White Sands Healthcare

Based on record review and interview, the facility failed to report an allegation of abuse for 1(R #4) of 8(R #1-8) residents reviewed for abuse, when staff waited 7 days to report witnessed staff to resident abuse. If the staff fail to report allegations of abuse to the facility administration, then corrective measured may not be acted on and the facility would be unable to assure residents are free from abuse.

The findings are:Cross reference findings for F600A.

Record review of R #4's complaint report dated 08/29/25 revealed on 08/22/25 an alleged incident of abuse had occurred as follows:- Certified Nurse Aide (CNA) #1 had witnessed NAIT (Nurse Aide in Training) #2 cover R #4's mouth with hand, tap his mouth with her hand, and told R #4 to shut up.-The incident was reported to the management team on 08/29/25. NAIT #2 continued to work until management was notified of incident. NAIT #2 remained in the unit and the residents in the unit were at risk for further abuse by the accused NAIT #2.B.

Record review of facility timesheets identified that NAIT #1 worked at the facility on 08/22/25, 08/24/25, 08/27/25 and 08/28/25.C.

On 10/14/25 at 2:40 pm during interview with Registered Nurse RN) #1 confirmed that CNA #1 told her about the incident on 08/22/25 and CNA #1 reported to RN #1 that she [CNA #1] didn't know what to do about it [reason for not reporting sooner.] RN #1 immediately reported what CNA #1 told her to the Unit Manager/LPN #2 on 08/29/25. D. On 10/14/25 at 2:42 PM during interview with the Director of Nursing (DON), she confirmed the facility failed to report the allegation of abuse within the required two-hour timeframe because she did not become aware of the allegation until 08/29/25. DON confirmed that the initial report was submitted to the State Agency on 08/29/25, seven days after the incident.

Based on interview and record review, Immediate Jeopardy (IJ) was identified, and the Administrator and Director of Nursing were notified in person on 11/17/25 at 6:15 pm.The facility took corrective action by providing an acceptable Plan of Removal (POR) on 11/18/25 at 1:55 pm which verified implementation of the plan of removal as of 09/03/25.

Immediate Jeopardy was removed on 09/03/25, which constituted Past Non-Compliance IJ.

Plan of removal:R #4 was immediately assessed by using a Trauma Informed Assessment. No immediate concerns noted.

Completed 08/29/25.Tele-visit with Psych provider, agreed with Trauma Informed Assessment for R #4, no immediate trauma and will continue psych caseload.

Completed 08/29/25.Safe survey for all facility residents were immediately initiated with no immediate concerns verbalized.

Residents verbalized desire to continue living in facility and feel safe.

Completed 09/03/25 and then again on 11/18/25.Referral for additional spiritual services for support within the community for R #4 via hospice team.

Completed 08/29/25.R #4's Care Plan updated for trauma-informed care.

Record review of R #4 records on 10/14/25 verified the above records.All staff were re-educated on 08/29/25 and 08/30/25.1.

Abuse and neglect definition, signs and symptoms of abuse and reporting and when to report.2.

Zero-tolerance expectation.3.

Resident rights.4.

Mandatory reporting within 2 hours.

Record review of Training sign-in sheets on 10/14/25 verified staff training was conducted for all facility staff on 08/29/25 and then again on 09/30/25.Interviews with NAIT #1, CNA #1-3 on 10/14/25 verified that they received the above training.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

11/18/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

White Sands Healthcare

5715 North Lovington Highway Hobbs, NM 88240

SUMMARY STATEMENT OF DEFICIENCIES

Based on interview and record review, the facility failed to ensure a Nurse Aide in Training (NAIT) completed a Nurse Aide Training and Competency Evaluation Program (NATCEP) or a Competency Evaluation Program (CEP) within four months of being employed at the facility.

This deficient practice is likely to affect all 108 residents residing at the facility by allowing untrained staff to provide direct care to residents.

The findings are:A.

Record review of NAIT #1's personnel record reviewed the following:1. NAIT #2's hire date was 11/15/24.2. NAIT #2 became a Nurse Aid in training on 02/16/25.3. NAIT #2's date of Certified Nurse Aide certification was 8/26/25.B.

Record review of NAIT #2's timesheet revealed NAIT #2 worked a total of 99 shifts between 02/16/25 and 08/26/25.C. On 10/14/25 at 5:29 pm, during an interview with the Human Resources Director (HRD), she confirmed NAIT #2 received her certification late and continued to work shifts during that time.

She stated her expectation is for all nurse aids to become certified within four months.

Facility ID: