BATTLE MOUNTAIN GENERAL HOSPITAL
Government - Hospital district
25 Beds
Independent
Data: November 2025
Trust Grade
80/100
#5 of 65 in NV
Photo by Jimmy Louis
Last Inspection: February 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Battle Mountain General Hospital has a Trust Grade of B+, which means it is above average and recommended for families considering a nursing home. It ranks #5 out of 65 facilities in Nevada, placing it in the top half of the state, and is the only option in Lander County. The facility's performance is stable, with 9 issues reported in both 2024 and 2025, and it has no fines on record, indicating a good compliance history. However, while staffing is a strength with a 5/5 rating and 0% turnover, which is significantly lower than the state average, it has concerning RN coverage, being lower than 93% of Nevada facilities. Specific incidents of concern include failures to obtain consent for medication changes for two residents and a significant weight loss in another resident, which could indicate potential harm. Overall, while there are notable strengths in staffing and compliance, the facility does have areas needing attention.
- Trust Score
- B+
- In Nevada
- #5/65
- Safety Record
- Low Risk
- Inspections
- Holding Steady
- Staff Stability ○ Average
- Turnover data not reported for this facility.
- Penalties ✓ Good
- No fines on record. Clean compliance history, better than most Nevada facilities.
- Skilled Nurses ⚠ Watch
- Each resident gets only 22 minutes of Registered Nurse (RN) attention daily — below average for Nevada. Fewer RN minutes means fewer trained eyes watching for problems.
- Violations ⚠ Watch
- 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
80/100
Top 7%
No red flags
9 → 9 violations
★★★★★
5.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★★★
5.0
Care Quality
★★★★☆
4.0
Inspection Score
↔
Stable
2024: 9 issues
2025: 9 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
No Significant Concerns Identified
This facility shows no red flags. Among Nevada's 100 nursing homes, only 0% achieve this.
The Ugly 31 deficiencies on record
Feb 2025
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0552
(Tag F0552)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a resident consented to a change ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a resident consented to a change in a psychotropic medication when the Physician increased the dose of the medication and a consent was obtained prior to administration of a new psychotropic medication for 2 of 12 sampled residents (Residents #1 and #3). This deficient practice had the potential for a resident to not have the opportunity to make an informed decision prior to receiving medications affecting the resident's mind, emotions, and behavior.
Findings include:
Resident #1
Resident #1 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, anxiety disorder, unspecified, and schizoaffective disorder, bipolar type.
A Physician's order for Resident #1, dated 01/31/2025, documented lorazepam oral tablet 1 milligram (mg), give one tablet by mouth two times a day for anxiety.
The clinical record for Resident #1 included an Informed Consent for Ativan (lorazepam) 0.5 mg by mouth twice daily. The consent was signed by the resident's representative on 12/30/2020.
On 02/06/2025 at 8:38 AM, the Long-Term Care (LTC) Coordinator confirmed Resident #1 was receiving lorazepam 1 mg twice daily and Resident #1's Informed Consent for lorazepam was not for the current dose the resident was receiving. The LTC Coordinator verbalized a new consent should have been obtained when the order to increase the resident's dose of lorazepam was received and prior to administration of the medication.
Resident #3
Resident #3 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified, insomnia, developmental disorder of scholastic skills, unspecified, and other specified anxiety disorders.
A Physician's order for Resident #3 dated 11/17/2024, documented Trazadone HCL oral tablet 100 mg, give one tablet by mouth two times a day for increased anxiety or agitation.
A Physician's order for Resident #3 dated 01/11/2025, documented Belsomra oral tablet 5 mg, give one tablet by mouth at bedtime for insomnia.
The clinical record for Resident #3 lacked documented evidence of an Informed Consent for Trazadone and Belsomra.
On 02/05/2025 at 10:54 AM, the LTC Coordinator confirmed Resident #3 was receiving Trazadone HCL 100 mg twice daily and Belsomra 5 mg once daily and the facility lacked an Informed Consent for both medications.
