Las Colinas Post Acute

Inspectors wroteBased on interview and record review, the facility failed to ensure their Change in a Resident Condition or Status policy and procedure was implemented for one of three sampled residents (Resident 1) when Resident 1's spouse was not informed of Resident 1s transfer to the hospital. This failure had the potential to place Resident 1 and Resident 1's spouse in emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure their Charting and Documentation, Change in a Resident Condition or Status policy and procedure was implemented for one of three sampled residents (Resident 1) when Resident 1's face sheet listed an incorrect phone number of Resident 1's spouse. This failure resulted in Resident's 1's spouse not being informed of Resident 1's transfer to the hospital.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label the food belonging to one unsampled resident (Resident 121). This deficient practice could potentially raise the risk of foodborne illnesses among residents, due to staff inability to verify the safety and freshness of the food. During an observation in the facility family room and concurrent interview with Kitchen Staff (KS) on 8/27/25 at 6:00 AM., a closed black bag containing noodles and one plastic container of soup without label were found inside the shared residents' refrigerator for food brought in by family and visitors. A posting outside the shared residents' refrigerator stated All food must have resident's name, room number and date. If any information is missing, it will be thrown out. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention measures when:Certified Nursing Assistant (CNA) 1 did not perform handwashing before and after handling nasal cannula (flexible tube to deliver oxygen into the nose) to Resident 186. The incentive spirometer (a handheld device that exercises your lungs and measures how much air you can breathe in) placed at Resident 148's bedside, was unlabeled and not properly stored. The temperature settings for two of three dryers in the laundry area were below the normal range. The glucometer machine (a device used to measure how much sugar is in the blood) used for Residents 131, 93, and 69 was not sanitized. Licensed Vocational Nurse (LVN) 9 did not disinfect the blood pressure (BP) device prior to measuring the BP of Resident 110. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two out of three laundry dryers were heating properly as per the manufacturer's recommendations. This failure could prolong the heating cycle of the dryers, consequently delaying the availability of clean clothes and linens for residents. During a tour of the laundry area, on 8/26/25 at 2:23 PM, all three dryers in the laundry were observed to be in use with settings on High. Dryer 1 had towels, Dryer 2 had bed sheets, and Dryer 3 had residents' clothes. The temperatures of the dryers were noted as follows: Dryer 1 at 140 degrees Fahrenheit, Dryer 2 at 230 degrees Fahrenheit, and Dryer 3 at 100 degrees Fahrenheit. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the main entrance door frame was sealed and the door closed properly, creating entry points for pests. This failure had the potential to affect the health and well-being of 207 residents by allowing disease carrying pests an easy entry point into the facility, which could aversely affect residents' health and well-being. During an observation on 8/26/25 at 8:25 AM, at the facility's main entrance, gaps were noted in the door frame. During an interview with Resident 103 on 8/26/25 at 9:05 AM, Resident 103 stated being bitten by a mosquito three days prior and believed the mosquitoes were entering through the main entrance when people came and went. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure advance care planning was completed properly for 8 of 18 sampled residents (Residents 8, 10, 13, 15, 76, 96, 141 and 170) when: A Physician Orders for Life Sustaining Treatment (POLST, a medical form that documents a patient's wishes regarding end-of-life care) was not completed for Resident 141. There was no documentation to indicate Resident 170 received written information addressing advance directives (a document that communicates a person's wishes about health care decisions in the event the person becomes incapacitated of making health care decisions). Resident 13 was not reassessed properly for advance directive. There was no documentation to indicate Resident 96 received written information addressing advance directives. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure two of five residents (Residents 12 and 162) were kept free from unnecessary medications when:1. Resident 162 was not consistently offered non-pharmacological interventions prior to receiving Ativan (a medication used to treat anxiety) as ordered by the physician.2. Resident 12 received Depakote (a medication used as a mood stabilizer) without an accurate diagnosis. These failures put the residents at risk of adverse effects from the medications. 1. A review of Resident 162's Face Sheet (front page of the chart that contains a summary of basic information about the resident), indicated Resident 162 was admitted to the facility on [DATE], with diagnoses including anxiety. During a concurrent interview and record review with LVN 2 on 8/27/25 at 7:24 AM, Resident 162's Order Summary Report was reviewed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to comprehensively and accurately assess hearing for one of 35 sampled residents (Resident 68). This failure had the potential to result in Resident 68's care needs not being effectively met. During a concurrent observation and interview with Resident 68 on 8/25/25 at 11:16 AM, Resident 68 stated having hard of hearing and the need for people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but they were broken. Resident 68 further stated informing Social Services (SS) about the need to replace hearing aid. A review of Resident 68's admission Records dated 8/27/25, indicated resident was admitted on [DATE]. A review of Resident 68's History and Physical (H&P), dated 10/2/24, indicated, diagnoses which include hearing loss. [...]

