Windemere at Westover Hills: Immediate Jeopardy Violations - TX
The facility is Windemere at Westover Hills, on Christus Hills on the city's west side. The Immediate Jeopardy designation, one of the most serious findings federal inspectors can issue, was triggered by failures in how the facility monitored and responded to changes in resident condition. It affected a small number of residents.
The Director of Nursing described the system herself during an interview with inspectors on April 14. Nurses were supposed to review vital signs for every resident assigned to them each shift. They were supposed to document on a log whether any trends or patterns appeared. They were supposed to sign that log, contact a physician if something was wrong, and complete a progress note or a formal communication called an SBAR, which stands for Situation, Background, Assessment, and Recommendation, if the situation required it.
That system was not working.
The Director of Nursing told inspectors that abnormal vital signs were reported to the physician or nurse practitioner and that SBARs were completed for all residents identified as having concerning readings. But the inspection record makes clear the facility had only recently been forced to confront how far short of that standard it had fallen. Three days before inspectors sat down with the Director of Nursing, on April 11, a regional director of clinical services had come in and personally re-trained her on her own responsibilities, covering vital sign monitoring, a Hydration Monitoring Tool, physician notifications, changes in condition, the SBAR process, and abuse and neglect.
The executive director received the same in-service on the same day.
That both the Director of Nursing and the Executive Director needed to be retrained on basic clinical oversight protocols in the middle of a federal inspection is the kind of detail that sits at the center of what inspectors found. These were not front-line aides who had missed a training session. These were the two people most responsible for ensuring care was delivered correctly, and a regional supervisor had to come in and walk them through their own jobs.
The Director of Nursing also told inspectors that she, her designee, and the staffing coordinator were responsible for making sure all new hires, per-diem staff, and agency workers were trained before their first shift on abuse and neglect identification, the Stop and Watch Early Warning Tool, how to recognize and respond to changes in resident condition, and the SBAR process. Whether that training had been happening consistently before inspectors arrived is not stated in the record. What is stated is that it was identified as a gap serious enough to address during an active Immediate Jeopardy investigation.
The Stop and Watch tool is a structured observation checklist designed to help nursing assistants and other direct care workers recognize early warning signs that a resident may be declining, things like a change in eating habits, unusual behavior, or increased confusion. Its presence on the retraining list suggests the facility's problems extended beyond nurses and physician calls. The people closest to residents each day may not have been equipped to recognize when something was going wrong.
The facility's policy on physician notification was revised in April 2025, during the inspection period, and was updated to include a specific provision: that residents who request to go to the hospital must be reported to the physician. That this needed to be written into policy as a new requirement is its own statement about what may have been happening before.
Inspectors formally removed the Immediate Jeopardy designation on April 16 at 11:16 in the morning, after the facility demonstrated it had put a Plan of Removal in place. But removal of the designation did not mean the facility was back in compliance. Inspectors noted that Windemere remained out of compliance at the conclusion of the survey, at a scope of isolated and a severity level reflecting no actual harm but the potential for more than minimal harm. The facility was still in the process of monitoring whether its corrective actions were actually working.
That distinction matters. Immediate Jeopardy means inspectors believed residents were at risk of serious injury, serious harm, serious impairment, or death. The removal of that designation means the facility took steps sufficient to reduce that immediate risk. It does not mean the underlying failures have been fully corrected. The monitoring was ongoing as of the date inspectors completed their work.
What the record does not say is how long the vital sign monitoring failures had been occurring before inspectors arrived. It does not say whether any resident experienced a deterioration in condition during the period when vital signs were not being reliably tracked or reported. It does not name the residents who were affected. The inspection covers a small number of people, described in regulatory language as "few," but the record does not describe what happened to them individually or what specific vital sign readings were missed.
What it does say is that the system for catching deterioration before it became a crisis, the shift-by-shift logging, the trend identification, the physician calls, the formal clinical communications, was not functioning. And that the people responsible for making sure it functioned had to be retrained on their own responsibilities while federal inspectors were in the building.
Windemere at Westover Hills is a licensed nursing facility operating under Medicare and Medicaid certification, assigned provider identification number 676402. The inspection was completed April 16, 2025.
The regional clinical director who came in on April 11 to retrain facility leadership is not named in the inspection record. Neither are the residents whose vital signs went unreviewed. The log that nurses were supposed to sign each shift, the one meant to create a paper trail showing that someone had looked at the numbers and decided whether to act, sits somewhere in that facility now, presumably being filled out. Whether it is being filled out correctly, and whether the physicians are actually being called when the numbers are bad, is what the monitoring period is meant to determine.
For the residents whose conditions were tracked on that log, or were supposed to be, the answer was not yet known when inspectors left.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Windemere At Westover Hills from 2025-04-16 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 27, 2026 · Our methodology
WINDEMERE AT WESTOVER HILLS in SAN ANTONIO, TX was cited for immediate jeopardy violations during a health inspection on April 16, 2025.
The facility is Windemere at Westover Hills, on Christus Hills on the city's west side.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.