The Nm Behavioral Health Institute At Las Vegas
Inspection history, citations, penalties and survey trends for this long-term care facility in Las Vegas, New Mexico.
- Location
- 3695 Hot Springs Boulevard, Las Vegas, New Mexico 87701
- CMS Provider Number
- 325104
- Inspections on file
- 19
- Latest survey
- December 12, 2025
- Citations (last 12 mo.)
- 42
Citation history
Health deficiencies cited at The Nm Behavioral Health Institute At Las Vegas during CMS and state inspections, most recent first.
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.
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.
Latest citations in New Mexico
Surveyors found that the facility did not provide required written transfer and bed-hold notices when several residents were sent to the hospital for events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding. Medical records lacked written transfer notices and bed-hold notifications, and the transfer information that should have been given to residents or their representatives did not include mandated details about appeal rights, how to request an appeal, or how to contact the State LTC Ombudsman. The Social Services Director reported that she does not notify the Ombudsman of hospital transfers and only sends a monthly email list of discharged residents, without written copies of transfer or discharge notices.
Two cognitively impaired residents with dementia and significant behavioral and continence needs were sent to a local ER after falls and were discharged back to the facility’s care, but the facility failed to provide timely transportation for their return. In both cases, hospital discharge times were documented, yet ER staff reported making multiple unsuccessful calls to the facility, reaching the Administrator only after repeated attempts. One resident, described as very disoriented, remained in the ER for several hours after discharge without 1:1 supervision, while the other waited approximately 11 hours, during which ER staff observed increasing confusion and attempts to get out of bed. The Administrator acknowledged awareness of the discharges, the lack of 24-hour transportation, and that the residents were not picked up until many hours after they had been discharged from the ER.
Two residents who required staff assistance for ADLs and transfers reported neglectful and rude behavior by a CNA and delayed nursing response to care needs. One resident with a history of cerebral infarction and schizophrenia stated that a CNA mocked him and that his requested wound dressing change was not performed for several hours, which was later corroborated by video showing a long gap between the CNA’s visit and the nurse’s entry to the room. Another resident with a right femur fracture, type II DM, and repeated falls, who needed one-person assistance for mobility and self-care, reported that a CNA refused to help and told her she could do some care herself, making her feel she was not trying in her recovery. Documentation and interviews confirmed that staff did not provide timely wound care or required assistance, and that these interactions caused residents to feel uncomfortable and negatively about their care.
A resident with a history of opioid dependence and polysubstance abuse was on a secure unit with a care plan that included safety risk evaluations and monitoring for signs of substance abuse. Staff later observed the resident discarding an empty Suboxone packet, even though the resident was not prescribed this medication, and the incident was reported to the on-call provider with subsequent monitoring and a room search. However, the care plan was not revised to reflect this new substance-related event, and both the DON and Administrator acknowledged that the care plan should have been updated when this new risk and behavior were identified.
Surveyors identified that a medication cart on the north hall was left unlocked and unattended outside a resident room. An LPN acknowledged that the cart was hers and that she had not locked it before leaving to answer a call light, despite facility expectations. The DON confirmed that all medication and treatment carts are required to remain locked when not in use or when staff are away from them.
Surveyors found that a document containing multiple residents’ PHI, including full names, room numbers, and code status, was left unattended and visible on a south nurse’s station counter. An RN confirmed the document was a resident list with PHI and acknowledged it had been left exposed and that such information should not be left unattended.
Surveyors found that a lunch tray return cart containing uncovered, soiled food trays and dishes was left unattended in a main hallway outside an activity room. The housekeeping/laundry manager acknowledged seeing the unattended cart, and the Dietary Manager confirmed that such carts are supposed to remain only in designated areas, such as near the nurse’s station or in the kitchen, and should be returned to the kitchen for cleaning as soon as all trays are collected. This failure was cited as likely to expose all residents to potential pathogens associated with food waste.
Two residents with scheduled showers reported that they were offered or received showers in very cold water during a prolonged period when hot water was not reliably available in care areas. One resident stated he refused cold showers and was only offered sponge baths once or twice, despite his preference to stay clean. Another resident reported receiving cold showers, including being rinsed with cold water while still soaped, and subsequently began refusing showers and bed baths due to the cold water. A CNA confirmed that water in the shower rooms was “ice cold” for several months, leading to resident complaints and refusals, while the Maintenance Director reported that a needed part to correct the hot water problem was on back order, delaying resolution and resulting in the facility not honoring residents’ bathing preferences.
