Windemere at Westover Hills: Immediate Jeopardy - TX
The March incident at Windemere at Westover Hills triggered an immediate jeopardy citation from federal inspectors, who found the facility failed to provide appropriate treatment when the resident complained of generalized pain and repeatedly asked for emergency care.
Licensed Vocational Nurse A documented the resident's vital signs at 11:14 a.m. on March 11: blood pressure 80/42, heart rate 70, respiratory rate 18, oxygen saturation 92%, temperature 97.9 degrees. The resident "complains of generalized pain and requesting to be sent out to [Hospital] to see Nephrologist," the nurse wrote.
Instead of calling an ambulance, the nurse contacted the former assistant director of nursing, identified as RN OO. The administrator told her not to send the resident to the hospital but to inform the nurse practitioner and transport him to his scheduled dialysis appointment.
"Resident voiced understanding," the nurse documented, then arranged transport via ambulance company at 9:40 a.m.
The occupational therapist saw the resident before he left. He complained of maximum pain to his posterior neck and refused therapy. "He reported after dialysis he was planning to go to [Hospital] (by [Rideshare] if he had to) to get a full assessment to find out why he has been feeling sick, having increased neck pain and having issues with low bp," the therapist wrote.
At the dialysis center, staff found his blood pressure had dropped further to 88/43. The treatment nurse documented: "Patient is hypotensive; MD was notified of low BP, verbal order given to bolus 500 mLs of NS at start of treatment and see if BP stabilizes."
The dialysis center called the nursing home. Staff there confirmed the resident's blood pressure was 80/42 and that he had requested hospital transport before arriving at dialysis.
"Patient agreed to dialyze first then go to the [Hospital] post treatment, if still needed," the dialysis nurse wrote. But after receiving IV fluids, the resident continued requesting hospital care for "generalized weakness and hypotension."
The dialysis center stopped treatment early due to "Patient Choice (AMA, feels unwell)" and transported him to the hospital.
Hospital records show he received 1,500 cc of fluids. His blood pressure improved to 110/55 before discharge.
During inspection interviews, LVN A said she reported the resident's condition to RN OO, the dialysis nurse, and believed she also contacted the nurse practitioner. She said RN OO told her not to send the resident to the hospital because "Resident #1 usually had low BPs and it would be best for him to go to dialysis."
The nurse said she was told the resident would see his nephrologist at the dialysis center, though she didn't know if one was actually present there.
"LVN A said she was asked by the dialysis center why Resident #1 was not sent to the hospital when he requested to go," inspectors wrote.
When contacted by inspectors, Nurse Practitioner H said she was never notified of the resident's condition. Had she been informed, "Resident #1 would have been sent to the hospital via EMS," she said. "She would not have told the facility staff to send Resident #1 to dialysis because he was hypotensive, and his BP was not sustainable for dialysis or everyday life."
RN OO, the former assistant director who was no longer employed at the facility, told inspectors he didn't remember the March incident. But he said standard protocol required calling the physician for orders when residents request hospital transport, and patients were "usually transported to the hospital per resident request."
"RN OO said he would not have sent Resident #1 to dialysis; the physician would have been contacted for orders," the inspection report states.
The director of nursing acknowledged the facility's failure during interviews. "LVN A should have sent Resident #1 to the hospital on 3/11/25, adding this was the resident's right," she told inspectors.
But she also defended the decision, saying the resident's blood pressure fluctuations were common for dialysis patients and that LVN A thought he could see his nephrologist faster at the dialysis center.
The dialysis center supervisor confirmed no physician was on-site. When the center's physician was notified of the low blood pressure, he ordered IV fluids to rule out dehydration. When that failed to resolve the hypotension, the resident had to be hospitalized.
The resident's care plan specifically identified him as at risk for abnormal blood pressure related to renal failure and required staff to notify the medical director of blood pressure concerns.
Federal inspectors issued the immediate jeopardy citation on April 14, finding the facility placed residents "at risk for a delay in medical treatment, decline in health, and death."
The facility immediately implemented corrective measures. All 88 staff members received training on abuse and neglect reporting. Thirty licensed nurses were re-educated on recognizing condition changes and physician notification protocols. Forty unlicensed staff and therapists learned the "Stop and Watch" early warning system for identifying resident condition changes.
Management revised the physician notification policy to specifically include situations when residents request hospital transport.
The facility began requiring daily vital signs checks for all residents and implemented a tracking system for abnormal values. The director of nursing now reviews a daily hydration dashboard to monitor for condition changes.
During follow-up interviews, 37% of facility staff confirmed they received the mandated training on proper notification procedures, documentation using SBAR format, and protocols for residents requesting hospital care.
The immediate jeopardy designation was removed April 16 after inspectors verified the corrective actions, though the facility remained out of compliance pending evaluation of the plan's effectiveness.
The resident with end-stage renal disease was no longer at the facility when inspectors completed their investigation.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 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.
Licensed Vocational Nurse A documented the resident's vital signs at 11:14 a.m.
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.