Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Lev At Winchester during CMS and state inspections, most recent first.
A resident with multiple diagnoses and no cognitive impairment was not included in the development or review of her care plan after her initial admission. Despite regular MDS assessments, there was no evidence of care plan meetings or invitations for her participation, and staff interviews revealed uncertainty about care plan meeting requirements and scheduling.
The facility did not ensure RN coverage for at least eight consecutive hours per day, seven days a week, over several months. Payroll and staffing records showed multiple days, especially weekends, without an RN on duty, leaving staff without necessary RN supervision for nursing activities and emergency coordination. The issue was acknowledged by facility leadership and attributed to staff call-ins and no-shows.
A resident did not receive appropriate care for existing pressure ulcers, and preventive measures were not consistently implemented to avoid the development of new ulcers. Surveyors observed lapses in pressure ulcer management and insufficient monitoring of at-risk individuals.
The facility did not provide equal treatment to all residents in matters of transfer, discharge, and services, with differences noted based on payment source.
Two residents with severe cognitive impairment had MDS assessments that failed to accurately document their oral health conditions. One resident was missing all natural teeth and dentures, while another had decayed and missing teeth, but both were incorrectly coded as having no oral issues. Staff interviews confirmed the inaccuracies in the assessments.
A nurse was observed carrying a soiled towel by hand from a resident's room and placing it in a hallway linen barrel without using a bag, contrary to infection control policy. The nurse acknowledged forgetting the required procedure, and the facility's infection preventionist confirmed that soiled linen should be bagged to prevent cross-contamination. The resident involved had multiple chronic health conditions.
The facility failed to ensure proper storage and removal of expired medications from nurse medication carts, with observations revealing expired oral and suppository medications. Interviews with LVNs and the DON highlighted lapses in checking and removing expired medications, contrary to facility policies.
The facility did not have RN coverage for at least eight consecutive hours on a specific day, as required by regulations. This was confirmed by staffing data and the monthly schedule. The DON noted the absence of her signature on the staffing posting for that day, indicating no RN coverage. The Administrator acknowledged the risk of inadequate care guidance without RN presence.
The facility failed to ensure a resident with COPD and dementia received the correct oxygen flow rate as ordered by the physician. Staff members incorrectly set the oxygen flow rate at 2 liters per minute instead of the ordered 3 liters per minute, leading to inadequate respiratory support.
Failure to Involve Resident in Care Plan Development
Penalty
Summary
The facility failed to ensure that a resident was given the right to participate in the development and implementation of her person-centered plan of care. Despite having quarterly Minimum Data Set (MDS) assessments completed, there was no evidence that care plan meetings were conducted or that the resident was invited to participate in such meetings after her initial care plan conference. The resident, who had diagnoses including a mental disorder, vascular dementia, multiple sclerosis, and major depressive disorder, and who demonstrated no cognitive impairment with a BIMS score of 14, reported never attending a care plan meeting to discuss her care. She expressed uncertainty about the assistance being provided and her continued stay at the facility, as well as dissatisfaction with the handling of her dental issues. Interviews with facility staff, including the Unit Manager, MDS Nurse, DON, and Administrator, revealed a lack of clarity regarding the scheduling and requirements for care plan meetings. Staff indicated that care plan meetings were typically held upon admission or when requested by family members, but could not confirm that quarterly meetings were held for the resident in question. Review of facility policy indicated that residents should be informed of and participate in care planning at regular intervals, but documentation and staff interviews did not support that this occurred for the resident after her initial admission.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to provide the services of a registered nurse (RN) for at least eight consecutive hours per day, seven days a week, as required. Record review and interviews revealed that during four out of five months reviewed, there were multiple days when no RN was on duty for the required hours. Specifically, there was no RN coverage on one day in January, three days in February, one day in April, and two days in May. Payroll records and CMS PBJ Staffing Data confirmed these gaps, particularly on weekends, with no RN present on several Saturdays and Sundays across the reviewed months. Interviews with the Administrator and Corporate nurse confirmed awareness of the RN coverage problem, attributing the issue to staff call-ins and no-shows. The facility's own policy requires RN coverage for at least eight consecutive hours daily and designates a full-time RN as Director of Nursing. The lack of RN coverage left staff without supervisory support for RN-specific nursing activities and coordination of emergency care, as noted in the findings.
Failure to Provide Adequate Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent the development of new ulcers. This deficiency was identified through surveyor observations and review of care practices, indicating that residents did not consistently receive the necessary interventions to manage existing pressure ulcers or prevent new ones from forming. The report notes lapses in the implementation of pressure ulcer prevention protocols and inadequate monitoring of residents at risk for skin breakdown.
Failure to Ensure Equal Treatment Regardless of Payment Source
Penalty
Summary
The facility failed to treat all residents equally regarding transfer, discharge, and the provision of services, regardless of their payment source. This deficiency indicates that some residents may have experienced differences in how they were transferred, discharged, or received services based on their payment method. The report specifically notes the lack of equal treatment but does not provide further details about individual residents or specific incidents.
