Windemere at Westover Hills: Immediate Jeopardy Violation - TX
The declaration, issued during an inspection that began in April 2025, meant inspectors had concluded that the facility's failures had placed residents in a situation where serious injury, serious harm, or death was likely unless immediate action was taken. Windemere had to move fast to get out of it.
What inspectors found at the root of the problem was not a single missed reading or a single nurse who fell short. It was a system that had stopped working, and leadership that had not caught it.
The Director of Nursing told inspectors on April 13 that nurses were expected to obtain and document vital signs every shift, and that she or the weekend supervisor reviewed the daily report for abnormal values. That was the policy. That was what was supposed to be happening. The inspection record does not describe it as what was actually happening, and the facility's scramble in the days that followed suggests the gap between policy and practice had grown wide enough to endanger the people living there.
On April 11, four days before the inspection concluded, the facility's Regional Director of Clinical Services came in and ran an in-service for the Executive Director and the Director of Nursing. The topics covered that day read like a checklist of everything that had broken down: physician notification, change in condition, abuse and neglect, SBAR communication, and the Hydration Dashboard. SBAR, which stands for Situation, Background, Assessment, and Recommendation, is a structured format nurses use to communicate urgent patient information to physicians. That nurses needed to be retrained on how to tell a doctor that something was wrong with a resident tells you something about how far the communication had slipped.
Two days later, on April 13, the Director of Nursing gathered all eight nurse supervisors and trained them on a new tool: the Vital Sign Monitor Tracking Tool. Three of those supervisors, identified in the inspection record as RN F, LVN I, and LVN LL, spoke with inspectors later that afternoon. They described what they had just been told to do: review their assigned residents' vital signs every shift for trends, sign the form confirming they had done it, hand the form to the Assistant Director of Nursing or the Director of Nursing, and complete a Change in Condition form and notify the physician or nurse practitioner for any abnormal values. They had learned all of this that same day.
The Director of Nursing spoke with inspectors twice on April 14. In the first conversation, at 3:38 in the afternoon, she said she had reviewed vital signs for 100 percent of residents currently living at the facility. She said all abnormal values had been reported to the physician or nurse practitioner, and that SBARs had been completed for every resident identified. She said she, a designee, or the staffing coordinator were responsible for making sure all new hires, PRN staff, and agency workers were trained on abuse and neglect, the Stop and Watch Early Warning Tool, change in condition, and SBAR before the start of their next shift.
Two minutes later, she added more. A log had been put in place. Nurses were now expected to review vital signs for their assigned residents, document on the log whether any trends or patterns had been found, sign the log, contact the physician if needed, and complete a progress note or SBAR if needed.
A tracking log. A new form. A sign-off sheet. These are the structures a facility builds when the old structures have failed, and when regulators are watching.
The Executive Director told inspectors on April 14 that she, too, had been in-serviced on April 11 by the Regional Director of Clinical Services. Her list of topics matched the Director of Nursing's almost exactly: change in condition, abuse and neglect, notifying physicians about changes in resident condition, SBAR, the Hydration Dashboard, vital signs, and weight summaries. The Executive Director of a nursing home being trained by a regional supervisor on how physicians should be notified when a resident's condition changes is not a routine professional development moment. It reflects something that had gone wrong at a level that reached the top of the building's leadership.
The facility also revised its physician notification policy that month. The updated version, dated April 2025, added language about resident requests to go to the hospital. The inspection report does not explain what prompted that specific addition, but the timing places it squarely inside the period when inspectors were on-site and the facility was trying to demonstrate it had fixed what was broken.
Inspectors informed the Executive Director, the Director of Nursing, and the Regional Director of Clinical Services and Nursing that the immediate jeopardy had been removed on April 16 at 11:16 in the morning. The facility had moved quickly enough, and made enough visible changes, to satisfy the threshold for lifting the most serious designation.
But the inspection did not end cleanly. Even after the immediate jeopardy was removed, Windemere remained out of compliance. Inspectors found the scope of the remaining violation to be isolated and the severity to be no actual harm with the potential for more than minimal harm. The reason: the facility was still in the process of monitoring whether its own plan was actually working. The new tracking tool, the new log, the new sign-off sheets, the retraining of every nurse supervisor, the in-services for the Executive Director and Director of Nursing — all of it had been put in place within a five-day window while federal inspectors were present. Whether it would hold once those inspectors left was a question the facility could not yet answer.
That uncertainty is not a technicality. Vital signs are among the most basic tools a nursing facility has for knowing whether a resident is deteriorating. Blood pressure that drops without anyone noticing. A fever that climbs through three shifts without a physician being called. A pulse that has been running fast for two days and nobody has documented a trend. These are the moments when early intervention can prevent a hospitalization, or prevent something worse. When the system for catching those moments stops functioning, residents who cannot advocate for themselves, who may not be able to say that something feels wrong, depend entirely on the nurses assigned to them to notice and act.
At Windemere at Westover Hills in April 2025, inspectors found that the system for noticing had broken down badly enough to constitute immediate jeopardy. The facility rebuilt it in five days under federal scrutiny. Whether it holds is the part the inspection report cannot tell you.
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.
Windemere had to move fast to get out of it.
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.