Windemere At Westover Hills
WINDEMERE AT WESTOVER HILLS in SAN ANTONIO, TX — inspection on April 16, 2025.
Found 4 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.
Inspection Findings
During an interview on 4/14/25 at 3:40 pm, the DON said she was responsible for ensuring nurses reviewed resident VS every shift.
The DON further stated a log was implemented and nurses were expected to review VS for their assigned resident, document on the log whether any trends/patterns were identified, sign the log, contact the physician/MD if needed, and complete a progress note or SBAR if needed.
During an interview on 4/14/25 at 3:43 pm, the DON said she was in-serviced on 4/11/25 by the RDCS regarding her responsibility related to VS, the Hydration Monitoring Tool, physician notifications, CIC, SBAR, and abuse/neglect.
During an interview on 4/14/25 at 3:46 pm, the ED said she was in-serviced on 4/11/25 by the RDCS regarding CIC, abuse/neglect, notifying the physicians regarding any changes in resident condition, SBAR, Hydration Dashboard, VS, and weight summaries.
Record review of the facility policy Physician Notification, revised April 2025, reflected it was updated to include resident requests to go to the hospital.
The ED, DON, and RDCN were informed the Immediate Jeopardy was removed on 4/16/25 at 11:16 am.
While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.
676402 04/16/2025
Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251
During an interview on 4/14/25 at 3:38 pm, the DON said she reviewed VS for 100% of residents residing at the facility.
The DON further stated all abnormal VS were reported to the physician/NP and SBARs completed for all residents identified. the DON said she/designee/staffing coordinator were responsible for ensuring all new hires, PRN and agency staff were in-serviced related to abuse/neglect, Stop and Watch Early Warning Tool, change in condition, and SBAR, prior to the start of their next shift.
During an interview on 4/14/25 at 3:40 pm, the DON said she was responsible for ensuring nurses reviewed resident VS every shift.
The DON further stated a log was implemented and nurses were expected to review VS for their assigned resident, document on the log whether any trends/patterns were identified, sign the log, contact the physician/MD if needed, and complete a progress note or SBAR if needed.
During an interview on 4/14/25 at 3:43 pm, the DON said she was in-serviced on 4/11/25 by the RDCS regarding her responsibility related to VS, the Hydration Monitoring Tool, physician notifications, CIC, SBAR, and abuse/neglect.
During an interview on 4/14/25 at 3:46 pm, the ED said she was in-serviced on 4/11/25 by the RDCS regarding CIC, abuse/neglect, notifying the physicians regarding any changes in resident condition, SBAR, Hydration Dashboard, VS, and weight summaries.
Record review of the facility policy Physician Notification, revised April 2025, reflected it was updated to include resident requests to go to the hospital.
The ED, DON, and RDCN were informed the Immediate Jeopardy was removed on 4/16/25 at 11:16 am.
While the IJ was removed, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal.
During an interview on 4/13/25 at 12:32 pm, the DON said nurses were expected to obtain and document VS every shift and she or the weekend supervisor would review the report daily for abnormal values.
Record review of staff training reflected the ED and DON were in-serviced on 4/11/25 by RDCS regarding physician notification, change in condition, abuse/neglect, SBAR, and Hydration Dashboard review.
Record review of staff training reflected 8 of 8 nurse supervisors were in-serviced on 4/13/25 by the DON regarding the Vital Sign Monitor Tracking Tool.
Interviews between 4/13/25 at 1:47 pm - 2:00 pm with 3 nurse supervisors (RN F, LVN I, and LVN LL) revealed an in-service was conducted regarding the Vital Sign Monitor Tracking Tool.
The nurse supervisors said they were expected to review their assigned residents' VS every shift for trends, sign the form to document completion, and give it to the ADON/DON.
The nurse supervisors further stated they were expected to complete a CIC form and notify the physician/NP for any abnormal values noted.
During an interview on 4/14/25 at 3:38 pm, the DON said she reviewed VS for 100% of residents residing at the facility.
The DON further stated all abnormal VS were reported to the physician/NP and SBARs completed for all residents identified. the DON said she/designee/staffing coordinator were responsible for ensuring all new hires, PRN and agency staff were in-serviced related to abuse/neglect, Stop and Watch Early Warning Tool, change in condition, and SBAR, prior to the start of their next shift.
During an interview on 4/14/25 at 3:40 pm, the DON said she was responsible for ensuring nurses reviewed resident VS every shift.
The DON further stated a log was implemented and nurses were expected to review VS for their assigned resident, document on the log whether any trends/patterns were identified, sign the log, contact the physician/MD if needed, and complete a progress note or SBAR if needed.
During an interview on 4/14/25 at 3:43 pm, the DON said she was in-serviced on 4/11/25 by the RDCS regarding her responsibility related to VS, the Hydration Monitoring Tool, physician notifications, CIC, SBAR, and abuse/neglect.
During an interview on 4/14/25 at 3:46 pm, the ED said she was in-serviced on 4/11/25 by the RDCS regarding CIC, abuse/neglect, notifying the physicians regarding any changes in resident condition, SBAR, Hydration Dashboard, VS, and weight summaries.
Record review of the facility policy Physician Notification, revised April 2025, reflected it was updated to include resident requests to go to the hospital.
676402
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676402 B.
Wing 04/16/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251
During an interview on 4/13/25 at 12:32 pm, the DON said nurses were expected to obtain and document VS every shift and she or the weekend supervisor would review the report daily for abnormal values.
Record review of staff training reflected the ED and DON were in-serviced on 4/11/25 by RDCS regarding physician notification, change in condition, abuse/neglect, SBAR, and Hydration Dashboard review.
Record review of staff training reflected 8 of 8 nurse supervisors were in-serviced on 4/13/25 by the DON regarding the Vital Sign Monitor Tracking Tool.
Interviews between 4/13/25 at 1:47 pm - 2:00 pm with 3 nurse supervisors (RN F, LVN I, and LVN LL) revealed an in-service was conducted regarding the Vital Sign Monitor Tracking Tool.
The nurse supervisors said they were expected to review their assigned residents' VS every shift for trends, sign the form to document completion, and give it to the ADON/DON.
The nurse supervisors further stated they were expected to complete a CIC form and notify the physician/NP for any abnormal values noted.
During an interview on 4/14/25 at 3:38 pm, the DON said she reviewed VS for 100% of residents residing at the facility.
The DON further stated all abnormal VS were reported to the physician/NP and SBARs completed for all residents identified. the DON said she/designee/staffing coordinator were responsible for ensuring all new hires, PRN and agency staff were in-serviced related to abuse/neglect, Stop and Watch Early Warning Tool, change in condition, and SBAR, prior to the start of their next shift.
During an interview on 4/14/25 at 3:40 pm, the DON said she was responsible for ensuring nurses reviewed resident VS every shift.
The DON further stated a log was implemented and nurses were expected to review VS for their assigned resident, document on the log whether any trends/patterns were identified, sign the log, contact the physician/MD if needed, and complete a progress note or SBAR if needed.
676402
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676402 B.
Wing 04/16/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Windemere at Westover Hills 11106 Christus Hills San Antonio, TX 78251
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.