Below average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Las Colinas Of Westover during CMS and state inspections, most recent first.
Two residents with documented contractures did not have these conditions reflected in their care plans, despite assessments and staff acknowledgment of their needs. Staff interviews confirmed the omission, and facility policy requires such needs to be addressed in care plans with specific interventions.
Multiple MDS assessments were coded inaccurately. One resident’s quarterly MDS showed an anticoagulant instead of an antiplatelet, another resident’s quarterly MDS omitted Risperidone and Aspirin, a third resident’s annual MDS did not capture a fall documented in an incident report and care plan, and a discharge MDS was coded as unplanned even though the record showed a planned respite discharge. The DON and MDS coordinator stated the MDS information must accurately reflect resident status because it is used in the care plan and payment process.
Incomplete Care Plans for Specific Resident Needs: The facility failed to ensure care plans reflected key resident needs for three residents. One resident with an indwelling catheter had an active order for a Foley leg strap, but the care plan only addressed tubing checks. Another resident with hypothyroidism was receiving levothyroxine and aspirin, but neither condition nor the antiplatelet medication was included in the care plan. A third resident had electronic monitoring in her room with RP consent, but that monitoring was not reflected in the care plan. Staff stated these items should have been included because the care plan communicates resident-specific care needs.
A resident lacked a physician order for oxygen, including the liters per minute to be used, while two other residents were observed with portable O2 tanks set at 2 L/min and the gauges in the red zone. The residents had COPD or other respiratory diagnoses, were receiving therapeutic oxygen, and staff acknowledged the tanks should not have been allowed to reach the red zone and that an oxygen order should have been in place.
Missing Required Staff Training Documentation: The facility failed to maintain an effective training program for multiple employees. Record review showed that the Administrator, DON, Activity Director, several LVNs, CNAs, RNs, an ADON, and other staff lacked evidence of required annual training, while a Social Worker, Dietary Manager, and Restorative Aide did not receive required training upon hire.
The facility failed to ensure QAPI training was completed for 19 of 24 employees reviewed, including the Administrator, DON, ADON, Activity Director, multiple LVNs, CNAs, RNs, and support staff. Record review showed no evidence of annual QAPI training for several employees and no evidence that the Dietary Manager, Social Worker, and Restorative Aide P completed QAPI training upon hire. HR stated the training packet used for new hire and annual training did not include QAPI, and the Administrator, DON, and ADON each stated they were responsible for staff training but were unaware QAPI was omitted.
Failure to Complete Required Ethics Training: The facility failed to ensure ethics training was completed for 19 of 24 employees reviewed. Several staff, including the DON, Administrator, ADON, Activity Director, LVNs, CNAs, RNs, and others, had no evidence of annual ethics training, and the Dietary Manager, Social Worker, and a Restorative Aide did not complete ethics training upon hire. HR, the ADON, the DON, and the Administrator stated they were responsible for staff training, and HR confirmed the new-hire training packet did not include ethics training.
CNA Annual Training Deficiencies: The facility failed to ensure 7 CNAs received the required minimum 12 hours of annual in-service training. Record review showed each CNA had less than the required annual training hours, and HR, the ADON, the DON, and the Administrator all acknowledged the training packet used for hire and annual training did not include communication, QAPI, or ethics training.
A resident with an indwelling urinary catheter, urinary retention, and moderately impaired cognition was observed without the ordered Foley leg strap during catheter care and again later while sitting at the bedside. The care plan did not reflect the leg strap need, although active orders directed staff to secure the tubing with a leg strap at all times. The resident stated the tubing pulled and caused discomfort, and the DON stated the strap was important to prevent pulling or dislodgement.
Improper Storage of Refrigerated Eye Drops: A resident’s brand-new Latanoprost eye drops were found stored at room temperature in a nursing cart even though the box label said refrigerate. The resident had a physician order for the medication, and an LVN stated the drops had been kept on the cart instead of in a refrigerator; the DON stated the medication would not reach therapeutic effects.
A resident with severe cognitive impairment, dementia, and multiple psychiatric and swallowing diagnoses had an order for PRN oxygen for SOB, and nursing notes showed oxygen was given on several days. However, the MAR had no initials for the PRN oxygen, and an LVN stated she did not look for the order on the MAR or initial it after providing the oxygen. The DON stated documentation of nursing care is a professional expectation and that if it was not documented, it was not done.
Improper glove changes and hand hygiene during incontinent care were observed for two residents with bowel and bladder incontinence. One CNA handled a soiled brief and continued care without cleaning hands or changing gloves, and another CNA touched a clean brief with soiled gloves, then reused the same brief after sanitizing hands and changing gloves. Both CNAs stated cross contamination could occur, and the DON stated this type of peri care could lead to cross contamination and spread of bacteria.
Unsanitary and Unsafe Resident Restrooms: Two resident restrooms were found in poor condition. One resident with moderate cognitive impairment and fall risk had a shower floor wet from a leaking shower head, and another resident with severe cognitive impairment had what staff identified as old human feces on the restroom floor near the toilet. Staff interviews confirmed the wet floor and the fecal matter, and the DON stated both restrooms should have been clean.
A Beauty Shop was found unlocked and unoccupied, containing flammable and potentially harmful materials such as hairspray, hair dye, sanitizing wipes, hair setting solution, and a nail dryer. The Administrator confirmed the area should have been secured to prevent resident access to these items.
