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Complaint Investigation

Westover Hills Rehabilitation And Healthcare

August 21, 2025 · San Antonio, TX · 9922 State Hwy. 151
Citations 2
CMS Rating 4/5
Beds 124
Provider ID 676281
Healthcare Facility
Westover Hills Rehabilitation And Healthcare
San Antonio, TX  ·  View full profile →
Inspection Summary

WESTOVER HILLS REHABILITATION AND HEALTHCARE in SAN ANTONIO, TX — inspection on August 21, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0641
Resident Assessment and Care Planning Deficiencies
Potential for More Than Minimal Harm

During an interview on 8/21/25 at 11:47 a.m. MDS C stated she was informed on 8/20/25 that Resident #1 had behaviors of looking for a family member and would require staff to reorient him. MDS C stated they would normally run a 24 hours report in the morning and filter for key words to find any resident with changes in condition. MDS C stated the ADONs also assist with looking over the 24 hour reports and updating any assessments or care plans. MDS C stated she had recently been out for personal reasons and was not aware the resident had a change in condition. MDS C stated by not updating changes in the resident's care plan staff would not be aware of how to treat the resident.

The MDS C stated staff used the care plan to be aware of resident behaviors and would also prompt care areas in the point of care nursing aides used.

During an interview on 8/21/25 at 12:09 p.m. ADON D they would run a 24-hour report and read the report to see if any residents had a change in condition. ADON D stated there were 3 ADONs who would split up the reports according to hallways. ADON D stated however 1 of the ADONs had recently started and another ADON had been out of FMLA.

The ADON stated the DON was also helping her read the 24-hour reports daily. ADON D stated she was not aware of the nursing progress note from 8/5/25 where the resident was exhibiting exit seeking and wandering behaviors. ADON D stated had she seen that note she would have spoken to the resident to see what was going on, spoken to the nursing staff, and made the DON aware. ADON D stated they would also notify the doctor and see if they needed to update any orders. ADON D stated they would also need to look at his elopement and wandering assessment and update it. ADON D stated 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.

During an interview on 8/21/25 at 12:23 p.m. the DON stated the ADONs would look over the 24-hour reports, notify MDS, and bring up any changes in patient conditions during their morning meetings.

The DON stated she became aware of Resident #1's nursing note from 8/5/25 on 8/20/25 while performing an audit.

The DON stated they care planned the behaviors.

The DON stated she was unaware the resident ever had wandering behaviors and no one ever reported to her he had any behaviors of being in other resident rooms.

The DON stated the ADONs were responsible for reviewing the 24-report and updating the wandering assessment.

The DON stated it was important to update care plans and assessments so staff could follow the residents plan of care and return him to his room safely.

Record review of the facility's policy titled Resident Assessment, no date, stated Policy: It is the policy of this facility to perform resident assessment.

Procedure: Each resident will be assessed by the licensed nurse. 2.

Each time there is a change in the mental or physical condition of the resident that may significantly affect his or her ability to perform the activities of daily living 3.

Every quarter. 4. If there is a significant change, it will be reported to physician and orders to carried out.

Additional assessments will be performed as needed. (i.e., fall risk assessment, pain evaluations, enabling device assessment, etc).

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/21/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Westover Hills Rehabilitation and Healthcare

9922 State Hwy. 151 San Antonio, TX 78251

SUMMARY STATEMENT OF DEFICIENCIES

During an interview on 8/21/25 at 12:09 p.m. ADON D they would run a 24-hour report and read the report to see if any residents had a change in condition. ADON D stated there were 3 ADONs who would split up the reports according to hallways. ADON D stated however 1 of the ADONs had recently started and another ADON had been out of FMLA.

The ADON stated the DON was also helping her read the 24-hour reports daily. ADON D stated she was not aware of the nursing progress note from 8/5/25 where the resident was exhibiting exit seeking and wandering behaviors. ADON D stated had she seen that note she would have spoken to the resident to see what was going on, spoken to the nursing staff, and made the DON aware. ADON D stated they would also notify the doctor and see if they needed to update any orders.

ADON D stated they would also need to look at his elopement and wandering assessment and update it.

ADON D stated 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.

During an interview on 8/21/25 at 12:23 p.m. the DON stated the ADONs would look over the 24-hour reports, notify MDS, and bring up any changes in patient conditions during their morning meetings.

The DON stated she became aware of Resident #1's nursing note from 8/5/25 on 8/20/25 while performing an audit.

The DON stated they care planned the behaviors.

The DON stated she was unaware the resident ever had wandering behaviors and no one ever reported to her he had any behaviors of being in other resident rooms.

The DON stated the ADONs were responsible for reviewing the 24-report and updating the wandering assessment.

The DON stated it was important to update care plans and assessments so staff could follow the residents plan of care and return him to his room safely.

Record review of the facility's policy titled Comprehensive [NAME]-Centered Care Planning, dated 12/23, stated Policy: It is the policy of this facility that the interdisciplinary team (IDT) shall develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment.

The IDT team will also develop and implement a baseline care plan for each resident, within 48 hours of admission, that includes minimum healthcare information necessary to properly care for each resident and instructions needed to provide effective and person-centered care that meet professional standards of quality care.4.

The facility IDT will develop and implement a comprehensive person-centered, culturally-competent, and trauma-informed care plan for each resident within seven (7) days of completion of the Resident Minimum Data Set (MOS) and will include resident's needs identified in the comprehensive assessment. 6.

The resident's comprehensive plan of care will be reviewed and/or revised by the IDT after each assessment, including both the comprehensive and quarterly review assessments.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SAN ANTONIO, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from WESTOVER HILLS REHABILITATION AND HEALTHCARE or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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