Inspectors wroteThe facility failed to develop and implement a comprehensive care plan needed to address hearing difficulty, for one of 35 sampled residents (Resident 68). This failure had the potential to result in the residents' care needs not being met effectively During a concurrent observation and interview with Resident 68 on 8/25/25 at 11:16 am, Resident 68 stated having hard of hearing and the need for people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but they were broken. Resident 68 further stated informing Social Services (SS) about the need to replace hearing aid. A review of Resident 68's admission Records dated 8/27/25, indicated resident was admitted on [DATE]. A review of Resident 68's History and Physical (H&P), dated 10/2/24, indicated, diagnoses which includes hearing loss. [...]

Inspectors wroteBased on interview and record review, the facility failed to revise the plan of care for two of 35 sampled residents (Residents 12 and 162). This failure put the residents at risk for their care needs to go unmet.1. A review of Resident 12's Face Sheet (front page of the chart that contains a summary of basic information about the resident) indicated Resident 12 was admitted on [DATE]. During a concurrent interview and record review with RN 4 on 8/29/25 at 11:53 AM, Resident 12's Order Listing Report was reviewed. The Order Listing Report indicated Resident 12 had a peripheral IV started on 7/15/25, and the order was discontinued on 7/18/25. A review of the plan of care showed a care plan problem dated 7/15/25, for vascular access, resident at risk for complications due to the presence of a peripheral line. RN 4 stated Resident 12 did not have a current peripheral IV access line. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to replace the broken hearing aids for one of 35 sampled residents (Resident 68). This failure had the potential to prevent effective communication, diminished activities of daily living and resident becoming less engaged in their overall care and well-being. During a concurrent observation and interview with Resident 68 on 8/25/25 at 11:16 am, Resident 68 stated having hard of hearing and the need for people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but they were broken. Resident 68 further stated informing Social Services (SS) about the need to replace hearing aid. A review of Resident 68's admission Records dated 8/27/25, indicated resident was admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist in obtaining new hearing aid for one of the 35 sampled residents (Resident 68). This deficient practice has the potential to cause a decline in Resident 68's ability to communicate and participate in social activities. During a concurrent observation and interview with Resident 68 on 8/25/25 at 11:16 AM, Resident 68 stated having hard of hearing and the need for people to speak loudly to hear them. Resident 68 also stated having hearing aids upon admission in September 2023, but they were broken. Resident 68 further stated informing Social Services (SS) about the need to replace hearing aid. A review of Resident 68's admission Records dated 8/27/25, indicated resident was admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure oxygen therapy was administered continuously in accordance with physician's order for one of two sampled residents investigated for oxygen treatment (Resident 141). This failure may cause Resident 141 to have difficulty breathing, potentially leading to respiratory failure. During an observation, on 8/25/25, at 2:47 PM, Resident 141 was in bed, awake, and showed no signs of pain, discomfort, or distress. An oxygen concentrator (a medical device that supplies up to 95% pure oxygen to patients through a mask or nasal tube) was noted by Resident 141's bedside. It was observed that the oxygen concentrator was turned off. During an interview with Licensed Vocational Nurse (LVN) 1, on 8/25/25, at 3:02 PM, LVN 1 stated that Resident 141's oxygen was supposed to be administered continuously. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to replace e-Kits (e-Kit , a collection of prescription drugs, and related supplies, intended to provide immediate medical treatment for injuries and illnesses) in a timely manner, and to accurately complete the e-Kit Usage Slip form. This failure had the potential to delay medication administration for residents in need of emergency medical treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medications were stored in a safe manner when: 1. Loose medications were found in the medication cart,2. Expired medications were not removed and discarded from one medication room; and3. The bleach wipes were found stored together with the medications. These failures posed the risk for medication errors, cross contamination, and for medications to have lost their integrity and potency and affect the residents' health outcomes. 1. During a medication cart inspection and concurrent interview with Licensed Vocational Nurse (LVN) 5 on 8/27/25 at 12:03 PM, three loose tablets (one round, white tablet; one round pink tablet, and one round, orange tablet) were observed at the bottom of the medication cart drawer. LVN 5 was not able to identify the medications. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure eight of 11 sampled residents (Residents 196, 83, 116, 34, 11, 146, 92, and 62) knew the location of the survey results binder. This failure had the potential to keep residents, family members, and visitors from easily reviewing the most recent survey results and the facility's plan of corrections, which are essential for making informed decisions about living at the facility. During an interview on 8/25/25 at 1:50 PM, eight of 11 residents polled at the resident council meeting did not know the location of the survey results binder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for five of 77 resident rooms. This failure had the potential to limit the freedom of movement of the residents that occupied these rooms, which may place them at risk for injury. During the entrance conference interview with the Administrator (ADM), on 8/25/25, at 9:23 AM, the ADM stated the facility had resident rooms with less than the required square footage (80 sq. ft. of livable space). During the environmental tour with the Maintenance Services Director (MTD) on 8/28/25, at 2:06 PM, five of the 77 resident rooms were observed to be less than 80 sq. ft. per resident. The residents' rooms and their measurements were noted as follows:a. room [ROOM NUMBER] (3 beds) measured 223.54 sq. ft. (74.5 sq. ft. per resident).b. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to follow its policy to provide dental assessment to one of three sample residents (Resident 1) within ninety days of admission. This failure had the potential to place Resident 1 ' s overall health and safety at risk when Resident 1 was not provided with a dental assessment to meet the needs of the resident. Findings. [...]