A resident's face sheet did not include several diagnoses—Primary Osteoarthritis of both shoulders and Polyneuropathy—that were documented by a nurse practitioner elsewhere in the medical record. The face sheet only listed other conditions, and this omission was confirmed by the DON, who recognized the importance of accurate documentation for communication with outside providers.
A facility failed to maintain resident dignity during ADL care. An LVN stood while feeding two residents with dementia, requiring them to look up, which was acknowledged as a dignity issue. Another LVN left a resident exposed by holding a door open during a discussion, compromising privacy. The DON confirmed the need for privacy measures.
The facility did not adequately inform residents about the location of survey results. Eight residents were unaware of where to find these results, and an observation revealed the binder was not easily visible in the lobby. Interviews with the AD and ADM confirmed the lack of communication and signage regarding the survey results binder's location.
The facility failed to maintain food safety standards as observed in their kitchen operations. The Dietary Manager and Aide did not wear beard restraints, and hair restraints were improperly worn, risking contamination. Additionally, items in the walk-in refrigerator were not labeled, violating facility policy and FDA guidelines.
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper wound care for two residents and inadequate sanitation of a shower chair. One resident received wound care without Enhanced Barrier Precautions, while another had wound care with improperly stored supplies and inadequate glove changes. Additionally, a shower chair was found soiled with feces, indicating a lack of proper cleaning by staff.
The facility failed to maintain an effective pest control program, leading to the presence of gnats and other pests. Observations showed gnats on food containers and flying around the facility, with residents expressing concerns about gnats and roaches. Despite regular pest control treatments, the issue persisted, as noted in service reports and resident feedback.
A facility failed to conduct a PASARR Level II assessment for a resident with Schizoaffective Disorder and Major Depressive Disorder, as required. The resident was admitted with these diagnoses, but the PASARR Level 1 Screening incorrectly indicated no mental illness. The MDS Coordinator did not re-submit a Level I screening, believing the resident would not qualify for services due to a primary diagnosis of Dementia, contrary to facility policy.
A facility failed to document the use of side rails in a resident's baseline care plan within 48 hours of admission. Despite a bed rail evaluation and consent indicating their necessity, the care plan incorrectly stated no safety devices were used. Observations confirmed the use of side rails, and the resident reported needing them for mobility due to weakness.
A resident with a history of stroke and foot issues did not receive proper foot care, including podiatry services, despite requests from the resident and their responsible party. The resident's toenails were thickened and in need of trimming, and there was no documentation of podiatry appointments in the resident's records. The DON acknowledged the importance of podiatry care, but the facility's policy on podiatry care was not provided.
A resident with a catheter did not receive proper care according to facility policy, as the urinary meatus was not cleaned during the procedure. The resident, who has a history of urinary issues and vascular dementia, expressed pain during the care. The CNAs involved acknowledged the oversight, and the DON confirmed the importance of following the correct procedure to prevent infection.
A resident with a history of cerebral infarction and respiratory issues was found with her oxygen nasal cannula and tubing on the floor, contrary to facility policy requiring storage in a plastic bag to prevent infection. Staff acknowledged the oversight, and the contaminated equipment was disposed of. The resident's care plan lacked focus on oxygen therapy despite physician orders.
The facility failed to ensure proper use of bed rails for two residents, lacking informed consent and safety assessments. One resident with cognitive impairments had bed rails without consent, while another resident's consent form was incomplete. Facility policy requires assessments and documentation, which were not adequately addressed.
A resident in a facility experienced a methadone overdose due to a medication administration error. The resident, who had no order for methadone, was mistakenly given the medication intended for another resident. The error was attributed to staff not following the facility's medication administration policy, including verifying the resident's identity and medication details. The incident resulted in the resident being hospitalized with confirmed methadone overdose.
A resident in a long-term care facility experienced a methadone overdose due to a medication error. The resident, who did not have a methadone prescription, received the drug intended for another resident. Staff interviews and record reviews revealed that multiple staff members administered the wrong medication, leading to the overdose. The resident exhibited overdose symptoms and required hospital treatment. The error was attributed to pre-pulling medications, which caused confusion about the correct administration.
The facility failed to update care plans for two residents after falls resulting in fractures, despite physician orders and staff observations. The care plans lacked necessary interventions, confirmed by the DON and staff interviews.
Failure to Include Contractures in Care Plans for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive, person-centered care plans for two residents with contractures. Despite both residents having documented impairments and contractures in their medical records, assessments, and therapy notes, their care plans did not reflect these conditions. Staff interviews confirmed that both residents required assistance related to their contractures, such as help with eating and the use of splints or therapy interventions. However, the care plans lacked any mention of contractures or related interventions, contrary to facility policy and the residents' identified needs. Multiple staff members, including the MDS nurse, ADONs, and DON, acknowledged the presence of contractures and the importance of including them in care plans. The facility's own policies require care plans to address mobility and range of motion, including contractures, with specific interventions. Despite this, the care plans for both residents were not updated to include these needs, resulting in a failure to ensure that services were described and provided to maintain or improve the residents' physical, mental, and psychosocial well-being.
