Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Windemere At Westover Hills during CMS and state inspections, most recent first.
A resident with end stage renal disease experienced a significant drop in blood pressure prior to dialysis, but the physician or NP was not promptly notified as required by facility policy. The resident was sent to dialysis, where hypotension persisted and IV fluids were administered before the resident was transferred to the hospital. Documentation and interviews confirmed that the required provider notification did not occur, resulting in a deficiency.
A resident with end stage renal disease and a history of low blood pressure experienced hypotension, generalized pain, and requested to go to the hospital. Nursing staff did not immediately notify the provider or send the resident to the hospital, instead sending the resident to dialysis as scheduled. At dialysis, the resident's condition did not improve and the dialysis center arranged for hospital transfer. Facility staff did not follow protocols for physician notification and resident requests, resulting in a delay in care.
The facility failed to conduct PASARR Level II Evaluations for three residents with mental illness, including schizophrenia, psychosis, and bipolar disorder. Despite clear diagnoses, the PASARR Level 1 Screenings did not identify these conditions, and necessary evaluations were not completed. The absence of the MDS Nurse contributed to this oversight.
The facility failed to maintain food service safety standards, as clean utensils and dishware were found with food particles from previous meals. Residents reported this issue, and observations confirmed the presence of food particles. Interviews with dietary staff acknowledged the deficiency, which violated the facility's sanitization policy.
The facility failed to distribute resident mail received on Saturdays until the following Monday, as confirmed by interviews with staff and residents. The receptionist placed Saturday mail in the BOM's mailbox, who does not work weekends, and the AD distributed it on Mondays. The Administrator acknowledged the issue and stated that the practice would change to ensure timely mail distribution.
A resident with vascular dementia did not receive a timely quarterly MDS assessment, which was completed 130 days after the annual assessment, exceeding the 120-day requirement. Facility staff confirmed the delay, acknowledging the importance of timely assessments for accurate care planning.
The facility failed to ensure accurate MDS assessments for two residents, leading to deficiencies in their care plans. One resident's MDS did not reflect their upper extremity ROM impairment, while another's inaccurately indicated significant weight loss. Staff interviews confirmed these inaccuracies, highlighting the importance of precise assessments to guide care. The facility lacked a policy defining inaccurate MDS assessments.
A resident's quarterly MDS assessment was signed by an LVN instead of an RN, contrary to facility policy and RAI criteria. The resident, diagnosed with unspecified vascular dementia, had their assessment completed without the required RN certification, as confirmed by interviews with the LVN and ADON.
The facility failed to update care plans for two residents following assessments. One resident's care plan inaccurately reflected significant weight loss, while another's did not include the use of side rails for bed mobility, despite physician orders. Interviews confirmed these inaccuracies, which could lead to improper care.
A resident was left with a cup of medications at her bedside during a televisit with her doctor, contrary to facility policy. The ADON and LVN involved admitted to not following best practices, as medications should not be left unattended with residents. This incident involved a resident with multiple health conditions, and the failure to properly manage medication administration could lead to misuse or adverse effects.
The facility failed to maintain accurate medical records for three residents. An LVN did not document an assessment after a resident's fall, another resident's assist rail evaluation was unsigned, and a third resident's family consent for side rail use was not obtained. These lapses in documentation and communication among staff compromised the accuracy of medical records.
A medication cart in the facility was found unattended and unlocked, containing residents' medications, including controlled narcotics. The cart was left in the hall away from the nurse's station, with no staff in the immediate area. The facility's policy requires all medications to be stored in locked compartments, with narcotics under double lock, and keys held by authorized personnel.