The facility policy titled Resident Rights, revised 05/2021, documented the resident had the right to be notified in advance about any changes in treatment decisions and the right to refuse medical treatment.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3
Resident #3 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus without compli...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3
Resident #3 was admitted to the facility on [DATE], with diagnoses including type 2 diabetes mellitus without complications, nutritional deficiency, unspecified, developmental disorder of scholastic skills, lactose intolerance, unspecified, and gastro-esophageal reflux disease without esophagitis.
Resident #3's clinical record documented Resident #3 had a -5.1% weight change from 12/13/2024 to 01/01/2025 and a -10.7% weight change from 11/04/2024 to 02/04/2025.
Resident #3's Quarterly Minimum Data Set 3.0 (MDS), Section K0300 - Weight Loss, dated 01/04/2025, documented Resident #3 was not on a weight loss regimen.
A Quarterly Nutritional assessment dated [DATE], documented the Registered Dietitian noted Resident #3 had a significant weight loss of 5%.
A Dietary Progress Note dated 01/17/2025, documented Resident #3 had a weight change of -5.2% in the last 30 days. The resident's significant weight loss was attributed to pneumonia, medication change leading to decreased appetite and overall intake reduction.
The Comprehensive Care Plan for Resident #3 dated 01/08/2025, lacked a care plan addressing Resident #3's significant weight loss interventions and goals.
On 02/05/2025 at 8:13 AM, the LPN/LTC Coordinator confirmed Resident #3 had significant weight loss and lacked a care plan to identify the goals and interventions to address the weight change.
On 02/05/2025 at 9:33 AM, the CNO confirmed Resident #3 had significant weight loss and lacked a care plan to identify and direct the goals and interventions to address the resident's weight change.
A facility policy titled Baseline/Comprehensive Care Plan and Short Term Care Plan, reviewed 12/08/2017, documented the facility will provide an individualized, interdisciplinary plan of care for all residents that shall be appropriate to the resident's needs, strengths, results of diagnostic testing limitations and goals. The care plan shall describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being as required. Care plans will be re-evaluated with a significant change of condition.
Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's Comprehensive Care Plan included 1) a care plan addressing the resident's wound for 2 of 12 sampled residents (Residents #6 and #5) and 2) a care plan addressing a resident's significant weight loss for 1 of 12 sampled residents (Resident #3). This deficient practice had the potential to result in a resident not receiving consistent care of the resident's wound and potential worsening of the wound, and consistent care addressing a resident's weight loss and potential further unplanned weight loss.
Findings include:
Resident #6
Resident #6 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis and other specified nutritional deficiencies.
On 02/03/2025 at 1:52 PM, Resident #6 verbalized the resident had a wound on the resident's backside.
An order for Resident #6, dated 01/27/2025, documented to apply Mepilex Border (an absorbent foam dressing for treating chronic and acute wounds) sacrum dressing on Monday, Wednesday, and Friday. Cleanse the area, apply skin prep, apply SilvrStat gel (a water-based gel containing silver used to treat wounds), apply Silvercel Non-Adherent (an antimicrobial alginate dressing), and then apply dressing.
A Progress Note, dated 02/03/2025, documented Resident #6's skin assessment was completed during and after the resident's shower. The resident's coccyx area was red and open.
The Comprehensive Care Plan for Resident #6 lacked a care plan addressing Resident #6's wound care interventions and goals.
On 02/04/2025 at 11:18 AM, the Licensed Practical Nurse (LPN) for Resident #6 verbalized wound care and dressing changes for Resident #6 were completed by the Physical Therapist (PT). The LPN explained Resident #6 did not have an open wound and PT only applied a Mepilex to the resident's coccyx to cushion the area where the resident had a wound previously. The LPN confirmed the wound care/wound prevention measures should have been care planned to ensure orders for the resident's wound care/wound prevention were communicated to all disciplines involved in the resident's care.
On 02/04/2025 at 2:52 PM, the PT verbalized the PT was not providing the wound care for Resident #6. The PT verbalized the PT had assessed the wound and gave direction to the nursing staff on how to complete the wound care.
On 02/05/2025 at 10:39 AM, the Chief Nursing Officer (CNO) verbalized the resident's wound care should have been care planned and care planning would have helped with communication across disciplines.
