Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at The Nm Behavioral Health Institute At Las Vegas during CMS and state inspections, most recent first.
The facility failed to document that 2 of 5 nurse aides completed NATCEP or CEP within 4 months of hire. Record review showed one aide was not yet certified and had not taken the certification test, while another aide’s certification had expired and she had not registered for training. The DON confirmed both aides continued working shifts despite these issues and stated her expectation that nurse aides become certified within 4 months of hire.
Failure to ensure CNA competency and proper supervision during a mechanical lift transfer. A resident fell out of a mechanical lift sling during a transfer performed by two nurse aides who were not certified, resulting in the resident landing on the floor and sustaining a head laceration. Record review and interviews showed one aide had completed CNA training but was not yet certified, the other aide was also not certified and was being trained by the first aide, and another aide’s certification had expired years earlier while still working shifts. The DON and ADM confirmed the staffing and certification issues and that uncertified aides were being used inappropriately during resident care.
A resident's care plan was not revised after she was diagnosed with non-Alzheimer's dementia. Her MDS showed the diagnosis and noted that a BIMS was not completed because she was rarely or never understood, but the care plan did not include any goals or interventions for her dementia or the care and support she needed. The DON confirmed the care plan did not meet expectations.
The facility failed to ensure an annual performance review was completed for one CNA reviewed. Record review showed the CNA's most recent evaluation was on file, and the DON could not confirm that a yearly evaluation had been completed since then, stating HR tracks the evaluations and sends them for employee signature when due.
A compromised bubble card containing clonazepam for a resident and an expired 25-gauge needle were found in a locked medication cart. An LPN confirmed the bubble pack was opened and the needle was expired, and the DON confirmed both items should have been discarded properly but were not.
A resident with epilepsy, bipolar disorder, HIV, and a history of TBI was discharged to a local psychiatric hospital without prior written notification to the guardian about the transfer or discharge and the reasons for the move. The social worker attempted a phone call to the guardian shortly before discharge but was unsuccessful, and the DON later confirmed the guardian was not notified before the discharge.
Accurate MDS assessments were not completed for two residents. One resident with Alzheimer’s disease, DM2, and HTN was found with left hip pain, swelling, outward rotation of the foot, and inability to bear weight, was sent to the hospital, and was later reported to have a comminuted left femur fracture, yet the MDS stated no recent falls or fall-related fractures. Another resident had documented hearing difficulty, a hearing aid fitting appointment, and hearing aids present in the room, but the annual MDS indicated no hearing appliance was used; the resident said the hearing aids did not fit and staff were aware he needed them.
Failure to Complete Baseline Care Plans Within 48 Hours: The facility failed to create an accurate baseline care plan within 48 hours for two residents. One resident had COPD, O2 dependence, dementia, blindness, and other conditions, but the baseline plan omitted dietary needs. Another resident with Alzheimer's disease, DM2, HTN, and a left hip surgical incision had no baseline care plan in the EHR, and the DON confirmed the omission.
Failure to include hearing aid needs in the care plan: A resident with hearing impairment had hearing aids at bedside but did not wear them because they did not fit. The care plan and MDS did not reflect hearing aid use, and the resident reported telling multiple staff about the problem and requesting a new hearing aid without receiving a response. The SSS and MDS coordinator both stated they were not aware of the resident’s hearing aid needs.
A resident with CVA/TIA/stroke history, quadriplegia, and right hand contracture had a physician order to wear a derma saver palm pillow on the right hand whenever awake. During two observations, the resident was awake but the palm pillow was on the bedside table instead of on the hand, and an LPN and a PCA both confirmed the order was not being followed.
Failure to assist a resident with hearing aid services. A resident with HOH had hearing aids left on the bedside table and stated they did not fit, so he did not wear them. He reported telling multiple staff that he needed a new pair but received no response. A PCA confirmed the resident was HOH and would benefit from properly fitting hearing aids, and the SSS said she was not aware the resident needed hearing aid services unless nursing notified her.
A resident with a documented allergy to peas and a restriction against chocolate was served pasta containing peas and chocolate pudding during a meal observation. The resident told staff he could not eat the items because of the allergy and restriction, and a CNA confirmed the meal ticket listed both restrictions and that the foods should not have been served.