MDS Assessments Did Not Match Resident Status
Penalty
Summary
The facility failed to accurately code multiple residents’ MDS assessments so that the assessments did not reflect the residents’ actual status. For Resident #43, the quarterly MDS dated [DATE] showed that she took an anticoagulant and did not show that she took an antiplatelet medication, even though her active orders showed Aspirin ordered on 02/24/2025 and no anticoagulant order. Her record also showed diagnoses including COPD, type II diabetes mellitus, dysphagia, dementia, depression, and cognitive communication deficit. Her BIMS score was 0 of 15, indicating severe cognitive impairment, and she was dependent on most ADLs. For Resident #62, the quarterly MDS dated [DATE] did not reflect her antipsychotic or antiplatelet medications. Her active orders showed Risperidone twice daily since 05/21/2025 and Aspirin EC Low Dose 81 mg daily since 05/23/2025. The MDS also coded that she did not receive antipsychotic medication since admission or prior OBRA assessment, and the antiplatelet item was not checked. Her record included diagnoses of COPD, dementia, type II diabetes mellitus, major depressive disorder, bipolar disorder, hypothyroidism, and depression. Her BIMS score was 8 of 15, and she required substantial assistance with most ADLs. For Resident #75, the annual MDS dated [DATE] did not reflect a fall that occurred on 05/22/2025, even though an incident report documented a fall and the care plan addressed high fall risk and the resident being found on a fall mat. The MDS section for falls since admission or prior assessment was coded as no falls. For Resident #106, the discharge MDS dated 07/26/2025 coded the discharge as unplanned and return not anticipated, even though the physician order summary and progress notes showed a respite stay with a planned return/discharge timeframe. The MDS coordinator stated the discharge MDS was miscoded and should have been coded as a planned discharge.
Incomplete Care Plans for Specific Resident Needs
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for 3 residents, and the care plans did not reflect specific needs identified in assessments, orders, and observations. Resident #37 had an indwelling urinary catheter and an active order to secure the Foley tubing with a leg strap at all times to prevent pulling, but the comprehensive care plan only addressed checking the tubing for kinks each shift and did not include the leg strap requirement. Resident #62 had diagnoses including hypothyroidism and was receiving Levothyroxine Sodium daily, as well as Aspirin EC Low Dose 81 mg daily, but her comprehensive care plan did not reflect treatment for hypothyroidism or the use of an antiplatelet medication. Resident #75 had severe cognitive impairment, was dependent for ADLs, and had electronic monitoring in her room with a camera visible from the doorway that triggered with motion. A consent for electronic monitoring had been signed by her RP, but the comprehensive care plan did not reflect that electronic monitoring was in place. During interviews, staff stated that these items needed to be care planned because they were specific parts of the residents’ care or preferences and that the care plan communicates what care each resident requires. The DON also stated that missing information from the care plan could result in care not being transferred to the CNA Kardex. The report also states that the ADM said information from MDS assessments is transferred to the care plan and that if the MDS is inaccurate, the care plan could be inaccurate and care could be missed. Facility policy required the IDT, with the resident and family or legal representative, to develop and implement a comprehensive person-centered care plan describing services to attain or maintain the resident’s highest practicable physical, mental, and psychological well-being.
Oxygen Therapy Orders and Tank Monitoring Not Maintained
Penalty
Summary
The facility failed to ensure that residents receiving oxygen therapy had appropriate orders and safe oxygen administration. Resident #35 had diagnoses including obesity class 3, pulmonary hypertension, congestive heart failure, pleural effusion, and fluid overload. His admission assessment documented that he received oxygen therapy, and his care plan included a focus for oxygen therapy related to ineffective gas exchange. However, the physician order summary dated 10/01/2025 did not contain any oxygen order or any order specifying liters per minute. During observation, he was seen wearing oxygen set at 2.5 liters, and he stated he used oxygen pretty much all the time and usually had it set at 2 or 3 liters. Staff interviews confirmed that an order should have been present and that the nurse was responsible for obtaining it. Resident #43 had diagnoses including COPD, dysphagia, dementia, depression, and cognitive communication deficit. Her MDS showed severely impaired cognition, and her care plan included oxygen therapy interventions, including providing extension tubing or portable oxygen for ambulatory residents and ensuring oxygen was given if the resident was allowed to eat. Her active orders included oxygen at 2 to 4 L/min via nasal cannula continuously for shortness of breath. On observation in the dining room, she was sitting at a table with a portable oxygen tank set at 2 L/min, and the pressure gauge was in the red zone. She was observed again with the DON and the tank gauge remained in the red zone. The nurse stated the tank should not have been in the red zone and that she had been trained to change the tank when the pressure gauge was near or in the red zone. Resident #62 had diagnoses including COPD, dementia, type II diabetes mellitus, major depressive disorder, bipolar disorder, and hypothyroidism. Her MDS showed moderately impaired cognition, and her care plan included oxygen therapy interventions similar to those for ambulatory residents. She was observed sitting in a common area near the nurses’ station with a portable oxygen tank set at 2 L/min via nasal cannula and the pressure gauge in the red zone. She was observed again with the DON and the tank remained in the red zone. The nurse stated he had equipped her with a full tank earlier, that an E tank at 2 L/min lasts about 4 hours, and that the tank should not have been in the red zone. The DON stated the nurses needed to check portable oxygen tanks and that the gauges should never get into the red zone.
Missing Required Staff Training Documentation
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for 19 of 24 employees reviewed for training requirements. Record review showed that the Administrator, DON, Activity Director, LVN G, LVN L, CNA M, CNA N, CNA O, CNA Q, CNA R, CNA S, CNA T, RN U, RN V, LVN W, and ADON X did not have evidence of required annual training in the previous 12 months. The report also identified that the Social Worker, Dietary Manager, and Restorative Aide P did not receive required training upon hire. Personnel record review and training log review were used to identify the missing training documentation. The Administrator had a hire date of 02/08/2021 and no evidence of annual training in the prior 12 months. The DON had a hire date of 11/21/2022 and no evidence of annual training in the prior 12 months. The Dietary Manager and Social Worker were hired on 09/02/2025 and did not complete required training upon hire, and Restorative Aide P was hired on 08/26/2025 and also did not complete required training upon hire. Similar missing annual training documentation was found for the remaining listed employees.
