Las Colinas of Westover failed to include Primary Osteoarthritis Left Shoulder, Primary Osteoarthritis Right Shoulder, and Polyneuropathy Unspecified on Resident #1's face sheet, according to a November 25 federal inspection triggered by a complaint.
The resident had intact cognition with a score of 15 on cognitive testing. His care plan from September documented pain related to immobility. But when inspectors reviewed his face sheet — the document the facility uses to communicate a resident's health status to hospitals and outside providers — the arthritis and nerve damage diagnoses were nowhere to be found.
Instead, the face sheet listed only Chronic Respiratory Failure with Hypoxia, Unspecified Protein-Calorie Malnutrition, and Unspecified Combined Systolic and Diastolic Heart Failure as his conditions.
The missing diagnoses appeared five days earlier in notes from the resident's nurse practitioner dated November 20. But that information never made it to the primary record that follows residents when they need emergency care or specialist treatment.
Director of Nursing confirmed during the inspection that complete face sheets were critical for resident safety. She told inspectors 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 nursing director blamed the gap on poor communication, saying "the Nurse Practitioner had not informed the facility of these diagnoses." She promised to address the issue with the practitioner to improve future communication.
Polyneuropathy causes numbness, tingling, and pain in hands and feet due to nerve damage. Primary osteoarthritis in both shoulders would cause chronic joint pain and stiffness that could affect a resident's mobility and quality of life. Without this information on the face sheet, emergency room doctors or specialists might miss crucial context for the resident's symptoms.
The facility's own policy requires medical records to contain "an accurate representation of the actual experience of the resident through complete, accurate, and timely documentation." The missing diagnoses violated this standard.
Federal inspectors found the documentation failure during a complaint investigation at the 9738 Westover Hills Boulevard facility. The inspection reviewed 15 residents' records and found the incomplete documentation affected one resident.
The missing diagnoses represented conditions that would require ongoing pain management and could impact the resident's care plan, medication needs, and treatment decisions. Arthritis in both shoulders combined with nerve damage would likely affect the resident's daily activities, physical therapy needs, and pain medication requirements.
Las Colinas of Westover has 120 beds and serves residents requiring skilled nursing care and rehabilitation services. The facility is part of a larger network of nursing homes in Texas.
The inspection report noted that incomplete medical records could "result in inadequate care due to incomplete and inaccurate medical records." When hospitals or specialists receive incomplete information about a resident's conditions, they may miss important factors in diagnosis and treatment decisions.
The nursing director's acknowledgment that face sheets serve as the "primary method of communication" to outside providers highlighted the significance of the omission. Emergency responders, hospital staff, and consulting physicians rely on these documents to understand a resident's full medical picture.
The resident's care plan already addressed pain related to immobility, suggesting staff were aware of his discomfort. But the missing shoulder arthritis diagnoses meant outside providers wouldn't know the specific source of his joint pain or the need for arthritis-related treatments.
The communication breakdown between the nurse practitioner and facility staff revealed a gap in the system designed to keep medical records current and complete. The nursing director's promise to improve communication with the practitioner suggested the facility recognized the seriousness of the documentation failure.
Federal regulations require nursing homes to maintain complete and accurate medical records that reflect each resident's current health status. The missing diagnoses at Las Colinas of Westover represented exactly the kind of gap that could compromise resident care when they need it most.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Las Colinas of Westover from 2025-11-25 including all violations, facility responses, and corrective action plans.