A resident’s chart contained an active order to change a catheter monthly and PRN even though the resident no longer had a catheter. The MDS stated the resident did not use any catheter, the resident said he had not had one in a long time, and a progress note documented that the physician wanted the catheter removed and physically removed it. The DON confirmed the order was never discontinued and should have been.
A resident experienced unwanted touching by an Activities Assistant, who kicked her on the buttocks, leading to increased isolation and fear. The incident was initially perceived as horseplay by staff, but later considered abusive by the DON and Interim Administrator after reviewing video footage. The lack of immediate intervention and reporting by staff who witnessed the incident highlights a deficiency in recognizing and addressing abuse.
The facility's kitchen was found to have multiple sanitation deficiencies, including improper hand hygiene and glove use by staff, failure to label and protect open food items, inadequate use of hair restraints, and incorrect sanitizing of dishes. Disposable wares were also left unprotected, increasing the risk of contamination. These issues were observed despite existing policies and staff training.
A resident with a Stage II pressure ulcer on the coccyx did not receive timely updates to their treatment plan, as required by their care plan. Despite the ulcer showing no improvement and even worsening, the treatment remained unchanged beyond the specified two-week period. Interviews with an LPN and the DON confirmed the lack of timely treatment adjustments, resulting in the ulcer's progression.
A resident at risk for falls was found on the floor after attempting to transfer independently, resulting in a hip fracture. The facility used a call light attached to the resident's clothing to alert staff, which was identified as a form of restraint by the DON. This practice was contrary to the care plan, which required the call bell to be within reach and staff to educate the resident on its use.
The facility failed to provide nutritionally calculated recipes for pureed diets, potentially affecting residents' nutritional needs. Observations showed that pureed meals, including enchiladas, carrots, carrot cake, and beans, were prepared without specific recipes, leading to flavorless and watery dishes. Interviews revealed that not all menu items had approved recipes, and the use of thickening powder was excessive. The facility's audits did not include pureed food preparation, contributing to the deficiency.
The facility failed to provide food that accommodated the preferences of two residents, leading to a deficiency in dietary services. A resident on a therapeutic diet and another on a regular LCS, bland diet were unable to receive their requested chicken sandwiches due to insufficient alternate meal options sent to the unit. The Dietary Manager stated that residents must wait until meal service is completed to have their alternate requests fulfilled, resulting in potential delays.
The facility failed to provide restorative nursing services as ordered for three residents, leading to a deficiency in care standards. A resident was supposed to receive weekly upper extremity exercises but was only offered six sessions out of eight opportunities. Another resident was ordered to receive ambulation and ROM services but was only offered one session out of eight opportunities. A third resident was ordered to receive weekly ROM services but was only offered three sessions out of fourteen opportunities over two months. Staffing issues were cited as the reason for the inconsistency.
The facility failed to ensure CNAs received the required 12 hours of in-service training annually. Two CNAs were found to have incomplete training hours, yet continued to work significant shifts. The DON confirmed the deficiency, acknowledging that CNAs should not work without completing required training.
A resident was kicked by an activities assistant in a playful manner, but the incident was not immediately reported to a supervisor or the state agency. The resident felt uncomfortable and anxious, avoiding activities when the assistant was present. Staff witnesses did not intervene, perceiving the interaction as playful, although they acknowledged it was inappropriate. The incident was reported to the appropriate authorities two days later, indicating a failure in timely reporting protocols.
Nurse Aide Training and Certification Deficiencies
Penalty
Summary
The facility failed to provide documentation confirming that 2 of 5 nurse aides had completed a Nurse Aide Training and Competency Evaluation Program or a Competency Evaluation Program within four months of employment. Record review showed NA #1 was a current employee with a hire date and had completed nurse aide training, but was not certified and had not taken the certification test as of the review date. Record review also showed NA #3 was a current employee with an original hire date and rehire date, had completed original certified nurse aide training, but her certification had expired and she had not registered to attend NATCEP or CEP training. During interview, the DON confirmed NA #1 received certified nurse aide training late and continued to work shifts during that time, and confirmed NA #3 had been working shifts even though her certification had been expired since 2017. The DON stated her expectation was for all nurse aides to attend certified nurse aide training and become certified within four months of hire date.
