Westover Hills Rehabilitation And Healthcare

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the shoulder and stated something in Spanish as he pointed out the window. Resident #2 stated she told him to leave her room, and he did. 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).

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Westover Hills Rehabilitation and Healthcare

9922 State Hwy. 151 San Antonio, TX 78251

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

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 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.

Event ID:

Facility ID:

If continuation sheet