Surveyors observed that unused medications were improperly discarded in a trash bin attached to a medication cart on the north hallway, rather than being disposed of in a designated drug disposal container. Two pills, a round blue tablet stamped "61" and an oblong orange tablet stamped "20," were found together in an unlabeled medication cup in the trash. An RN confirmed the medications were discarded there and acknowledged that unused medications should be placed in the drug buster container in the cart drawer. The Unit Manager also confirmed that facility practice requires all unused medications to be disposed of using the drug buster and that controlled substances must be destroyed by two licensed staff and documented on the narcotic count sheet.
The facility failed to follow documented allergy information, diet orders, and meal tickets for three residents. A resident with a documented chocolate allergy was served chocolate ice cream after requesting it, and the Nutrition Director admitted not reading the allergy notation on the meal ticket. Another resident on a pureed diet received whole mandarin oranges instead of pureed fruit, which a CNA confirmed. A third resident whose meal ticket called for a grilled Swiss sandwich received a sandwich that was not grilled, as confirmed by a CNA and a dietary manager.
Failure to Provide Required Written Transfer, Appeal, Ombudsman, and Bed-Hold Notices During Hospitalizations
Penalty
Summary
Surveyors identified that the facility failed to provide required written transfer and bed-hold information for multiple residents who were hospitalized. For three residents who experienced transfers to the hospital after events such as falls with injury, unresponsiveness, and episodes of nausea, vomiting, and bleeding, record review showed there were no written transfer notices or written bed-hold notices in their medical records. Specifically, one resident transferred after a fall on 01/31/26 had no documented written transfer notice or bed-hold notice. Another resident transferred on 02/27/26 for nausea, vomiting, and bleeding, and later readmitted on 03/05/26, had no written transfer notification that included information on appeal rights or Ombudsman contact, and no written bed-hold notification. A third resident transferred on 01/29/26 after a fall with a forehead laceration and again on 03/17/26 for unresponsiveness, also had no documented written transfer or bed-hold notices for either hospitalization. The deficiency also included the facility’s failure to provide required content in transfer notices and to notify the State Long-Term Care Ombudsman in writing. For the residents reviewed, there was no evidence that written transfer notices were provided to the residents or their representatives in a language and manner they could understand, and the notices were missing required elements such as a statement of appeal rights, the name, mailing and email address, and phone number of the entity receiving appeals, and information on how to obtain and complete an appeal form. The notices also lacked the name, phone number, and mailing and email address of the State Long-Term Care Ombudsman, and written copies of the transfer notices were not sent to the Ombudsman. During interview, the Social Services Director confirmed that transfer and bed-hold notices were not documented for at least one resident’s hospitalization, that she does not notify the Ombudsman about transfers to the hospital, and that she only emails a monthly list of residents discharged from the facility without sending written copies of transfer or discharge notices.
Failure to Timely Retrieve Residents From ER After Discharge
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from neglect by not arranging timely transportation back to the facility after emergency room (ER) discharge. A consumer complaint alleged that residents sent to the local ER were being left there for extended periods after discharge. For one resident with an admission date of 10/13/25, records showed multiple cognitive and behavioral diagnoses, including Alzheimer’s disease, vascular dementia with agitation and other behavioral disturbances, mild cognitive impairment, cognitive communication deficit, and restlessness and agitation. A change of condition MDS documented a Brief Interview for Mental Status (BIMS) score of 1 and frequent incontinence of urine and bowel. Nursing progress notes for this resident showed that 911 was called at 3:00 AM and the resident was transferred to the ER after a fall. Hospital discharge instructions indicated the resident was discharged from the ER at approximately 5:21 AM, while the ER nurse reported discharge at about 5:30 AM. The ER nurse stated she made numerous calls to the facility but was unable to reach anyone. She reported that the resident was very disoriented and that the ER did not have enough staff to provide 1:1 supervision. The ER nurse eventually reached the Administrator, who stated staff would come to pick up the resident as soon as possible. Facility records showed the resident was not discharged from the facility on that date, and the ER nurse reported that facility staff did not pick the resident up until approximately 8:30 AM, several hours after discharge. A second resident, admitted on 11/25/25, had diagnoses including Alzheimer’s disease, dementia with behavioral disturbance, bipolar disorder with severe depression and psychotic features, depression, and anxiety disorder. The admission MDS documented a BIMS score of 2, frequent urinary incontinence, constant bowel incontinence, and a need for substantial/maximal assistance with toileting hygiene. Nursing notes showed this resident was sent to the ER for evaluation after a fall and did not return until the following morning. Hospital discharge instructions documented discharge from the ER at 10:16 PM, and the Administrator confirmed being notified of the discharge at about 10:30 PM and that the facility did not have 24-hour transportation. The Administrator acknowledged the resident was not picked up until approximately 9:00 AM the next day. The ER nurse reported making several calls to the facility that went to voicemail, eventually reaching the Administrator, who initially stated staff were on the way, then stopped answering calls. During the approximately 11-hour wait, the ER nurse stated the resident was confused, attempted to get out of bed, and became more confused as the night progressed.