The facility policy titled Baseline/Comprehensive Care Plan and Short-Term Care Plan, reviewed 12/08/2017, documented the planning for care, treatment, and services would include the frequency of care, services, and treatments, and the team members responsible for the care, services, and treatment.
Cross reference with tag F686
Resident #5
Resident #5 admitted to the facility on [DATE], with diagnoses including wedge compression fracture of unspecified lumbar vertebrae, essential (primary) hypertension, and gout, unspecified.
A Skin assessment dated [DATE], documented an LPN had inspected a large slit in the left abdominal fold area for Resident #5. The LPN placed steri-strips (wound closure strips made of porous surgical tape used to close small wounds in a manner which pulls the skin on either side of the wound together) over the area instead of the Nystatin powder which was normally used and would monitor closely.
A Nursing Progress Note dated 01/28/2025, documented Resident #5 was monitored closely for a large slit to the left abdominal fold, steri-strips remained intact, and would continue to monitor the resident.
A Nursing Progress Note dated 01/29/2025, documented Resident #5 had a slit under the left abdominal fold which had steri-strips in place.
A Nursing Progress Note dated 01/30/2025, documented Resident #5 had a slit to the left abdominal fold. The area was red in color and new steri-strips were applied.
A Nursing Progress Note dated, 01/30/2025, documented the steri-strips on Resident #5's left abdominal fold were coming off and would be replaced the next morning before the resident left the facility for a couple of days to visit with family.
The Comprehensive Care Plan for Resident #5 lacked a care plan addressing Resident #5's wound care treatments, interventions, and goals of the left abdominal skin tear.
On 02/05/2025 at 11:31 AM, the CNO explained the Comprehensive Care Plan was used to direct the resident's care. The CNO confirmed Resident #5 had a skin tear to the left abdominal fold and lacked a care plan to identify goals and interventions to address the skin tear. The CNO explained the expectation of nursing to care plan a wound, the interventions used, and goals.
On 02/05/2025 at 12:42 PM, the LPN/Long Term Care (LTC) Coordinator confirmed Resident #5 had a skin tear to the left abdominal fold and lacked a care plan to identify goals and interventions to address the skin tear. The LPN/LTC Coordinator explained the Comprehensive Care Plan gave nursing the whole picture of the resident and how to provide care to the resident and should have included the care and treatment of the left abdominal skin tear.
The Nevada Nursing Practice Standards documented an LPN shall determine before the performance of any task that he or she has the knowledge, skill and experience to perform the task competently. An LPN shall contribute to the plan of care established for a patient by recording and reporting to the appropriate person his or her observations by conducting a focused nursing assessment.
Cross referenced to F684.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to ensure a Licensed Practical Nurse (LPN) adhered to professional standards of nursing practice when the LPN failed to ensure 1) the physician was notified of an abdominal fold skin tear, 2) a physician's order was in place prior to administering wound care, and 3) the care and treatment of a wound was documented for 1 of 12 sampled residents (Resident #5). This deficient practice had the potential to result in a resident not receiving consistent care of the resident's wound and potential worsening of the wound.
Findings include:
Resident #5
Resident #5 was admitted to the facility on [DATE], with diagnoses including wedge compression fracture of unspecified lumbar vertebrae, essential (primary) hypertension, and gout, unspecified.
A Physician Order dated 11/21/2024, documented for Resident #5 Nystatin External Powder 100000 unit/gram topical, apply to affected areas topically every 6 hours as needed for candidiasis. Start 11/21/2024.
A Skin assessment dated [DATE], documented Resident #5 an LPN had inspected a large slit in the left abdominal fold area. The LPN placed steri-strips (wound closure strips made of porous surgical tape used to close small wounds in a manner which pulls the skin on either side of the wound together) over the area instead of the Nystatin powder which was normally used and would monitor closely.
A Nursing Progress Note dated 01/28/2025, documented Resident #5 was monitored closely for a large slit to the left abdominal fold, steri-strips remained intact, and would continue to monitor the resident.
A Nursing Progress Note dated 01/29/2025, documented Resident #5 had a slit under the left abdominal fold which had steri-strips in place.