Inaccurate MDS Assessments of Oral Health Status
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments accurately reflected the oral health status of two residents. For one resident with severe cognitive impairment and a history of dementia, depression, and anxiety, the significant change MDS assessment incorrectly indicated that she had all her natural teeth without problems, despite observations and interviews confirming she had no teeth and was missing her dentures. This resident expressed difficulty eating her provided diet and reported that her dentures had been lost at the facility. Her care plan documented dental problems related to missing dentures, but this was not reflected in the MDS assessment. Another resident, also with severe cognitive impairment and multiple medical diagnoses including vascular dementia and multiple sclerosis, had a comprehensive MDS assessment that failed to note her decaying and missing teeth. Dental records indicated several decayed teeth and a missing crown, and the resident reported pain and a desire to see a dentist. During interviews, both the MDS coordinator and the corporate MDS nurse acknowledged that the assessments were coded incorrectly and did not accurately represent the residents' oral health status.
Failure to Follow Infection Control Protocol for Soiled Linen Handling
Penalty
Summary
A deficiency was identified when a licensed vocational nurse (LVN) failed to follow proper infection control procedures while handling soiled linen. The LVN was observed exiting a resident's room wearing one glove and carrying a large, soiled towel in her hand, which she then transported up the hallway and placed directly into a soiled linen barrel. The LVN admitted during an interview that she was aware of the requirement to transport soiled linen in a bag for infection control purposes but stated she forgot to do so because she was moving too quickly. The facility's infection control preventionist confirmed that soiled linen should be bagged to prevent cross-contamination, in accordance with facility policy and national standards. The resident involved was an elderly female with multiple diagnoses, including heart failure, hypertension, chronic kidney disease, neuromuscular dysfunction of the bladder, type 2 diabetes mellitus, and major depression. The incident was documented through observation, staff interviews, and record review, which revealed that the facility's established infection prevention and control program was not properly implemented in this instance. The failure to follow standard precautions and facility policy for handling soiled linen created a risk for cross-contamination and infection transmission among residents, staff, and visitors.
Expired Medications Found in Nurse Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, and only authorized personnel had access to the keys for three nurse medication carts. During observations, it was found that two of the three nurses' medication carts contained expired oral medications, and one cart contained expired suppository medication. Specific expired medications included Ondansetron HCL, Benzonatate, Hyoscyamine, Clonidine, and Bisacodyl. These expired medications were discovered during observations with LVN A, LVN B, and the ADON. Interviews with LVN A and LVN B revealed that they had overlooked the expired medications on their carts, acknowledging that expired medications should be removed to prevent administration to residents. The DON confirmed that both nurses and pharmacy staff were responsible for removing expired medications to prevent their use. The facility's policies on medication storage and destruction of unused drugs were reviewed, indicating that unused, contaminated, or expired prescription drugs should be disposed of according to state laws and regulations.
Failure to Ensure RN Coverage
Penalty
Summary
The facility failed to ensure the presence of a registered nurse (RN) for at least eight consecutive hours a day, seven days a week, as required by regulations. Specifically, there was no RN coverage on Sunday, June 2, 2024. This deficiency was identified through a review of the CMS' PBJ Staffing Data Report for FY Quarter 2, 2024, which indicated low weekend staffing. The monthly staffing schedule for June 2024 confirmed the absence of RN coverage on the specified date. During interviews, the Director of Nursing (DON) acknowledged that she typically signed the Staffing Daily Posting when filling in for staff, but her signature was absent for June 2, 2024. The DON expressed concerns about the lack of RN coverage affecting resident satisfaction and the ability to address family issues, complaints, or concerns. The Assistant Director of Nursing (ADON) was unable to articulate the risks associated with the deficiency. The Administrator, who had been with the facility for over a year, recognized the state guidelines requiring RN coverage and acknowledged the risk of inadequate guidance for proper resident care without RN presence.
Failure to Provide Correct Oxygen Flow Rate
Penalty
Summary
The facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice. Specifically, the facility did not set the oxygen flow rate at 3 liters per minute as ordered for a resident with chronic obstructive pulmonary disease (COPD) and dementia. The resident was observed multiple times holding the nasal cannula (NC) in her hand, and the oxygen flow rate was found to be incorrectly set at 4 and 5 liters per minute by different staff members. The Licensed Vocational Nurse (LVN) and Wound Care Nurse both adjusted the oxygen flow rate to 2 liters per minute, mistakenly believing that was the correct order. The Director of Nursing (DON) was unaware that the resident was adjusting the oxygen flow rate and stated that the nurses were responsible for ensuring the correct flow rate as per the physician's orders. The LVN later reviewed the physician's order and confirmed that the correct flow rate was 3 liters per minute, not 2 liters per minute as she had assumed. The resident's medical history included severe cognitive impairment and a diagnosis of COPD, requiring oxygen therapy. The facility's failure to adhere to the physician's order for the oxygen flow rate could have resulted in inadequate respiratory support for the resident. The facility's Oxygen Administration policy required checking the physician's order for the correct liter flow and method of administration, which was not followed in this case. The LVN admitted to not checking the physician's order and assuming the flow rate based on other residents' orders, leading to the incorrect administration of oxygen therapy for the resident.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurel Court | 3.5 mi | ★★★★★ | 3 | 0 |
| Friendship Haven Healthcare And Rehabilitation Cen | 5.9 mi | ★★★★★ | 2 | 0 |
| Oasis At Pearland | 9 mi | ★★★★★ | 4 | 0 |
| Thrive Rehabilitation Of Pearland | 9.3 mi | ★★★★★ | 27 | 5 |
| The Heights Of League City | 9.4 mi | ★★★★★ | 10 | 2 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.