Westover Hills Rehab: Pressure Ulcer Report Buried - TX
That decision, made jointly by the Director of Nursing and the Administrator, is now at the center of a federal deficiency citation against the facility at 9922 State Highway 151.
The resident at the center of the complaint, identified in inspection records only as Resident 1, was already dealing with complications from a left knee surgery following a fall she had at home. On the morning of May 18, 2026, a nurse practitioner assessed her with a change of condition and the facility sent her to the hospital for evaluation and treatment. Three days later, on or about May 21, the resident's family representative called the Director of Nursing, upset. The family said Resident 1 had pressure ulcers on her back and buttocks.
What happened next is the story.
The Director of Nursing discussed the complaint with the Administrator. Together, they reviewed interviews and records. Two licensed vocational nurses, identified in the inspection report as LVN A and LVN B, had administered an enema to Resident 1 on the evening of May 17, the night before she was sent out. Neither nurse, according to the DON, observed any skin breakdown at that time.
Based on that, the two administrators concluded the allegation was, in their words, without merit.
They did not report it to the state.
The DON told inspectors that the facility's policy was to report allegations of abuse, neglect, or exploitation with injury within two hours and without injury within 24 hours. She acknowledged that standard. Then she explained why it didn't apply here: she and the Administrator had decided the allegation didn't rise to the level of a self-report because there was no evidence.
That reasoning is precisely what inspectors flagged as the violation.
The facility's own Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, dated April 2001, states that residents have the right to be free from abuse and neglect, and that the facility must identify and investigate all possible incidents. It also requires the facility to investigate and report any allegations within the time frames required by federal requirements. The policy does not include a clause allowing administrators to pre-screen complaints and decide on their own which ones are credible enough to report.
The distinction matters. A family member called to report visible wounds on a resident's body. That is an allegation. Whether or not the allegation turns out to be substantiated is something an investigation, and in some cases a state agency, is supposed to determine. The facility collapsed those two steps into one, deciding simultaneously that the complaint lacked evidence and that no outside reporting was therefore necessary.
Inspectors were not persuaded.
The deficiency was cited at a level of minimal harm or potential for actual harm, affecting a small number of residents. That is among the lower tiers of severity in the federal citation system. But the nature of what was cited, a failure to report an allegation of neglect involving visible physical injury to a resident, touches something more fundamental than a paperwork lapse.
Pressure ulcers, sometimes called bedsores, develop when sustained pressure cuts off blood flow to skin and underlying tissue, typically over bony areas like the tailbone and hips. They are among the most closely watched indicators in nursing home care because they are often preventable with proper repositioning, skin assessments, and attention to a resident's condition. When a resident who has been in a facility's care develops them, and a family member calls to report it, that call is supposed to trigger a process, not a private administrative conversation that ends with the complaint being set aside.
Resident 1's situation had layers of vulnerability that make the sequence of events harder to read charitably. She was recovering from knee surgery following a fall. She had been assessed with a change of condition the morning of May 18. She was sent to the hospital. Then, three days after that hospitalization, her family called to say she had pressure ulcers. The two nurses who had been with her the night before she was sent out said they saw nothing. The administrators took that as the end of the inquiry.
The family representative who made that phone call on May 21 was upset. The inspection report doesn't say what happened next for them, whether they were told the complaint had been closed, whether they were offered any documentation, whether anyone followed up with them at all. What the report does say is that the facility did not contact the state agency.
There is a reason the reporting requirement exists independent of a facility's internal judgment about credibility. Families are not always wrong. Staff members are not always right. An enema administered the evening before a hospitalization does not constitute a comprehensive skin assessment, and the absence of a documented observation is not the same as documented intact skin. The DON's account of what the nurses said, filtered through an administrative conversation, is not an investigation.
The facility's 2001 policy uses the word "possible" deliberately. Identify and investigate all possible incidents. Not all confirmed incidents. Not all incidents that management finds plausible. Possible ones.
Westover Hills Rehabilitation and Healthcare is a licensed skilled nursing facility operating under the Medicare and Medicaid programs. The complaint inspection was conducted May 23, 2026, and the deficiency statement was printed August 8, 2026.
The family member who called on May 21 was upset enough to reach out. That call was the system working the way it is supposed to work. What happened after it, two administrators deciding between themselves that the concern didn't need to go any further, is what inspectors found unacceptable.
Resident 1 had already been sent to the hospital once. Her family was watching. They saw something that alarmed them enough to call. Whether the pressure ulcers were new, whether they developed at the facility or elsewhere, whether they were serious or superficial, none of that was for the Director of Nursing and the Administrator to resolve in a private conversation and then close.
That is what the report says happened.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Westover Hills Rehabilitation and Healthcare from 2026-05-23 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.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 16, 2026 · Our methodology
WESTOVER HILLS REHABILITATION AND HEALTHCARE in SAN ANTONIO, TX was cited for violations during a health inspection on May 23, 2026.
Three days later, on or about May 21, the resident's family representative called the Director of Nursing, upset.
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.