Westover Hills Rehab: Care Plan Failures - TX
Federal inspectors found that Westover Hills Rehabilitation and Healthcare violated care planning requirements after a nursing progress note from August 5 documented new wandering behaviors that were never communicated to supervisors or incorporated into the resident's treatment plan.
The facility's MDS Coordinator stated she was unaware the resident had experienced a change in condition. She had been out for personal reasons and acknowledged that without updated care plans, "staff would not be aware of how to treat the resident."
Staff used care plans to understand resident behaviors and guide daily care through point-of-care systems used by nursing aides. The failure to update assessments meant caregivers remained unaware of the resident's new tendency to wander and enter other residents' rooms.
Assistant Director of Nursing D explained that three ADONs typically split responsibility for reviewing 24-hour reports according to hallways to identify changes in resident conditions. However, one ADON had recently started and another had been out on FMLA leave, creating gaps in oversight.
ADON D stated she was unaware of the August 5 nursing progress note documenting the resident's exit-seeking and wandering behaviors. Had she seen the note, she would have spoken with the resident to understand what was happening, discussed the situation with nursing staff, and notified the Director of Nursing.
The protocol also required notifying the doctor to determine if new orders were needed and updating the resident's elopement and wandering assessment. None of these steps occurred.
"Failing to update the resident assessments could cause someone to miss a new onset mental issue or condition and implementing any interventions to protect other residents and respect their privacy," ADON D told inspectors.
The Director of Nursing discovered the August 5 nursing note on August 20 while performing an audit. She stated the facility then developed a care plan for the behaviors, but acknowledged she had been unaware the resident ever exhibited wandering behaviors.
Nobody had ever reported to the DON that the resident was entering other residents' rooms.
The DON emphasized that ADONs were responsible for reviewing 24-hour reports and updating wandering assessments. She explained it was critical to update care plans and assessments "so staff could follow the residents plan of care and return him to his room safely."
The facility's own policy, titled Comprehensive Person-Centered Care Planning and dated December 2023, requires the interdisciplinary team to develop comprehensive care plans that include measurable objectives and timeframes to meet residents' medical, nursing, mental and psychosocial needs identified in assessments.
The policy mandates that care plans be reviewed and revised after each assessment, including both comprehensive and quarterly reviews. It also requires developing baseline care plans within 48 hours of admission and comprehensive plans within seven days of completing the Minimum Data Set.
The breakdown occurred despite multiple layers of oversight designed to catch changes in resident conditions. Three ADONs were supposed to divide responsibility for reviewing daily reports, with the DON providing additional support during morning meetings where changes in patient conditions should be discussed.
The MDS Coordinator noted that ADONs typically assist with reviewing 24-hour reports and updating assessments or care plans based on documented changes. The system failed when staff absences and new employee training created gaps in this review process.
Federal inspectors determined the violation caused minimal harm or potential for actual harm, affecting few residents. However, the failure to update care planning left the wandering resident without appropriate interventions and potentially compromised the privacy and safety of other residents whose rooms he was entering.
The case illustrates how staffing challenges and communication breakdowns can undermine basic care planning requirements, even when facilities have detailed policies in place. The resident's behavioral changes went unaddressed for over two weeks simply because supervisors failed to review existing documentation that clearly identified the new concerns.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westover Hills Rehabilitation and Healthcare from 2025-08-21 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
WESTOVER HILLS REHABILITATION AND HEALTHCARE in SAN ANTONIO, TX was cited for violations during a health inspection on August 21, 2025.
The facility's MDS Coordinator stated she was unaware the resident had experienced a change in condition.
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.