Inspectors wroteBased on interview and record review, the facility failed to report one of four sampled residents (Resident 1) to a state agency when Resident 1 was noticed to have a blanchable redness to left side of face near left eye. This failure has the potential to affect (Resident 1) ' s health, safety and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an accurate record of Lactulose (medication used to reduce the amount of ammonia in the blood of patients with liver disease) for one of four sample residents (Resident 1) when on January 25, 2025, at 9:00 PM, License Vocational Nurse (LVN1) did not sign on Resident 1 MAR that Lactulose was given. This failure potentially resulted in Resident 1 readmission to the hospital with ammonia level of 124 µmol/L (Micromoles per liter a unit used to measure the concentration of a substance in a solution). Normal blood ammonia level for ESRD patient is generally considered to be below 35 micromol/L.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1), had documented foley catheter monitoring was completed per shift as ordered. This failure resulted in a late entry documentation over 30 days and placed Resident 1's health and safety at risk when Resident 1 was sent out to acute hospital for further evaluation.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow Its policy and procedure to provide Activities of Daily Living Services (ADLS) and ensure call lights are answered in timely manner for 2 of 3 sampled residents. (Residents 1 and 3). This failure had the potential to place two clinically compromised Residents (Resident 1 and 3) ' s health and safety at risk. When the residents ' activities of daily living were not met in timely manner.

Inspectors wroteBased on interview and record review the facility failed to ensure proper care was provided to prevent a pressure ulcer/injury (Pressure ulcers are injury that breaks down the skin and underlining tissue. They are caused when an area of skin is placed under pressure), from developing a stage 4 pressure injury to the coccyx (tailbone area), left heel dry blister, open blister left thigh, blister to right thigh, and open blister to lower back for one of three sampled residents (Resident 1). This failure placed a clinically compromised Residents (Resident 1) health and safety at risk. When the facility failed to prevent the formation of pressure ulcers to Resident 1 skin.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow policy and procedure to ensure the call lights were answered in a timely manner to provide care and services for two of three residents (Resident 1 and Resident 2). This failure had the potential to place two clinically compromised Residents (Resident 1 and Resident 2) health and safety at risk when residents call lights were not answered promptly to assist with their activities of daily living.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 1), was discharged home with the correct medication packs as ordered by physician. This failure contributed to a clinically compromised Resident 1 being discharged with 4 medications packs not prescribed and belonging to another resident.

Inspectors wroteBased on interview and record review, the facility failed to reassess and monitor one of three sampled residents (Resident 1) for signs and symptoms of depression with mood changes after Resident 1's family member expressed her father's feelings of wanting to die. This failure led to the decline of Resident 1's mental health and psychosocial (emotional) wellbeing which resulted in Resident 1's death by suicide on October 27, 2023.