Failure to Complete Required QAPI Training
Penalty
Summary
The facility failed to ensure QAPI training was completed for 19 of 24 employees reviewed for training requirements. Record review showed that the Administrator, DON, Activity Director, multiple LVNs, CNAs, RNs, the ADON, and other direct care and support staff did not have evidence of annual QAPI training in the prior 12 months. Record review also showed that the Dietary Manager, Social Worker, and Restorative Aide P did not complete QAPI training upon hire. Personnel records showed hire dates for the affected employees, including staff hired in 2021 through 2025, and the training logs provided by human resources did not show QAPI training completion as required. For the employees reviewed, the facility could not provide documentation that the required QAPI training had been completed either at hire or annually, depending on the employee’s role and hire date. A policy identifying required training topics and frequency of training was requested from HR and the Administrator but was not provided prior to exit. During interviews, HR stated the facility used a training packet for staff upon hire and annually, but that the packet did not include QAPI training. HR, the ADON, the DON, and the Administrator each stated they were responsible for ensuring staff completed required training, and each acknowledged they were unaware that QAPI training was not included in the packet. The Administrator stated he was ultimately responsible for ensuring staff received the required training, and the DON stated she supervised the ADON who was responsible for ensuring staff received training upon hire and annually.
Failure to Complete Required Ethics Training
Penalty
Summary
The facility failed to ensure ethics training was completed for 19 of 24 employees reviewed for training requirements. Record review showed that the Administrator, DON, Activity Director, multiple LVNs, CNAs, RNs, the ADON, and other staff did not have evidence of annual ethics training in the prior 12 months. In addition, the Dietary Manager, Social Worker, and Restorative Aide did not complete ethics training upon hire. Personnel records and training logs were reviewed for each identified employee. The Administrator had a hire date of 02/08/2021 and no evidence of annual ethics training in the previous 12 months. The DON, hired 11/21/2022, also had no evidence of annual ethics training. The Activity Director, hired 01/05/2021, had no evidence of annual ethics training. The Dietary Manager, Social Worker, and Restorative Aide were hired in 2025 and did not complete ethics training upon hire. Interview with HR, the ADON, the DON, and the Administrator confirmed that HR and the ADON were responsible for ensuring staff completed training upon hire and annually. HR stated the training packet used for new hires did not include ethics training. The ADON stated she was unaware ethics training was not in the packet, and the DON and Administrator stated they were not aware the training packet lacked ethics training. A policy identifying required training topics and frequency was requested from HR and the Administrator but was not provided prior to exit.
CNA Annual Training Deficiencies
Penalty
Summary
The facility failed to ensure CNAs received the required minimum 12 hours of annual in-service training for 7 of 7 CNAs reviewed: CNA M, CNA N, CNA O, CNA Q, CNA R, CNA S, and CNA T. Record review showed each of these CNAs had less than 12 hours per year of required in-service training during the previous 12 months. The personnel records reviewed included hire dates for each CNA, and the training logs provided by HR did not show the required annual training hours had been completed. During interviews, HR stated the facility used a training packet that staff were to complete upon hire and again annually, but the packet did not include communication training, QAPI training, or ethics training. HR stated it was the responsibility of HR and the ADON to ensure staff completed the packet upon hire and annually. The ADON stated she and HR were responsible for ensuring staff completed initial and annual training and said she was unaware the packet did not include communication, QAPI, and ethics training. The DON stated she supervised the ADON, and the Administrator stated he was ultimately responsible for ensuring staff received the required training. A policy identifying required training topics and frequency was requested from HR and the Administrator but was not provided prior to exit.
Failure to Maintain Foley Leg Strap for Resident with Indwelling Catheter
Penalty
Summary
Resident #37, a readmitted female with diagnoses including fracture of the neck of the left femur, COPD, permanent atrial fibrillation, and urinary retention, had an indwelling urinary catheter and required partial assistance with ADLs. Her annual MDS reflected a BIMS score of 10 out of 15, indicating moderately impaired cognition, and she could understand and be understood. Her comprehensive care plan identified that she had an indwelling catheter and included an intervention to check tubing for kinks each shift, but it did not reflect a need for a urinary catheter leg strap. Her active orders, however, directed staff to secure the Foley tubing with a leg strap at all times to prevent pulling, with a start date of 08/14/2024. During observation on 10/02/2025, CNA C provided catheter care and Resident #37 did not have a leg strap in place. On 10/03/2025, the resident was again observed sitting on the side of her bed without a catheter leg strap. The resident stated she preferred having the leg strap because when the tubing pulled, she felt discomfort. The DON stated the leg strap was important because it kept the tubing from pulling or dislodging the bulb that held it in place, and she noted that trauma to the neck of the bladder and potential infections could occur. She also stated the leg strap may have gotten wet in the shower and was never replaced.
