Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 2 | 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 |
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