Inspectors wroteBased on interview and record review, the facility failed to follow the physician order to provide ileostomy (an opening in the belly that is made during surgery for the stool to empty out) care for one of two sampled residents (Resident 1). This failure had the potential for Resident 1 to have unmet needs, such as psychosocial and physical harm, and potentially cause skin breakdown to the ileostomy area.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement infection control and prevention measures when: 1. Chlorox Healthcare Bleach Germicidal Wipes (wipes used to disinfect surfaces and devices) was used by a licensed staff after its expiration date. 2. A Licensed Vocational Nurse (LVN 7) failed to perform hand hygiene when she entered rooms [ROOM NUMBERS] in the yellow zone (a designated area for symptomatic, suspected COVID-19, and residents awaiting test results; COVID-19 exposed residents; and newly admitted or re-admitted residents under observation for COVID-19 and/or with unknown COVID-19 vaccination status or declined COVID-19 vaccination) to administer medications. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure call light was accessible for one sampled resident (Resident 20). This failure had the potential for Resident 20's needs not to be met timely when she needed assistance.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR- a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was re-evaluated after a Significant Change in Status Assessment (SCSA- a comprehensive Minimum Data Set [MDS- a facility assessment tool] assessment done for resident that must be completed when a resident meets the significant change guidelines for either improvement or decline), for one resident reviewed for PASRR (Resident 161). This failure had the potential for Resident 161 not to receive the care and services most appropriate for his needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow up with the physician, recommendations from Physical Therapy (PT) Services (official release from exercise treatment for strength, movement, and flexibility for those that have typically been immobilized) after discharge to Restorative Nursing Assistant (RNA) program (program designed to provide restorative and rehabilitative care for residents by using techniques to increase strength capacity and well-being) for one of one sampled residents (Resident 60). This failure had the potential to result in Resident 60 losing strength, flexibility, muscle mass, pain, skin issues, falls, and contractures (tightened muscles).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure standard order for house nourishment was followed as ordered by the physician. This failure had the potential to adversely affect the health and safety of Resident 86 for not receiving nutritional intervention needed for Resident 86 nutritional problems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure complete and accurate documentation of resident's order summary report were provided in one of two sampled residents reviewed for medical records (Resident 110). This failure had the potential for Resident 110 to receive inconsistent care coordination and unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet (sq. ft.) of livable space per resident for five of 77 resident rooms. This failure had the potential to limit the freedom of movement of the residents that occupied these rooms, which may place them at risk for injury.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the competency of supervisory staff for the kitchen when the Dietary Services Supervisor (DSS) did not know the appropriate procedure for thawing meat. This failure had the potential for the contamination of meat leading to food borne illness for 167 residents who ate food from the kitchen out of a facility census of 181.

Inspectors wroteBased on observation, interview, and facility document review, the facility failed to ensure the competency of staff when: 1. A cook did not use appropriate procedures to ensure food was served at a safe temperature; and 2. A cook was not able to demonstrate appropriate procedures for calibrating a thermometer. This failure had the potential for food to be served at an unsafe temperature and lead to food borne illness for 167 residents who received food from the kitchen out of a facility census of 181.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to cook vegetables in a way to preserve the nutritional content and palatability, when frozen vegetables were left to cook in the oven 2 to 3 hours before serving. This failure had the potential to decrease the nutritive content and palatability in the vegetables and result in a nutrition deficiency for 167 residents who consumed food from the kitchen, out of a facility census of 181 residents.

Inspectors wroteBased on observation, interview, and facility record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service to follow safe food handling and sanitation when: 1. The inside of the ice machine was not clean; 2. Staff personal clothing was stored in an area with single use food service items; 3. Cooking equipment was stacked and stored wet; 4. A food storage cabinet was not clean; and 5. Food preparation tools were not clean and stored in a wooden box that was not clean. These findings had the potential to cause contamination of food leading to food borne illness for 167 residents who received food from the kitchen out of a facility census of 181 residents.

Inspectors wroteBased on interview and facility document review, the facility failed to have a policy for storing food safely that was brought in by family and visitors. This failure did not allow residents to have food brought in by family and visitors stored safely for them to eat at a later time for 167 residents that consumed food by mouth out of a facility census of 181.

Inspectors wrote3. During an observation and concurrent interview, on May 20, 2019 at 3:53 PM, with Resident 179, a plastic covered container of pineapple dated 5/20, and a second plastic covered, manufactured mixed fruit cup containing pineapple, was on Resident 179's over-bed table. Resident 179 stated she required assistance to eat, as she was not able to open the snack containers. Resident 179 further stated she could not eat the fruit cup snacks provided by the staff (the resident did not recall the name of the staff who placed the pineapple cup), as she identified pineapple in both cups, and was allergic to pineapple. During an observation and concurrent interview, on May 20, 2019 at 4:04 PM, with the Certified Nurse Assistant/Restorative Nurse Aide 1 (CNA/RNA 1,) she confirmed the mixed fruit cup on Resident 179's over-bed table contained pineapple and removed it from the resident's table. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not accurately complete two annual RAI-MDS assessments (The Resident Assessment Instrument - Minimum Data Set (RAI-MDS) is the standardized assessment tool for admission, quarterly, significant change in health status and annual assessments for each resident,) under neurological diagnoses for Resident 160. This failure had the potential for inappropriate or insufficient provision of dementia-related care for one resident (Resident 160) in a universe of 35 vulnerable sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a hemodialysis (the process of removing waste products and excess fluid from the body) access site (AV shunt site - a surgical connection made between an artery and a vein for hemodialysis) dressing was removed and kept visible for the staff to observe any potential bleeding after dialysis treatment affecting one of three sampled residents (Resident 55). The facility did not follow the physician's order to remove the resident's left AV shunt dressing four hours after dialysis. This failure had the potential to affect the resident's health and safety.

Inspectors wroteBased on observation, interview, and record review the facility failed to meet the required 80 square (sq.) footage (ft.) for five of 77 resident rooms. This failure had the potential to limit the freedom of movement of the residents that occupied the rooms, which may place them at risk for injury.