A Nursing Progress Note dated 01/30/2025, documented Resident #5 had a slit to the left abdominal fold. The area was red in color and new steri-strips were applied.
A Nursing Progress Note dated, 01/30/2025, documented the steri-strips on Resident #5's left abdominal fold were coming off and would be replaced the next morning before the resident left the facility for a couple of days to visit with family.
Resident #5's clinical record lacked the following documentation:
-measurements of the abdominal skin tear,
-physician notification of the abdominal skin tear,
-a physician order to treat the abdominal skin tear, and
-a care plan describing the care and interventions provided for the abdominal skin tear.
On 02/05/2025 at 11:26 AM, the Chief Nursing Officer (CNO) explained Resident #5's clinical record did not contain physician notification of a new wound or an order to provide wound care related to the LPN's skin assessment findings on 01/28/2025. The CNO confirmed the LPN's description of the left abdominal fold skin tear as a large slit and did not provide measurements of length, width, or depth or staging of the site. The CNO expected the LPN to document skin assessment findings consistent with nursing practice documentation, measure and document the skin tear, contact the physician with the assessment findings, and receive an order prior to wound care provided to the resident.
The CNO confirmed the facility's standard of practice followed the Nevada Nurse Practice Act and explained the LPN was not acting within the LPN's scope of practice.
On 02/05/2025 at 12:42 PM, an LPN explained the LPN had assessed Resident #5 for a large skin tear of the abdominal fold after receiving a shower on 01/28/2025, and had mistakenly described the skin tear as a large slit. The LPN confirmed applying steri-strips to the left abdominal fold skin tear after the skin assessment and without a physician's order on 01/28/2025. The LPN explained the description of the skin tear as a large slit was not a properly documented wound observation, had not provided measurements of the skin tear, and had not documented physician notification of the skin tear.
On 02/05/2025 at 1:12 PM, the LPN confirmed Resident #5's clinical record did not contain a physician's order for wound care and would require a physician's order prior to any wound care. The LPN confirmed the LPN did not receive a wound care order from the physician and performed wound care without an order from 01/28/2025 through 01/31/2025. The LPN explained it was not within an LPN's scope of practice to provide wound care without a physician's order.
The Nevada Nursing Practice Standards documented an LPN may not independently carry out those duties which require the substantial judgment, knowledge and skill of a registered nurse. An LPN shall determine before the performance of any task that he or she has the knowledge, skill and experience to perform the task competently. An LPN shall contribute to the plan of care established for a patient by recording and reporting to the appropriate person his or her observations by conducting a focused nursing assessment.
A job description titled Licensed Practical Nurse, undated, documented the LPN would:
-effectively communicate with all health care members regarding resident symptoms, reactions, and progress,
-demonstrate knowledge and application of job duties within the scope of practice for an LPN,
-note and initiate physician orders, verifying and clarifying conflicting or questionable orders when necessary, and
-perform any and all professional nursing duties within the LPN's scope of practice.
Cross referenced to F656.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Pressure Ulcer Prevention
(Tag F0686)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's pressur...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident's pressure ulcer was assessed and described in the electronic health record per facility policy for 1 of 12 sampled residents (Resident #6). This deficient practice had the potential for a resident to receive inadequate wound care and complications in healing due to the inability of staff to accurately monitor the wounds progress potentially impacting the resident's safety.
Findings include:
Resident #6
Resident #6 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis and other specified nutritional deficiencies.
On 02/03/2025 at 1:52 PM, Resident #6 verbalized the resident had a wound on the resident's backside.
An order for Resident #6, dated 01/27/2025, documented to apply Mepilex Border (an absorbent foam dressing for treating chronic and acute wounds) sacrum dressing on Monday, Wednesday, and Friday. Cleanse the area, apply skin prep, apply SilvrStat gel (a water-based gel containing silver used to treat wounds), apply Silvercel Non-Adherent (an antimicrobial alginate dressing), and then apply dressing.
A Physical Therapy Progress Note, dated 01/02/2025, documented the Physical Therapist (PT) was called to assess the resident's posterior pressure ulcer. Nursing would continue to monitor the pressure sore and dress with a sacral bandage. If the pressure sore worsened nursing would contact PT to further assess the wound.