Failure to Notify Physician of Significant Change in Resident Condition
Penalty
Summary
The facility failed to immediately notify a resident's physician when there was a significant change in the resident's physical condition. Specifically, a resident with end stage renal disease, who was receiving dialysis, had a blood pressure reading of 80/42 prior to being transported to dialysis. The low blood pressure was documented by an LVN, who reported the finding to the ADON and the resident, but did not directly notify the physician or nurse practitioner as required by facility policy. The resident was subsequently transported to dialysis, where the dialysis nurse also noted hypotension and contacted the nephrologist, who ordered IV fluids. Despite these interventions, the resident's blood pressure remained low, and the resident was sent to the hospital for further evaluation and treatment. Interviews and record reviews revealed inconsistencies and lack of clarity regarding whether the physician or nurse practitioner was notified of the resident's low blood pressure prior to dialysis. The LVN involved stated she believed she had notified the nurse practitioner, but could not provide documentation or evidence of this communication. The nurse practitioner and other facility staff interviewed denied receiving notification about the resident's condition. Facility policy required prompt notification of the physician or nurse practitioner in the event of significant changes in a resident's condition, such as abnormal vital signs, but this protocol was not followed in this instance. The deficiency was identified as Immediate Jeopardy due to the failure to notify the physician of a significant change in the resident's condition, which resulted in delayed medical intervention. The facility's own policies and staff interviews confirmed that the expectation was for the physician or nurse practitioner to be notified of such changes, but this did not occur. The event was further substantiated by documentation from the dialysis center and hospital, as well as interviews with facility staff, all indicating that the required notification was not made in a timely manner.
Failure to Respond to Resident's Request and Change in Condition
Penalty
Summary
A deficiency occurred when a resident with end stage renal disease, who was receiving dialysis and had a history of low blood pressure, was found to have a blood pressure of 80/42, complained of generalized pain, and requested to be sent to the hospital. Despite the resident's request and abnormal vital signs, the nursing staff did not immediately intervene or send the resident to the hospital. Instead, the resident was sent to dialysis as scheduled after the charge nurse consulted with the former ADON, who advised that the resident usually had low blood pressure and should proceed to dialysis. The nurse documented the resident's request and low blood pressure but did not notify the nurse practitioner or physician for further orders regarding the hospital transfer at that time. At the dialysis center, the resident continued to experience hypotension and generalized weakness, and again requested to be sent to the hospital. The dialysis nurse contacted the nephrologist, who ordered intravenous fluids to stabilize the resident's blood pressure. When the resident's condition did not improve, the dialysis center arranged for the resident to be sent to the hospital. Interviews with facility staff revealed that the nurse practitioner was not notified of the resident's condition prior to dialysis, and stated that, had she been informed, she would have ordered the resident to be sent to the hospital via EMS due to the unsustainable blood pressure. Facility policy required prompt notification of the physician and resident representative in the event of significant changes in a resident's condition, including abnormal vital signs and requests to go to the hospital. However, the staff failed to follow these protocols, resulting in a delay in medical intervention for the resident. The deficiency was identified as Immediate Jeopardy due to the failure to provide treatment and care in accordance with professional standards, the resident's care plan, and the resident's expressed preferences.
Failure to Conduct PASARR Level II Evaluations for Residents with Mental Illness
Penalty
Summary
The facility failed to ensure that all residents with mental illness were provided with a Pre-Admission Screening and Resident Review (PASARR) Level II Evaluation and Assessment. This deficiency was identified for three residents who were reviewed for PASARR services. Resident #9, who had several diagnoses related to mental illness including paranoid schizophrenia and major depressive disorder, was not identified as having a mental illness on the PASARR Level 1 Screening. The Senior Director of Nursing (DON) acknowledged that a Form 1012 should have been completed to determine if further evaluation was needed, but it was not done due to the absence of the MDS Nurse. Resident #27 was admitted with a diagnosis of unspecified psychosis, yet her PASARR Level 1 Screening did not indicate a mental illness. Her quarterly MDS assessment revealed a BIMS score of 0, indicating she was unable to complete the Brief Interview for Mental Status, and she had a diagnosis of depression with psychotic symptoms. Despite these indicators, a PASARR Level II assessment was not conducted. Similarly, Resident #38 was admitted with a diagnosis of bipolar disorder, which was reflected in her quarterly MDS and care plan. However, her PASARR Level 1 Screening also failed to identify her as having a mental illness. An interview with an LVN confirmed that residents with a diagnosis of mental illness should have another PASARR completed and submitted to local authorities for evaluation of specialized services, which was not done in this case.
Deficient Food Service Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as evidenced by the presence of food particles on clean utensils and dishware. During a confidential group meeting, residents reported that utensils and dishware often had food particles from previous meals. Subsequent observations in the kitchen confirmed these reports, with food particles found on both utensils and dishware that were supposed to be clean. Interviews with Dietary Aide H and the Dietary Manager corroborated the findings, as both acknowledged that the utensils and dishware had been cleaned but still had food particles remaining. The facility's policy on sanitization, revised in November 2022, mandates that the food service area be maintained in a clean and sanitary manner, which was not upheld in this instance.
