Health inspection·December 5, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, observation, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 2 of 9 residents (Residents #1 and #2) reviewed for care plans. Residents #1 and #2's care plans reflected contractures. This failure could place residents at risk by not having their needs met and not receiving appropriate care. The findings included:Record Review of Resident #1's admission Record, dated 09/16/2025, reflected he was a [AGE] year-old with admission date 05/10/2025, discharge date [DATE], and diagnoses to include age-related cognitive decline. Record Review of Resident #1's Care Plan, closed date 07/07/2025, did not reflect contractures. Record Review of Resident #1's admission MDS assessment, dated 05/23/2025, reflected a BIMS score of 14 out of 15, indicating intact cognition. It further reflected Resident #1 had impairment on both sides of his lower extremity and his upper extremity. Record Review of Resident #1's order summary report, dated 09/16/2025, reflected May wear bilateral hand contracture cushion as tolerated Record Review of Resident #1's OT Evaluation & Plan of Treatment, dated 05/23/2025 to 06/21/2025, reflected during Musculoskeletal System Assessment, Resident #1 had functional limitations present due to contractures. Record Review of Resident #2's admission Record, dated 09/18/2025, reflected he was a [AGE] year-old with initial admission date 06/01/2024, re-admission date 04/24/2025, and diagnoses to include lack of coordination, muscle wasting and atrophy, and age-related physical debility. Record Review of Resident #2's Care Plan, closed date 07/07/2025, did not reflect any mention of contractures. Record Review of Resident #2's admission MDS assessment, dated 05/23/2025, reflected a BIMS score of 12 out of 15, indicating intact cognition. It further reflected Resident #2 had impairment on one side of his upper extremity and impairment on both sides of his lower extremity. Interview on 09/17/2025 at 02:47 PM, CNA A revealed Resident #1 did need help eating sometimes due to trouble using his hands. Interview on 09/18/2025 at 02:11 PM, the DOR revealed Resident #1 was being seen by therapy to help with his contractures. He revealed they had ordered splints to help improve his strength. Interview and observation on 09/18/2025 at 02:51 PM, Resident #2 had a contracture to his left hand. He revealed the facility was aware of his left hand as they would help him when he needed, like strengthening exercises due to his contracture. Interview on 09/18/2025 at 03:30 PM, the MDS nurse revealed there were no contractures in the care plan. She mentioned when a resident had a contracture this would mean no mobility for the joint. She further revealed because Resident #1 was able to utilize the urinal and feed himself with plasticware, he was not contracted. She further revealed it was important to update care plans to give the best care Page 1 of 2 676328 676328 12/05/2025 Las Colinas of Westover 9738 Westover Hills Blvd San Antonio, TX 78251

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few possible to residents. She further revealed she oversaw that care plans were up to date, and she tried to update as best as she could for the residents in the facility. Interview on 09/18/25 at 04:15 PM, ADON B and ADON C revealed Resident #1 had a contracture. Interview on 09/18/2025 at 04:55 PM, the DON revealed Resident #1 had a contracture and therapy worked with him. She revealed Resident #1 had splints for his contractures. She further revealed she could not find contractures mentioned on Resident #1's care plan. She revealed it was important to have this on the care plan, so the team knew how to provide care to the residents. Interview on 09/18/2025 at 06:36 PM, ADON B and ADON C revealed Resident #2 had a contracture on his left hand and the facility would adjust his care accordingly. They revealed it should be care planned if a resident had a contracture. Interview on 09/18/2025 at 06:49 PM, the MDS nurse revealed Resident #2 did not have contractures in his care plan. Record Review of facility's policy, undated, Resident Mobility and Range of Motion, reflected 5. The care plan will include specific interventions, exercises and therapies to maintain, prevent avoidable decline in, and/or improve mobility and range of motion including contractures. Record Review of facility's policy, revised December 2016, Care Plans, Comprehensive Person-Centered reflected 8. The comprehensive, person-centered care plan will: b. Describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 676328 Page 2 of 2