A Nursing Progress Note, dated 02/03/2025, documented Resident #6's skin assessment was completed during and after the resident's shower. Resident #6's coccyx area was red and open.
The Skin Assessment Progress Notes for Resident #6 did not include wound measurements or documentation of the stage of the pressure ulcer.
The Comprehensive Care Plan for Resident #6 did not include a care plan to address the resident's wound, interventions for wound care, or the resident's goals for the wound.
On 02/04/2025 at 11:18 AM, the Licensed Practical Nurse (LPN) for Resident #6 verbalized PT completed the wound assessments but Resident #6 did not have an open wound. The LPN verbalized the resident's wound care should have been care planned and the nurse should have created the care plan when the order for wound care was received.
On 02/04/2025 at 2:52 PM, the PT verbalized the PT was not responsible for the wound care for Resident #6 and only assessed the wound if the nursing staff requested the PT to look at the wound and update the wound care orders.
On 02/05/2025 at 7:32 AM, the LPN verbalized the dressing to the resident's sacrum was changed by the night shift nurse. The LPN verbalized the wound should have had measurements documented since the Progress Notes documented the wound was open.
On 02/05/2025 at 10:39 AM, the Chief Nursing Officer (CNO) verbalized the wound measurements for Resident #6's wound should have been documented in the notes. The CNO explained the charting of Resident #6's wound should have included documentation of the wound size and include a good description of the wound's appearance. The CNO verbalized a care plan related to the resident's wound care would have facilitated communication between disciplines and across shifts.
The facility policy titled Wound Management, reviewed 01/25/2025, documented the assessment and description of wounds would include etiology and duration of the wound, anatomical location, dimensions (length x width x depth), wound appearance, tissue type, wound edges, condition of skin surrounding the wound, exudate: amount and type, odor, pain assessment, and signs of infection, foreign bodies, debris, and dressing remnants if present.
Cross reference with tag F656
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected most or all residents
Based on document review and interview the facility failed to maintain the required Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee members to inc...
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Based on document review and interview the facility failed to maintain the required Quality Assurance and Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee members to include the Infection Preventionist, Chief Nursing Officer and the Medical Director.
Findings include:
The facility provided a list of QAPI Committee members. The list documented the QAPI committee was comprised of the Chief Executive Officer, the Chief Nursing Officer, the Medical Director or designee, the Infection Preventionist, and two other facility staff.
On 02/06/2025 at 11:03 AM, the Risk Manager verbalized the QAPI committee required at a minimum the Administrator, the Director of Nursing, Medical Director or designee, the Infection Preventionist and two other staff members.
The Risk Manager provided the QAPI sign in sheets for the following dates, the following noted QAPI members were not on the QAPI meeting sign-in sheet and were not in attendance:
February 14, 2024 - Medical Director (MD)
March 13, 2024 - Infection Preventionist (IP), MD
April 10, 2024- IP, MD
May 14, 2024 - Chief Nursing Officer (CNO), MD
June 19, 2024 - IP, MD
July 10, 2024 - CNO, MD
August 14, 2024 - CNO, MD
September 11, 2024 - CNO, MD
October 9, 2024 - MD
November 13, 2024 - Chief Executive Officer, CNO, MD
December 11, 2024 - MD
On 02/06/2025 at 11:23 AM, the Risk Manager confirmed the aforementioned members of QAPI had not been in attendance at the identified meeting dates.
On 02/06/2025 at 11:52 AM, the Chief Executive Officer confirmed the missing members of QAPI on the identified meeting dates.
The facility policy titled Long Term Care Quality Assessment and Assurance Plan (QAPI), reviewed 04/10/2024, documented the Quality Assessment and Assurance Committee would consist at a minimum of the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of the facility's staff, at least one who must be the Administrator, Owner, a Board member or other individual in a leadership role, and the Infection Preventionist. The QAA meetings would be held at least quarterly and with enough frequency to conduct required QAPI activities.