Improper Storage of Refrigerated Eye Drops
Penalty
Summary
The facility failed to store medications under appropriate conditions of sanitation, temperature, light, moisture, ventilation, segregation, and security for 1 of 4 medication carts reviewed. In the 200-A unit nursing cart, Resident #47’s brand-new Latanoprost ophthalmic solution was observed stored at room temperature even though the box label indicated that it should be refrigerated. The resident was a 54-year-old female admitted with diagnoses including diffuse traumatic brain injury, ataxic gait, hemiplegia, seasonal allergic rhinitis, and dysphagia, and her quarterly MDS showed a BIMS score of 9 out of 15, indicating moderate cognitive impairment. The resident had a physician’s order for Latanoprost Ophthalmic Solution 0.005% to be instilled in both eyes every evening shift. During observation, the medication was found on the cart rather than in a refrigerator, and the LVN stated that the eye drops were stored at room temperature on the cart even though the label said refrigerate. The LVN also stated she did not know how long or why the eye drops had been stored on the cart instead of in the refrigerator. The DON stated that Resident #47’s brand-new eye drops would not reach therapeutic effects. The facility policy titled Storage of Medications stated that discontinued, outdated, or deteriorated drugs or biologicals shall not be used and shall be returned to the dispensing pharmacy or destroyed.
Failure to Document PRN Oxygen Therapy on MAR
Penalty
Summary
The facility failed to maintain Resident #75’s clinical record in accordance with accepted professional standards by not documenting her oxygen therapy on the MAR. Resident #75 was an elderly female admitted to the facility with diagnoses including Alzheimer’s disease, dysphagia, anxiety disorder, repeated falls, dementia, bipolar disorder, and psychosis. Her annual MDS reflected that she was usually understood, sometimes understood, had a BIMS score of 3 out of 15 indicating severe cognitive impairment, and was dependent on ADLs. Her care plan included a focus on treatment for URI and shortness of breath with exertion, with an intervention to administer oxygen as directed by the physician. Her active orders included oxygen at 2-5 L/min via NC as needed for shortness of breath, with oxygen saturations to be maintained greater than 92%. Progress notes documented that she received oxygen at 2 L/min via NC for shortness of breath on three consecutive days, and an O2 Saturation Summary also reflected oxygen use on those days. However, the MAR for the month showed no initials for the PRN oxygen on those dates. Observation of her room showed an oxygen concentrator with tubing and NC unbagged and draped over the machine. The LVN stated the oxygen order was new, she did not think it was on the MAR, and she checked saturations and provided oxygen without looking for it on the MAR or initialing it. The DON stated documentation of nursing care is a professional expectation, did not know why it was not done, and stated that if it was not documented, it was not done.
Improper glove changes and hand hygiene during incontinent care
Penalty
Summary
Provide and implement an infection prevention and control program was cited after observations and record reviews showed improper glove use and hand hygiene during incontinent care for two residents. Resident #57 was a readmitted female with diagnoses including senile degeneration of the brain, anxiety disorder, dysphagia, and schizophrenia. Her quarterly MDS reflected moderate cognitive impairment, moderate to extensive assistance with ADLs, and frequent bowel and bladder incontinence. Her care plan identified her as at risk for bowel and bladder incontinence and directed staff to keep her clean, dry, and odor free. During observation of incontinent care for Resident #57, CNA D cleaned the labia and perineal area, removed soiled gloves, sanitized hands, and put on clean gloves, then cleaned the backside. CNA D later went to clean her hands and put on clean gloves, returned to the bed, placed the clean brief under the resident, and pulled up the soiled brief from beneath the resident. CNA D did not clean her hands or change her gloves before continuing care after handling the soiled brief, and then finished closing the clean brief and straightening the bedding. In interview, CNA D stated she forgot to clean her hands again and put on clean gloves after removing the resident's soiled brief and acknowledged that cross contamination could occur and cause an infection. Resident #88 was a male with diagnoses including atherosclerotic heart disease, type II diabetes mellitus, dementia, major depressive disorder, and peripheral vascular disease. His quarterly MDS reflected moderate cognitive impairment, dependence on most ADLs, and bowel and bladder incontinence. During observation of incontinent care, CNA C sanitized her hands and put on clean gloves, cleaned the penis, scrotal area, and backside, then touched a clean brief with soiled gloves, pulled through the soiled drawsheet, and picked up the clean brief with soiled gloves before placing it back on a clean area. CNA C then removed her soiled gloves, sanitized her hands, put on clean gloves, and reused the same brief from the bedside table to reapply it to the resident. CNA C stated she should have gotten a clean brief instead of using the one she had touched with soiled gloves and acknowledged that cross contamination could occur and cause infections. The DON stated that not sanitizing hands and changing gloves during peri care could result in cross contamination, spread of bacteria, and lead to UTIs.
Unsanitary and Unsafe Resident Restrooms
Penalty
Summary
The facility failed to provide a safe, functional, and sanitary environment in 2 resident rooms reviewed. In Resident #37’s room, the restroom contained a shower area with no divider between the toilet and shower area, and the shower floor was wet because the shower head was leaking water. Resident #37 was a female with diagnoses including fracture of the neck of the left femur, COPD, muscle weakness, and obstructive and reflux uropathy. Her annual MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and she was independent with transfers and walking with a walker. Her care plan identified a fall risk related to impaired balance and included keeping the environment free of clutter. During observation, the wet shower floor was noted in Resident #37’s restroom. Resident #37 stated she used her restroom by herself for showers and toileting and did not know the shower floor was wet because the shower head was leaking. RN-K stated the leaking water had started that day and should have been fixed immediately to prevent possible falls. Maintenance later stated the shower head leak had been fixed after it was reported. In Resident #8’s room, a small brown lump on the floor to the left of the toilet inside the restroom was observed and appeared to be human feces. Resident #8 was unable to be interviewed due to impaired cognitive function. Her quarterly MDS showed a BIMS score of 0, severe cognitive impairment, partial/moderate assistance needed for transfers and walking, and frequent urinary incontinence with occasional bowel incontinence. LVN-L identified the material as human feces and stated it was old. The Housekeeping Director stated rooms and restrooms were cleaned daily and thought overnight CNAs might not have cleaned the area. The DON stated both residents’ restrooms should have been clean.
