Health inspection·November 25, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records that were complete and accurately documented for 1 of 15 (Resident #1) residents reviewed, in that: Resident #1's diagnoses of Primary Osteoarthritis Left Shoulder, Primary Osteoarthritis Right Shoulder, and Polyneuropathy Unspecified were not listed on his face sheet. This failure could result in inadequate care due to incomplete and inaccurate medical records. The findings were:Record review of Resident #1's face sheet, dated 11/25/2025, revealed he was admitted on [DATE] with diagnoses including: Chronic Respiratory Failure with Hypoxia, Unspecified Protein-Calorie Malnutrition, and Unspecified Combined Systolic (Congestive) and Diastolic (Congestive) Heart Failure. Record review of Resident #1's Quarterly MDS, dated [DATE], revealed a BIMS score of 15 which indicated intact cognition. Record review of Resident #1's care plan, dated 09/21/2025, revealed Pain related to Immobility. Record review of a provider note from Resident #1's Nurse Practitioner, dated 11/20/2025, revealed a list of diagnoses which included Primary Osteoarthritis Left Shoulder, Primary Osteoarthritis Right Shoulder, and Polyneuropathy Unspecified. Further review of Resident #1's face sheet revealed the diagnoses Primary Osteoarthritis Left Shoulder, Primary Osteoarthritis Right Shoulder, and Polyneuropathy Unspecified were not listed. During an interview with the DON on 11/25/2025 at 12:02 p.m., the DON confirmed that it was important to have all diagnoses listed on the residents' face sheets since it was the primary method of communication to outside providers, including hospitals, of a resident's health status. The DON stated that the Nurse Practitioner had not informed the facility of these diagnoses and that she would address the issue with him to ensure improved communication in the future. Record review of the facility policy, Documentation in Medical Record, 06/06/2025, revealed, Each resident's medical record shall contain an accurate representation of the actual experience of the resident.through complete, accurate, and timely documentation. Page 1 of 2 676328 676328 11/25/2025 Las Colinas of Westover 9738 Westover Hills Blvd San Antonio, TX 78251

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Based on observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable and homelike environment for 1 of 1 Beauty Shop, in that:The facility Beauty Shop was found unlocked on 11/25/25 and contained potentially harmful items.This deficient practice could result in residents living in an unsafe environment.The findings were:Observation on 11/25/2025 at 10:32 a.m., revealed the facility Beauty Shop was unlocked and unoccupied, and contained containers of potentially harmful materials including: hairspray labeled flammable, hair dye labeled can cause allergic reaction and may cause skin irritation, sanitizing wipes labeled flammable and avoid contact with eyes, hair setting solution labeled keep out of reach of children', and nail dryer labeled flammable.During an interview with the Administrator on 11/25/2025 at 10:40 a.m., the Administrator confirmed the Beauty Shop should have been secured so that residents would not come into contact with potentially harmful materials. He stated the shop was usually secure and the door must have been left unlocked accidentally. He stated it was the responsibility of all staff who utilize the Beauty Shop to ensure it remained locked when not in use.Record review of the facility policy, Quality of Life, Homelike Environment, undated, revealed, Residents are provided with a safe, clean, comfortable, and homelike environment. 676328 Page 2 of 2