MINOR
(C)
Minor Issue - procedural, no safety impact
MDS Data Transmission
(Tag F0640)
Minor procedural issue · This affected most or all residents
Based on interview and document review the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted timely for 3 of 11 months, starting February 2024. The deficient practice h...
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Based on interview and document review the facility failed to ensure Minimum Data Set (MDS) 3.0 assessments were transmitted timely for 3 of 11 months, starting February 2024. The deficient practice had the potential to impact resident care by also delaying the resident care plan.
Findings include:
September 2024: 23.1% of assessments transmitted late (3 of 13).
November 2024: 45.5% of assessments transmitted late (5 of 11).
December 2024: 15.7% of assessments transmitted late (1 of 3).
On 02/05/2025 at 10:00 AM, the Chief Nursing Officer (CNO) verbalized the CNO was responsible to submit the MDS assessments for the facility and confirmed the CNO had filed the aforementioned MDS assessments late.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0642
(Tag F0642)
Minor procedural issue · This affected most or all residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3
Resident #3 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #3
Resident #3 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, insomnia, and type 2 diabetes mellitus without complications.
A Quarterly MDS assessment for Resident #3, dated 10/04/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 10/13/2024, on section Z0500 designated for the signature of the RN Assessment Coordinator verifying assessment completion.
Resident #7
Resident #7 was admitted by the facility on 04/08/2021 and readmitted on [DATE], with diagnoses including epilepsy, unspecified, intractable, with status epilepticus, type 2 diabetes mellitus without complications, and anxiety disorder.
A Quarterly MDS assessment for Resident #7, dated 10/24/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 10/30/2024, on section Z0500 designated for the signature of the RN Assessment Coordinator verifying assessment completion.
Resident #13
Resident #13 was admitted to the facility on [DATE], with diagnoses including essential (primary) hypertension, unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety, and hemiplegia and hemiparesis following cerebral infarction affecting left non-dominant side.
An Annual MDS assessment for Resident #13, dated 11/23/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 11/28/2024, on section Z0500 designated for the signature of the RN Assessment Coordinator verifying assessment completion.
Resident #23
Resident #23 was admitted to the facility on [DATE], with diagnoses including hypothyroidism, unspecified, mild cognitive impairment of uncertain and unknown etiology.
An admission MDS assessment for Resident #23, dated 10/22/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 10/22/2024, on section Z0500 designated for the signature of the RN Assessment Coordinator verifying assessment completion.
Based on interview, clinical record review, and document review, the facility failed to ensure the Minimum Data Set 3.0 (MDS) assessments were certified as complete by a Registered Nurse (RN) for 13 of 13 residents reviewed for MDS completion (Residents #1, #2, #6, #12, #16, #3, #7, #13, #23, #17, #21, #14, and #5). This deficient practice had the potential for a comprehensive assessment to include inaccurate data as the result of the assessment requiring the substantial judgement, knowledge, and skill of an RN but being coordinated and completed by a Licensed Practical Nurse (LPN).
Findings include:
Resident #1
Resident #1 was admitted to the facility on [DATE], with diagnoses including edema, unspecified and nutritional deficiency, unspecified.
A Quarterly MDS assessment for Resident #1, dated 12/09/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 12/22/2024, on section Z0500 on the line designated for the signature of the RN Assessment Coordinator to verify assessment completion.
Resident #2
Resident #2 was admitted to the facility on [DATE], with diagnoses including pain, unspecified, and history of falling.
A Quarterly MDS assessment for Resident #2, dated 10/25/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 10/31/2024, on section Z0500 on the line designated for the signature of the RN Assessment Coordinator to verify assessment completion.
Resident #6
Resident #6 was admitted to the facility on [DATE], with diagnoses including multiple sclerosis and constipation, unspecified.
A Quarterly MDS assessment for Resident #6, dated 11/06/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 11/19/2024, on section Z0500 on the line designated for the signature of the RN Assessment Coordinator to verify assessment completion.
Resident #12 was admitted to the facility on [DATE], with diagnoses including unspecified glaucoma and nausea.
An Annual MDS assessment for Resident #12, dated 01/04/2025, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 01/18/2025, on section Z0500 on the line designated for the signature of the RN Assessment Coordinator to verify assessment completion.