Unlocked Beauty Shop with Hazardous Materials
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment by leaving the Beauty Shop unlocked and unoccupied, which allowed access to potentially harmful materials. During an observation, the Beauty Shop was found to contain items such as flammable hairspray, hair dye labeled as causing allergic reactions and skin irritation, flammable sanitizing wipes, hair setting solution labeled to be kept out of reach of children, and a flammable nail dryer. The Administrator confirmed that the Beauty Shop should have been secured and that it was the responsibility of all staff using the area to ensure it remained locked when not in use. Facility policy requires residents to be provided with a safe and homelike environment.
Incomplete Medical Record Documentation for Resident Diagnoses
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident. Specifically, the resident's face sheet did not include the diagnoses of Primary Osteoarthritis Left Shoulder, Primary Osteoarthritis Right Shoulder, and Polyneuropathy Unspecified, despite these conditions being documented in a nurse practitioner's note. The face sheet only listed other diagnoses such as Chronic Respiratory Failure with Hypoxia, Unspecified Protein-Calorie Malnutrition, and Unspecified Combined Systolic and Diastolic Heart Failure. The resident's care plan referenced pain related to immobility, and the resident was noted to have intact cognition based on a recent BIMS score. The omission of these diagnoses from the face sheet was confirmed during an interview with the DON, who acknowledged the importance of having all diagnoses accurately listed for communication with outside providers. The facility's policy requires that each resident's medical record accurately reflect the resident's experience through complete, accurate, and timely documentation. The failure to update the face sheet with all current diagnoses resulted in incomplete and inaccurate medical records for the resident.
Failure to Maintain Resident Dignity During ADL Care
Penalty
Summary
The facility failed to treat residents with respect and dignity during activities of daily living (ADL) care, affecting three residents. Licensed Vocational Nurse (LVN) A was observed standing while feeding two residents, both diagnosed with dementia and major depressive disorder, during their lunch meals. This practice required the residents to look up at the LVN, which was acknowledged by the LVN as a dignity issue. The LVN admitted to not having received formal training for feeding residents and stated that standing allowed her to move quickly between residents if needed. Additionally, LVN B was observed holding a door open while discussing a resident's care with a Certified Nursing Assistant (CNA), leaving the resident exposed to the hallway. The resident, diagnosed with Parkinson's and severe cognitive impairment, was dependent on staff for all ADLs. The privacy curtain was not drawn, compromising the resident's dignity. The Director of Nursing (DON) confirmed that staff should ensure privacy by closing doors and drawing curtains during resident care.
Failure to Post Survey Results Notice
Penalty
Summary
The facility failed to adequately inform residents and the public about the availability and location of survey results, certifications, and complaint investigations. During a group meeting, eight residents expressed unfamiliarity with the survey results and their storage location, indicating they had not seen any signs or binders labeled as such. An observation in the facility's lobby revealed a binder labeled 'Survey Results' among other binders, but it was not easily visible, and there was no sign indicating its location. Interviews with the Assistant Director (AD) and the Administrator (ADM) confirmed that the location of the survey results binder had not been communicated to residents, and there was no posted sign to guide them. The ADM was unaware of the requirement to post a sign indicating the binder's location.
Deficiency in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards in food storage, preparation, and service, as observed in their kitchen operations. During an inspection, it was noted that the Dietary Manager and Dietary Aide did not wear beard restraints, and both the Cook and Dietary Aide did not properly wear hair restraints, leaving hair exposed. This lack of proper hygiene practices could lead to hair falling into food, potentially causing foodborne illness among residents. Additionally, the facility did not label items stored in the walk-in refrigerator, such as pre-portioned drinks, cakes, and bowls of cereal, which is against the facility's policy and the U.S. FDA Food Code requirements. Interviews with the Dietary Manager and Dietary Aide confirmed that they had received training on appropriate hygiene practices, including the necessity of hair and beard restraints to prevent contamination. The Dietary Manager acknowledged the importance of labeling open food items in the refrigerator to avoid serving expired food, which could also lead to foodborne illness. Despite these acknowledgments, the facility's failure to implement these practices was evident during the survey, highlighting a significant deficiency in maintaining food safety standards.
Infection Control Deficiencies in Wound Care and Equipment Sanitation
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Resident #69, a severely cognitively impaired individual with a history of Parkinson's disease and muscle wasting, was provided wound care without the use of Enhanced Barrier Precautions (EBP). Despite the presence of an EBP sign on the resident's room door, the nursing staff did not utilize Personal Protective Equipment (PPE) during the procedure, which could lead to cross-contamination and infection control issues. Resident #90, a cognitively intact male with paraplegia and a stage 4 pressure ulcer, received wound care using supplies that were improperly stored and handled. The nurse used open and previously used supplies from a single baggie, and failed to change gloves between handling different ointments and applying them to the wound. Additionally, the resident's soiled brief was not changed before wound care, and the clean wound dressing was covered with the damp brief, increasing the risk of infection. In room [ROOM NUMBER], a shower chair was found soiled with feces, indicating a lack of proper cleaning and sanitation by the nursing staff. LVN A acknowledged the presence of the dried brown substance and stated that CNAs should clean the equipment after each use. The failure to maintain cleanliness of resident equipment poses a risk of cross-contamination and infection, especially for cognitively impaired residents who are anxious and easily agitated.