Failure to Ensure CNA Competency and Proper Supervision During Mechanical Lift Transfer
Penalty
Summary
The facility failed to ensure staff were trained and competent before providing care and failed to prevent untrained and uncertified nurse aides from training other nurse aides. During record review, R #12 was documented as falling out of a mechanical lift sling during a transfer performed by NA #1 and NA #2. R #12 landed on the floor, was found lying on his back with his left leg under the bed and his right leg propped on the bed, and had a laceration to the back of the head. The physician was notified and directed that the resident be sent to the hospital by ambulance, and the resident was transported out later that evening. Interviews and record review showed that NA #1 was not a certified nurse aide and had not yet taken the certification test, although she had completed CNA training late and continued working shifts. NA #2 was also not certified and had not completed CNA training, yet was being trained by NA #1 during the transfer. The DON confirmed that NA #3’s certification had expired since 2017 and that NA #3 had continued working shifts at the facility. The DON stated that floor nurses made assignments of which staff worked together and with which residents, but she did not notify them which staff were trained and certified. The ADM stated that one of two mechanical lift operators must be a certified nurse aide and confirmed that both aides involved in R #12’s transfer were not certified.
Care Plan Not Updated for Resident With Dementia
Penalty
Summary
The facility failed to revise the care plan for one resident after she was diagnosed with non-Alzheimer's dementia. Record review showed the resident was admitted to the facility on [DATE], and her quarterly MDS dated 10/09/25 listed non-Alzheimer's dementia among her active diagnoses. The MDS also indicated that a BIMS was not conducted because the resident is rarely or never understood. Review of the resident's care plan, last updated on 08/14/25, showed that it did not include any goals or interventions related to her dementia or the care and support she needs. During an interview on 12/11/25 at 11:43 am, the DON confirmed that the care plan did not meet expectations because it did not include the resident's dementia or the care and support she needs.
Annual CNA Performance Evaluation Not Completed
Penalty
Summary
The facility failed to ensure the annual performance review for CNA #2 was completed for 1 of 5 CNAs reviewed. Record review showed CNA #2 had a hire date of 05/18/13 and that the most recent annual performance evaluation on file was dated 10/29/24. During an interview on 12/12/25 at 11:43 am, the DON could not confirm whether CNA #2 had received an annual performance evaluation since 10/29/24 and stated that the facility's HR office keeps up with the evaluations and sends them when it is time for employees to sign the yearly evaluation. The DON also stated that evaluations are expected to be completed every 12 months.
Compromised Medication Packaging and Expired Needle Found in Medication Cart
Penalty
Summary
Medications and medical supplies were not properly stored in the locked medication cart in the unit. During observation, a medication bubble card labeled for Resident #70 and containing clonazepam 1 mg was found with one bubble opened and a small green pill visible inside, indicating the bubble pack was compromised. In the same observation, a 25-gauge needle was found with an expiration date of 09/10/25. During interview, the LPN confirmed that the bubble card was compromised and that the needle was expired. The DON later confirmed that the compromised medication inside the bubble card and the expired needle should have been discarded properly and did not happen.
Failure to Notify Guardian Before Discharge
Penalty
Summary
The facility failed to notify a resident's representative in writing of a transfer or discharge and the reasons for the move before the transfer took place for 1 of 3 residents reviewed for transfers and discharges. R #104 was admitted with diagnoses including epilepsy, bipolar disorder, HIV, and a history of traumatic brain injury, and had a BIMS score of 15, indicating cognitive intactness. On 09/23/25, the facility's social worker attempted to contact the resident's guardian by phone to inform them of the discharge but was unsuccessful, and this attempt was documented at 11:25 am. The resident was then discharged at 12:00 pm and sent to a local psychiatric hospital. During an interview on 12/12/25, the DON confirmed that the guardian was not notified prior to the discharge.