Failure to Timely Provide Wound Care and Required Assistance, Resulting in Resident Neglect
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents were free from neglect when staff did not respond appropriately to requests for care and assistance. One resident with a history of cerebral infarction due to embolism and schizophrenia, admitted on 01/30/26 and requiring staff assistance for ADLs and mechanical lift transfers, reported that a CNA was rude and mocking and that his wound dressing was not changed for several hours after he requested it. The Kardex showed he needed staff help for toileting, bathing, hygiene, bed mobility, dressing, and transfers. Nursing progress notes documented a change in condition on 03/02/26 after the resident stated the CNA was rude and would not assist as requested. The Administrator later confirmed, via video review, that the CNA entered the resident’s room at 2:30 am, the resident requested a dressing change, and no nurse entered the room until 5:00 am, despite the nurse’s statement that she went in “right away.” The DON also confirmed that the resident’s grievance described the wound dressing not being changed until hours after the request. Another resident, admitted with a right femur fracture, type II diabetes, and repeated falls, required one-person assistance for dressing, hygiene, bathing, bed mobility, and transfers, and could toilet herself with assistance for transfers. Nursing progress notes documented an alleged abuse incident on 03/02/26 in which this resident stated a CNA was rude, refused to help her, and told her she could perform some care tasks herself without staff assistance. An abuse questionnaire completed the same day showed the resident answered “Yes” to having interactions that made her feel uncomfortable or negative, and she reported that the CNA made her feel as though she was not trying with her own recovery. The Administrator and DON acknowledged that staff are expected to help residents as required and that staff interactions must be encouraging rather than making residents feel bad about needing assistance.
Failure to Revise Care Plan After Substance-Related Incident
Penalty
Summary
The deficiency involves the facility’s failure to revise a resident’s care plan after a significant substance-related incident. The resident was originally admitted with a diagnosis of opioid dependence and resided on a secure unit related to polysubstance abuse disorder. The existing care plan, dated 01/21/26, identified the resident as residing on a secure unit due to polysubstance abuse disorder with interventions to perform safety risk evaluations on admission, as needed, and upon changes in condition. The care plan also identified the resident as at risk for substance use disorder with interventions to monitor for signs or symptoms of substance abuse. On 02/01/26, nursing notes documented that staff observed the resident discarding an empty Suboxone packet in the trash, even though the resident was not prescribed Suboxone and denied taking any. Staff notified the on-call provider, who ordered monitoring for adverse reactions, and nursing staff and security conducted a room search that revealed no additional contraband. Despite this incident, the resident’s care plan was not updated to address the new substance-related event. During interviews, the DON acknowledged awareness of the incident and confirmed the care plan was not revised, and the Administrator stated her expectation that nursing would update the care plan when a new risk or behavior was identified and confirmed she would have expected the care plan to be updated for this resident.
Unattended, Unlocked Medication Cart on North Hall
Penalty
Summary
The deficiency involves the facility’s failure to ensure medications were properly stored and secured in accordance with professional standards and facility expectations. On 03/24/26 at 9:06 a.m., surveyors observed a medication cart on the north hall left unlocked and unattended outside a resident room. At 9:08 a.m., the LPN responsible for the cart confirmed during interview that the cart was hers, that it was unlocked and unattended, and acknowledged she should have locked it before responding to a call light. Later that day at 3:37 p.m., the DON stated in an interview that medication and treatment carts are expected to be locked at all times when nurses are away from them, confirming that the observed practice did not meet facility expectations. This deficient practice was cited as likely to allow unauthorized personnel access to medications, which could result in injury or overdosing.
Unattended PHI Document Left Exposed at Nurse’s Station
Penalty
Summary
Surveyors identified a deficiency in the facility’s protection of residents’ personal health information (PHI) when a document containing multiple residents’ full names, assigned room numbers, and code status was left unattended and exposed on the south nurse’s station counter. On 03/16/26 at 9:04 a.m., an observation revealed a piece of paper on a clipboard with complete resident information placed on top of the south nurse’s counter in public view. At 9:06 a.m., during an interview, RN #2 confirmed that the list contained residents’ names, room numbers, and code status, acknowledged that it had been left exposed and unattended, and stated that PHI should not be left unattended. No additional clinical details or medical histories of the residents listed on the document were provided in the report.