Pest Control Deficiency in Facility
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of gnats and other pests within the facility. Observations revealed multiple gnats on resident food containers and flying around the facility, including in resident rooms and near a wound care treatment cart. Residents expressed concerns about the pest problem during a group resident council meeting, mentioning issues with gnats and roaches. One resident reported seeing an exterminator only once and had to intervene to have his room sprayed. The Director of Nursing acknowledged the gnat problem, and the Administrator noted that pest control treatments were conducted regularly, although some residents hoarded food, contributing to the issue. The facility's pest prevention service reports indicated multiple pest control visits targeting various pests, including gnats, roaches, ants, and rodents, in both common areas and specific rooms. Despite these efforts, the presence of pests persisted, as evidenced by the observations and resident complaints. The facility's pest control policy, revised in August 2008, stated that an ongoing pest control program should be maintained to keep the building free of insects and rodents, yet the deficiency in effectively managing the pest problem was evident.
Failure to Conduct PASARR Level II Assessment for Resident with Mental Illness
Penalty
Summary
The facility failed to ensure that all Pre-Admission Screening and Resident Review (PASARR) Level 1 residents with mental illness were provided with a PASARR Level II Evaluation and Assessment. This deficiency was identified for one of the three residents reviewed for PASARR services. Specifically, the facility did not identify a resident as having diagnoses indicative of mental illness, such as Schizoaffective Disorder and Major Depressive Disorder, on the PASARR screening, which would have necessitated a PASARR Level II assessment. The resident in question was admitted to the facility with diagnoses including Dementia, Schizoaffective Disorder, and Major Depressive Disorder. Despite these diagnoses, the PASARR Level 1 Screening indicated that the resident did not have a mental illness. The MDS Coordinator acknowledged the oversight, stating that a Level I screening was not re-submitted because it was believed the resident would not qualify for services due to a primary diagnosis of Dementia. However, the facility's policy requires a new Level I screening and potentially a Level II assessment if there is a substantial change in mental status or a new mental health diagnosis.
Failure to Document Side Rail Use in Baseline Care Plan
Penalty
Summary
The facility failed to ensure that a baseline care plan included the necessary healthcare information for a resident within 48 hours of admission. Specifically, the nursing staff did not document the use of two 1/4 side rails for a resident who required them for mobility. This oversight was identified during a review of the resident's baseline care plan, which incorrectly indicated that no safety devices were used, despite a bed rail evaluation and consent form indicating their necessity. The resident, who was cognitively intact and admitted with a diagnosis of Other Malaise, had been in the facility for nine days at the time of the review. Observations confirmed the use of side rails, and the resident reported requesting them upon admission due to weakness. Interviews with the MDS Coordinator and the DON confirmed that the baseline care plan should have reflected the use of side rails to ensure their availability for the resident.
Failure to Provide Adequate Foot Care for Resident
Penalty
Summary
The facility failed to ensure that a resident received proper foot care, which is essential for maintaining mobility and good foot health. The resident, a male with a history of cerebral infarction, dysarthria, malnutrition, and unsteadiness of feet, had not seen a podiatrist despite having thickened toenails and other foot concerns. The resident's care plan included interventions to avoid mechanical trauma and to inspect and notify the physician of changes, but there was no documentation of nail care or podiatry appointments in the resident's electronic health record. Observations and interviews revealed that the resident expressed frustration over the lack of toenail trimming, which had not been addressed despite requests from the resident's responsible party (RP) since January 2024. The RP had been informed by multiple nurses that the resident was on the podiatry list, but the resident had not been seen by a podiatrist. The resident's toenails were observed to be thickened and in need of trimming, with the right great toenail being particularly problematic. The Director of Nursing (DON) was unable to find records of podiatry visits for the resident and acknowledged the importance of podiatry care, especially given the resident's arterial wounds. The facility's policy on podiatry care was requested but not provided by the time of the survey exit, indicating a lack of adherence to professional standards of practice in ensuring necessary foot care for the resident.
Inadequate Catheter Care Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate catheter care for a resident, leading to a deficiency in preventing urinary tract infections. The resident, a male with a history of urinary retention, hydronephrosis, obstructive uropathy, and vascular dementia, was observed receiving catheter care that did not adhere to the facility's policy or standards of care. During the procedure, the CNA did not clean the urinary meatus or surrounding area, which is a critical step in preventing infection. The resident expressed pain during the care, indicating potential issues with the procedure. The CNAs involved in the care acknowledged the omission of cleaning the urinary meatus, and the Director of Nursing confirmed that the staff should have followed the facility's policy to prevent cross-contamination and infection. The facility's policy and the CNA's competency validation both emphasize the importance of cleaning the urinary meatus and surrounding area as part of catheter care. Despite this, the procedure was not followed correctly, leading to a risk of infection for the resident.
