Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at 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.
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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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| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| La Vida Buena Healthcare | 1.4 mi | — | 8 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.