Inaccurate MDS Assessments for Fall-Related Fracture and Hearing Aid Use
Penalty
Summary
The facility failed to complete accurate MDS assessments for 2 residents reviewed. For one resident with diagnoses including Alzheimer's disease, type 2 DM, and HTN, the record showed she was found asleep in a chair, complained of left hip pain when assisted to her wheelchair, and was assessed by RN staff as having swelling to the left hip, outward rotation of the left foot, and inability to bear weight. She was sent to the hospital and later notified to have a comminuted fracture of the left femur. However, the readmission MDS section J1700 indicated no falls in the prior two to six months and no fractures related to a fall in the prior six months. During interview, the DON confirmed the MDS should indicate that she suffered a fracture related to a fall and that it was not accurate. For another resident, the record showed a hearing aid fitting appointment and an annual MDS that documented moderate hearing difficulty but indicated no hearing aid or other hearing appliance was used. During observation, a pair of hearing aids were found on the bedside table, and the resident stated he did not wear them because they did not fit and that he had told multiple staff he needed new hearing aids but had not received a response. He also stated he needed the hearing aids to enjoy activities. The SSS stated she did not recall whether he needed hearing aids and that nursing staff would need to inform her of such needs, and the MDS Coordinator stated she was not aware the resident had hearing aids and confirmed it should have been included in the MDS assessments.
Failure to Complete Baseline Care Plans Within 48 Hours
Penalty
Summary
The facility failed to create an accurate baseline care plan within 48 hours of admission for 2 of 3 residents reviewed for baseline care plans. For one resident, the record showed admission with chronic viral hepatitis C, COPD, dependence on supplemental oxygen, a history of traumatic brain injury, blindness in one eye with low vision in the other, and dementia. The baseline care plan was dated 04/29/25 and included impaired gas exchange related to hypoxia with oxygen as needed, potential for behavioral expressions related to impaired cognitive function secondary to dementia, risk for falls related to unsteady gait, and self-care deficits related to mobility/blindness, but dietary was not addressed on the plan. For another resident, the admission record showed diagnoses of Alzheimer's disease, type 2 diabetes mellitus, and essential hypertension, and progress notes documented a surgical incision on the left hip measuring two centimeters after readmission. The electronic health record contained no evidence of a baseline care plan, and the comprehensive care plan was not initiated until 10/30/25. During interview, the DON confirmed the facility failed to create and implement a baseline care plan for this resident when she was readmitted and stated that a baseline care plan is expected within 48 hours of admission.
Failure to Include Hearing Aid Needs in Care Planning
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident identified as having a hearing impairment and using a hearing aid. The resident’s record showed an appointment for hearing aid fitting, but the care plan dated 11/29/25 did not include any information about hearing aid use. The annual MDS assessment documented moderate hearing difficulty, with the speaker needing to increase volume and speak distinctly, but also indicated that no hearing aid or other hearing appliance was used. During an observation and interview on 12/08/25, a pair of hearing aids were seen on top of the resident’s bedside table. The resident stated he does not wear the hearing aids because they do not fit him and said he had told multiple staff that they did not fit and had requested a new one, but never received any response or action from the facility. The resident also stated he needs his hearing aids to enjoy activities provided in the facility. In interviews, the Social Services Supervisor stated she did not recall whether the resident needed hearing aids and said nursing staff would need to let her know if residents needed services like hearing aids. The MDS Coordinator stated she was not aware the resident had hearing aids and confirmed it should have been included in the MDS assessments but was not.
Failure to Follow Physician Order for Palm Pillow
Penalty
Summary
The facility failed to provide quality care that met professional standards for a resident with a history of CVA/TIA/stroke and quadriplegia. The resident’s care plan dated 10/22/25 identified impaired physical mobility related to right hand contracture, and a current physician order dated 12/04/25 directed that the resident wear a derma saver palm pillow on the right hand anytime he was awake. During observation on 12/10/25 at 2:27 pm, the resident was awake in his room and the derma saver palm pillow was observed on the bedside table rather than on his right hand. An LPN confirmed the resident was awake and not wearing the palm pillow, and confirmed it was on the bedside table. During a second observation on 12/11/25 at 2:40 pm, the resident was again awake in his room with the derma saver palm pillow on the bedside table. A PCA confirmed the pillow was on the bedside table and stated the resident should have been wearing it on his right hand when awake, but that did not happen.