Unattended Soiled Lunch Cart Left Uncovered in Hallway
Penalty
Summary
Surveyors identified a deficiency in the facility’s infection prevention and control program related to the handling of soiled food service equipment. On 03/24/26 at 12:58 pm, a lunch tray return cart containing soiled food trays and dishes that were uncovered was observed sitting unattended in the main hallway outside the activity room. At 1:06 pm, the housekeeping/laundry manager confirmed she saw the return cart left unattended in that location. At 1:08 pm, the Dietary Manager stated that lunch return carts should only be left in designated areas such as by the nurse’s station or inside the kitchen, and that the cart should be returned to the kitchen for cleaning as soon as all trays have been picked up, which did not occur in this instance. This deficient practice was noted as likely to expose all residents to potential pathogens associated with food waste.
Failure to Honor Resident Bathing Preferences During Prolonged Hot Water Issues
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate residents’ bathing preferences when hot water was not reliably available in resident care areas. Record review showed that one resident was scheduled to receive three showers per week on specific days, and another resident was scheduled for two showers per week. One resident reported that staff attempted to have him shower in cold water, which he refused, and that sponge baths were only offered once or twice during the period when the hot water was not working. He stated that he liked to be clean and did not feel like himself when he was dirty. A CNA reported that there was no hot water in resident care areas from the middle of December until early March, and that large barrels of warm water were brought to shower rooms to offer sponge baths, which this resident refused. Another resident, also on a scheduled twice-weekly shower regimen, stated that she received cold showers and began refusing showers because of how cold the water was. She described the water running cold unpredictably, including an instance when the water was initially warm but turned cold while she was still soaped, requiring rinsing with cold water, which she described as horrible. A social services note documented that this resident’s daughter reported the resident had been declining showers and bed baths offered because the water was too cold. A CNA corroborated that the water was “ice cold” and that residents began complaining and refusing showers around mid-December. The Maintenance Director stated that it took a while for hot water to reach the shower room and that a needed part to fix the cold-water problem was on back order, contributing to the prolonged period of inadequate hot water and resulting in residents not having their bathing preferences honored.
Improper Disposal of Unused Medications on Medication Cart
Penalty
Summary
Surveyors identified a deficiency related to accident hazards and inadequate supervision when unused medications were improperly discarded on the north hallway. During observation of the north hall nurses’ station, two medications were found in the trash bin attached to the medication cart, placed together inside an unlabeled medication cup. The pills were described as a round blue pill stamped with “61” and an oblong orange pill stamped with “20.” In an interview immediately following the observation, an RN confirmed that these medications were in the trash bin and stated that unused medications should instead be disposed of in the drug buster, a sealed container for drug disposal located in the bottom drawer of the cart. In a subsequent interview, the Unit Manager confirmed that all unused medications are to be disposed of using the drug buster and acknowledged that this did not occur, further stating that if the medications are controlled substances such as narcotics, two licensed personnel are required to dispose of them together and document the disposal on the narcotic count sheet. This deficient practice was noted as likely to affect any resident who might acquire and ingest the discarded medications, potentially causing medication side effects.
Failure to Follow Allergy, Diet, and Meal Ticket Requirements
Penalty
Summary
The facility failed to provide meals consistent with residents’ documented allergies, diet orders, and meal tickets for three residents. One resident, admitted with a documented allergy to chocolate, had a face sheet and lunch ticket indicating they were not to receive chocolate. During a lunch observation, this resident was served and was eating chocolate ice cream. An LPN confirmed the resident’s chocolate allergy and that the resident should not be eating chocolate. The Nutrition Director acknowledged that the meal ticket stated the resident should not have chocolate but reported serving chocolate ice cream after the resident requested it, stating he had not read that the resident was allergic to chocolate. Another resident, admitted with hypokalemia and ordered a regular/liberalized pureed diet per the MDS, had a lunch ticket indicating a pureed diet but was observed receiving whole mandarin oranges instead of pureed fruit. A CNA confirmed that the dessert was not pureed. A third resident’s meal ticket specified a grilled Swiss sandwich, but observation of the tray showed the sandwich was not grilled. During interviews, a CNA and a dietary manager confirmed that the sandwich was not grilled as ordered on the meal ticket.
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