Failure to Distribute Resident Mail on Saturdays
Penalty
Summary
The facility failed to uphold the residents' right to receive mail in a timely manner, as evidenced by the practice of not distributing mail received on Saturdays until the following Monday. During a confidential group meeting, residents expressed dissatisfaction with this practice, feeling it was disrespectful. Interviews with facility staff, including the receptionist, Business Office Manager (BOM), and Activity Director (AD), confirmed that mail received on Saturdays was placed in the BOM's mailbox, who does not work on weekends, and subsequently distributed to residents on Mondays by the AD. The Administrator acknowledged that residents should receive their mail on the day it is received and confirmed that the facility's practice would change to ensure this. The facility's policy on Resident Rights, revised in February 2021, guarantees residents access to mail, among other rights. This deficiency in mail distribution could potentially result in residents not receiving their mail in a timely manner, impacting their quality of life.
Failure to Complete Timely Quarterly MDS Assessment
Penalty
Summary
The facility failed to conduct a quarterly assessment for a resident using the specified review instrument within the required timeframe. Resident #45, who was diagnosed with unspecified vascular dementia, had an annual Minimum Data Set (MDS) assessment completed on May 6, 2024. However, the subsequent quarterly MDS assessment was not completed until September 13, 2024, which was 130 days later, exceeding the 120-day requirement. This delay in assessment could potentially affect the resident's care plan and the services they receive. Interviews with facility staff, including an LVN and the Assistant Director of Nursing (ADON), confirmed the oversight. The LVN acknowledged that the quarterly MDS assessment was completed on September 13, 2024, and stated that assessments should be completed every three months as per the MDS Resident Assessment Instrument (RAI) guidelines. The ADON reiterated the importance of timely assessments to ensure that the care plan accurately reflects the resident's needs. The facility's policy on comprehensive assessments, revised in March 2020, emphasizes the importance of conducting assessments in accordance with the RAI User Manual to develop person-centered care plans.
Inaccurate MDS Assessments Lead to Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to ensure accurate assessments for two residents, leading to deficiencies in their care plans. For one resident, the Minimum Data Set (MDS) staff did not accurately reflect the resident's range of motion (ROM) impairment in the upper extremity in the quarterly MDS dated June 10, 2024. This resident had a documented history of ROM impairment and left-sided hemiplegia due to a stroke, as noted in occupational therapy records and the care plan. The inaccurate MDS assessment could result in the resident not receiving appropriate care and services tailored to their needs. Another resident's quarterly MDS assessment inaccurately indicated significant weight loss, despite the resident having gained weight during the look-back period from June to September 2024. Interviews with facility staff, including an LVN and the Assistant Director of Nursing (ADON), confirmed the inaccuracy of the MDS assessment. The ADON emphasized the importance of accurate assessments and care plans, as they guide nursing staff in providing necessary care. The facility lacked a policy defining an inaccurate MDS, relying instead on the Resident Assessment Instrument (RAI) as a guide.
RN Signature Missing on Resident Assessment
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) signed and certified the completion of a resident assessment for one of the residents reviewed. Specifically, the quarterly Minimum Data Set (MDS) assessment for Resident #45, who was admitted with a diagnosis of unspecified vascular dementia, was completed and signed by a Licensed Vocational Nurse (LVN) instead of an RN. This occurred on 9/13/24, and the facility's policy requires that comprehensive assessments be conducted and coordinated by an RN. Interviews with the LVN and the Assistant Director of Nursing (ADON) confirmed that an RN's signature was necessary, as LVNs are not authorized to conduct resident assessments according to the Resident Assessment Instrument (RAI) criteria.
Failure to Update Care Plans for Two Residents
Penalty
Summary
The facility failed to ensure that the interdisciplinary team reviewed and revised the care plans for two residents following their assessments. For Resident #45, the care plan was not updated to reflect that she did not experience significant weight loss, despite her weight records showing an increase from 150 pounds to 157.80 pounds over a period of time. Interviews with LVN A and the ADON confirmed that the care plan, effective from 5/31/24, was inaccurate and had not been revised to reflect the resident's actual condition. This inaccuracy in the care plan could lead to the nursing staff not having the correct information to provide appropriate care. Similarly, Resident #70's care plan was not updated to include the use of side rails for bed mobility, despite a physician's order indicating their use for mobility and repositioning. Observations confirmed that the resident was using side rails while in bed, yet this was not reflected in the care plan. Interviews with LVN A and the Corporate RN highlighted the discrepancy, indicating that the care plan did not accurately reflect the resident's condition and needs. The facility's policy requires care plans to be reviewed and updated quarterly, upon each change in condition, and upon re-admission, which was not adhered to in these cases.