Failure to Assist Resident With Hearing Aid Services
Penalty
Summary
The facility failed to ensure a resident received proper treatment and assistive devices to maintain hearing abilities. The resident had a hearing aid fitting appointment documented in the record, but during observation the resident had a pair of hearing aids sitting on the bedside table and stated he did not wear them because they did not fit. He reported telling multiple staff that the hearing aids did not fit and asking for a new pair, but said he never received any response or action from the facility. He also stated he needed the hearing aids to enjoy some activities provided in the facility. A PCA confirmed the hearing aids were on the bedside table and that the resident was hard of hearing and would benefit from a properly fitting hearing aid. A Social Services Supervisor stated she did not recall whether the resident needed hearing aids and said nursing staff would need to notify her if residents needed services like hearing aids.
Food Served in Violation of Resident Allergy and Preference Restrictions
Penalty
Summary
The facility failed to provide food that accommodated a resident’s allergies and preferences for one resident observed for food preferences. Record review showed the resident’s face sheet and meal card indicated a no-chocolate restriction and an allergy to peas. During a dining observation, the resident was served pasta that contained peas and a bowl of chocolate pudding. The resident told staff that he could not eat the food because he was allergic to peas and chocolate. A CNA later confirmed that the resident’s meal ticket identified the pea allergy and restriction from chocolate, and that both foods were served when they should not have been.
Inaccurate catheter order remained active after catheter removal
Penalty
Summary
Resident #15 had an admission record showing diagnoses including bilateral hearing loss, type 2 diabetes mellitus, PTSD, bladder stones, benign prostatic hyperplasia with lower urinary tract symptoms, and a personal history of UTI. The resident’s current physician orders included an order dated 04/28/25 to change the resident’s catheter monthly and as needed. However, the resident’s MDS assessment dated [DATE] stated that the resident did not use a catheter of any kind. During observation and interview on 12/08/25, the resident did not have a catheter and stated that he had not had one in a long time. A progress note dated 07/25/25 documented that the physician wanted the catheter removed and physically removed the catheter. On 12/11/25, the DON confirmed that the catheter order was never discontinued and should have been.
Failure to Prevent Abuse Due to Misinterpretation of Horseplay
Penalty
Summary
The facility failed to prevent abuse for a resident when staff did not recognize the difference between horseplay and unwanted touching. The incident involved an Activities Assistant (AA) who kicked the resident on the buttocks, which was captured on camera footage. The resident reported feeling isolated and fearful of further abuse, leading to a decrease in participation in activities. The incident was witnessed by multiple staff members, including a Licensed Practical Nurse (LPN), but none intervened or reported it immediately. The resident expressed discomfort and fear following the incident, stating that she felt the staff member might repeat the behavior. Interviews with staff revealed that the incident was initially perceived as horseplay, but the resident's reaction and subsequent behavior indicated distress. The Activities Assistant involved was temporarily removed from the facility, and an investigation was conducted. However, the investigation's initial conclusion of horseplay was later questioned by the Director of Nursing (DON) and the Interim Administrator, who both considered the actions abusive. The report highlights a lack of immediate intervention and reporting by staff who witnessed the incident. The resident's increased isolation and anxiety were noted by several staff members, indicating a change in her behavior post-incident. The facility's Standards and Compliance department initially determined the incident as horseplay, but this was later challenged by higher management after reviewing the video footage, suggesting a need for clearer guidelines and training on recognizing and reporting abuse.
