Cycle 1
Health 2025-04-25 · Fire 2025-04-25
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
1 fire-safety deficiencies
Top issue: Smoke (1 deficiency)
San Antonio, TX
Westover Hills Rehabilitation And Healthcare
4-star overall rating with 3-star inspections with $20,156 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
9922 State Hwy. 151, San Antonio, TX
(210) 546-2273
Overall
4 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
124
Certified beds
Average residents
110
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
2011-05-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.54
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.02
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.13
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.58
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.11
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.58
CMS adjusted RN staffing hours
Adjusted total hours
3.70
CMS adjusted total nurse staffing hours
Case-mix index
1.27
Higher values indicate more complex resident acuity
RN turnover
43%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
35%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,732
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
28.92
Composite VBP score used to determine payment impact.
Payment multiplier
0.9852
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 18.09% · Performance 22.13% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
2.64
Baseline 8.58% · Performance 7.46% · Measure score 2.64 · Achievement 1.26 · Improvement 2.64
Total nurse turnover
6.80
Baseline 40.32% · Performance 35.87% · Measure score 6.80 · Achievement 6.80 · Improvement 2.38
Adjusted total nurse staffing
2.13
Baseline 3.26 hours · Performance 3.68 hours · Measure score 2.13 · Achievement 2.13 · Improvement 1.18
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.43% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 102 · Observed rate 9.8% · Lower 95% interval 7.56% |
| Discharge to community | 53.65% |
50.57%
3.1 pts better
|
No Different than the National Rate · Eligible stays 69 · Observed rate 49.28% · Lower 95% interval 42.01% |
| Medicare spending per beneficiary | 1 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 96.52% |
95.27%
1.2 pts better
|
Numerator 111 · Denominator 115 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 115 |
| Discharge self-care score | 57.89% |
53.69%
4.2 pts better
|
Numerator 33 · Denominator 57 |
| Discharge mobility score | 50.88% |
50.94%
0.1 pts worse
|
Numerator 29 · Denominator 57 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 115 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.46% |
7.12%
0.3 pts worse
|
No Different than the National Rate · Eligible stays 55 · Observed rate 9.09% · Lower 95% interval 4.47% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 156 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 70.18% |
56.45%
13.7 pts better
|
Numerator 40 · Denominator 57 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 44 · Denominator 44 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 41 · Denominator 41 |
| Resident COVID-19 vaccinations up to date | 0% |
25.2%
25.2 pts worse
|
Numerator 0 · Denominator 77 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.7 |
2.1
0.4 pts better
|
1.9
0.2 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.7 · Observed 1.4 · Expected 1.6 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
2.1
0.7 pts better
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.2 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.7% |
97.9%
0.8 pts better
|
95.5%
3.2 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.7% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.7% |
3.3%
0.4 pts worse
|
3.3%
0.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.3% · Q2 3.2% · Q3 2.7% · Q4 3.6% · 4Q avg 3.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.4% |
2.7%
2.3 pts better
|
11.4%
11 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 1.4% · 4Q avg 0.4% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
3.3%
0.6 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.8% · Q2 5.2% · Q3 0.0% · Q4 1.4% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 13.8% |
18.9%
5.1 pts better
|
19.6%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.9% · Q2 18.6% · Q3 10.3% · Q4 9.5% · 4Q avg 13.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 2.2% |
10.8%
8.6 pts better
|
16.7%
14.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 1.9% · Q3 3.1% · Q4 1.6% · 4Q avg 2.2% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.2% |
15.4%
8.2 pts better
|
16.3%
9.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q3 4.6% · Q4 7.7% · 4Q avg 7.2% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 10.4% |
16.1%
5.7 pts better
|
14.9%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 1.8% · Q3 12.5% · Q4 7.1% · 4Q avg 10.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 16.8% |
15.0%
1.8 pts worse
|
19.8%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 19.2% · Q2 13.3% · Q3 15.6% · Q4 18.6% · 4Q avg 16.8% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.2%
2.1 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.1% · Q2 0.0% · Q3 1.4% · Q4 2.8% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
89.7%
9.8 pts better
|
81.7%
17.8 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 99.0% · Q2 99.4% · Q3 99.7% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 13.2% |
12.0%
1.2 pts worse
|
12.0%
1.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 13.2% · Observed 13.5% · Expected 11.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.3% |
1.5%
1.2 pts better
|
1.6%
1.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 0.5% · Q3 0.0% · Q4 0.0% · 4Q avg 0.3% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 95.6% |
88.0%
7.6 pts better
|
79.7%
15.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 95.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 27.7% |
25.9%
1.8 pts worse
|
23.9%
3.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 27.7% · Observed 28.4% · Expected 24.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-03-15 · Fire 2024-03-15
14 health deficiencies
Top issue: Resident Assessment and Care Planning (5 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-01-20 · Fire 2023-01-20
12 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2025-04-25
K343 · Smoke Deficiencies
Fire Safety
Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.
Corrected 2025-05-23
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-21
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2025-09-19
D · Potential for more than minimal harm
2025-08-21
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-09-19
E · Potential for more than minimal harm
2025-04-25
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-02-14
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2024-06-17
J · Immediate jeopardy
2024-11-08
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-12-13
D · Potential for more than minimal harm
2024-11-08
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-12-13
E · Potential for more than minimal harm
2024-07-15
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-08-09
D · Potential for more than minimal harm
2024-07-15
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-08-09
E · Potential for more than minimal harm
2024-03-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-04-26
E · Potential for more than minimal harm
2024-03-15
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-15
F645 · Resident Assessment and Care Planning Deficiencies
Health
PASARR screening for Mental disorders or Intellectual Disabilities
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-15
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-15
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-15
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-15
F693 · Quality of Life and Care Deficiencies
Health
Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-15
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2024-04-26
D · Potential for more than minimal harm
2024-03-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-04-26
G · Actual harm
2023-11-10
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-11-10
D · Potential for more than minimal harm
2023-11-10
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2023-12-11
D · Potential for more than minimal harm
2023-07-14
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-14
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-14
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-14
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-07-14
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-08-25
D · Potential for more than minimal harm
2023-05-01
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-06-06
D · Potential for more than minimal harm
2023-03-25
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-04-30
E · Potential for more than minimal harm
2023-01-20
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-02-24
E · Potential for more than minimal harm
2023-01-20
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-02-24
D · Potential for more than minimal harm
2023-01-20
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-03-02
Penalties and ownership
What sits behind the stars
$12,519
2024-11-08
Fine
Fine · fine $12,519
Fine
$0
2024-11-08
Payment Denial
Payment Denial · denial start 2024-12-12 · 1 days
1 day denial
$7,637
2023-11-10
Fine
Fine · fine $7,637
Fine
Ownership
Guadalupe County Hospital Board
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Fiazuddin, Faraz
Operational/Managerial Control · Individual
Gann, Kody
Corporate Officer · Individual
Hoyler, Jerry
Operational/Managerial Control · Individual
Keetch, Chad
Corporate Officer · Individual
Sage Terrace Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Windemere At Westover Hills
San Antonio, TX
3-star overall rating with 2-star inspections with $8,281 in total fines with 7 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#2
Las Colinas Of Westover
San Antonio, TX
3-star overall rating with 2-star inspections with $38,630 in total fines with 12 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#3
Lakeside Nursing And Rehabilitation Center
San Antonio, TX
5-star overall rating with 4-star inspections with $14,611 in total fines with 4 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
Jump out