%
2.6 pts worse
|
16.7%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose ability to walk independently worsened | 9.2% |
15.4%
6.2 pts better
|
16.3%
7.1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.3% |
16.1%
6.8 pts better
|
14.9%
5.6 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with a urinary tract infection | 0.4% |
0.8%
0.4 pts better
|
1.7%
1.3 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 18.6% |
15.0%
3.6 pts worse
|
19.8%
1.2 pts better
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of long-stay residents with pressure ulcers | 7.3% |
4.2%
3.1 pts worse
|
5.1%
2.2 pts worse
|
Long Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who had an outpatient emergency department visit | 24.8% |
12.0%
12.8 pts worse
|
12.0%
12.8 pts worse
|
Short Stay · 20240701-20250630 |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.7% |
1.5%
0.2 pts worse
|
1.6%
0.1 pts worse
|
Short Stay · 2024Q4-2025Q3 |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 97.5% |
88.0%
9.5 pts better
|
79.7%
17.8 pts better
|
Short Stay · 2024Q3-2025Q2 |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 14.0% |
25.9%
11.9 pts better
|
23.9%
9.9 pts better
|
Short Stay · 20240701-20250630 |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-06-28 · Fire 2024-06-28
3 health deficiencies
Top issue: Nursing and Physician Services (1 deficiency)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Cycle 3
Health 2023-04-20 · Fire 2023-04-20
6 health deficiencies
Top issue: Infection Control (2 deficiencies)
2 fire-safety deficiencies
Top issue: Smoke (2 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-08
K929 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure precautions for handling oxygen cylinders and equipment are correctly followed.
Corrected 2025-08-26
D · Potential for more than minimal harm
2025-08-08
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2025-08-26
F · Potential for more than minimal harm
2024-06-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-06-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2024-07-19
E · Potential for more than minimal harm
2024-06-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2024-06-27
E · Potential for more than minimal harm
2024-06-28
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2024-06-27
F · Potential for more than minimal harm
2023-04-20
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-06
F · Potential for more than minimal harm
2023-04-20
K374 · Smoke Deficiencies
Fire Safety
Install smoke barrier doors that can resist smoke for at least 20 minutes.
Corrected 2023-04-06
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-12-05
F553 · Resident Rights Deficiencies
Health
Allow resident to participate in the development and implementation of his or her person-centered plan of care.
Corrected 2026-01-27
F · Potential for more than minimal harm
2025-08-08
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2025-08-26
E · Potential for more than minimal harm
2025-08-08
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2025-08-09
D · Potential for more than minimal harm
2025-08-08
F621 · Resident Rights Deficiencies
Health
Treat residents equally regarding transfer, discharge, and provision of services for all residents, regardless of payment source
Corrected 2025-08-09
D · Potential for more than minimal harm
2025-08-08
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-08-09
D · Potential for more than minimal harm
2025-08-08
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-08-09
E · Potential for more than minimal harm
2024-06-28
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2024-07-26
D · Potential for more than minimal harm
2024-06-28
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2024-07-26
E · Potential for more than minimal harm
2024-04-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2024-04-24
E · Potential for more than minimal harm
2023-04-20
F727 · Nursing and Physician Services Deficiencies
Health
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.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-04-20
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-04-21
E · Potential for more than minimal harm
2023-04-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-20
F697 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate pain management for a resident who requires such services.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-20
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-21
D · Potential for more than minimal harm
2023-04-20
F883 · Infection Control Deficiencies
Health
Develop and implement policies and procedures for flu and pneumonia vaccinations.
Corrected 2023-04-21
Penalties and ownership
What sits behind the stars
$3,174
2023-07-31
Fine
Fine · fine $3,174
Fine
Ownership
Oakbend Medical Center
5% Or Greater Direct Ownership Interest · Organization
Council, Jeff
Corporate Officer · Individual
Crayton, Tom
Corporate Officer · Individual
Douds, Robert
Corporate Officer · Individual
Freudenberger, Joseph
Corporate Officer · Individual
Freudenberger, Joseph
W-2 Managing Employee · Individual
Haley, Jeff
Corporate Officer · Individual
Martin, Melissa
Corporate Officer · Individual
Mefford, Ruthanne
Corporate Officer · Individual
Petrosewicz, Norma
Corporate Officer · Individual
Popatia, Amirali
Corporate Officer · Individual
Shkop, Aharon
Operational/Managerial Control · Individual
Ssc Alvin Operating Company LLC
Operational/Managerial Control · Organization
The Lev At Winchester LLC
Operational/Managerial Control · Organization
Uthman, Edward
Corporate Officer · Individual
Zerwas, John
Corporate Officer · Individual
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