Sanitation and Food Safety Deficiencies in Facility Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed through multiple instances of improper hand hygiene and glove use by staff. Staff members were seen moving between tasks involving dirty and clean items without changing gloves or washing hands, which is against the facility's Sanitation and Infection Control policy. This policy requires handwashing before handling food, after touching dirty items, and when moving from dirty to clean tasks. Interviews with the Supervisor and Director of General Services confirmed that staff were trained on these procedures, yet observations showed non-compliance, such as touching trash cans and then handling clean dishes without changing gloves or washing hands. Additionally, the facility did not adhere to its food storage policies, which require open food items to be labeled, dated, and protected from air exposure. Observations revealed open bags of pinto beans, sliced ham, and containers of beef and vegetable base left unprotected and undated in storage areas. Interviews with the Director of General Services and the Stocker indicated that daily checks were supposed to ensure compliance, but these open and unprotected items were overlooked. The facility also failed to ensure proper use of hair restraints and beard guards, as staff were observed with hair and facial hair not fully covered while preparing food. Furthermore, the sanitizing process for dishes was not followed according to the manufacturer's instructions, with items not being submerged in the sanitizing solution for the required time. Disposable wares were found unprotected in storage, contrary to the facility's policy. These deficiencies in maintaining sanitary conditions in the kitchen could potentially lead to cross-contamination and foodborne illnesses affecting all residents consuming food from the facility's kitchen.
Failure to Update Pressure Ulcer Treatment
Penalty
Summary
The facility failed to provide necessary treatment and services to prevent the development and worsening of pressure wounds for a resident. The resident, admitted on an unspecified date, had a care plan dated 07/09/24 that focused on impaired skin integrity related to a Stage II pressure injury on the coccyx. The care plan specified that if the pressure injury did not improve within two weeks, the treatment should be reassessed and the medical provider notified for a change in treatment. However, the records show that the pressure ulcer did not improve and even worsened over time, with no change in treatment within the specified two-week timeframe. The resident's pressure ulcer assessments from 07/05/24 to 08/21/24 indicated no improvement and even an increase in size, yet the treatment remained unchanged until after the two-week period. The Medication Administration Record revealed that the treatment was initially applied twice a day and then reduced to once a day without any reassessment or change in treatment as required by the care plan. Interviews with an LPN and the DON confirmed that the treatment did not change as expected, leading to the worsening of the pressure ulcer.
Improper Use of Call Light as Restraint
Penalty
Summary
The facility failed to ensure that a resident, identified as R #16, was free from accidents and hazards. The resident was admitted to the facility and was known to be at risk for falls, as documented in her care plan. Despite this, the facility used a call light attached to the resident's clothing to alert staff when she attempted to transfer on her own. This method was intended to notify staff by detaching from the wall and ringing when the resident moved. However, this practice was identified as a form of restraint by the Director of Nursing and was not in line with the facility's expectations. The deficiency was highlighted by an incident on 06/09/24, when the resident was found on the floor next to her bed after attempting to use the restroom independently. She sustained a left hip fracture and was diagnosed with two fractures at the emergency room. Observations and interviews with staff revealed that the call light was consistently attached to the resident's clothing, contrary to the care plan's instructions to keep the call bell within reach and educate the resident on its use. The Director of Nursing confirmed that the current use of the call light was inappropriate and should not have been happening.
Deficiency in Nutritionally Calculated Recipes for Pureed Diets
Penalty
Summary
The facility failed to provide nutritionally calculated recipes for pureed diets, which could potentially affect the nutritional requirements of residents consuming pureed foods. During an interview, the Supervisor mentioned that the menu included pork enchiladas, mixed vegetables, beans, and fruit, with an alternative of egg salad sandwich. However, residents on a pureed diet were served pureed carrots instead of mixed vegetables. Observations revealed that the Supervisor prepared pureed enchiladas without a specific recipe, using an unmeasured amount of thickening powder, and the facility did not have a recipe for pureed enchiladas. Further observations showed that the pureed carrots tasted flavorless, and the preparation did not follow the facility's recipe, which included additional ingredients like vegetable base and butter. The Supervisor also prepared pureed carrot cake and beans without following specific recipes, resulting in a watery carrot cake mixture and beans with unnecessary thickening powder. The facility lacked a recipe for pureed carrot cake, and the Supervisor relied on her experience rather than documented recipes. Interviews with the Director of Food Services and Dieticians revealed that while they were responsible for developing and approving menus and recipes, not all food items had corresponding recipes. The Dieticians emphasized the importance of having approved recipes for consistency, nutritional value, and flavor. They noted that the use of thickening powder should be minimal due to its lack of nutritional value. Despite performing competency audits, the facility did not include observations of pureed food preparation, contributing to the deficiency.