Failure to Provide Safe Respiratory Care
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care for a resident who required oxygen therapy, as observed during a survey. The resident, a cognitively intact female with a history of cerebral infarction, acute cough, and wheezing, was noted to have her oxygen nasal cannula and tubing on the floor of her room, with the nasal prongs touching the floor. This was observed while the resident was being assisted out of her room with portable oxygen. The facility's policy required that oxygen cannulae and tubing not in use should be kept in a plastic bag to prevent infection, but this was not adhered to. Interviews with staff revealed that the nasal cannula and tubing should not have been on the floor and were usually stored in a bag when not in use. The LVN present at the time of the observation acknowledged the oversight and disposed of the contaminated equipment. The Director of Nursing confirmed that the improper storage of the oxygen equipment could lead to infection. The resident's care plan did not address the need for oxygen therapy, despite physician orders for oxygen use and a referral to a pulmonologist for further evaluation.
Deficiencies in Bed Rail Use and Consent
Penalty
Summary
The facility failed to ensure the correct use of bed rails for two residents, leading to deficiencies in safety assessments and informed consent. For one resident, who was diagnosed with Dementia, Schizoaffective Disorder, and Major Depressive Disorder, the nursing staff did not obtain informed consent for the use of 1/4 bed rails, despite the resident's care plan indicating their use as mobility enablers. Observations confirmed the presence of bed rails, and interviews with the MDS Coordinator and the DON revealed that a family representative's consent was not obtained, which was necessary for the use of side rails. For another resident, who was cognitively intact and had been in the facility for nine days, the nursing staff failed to designate the reason for the use of 1/4 bed rails on the bed evaluation and did not properly complete the informed consent form. Although the resident requested the side rails for assistance with bed mobility and transfers, the consent form was incomplete, and the necessary components, such as a physician's order and care plan implementation, were not fulfilled. The facility's policy requires an assessment of the resident's symptoms, risk of entrapment, and the appropriateness of the bed's dimensions, which were not adequately addressed in these cases.
Medication Administration Error Leads to Methadone Overdose
Penalty
Summary
The facility failed to provide pharmaceutical services that ensured the accurate dispensing and administering of medications, leading to a methadone overdose in one resident. This resident, who had no physician order for methadone, was mistakenly given the medication intended for another resident. The error was discovered after the resident exhibited signs of overdose, including low oxygen saturation and decreased activity, prompting a transfer to the hospital where a methadone overdose was confirmed. Interviews and record reviews revealed that the methadone was administered by multiple staff members who failed to adhere to the facility's medication administration policy. The policy required verification of the resident's identity and the medication's details before administration, which was not followed. The Director of Nursing (DON) acknowledged that the error likely occurred due to pre-pulling medications, which led to confusion about which medications belonged to which residents. The facility's failure to adhere to proper medication administration procedures placed residents at risk of receiving incorrect medications, potentially resulting in severe consequences such as hospitalization or death. The incident highlighted a significant lapse in the facility's medication management system, necessitating immediate corrective actions to prevent future occurrences.
Medication Error Leads to Resident Overdose
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, resulting in a methadone overdose for one resident. This incident involved a resident who was admitted with diagnoses including coronary artery disease, heart failure, Parkinson's, and dementia with behaviors. The resident's electronic Medication Administration Record (eMAR) and physician orders did not include methadone, yet the resident received it, leading to an overdose. The only resident in the facility with a methadone prescription was another resident residing across the hall. Interviews and record reviews revealed that multiple staff members, including a Licensed Vocational Nurse (LVN) and two Medication Aides, administered methadone to the wrong resident. The error was discovered when the resident exhibited signs of overdose, such as decreased activity, low oxygen saturation, and agonal breathing. The resident was subsequently sent to the hospital, where they tested positive for methadone overdose and required Narcan to reverse the effects. The Director of Nursing (DON) acknowledged that the error might have occurred due to pre-pulling medications, which led to confusion about which pills belonged to which resident. The facility's policy on medication administration emphasizes verifying the resident's identity and checking the medication label three times to ensure the right resident, medication, dosage, time, and method of administration. However, these procedures were not followed, resulting in the significant medication error.
Care Plan Deficiencies for Two Residents
Penalty
Summary
The facility failed to provide services that maintain the residents' highest practicable physical, mental, and psychosocial well-being for two residents. Resident #1's care plan did not reflect a fall resulting in a shoulder fracture, and it lacked interventions such as a left arm sling, fall mats, and an orthopedic consult. Despite a high fall risk assessment and physician orders for a sling and orthopedic consult, the care plan was not updated. The Director of Nursing (DON) confirmed the omission and acknowledged responsibility for updating care plans related to incidents and accidents. Similarly, Resident #2's care plan did not address a fall that resulted in a hip fracture and a non-displaced fracture of the middle finger, with necessary interventions like a finger splint. Despite hospital discharge orders for a finger splint and staff observations of the splint, the care plan was not updated. Interviews with staff and the DON confirmed the care plan's deficiencies and the importance of timely updates to prevent potential injuries or further decline in residents' conditions.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 860 citations issued within 25 miles in the last 12 months — including the 17 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near San Antonio
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windemere At Westover Hills | 0.9 mi | ★★★★★ | 6 | 0 |
| Westover Hills Rehabilitation And Healthcare | 1.3 mi | ★★★★★ | 6 | 0 |
| Silver Creek Nursing And Rehabilitation | 1.8 mi | ★★★★★ | 0 | 0 |
| Lakeside Nursing And Rehabilitation Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Mystic Park Nursing & Rehabilitation Center | 4.5 mi | ★★★★★ | 11 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Las Colinas Of Westover.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.