Resident #16 was admitted to the facility on [DATE], with diagnoses including hypocalcemia and fibromyalgia.
An Annual MDS assessment for Resident #16, dated 11/01/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 11/14/2024, on section Z0500 on the line designated for the signature of the RN Assessment Coordinator to verify assessment completion.
Resident #17
Resident #17 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, pain in unspecified joint, and essential hypertension.
A Quarterly MDS assessment for Resident #17, dated 11/03/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 11/06/2024, on section Z0500 designated for the signature of the RN Assessment Coordinator verifying assessment completion.
Resident #21
Resident #21 admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including type two diabetes mellitus without complications, polyneuropathy, and essential (primary) hypertension.
A Quarterly MDS assessment for Resident #21, dated 11/11/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 11/24/2024, on section Z0500 designated for the signature of the RN Assessment Coordinator verifying assessment completion.
Resident #14
Resident #14 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance and anxiety disorder, unspecified.
A Quarterly MDS assessment for Resident #14, dated 11/15/2024, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 11/24/2024, on section Z0500 designated for the signature of the RN Assessment Coordinator verifying assessment completion.
Resident #5
Resident #5 admitted to the facility on [DATE], with diagnoses including wedge compression fracture of unspecified lumbar vertebrae, essential (primary) hypertension, and gout, unspecified.
A Quarterly MDS assessment for Resident #5, dated 01/01/2025, was signed by an LPN under Section Z - Assessment Administration. The section documented the signature certified the LPN had collected or coordinated collection for all sections of the MDS assessment and was signed by the LPN on 01/09/2025, on section Z0500 designated for the signature of the RN Assessment Coordinator verifying assessment completion.
On 02/04/2025 at 11:22 AM, the LPN confirmed the LPN had been signing the MDS assessments as the RN Assessment Coordinator verifying assessment completion for several months. The LPN verbalized the LPN was able to complete individual assessments on the MDS assessment, but a Registered Nurse should have signed the MDS as the person completing the assessment.
On 02/05/2025 at 10:41 AM, the Chief Nursing Officer (CNO) verbalized the LPN had signed all MDS assessments as the RN Assessment Coordinator for all MDS assessment completed between 10/31/2024 and 01/31/2025. The CNO verbalized the LPN could collect the data for the individual assessments, but the RN was required to sign the assessment to verify accuracy and completeness.
The facility policy titled MDS (Minimum Data Set), effective 05/14/2015, documented the Registered Nurse/MDS Coordinator would complete all sections of the MDS and was responsible for the final submission of the MDS.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0731
(Tag F0731)
Minor procedural issue · This affected most or all residents
Based on interview and document review, the facility failed to ensure residents, resident representatives, and resident's immediate family members were notified of the facility's waiver for the seven-...
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Based on interview and document review, the facility failed to ensure residents, resident representatives, and resident's immediate family members were notified of the facility's waiver for the seven-day Registered Nurse (RN) requirement for 22 of 22 residents residing in the facility. This deficient practice had the potential for residents to not be aware of the staffing waiver indicating the facility did not have RN coverage in the facility seven days a week.
Findings include:
The facility waiver for the seven-day RN requirement, dated 04/16/2021, documented the facility would notify residents of the facility (or responsible guardians or legal representatives) and members of their immediate families of the waiver.
On 02/04/2025 at 11:48 AM, the Chief Nursing Officer verbalized the facility had not notified residents or their representatives and family members of the waiver.
The facility policy titled Resident Rights, revised 05/2021, documented the resident had the right to be notified of all services available.
MINOR
(C)
Minor Issue - procedural, no safety impact
Staffing Information
(Tag F0732)
Minor procedural issue · This affected most or all residents
Based on observation, interview, and document review, the facility failed to ensure the daily posted nurse staffing information included the actual hours worked per shift for licensed and unlicensed s...
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Based on observation, interview, and document review, the facility failed to ensure the daily posted nurse staffing information included the actual hours worked per shift for licensed and unlicensed staff responsible for resident care for 4 of 4 dates the posting was observed. This deficient practice had the potential for residents and visitors to not be aware of the most up to date information regarding staffing in the facility.