Failure to Accommodate Resident Food Preferences
Penalty
Summary
The facility failed to provide food that accommodated the preferences of two residents, leading to a deficiency in dietary services. Resident #69, who was on a therapeutic diet, requested a chicken sandwich for dinner but did not receive it because the dietary department had only sent three chicken sandwiches for the unit, which housed 14 residents. This incident was documented in a facility incident report, indicating that the regular menu items were sent for all residents, but the alternate meal option was insufficient to meet the requests of all residents who preferred it. Similarly, Resident #9, who was on a regular LCS, bland diet with specific preferences, was also unable to receive a chicken sandwich due to the same shortage. The Dietary Manager acknowledged that only a set amount of alternate food is sent to the units, and if a resident requests an alternate meal that is unavailable, they must wait until meal service is completed before their request can be accommodated. This process could result in a considerable wait time for the residents, potentially affecting their nutritional intake and satisfaction with the dietary services provided.
Failure to Provide Ordered Restorative Nursing Services
Penalty
Summary
The facility failed to provide restorative nursing services as ordered by a physician for three residents, leading to a deficiency in professional standards of care. Resident #8 was supposed to receive weekly upper extremity exercises focusing on range of motion (ROM) but was only offered six sessions out of eight opportunities. The resident expressed dissatisfaction with the frequency of services, and the Physical Therapy Assistant (PTA) confirmed that the services were not consistently provided due to staffing issues. Resident #42 was ordered to receive weekly restorative nursing services focusing on ambulation and ROM but was only offered one session out of eight opportunities. The PTA acknowledged the lack of available staff to provide the necessary services. Similarly, Resident #52 was ordered to receive weekly ROM services but was only offered three sessions out of fourteen opportunities over two months. The Director of Nursing was unaware of the inconsistency in service provision and confirmed that residents should receive multiple sessions per week as expected.
Deficiency in CNA In-Service Training Hours
Penalty
Summary
The facility failed to ensure that Certified Nurse Aides (CNAs) received the required in-service training of no less than 12 hours per year. This deficiency was identified for two CNAs out of five randomly reviewed. CNA #1, hired on April 30, 2022, had completed only 8 out of the required 12 hours of training by their hire date. Similarly, CNA #2, hired on June 17, 2017, had completed only 10 out of the required 12 hours of training. Both CNAs continued to work significant hours during the review period without having completed the necessary training. The Director of Nursing confirmed that these CNAs did not meet the training requirements and acknowledged that they should not have been working with residents without completing the required training.
Failure to Timely Report Abuse Incident
Penalty
Summary
The staff at the facility failed to immediately report a witnessed incident of abuse involving a resident, which was not reported to a supervisor or the state survey agency within the required timeframe. The incident involved a resident who was kicked by an activities assistant, AA #1, in the buttocks. The resident expressed that she did not perceive the action as playful and felt uncomfortable participating in activities when AA #1 was present. The incident was witnessed by several staff members, including a Licensed Practical Nurse (LPN), but none intervened or reported the incident immediately. Camera footage from the day of the incident showed the resident walking down the hallway when AA #1 approached and kicked her. The resident reacted by rubbing her buttock and attempting to catch AA #1's leg when she kicked again. Despite the presence of other staff members, including an LPN and a technician, no one intervened or reported the incident at the time. The resident later reported feeling anxious and avoiding activities when AA #1 was present, indicating a change in her behavior following the incident. Interviews with staff revealed that they perceived the interaction as playful, although they acknowledged it was inappropriate. The incident was eventually reported to the Standards and Compliance department, Adult Protective Services, and the Health Care Authority by a Registered Nurse (RN) two days later. The delay in reporting the incident to the state agency highlights a failure in the facility's protocol for handling and reporting abuse, which could delay the implementation of measures to prevent further abuse.
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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 Las Vegas
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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Vida Buena Healthcare | 1.4 mi | ★★★★★ | 8 | 0 |
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