Medication Mismanagement at Bedside
Penalty
Summary
The facility failed to ensure that medications were not left at the bedside for a resident, which could lead to medication misuse or drug diversion. The incident involved a resident who was alert and cognitively intact, with multiple diagnoses including congestive heart failure, myasthenia gravis, and hypotension. The resident was observed walking out of her room with a medication cup containing several pills, which she had been given by a CNA while she was in a televisit appointment with her doctor. The CNA left the medication with the resident despite the resident's indication that she was discussing her medications with her doctor. The ADON intercepted the resident and redirected her back to her room, later returning with the medication cup and instructing the resident to take the pills. The ADON admitted to not knowing what one of the pills was and acknowledged that medications should not be left at the bedside, as residents could potentially throw them away, hoard them, or save them for later, leading to negative side effects. The ADON also admitted to not pulling the medications herself, which is against best practice. LVN B, who was responsible for the medication pass, admitted to leaving the medications at the bedside because the resident was alert and oriented, and she wanted to finish the medication pass quickly. LVN B acknowledged that this was an exception and not standard practice, as it could result in the resident not taking the medications, pocketing them, or experiencing harm. The Senior DON confirmed that medications should not be left with residents and that nurses should not administer medications they did not prepare themselves.
Deficiencies in Medical Record Documentation and Consent
Penalty
Summary
The facility failed to maintain accurate medical records in accordance with professional standards for three residents. For one resident, after experiencing a fall, an LVN did not document an assessment, despite the resident having a history of falls and being cognitively intact. The resident was moved between halls due to air conditioning issues, leading to confusion about which nurse was responsible. The LVN who initially assessed the resident after the fall did not document the incident, resulting in a lack of proper record-keeping. Another resident's assist rail/enabler evaluation was not signed or dated by the nurse who conducted the evaluation, rendering it invalid. This oversight was discovered during an observation where the resident was found in bed with two side rails up. Interviews with staff revealed that the admitting nurse typically assessed residents for side rail use, but in this case, the documentation was incomplete, compromising the validity of the evaluation. For a third resident, the facility failed to obtain consent from the family representative for the use of side rails. The resident was observed with side rails up, but the consent form was not signed by a family member. Interviews indicated that the admitting nurse was responsible for ensuring the consent was obtained, but this step was missed, leading to incomplete documentation. These deficiencies highlight lapses in documentation and communication among the nursing staff, potentially affecting the accuracy of medical records and resident care.
Unattended and Unlocked Medication Cart Found in Facility
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments under proper temperature controls, as required by their policy. During an observation, a nurse's medication cart was found unattended and unlocked in the middle of the hall, away from the nurse's station. No nursing staff were present in the immediate area, and the cart was assigned to a nurse who was not in the vicinity. The cart contained residents' medications, including injectable, controlled narcotics, and oral medications. Interviews with staff revealed that the facility's policy mandates that all medications should be stored in locked compartments, with narcotic medications requiring a double lock. The keys to these compartments should be in the possession of the nurse. The Assistant Director of Nursing (ADON) confirmed that an unlocked medication cart could risk residents not receiving the therapeutic effects of their medications or losing control of their property. A review of the facility's Medication Labeling and Storage policy corroborated these requirements, emphasizing that only authorized personnel should have access to the keys.
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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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Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Las Colinas Of Westover | 0.9 mi | — | 18 | 0 |
| Westover Hills Rehabilitation And Healthcare | 1.1 mi | — | 2 | 0 |
| Silver Creek Nursing And Rehabilitation | 1.9 mi | — | 0 | 0 |
| Lakeside Nursing And Rehabilitation Center | 2 mi | — | 0 | 0 |
| Legend Oaks Healthcare And Rehabilitation - West S | 4.2 mi | — | 11 | 0 |
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