Findings include:
The staff posting on the bulletin board in the long-term care hallway did not include the actual hours worked by licensed and unlicensed staff on the following dates:
- 02/03/2025.
- 02/04/2025.
- 02/05/2025.
- 02/06/2025.
On 02/06/2025 at 9:08 AM, the Chief Nursing Officer confirmed the posted nurse staffing information did not include the actual hours worked by staff.
The facility policy titled Resident Rights, revised 05/2021, documented the resident had the right to be notified of all services available.
Jan 2024
9 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to 1) ensure misappropriation of property w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, clinical record review, and document review, the facility failed to 1) ensure misappropriation of property was thoroughly investigated, 2) provide documentation of the investigation, and 3) provide a completed investigation for 1 of 2 residents investigated for FRI's (Resident #11).
Findings include:
Resident #11
Resident #11 was admitted to the facility on [DATE], with diagnoses including pseudobulbar affect, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
An initial FRI #NV00068139 with an allegation of a resident missing money from their personal bank account was submitted to the State Survey Agency on 03/10/23.
A final FRI report dated 03/15/23, was submitted to the State Agency, however lacked the conclusion of the investigation and documented the facility was not sure if the incident was substantiated at that time.
On 01/10/24 at 10:26 AM, the DON explained the DON did not have all of the investigative notes because the former LTC Coordinator kept the documents. The DON confirmed the LTC Coordinator's last day of employment was 10/31/23. The DON produced a timeline note from the LTC Coordiantor as the only documentation of the investigation. The DON confirmed the DON should have followed up with documentation to a complete investigation.
On 01/10/24 at 10:42 AM, the Chief Nursing Officer/Director of Nursing (DON) explained the Long Term Care (LTC) Coordinator had found multiple charges on Resident #11's debit card that the resident could not have withdrawn as the resident was confined to a bed and was considered to have severe cognitive impairment. The DON confirmed the resident's son had possession of Resident #11's debit card since the resident had admtted to the facility and had only given the facility a copy of the debit card to use for the resident's liability portion. The total amount of money withdrawn by the resident's son from the months of May 2022 through March 2023 was $1285.50.
The DON communicated the facility had accepted a Durable Power of Attorney (DPOA) for Healthcare Decisions the resident's son had produced upon admission and the facility notarized the document on 11/08/19. The facility later learned through another State Agency's investigation the DPOA was invalid as it was not signed by Resident #11 and had only contained the son's signature.
On 01/10/24 at 10:54 AM, the DON confirmed the DON was responsible for the investigation. The DON confirmed it was the facility's responsibility to protect the resident and the only follow up to the investigation was to request the District Attorney to grant guardianship of the resident. The DON confirmed the DON was responsible for follow up to the investigation and had not provided a report to local law enforcement, investigation follow up, or a completed investigation.
On 01/11/24 at 9:47 AM, the DON explained a Social Worker or LTC Coordinator would normally review the validity of the DPOA but the facility did not have either position filled when the resident admitted . The DON confirmed the DON was responsible to review the DPOA for validity and did not check the document or signatures that would authorize Resident #11's son to make decisions for the resident.
The facility policy titled Freedom from Abuse/Abuse Prohibition, last reviewed 10/11/23, documented residents would be free from abuse, neglect, and exploitation by staff, volunteers, consultants, family members, and legal guardians. Misappropriation of resident property was defined as the deliberate misplacement, exploitation, or wrongful or permanent use of a resident's belongings or money without the resident's consent. Residents with communication disorders and those that require heavy nursing care and/or are totally dependent on staff could be at greater risk for abuse, neglect, or misappropriation. Identified trends that constituted abuse, neglect, or misappropriation and would determine the direction for the investigation to follow.
If assault or theft was alleged or suspected, the local Sheriff's Office would be contacted for appropriate investigation. A Quality Review Report was used to communicate real or suspected abuse, neglect, or misappropriation by anyone to the LTC Supervisor, CNO, Chief Risk Officer, and Administrator. The facility would maintain a record of all incidents and reportable events.
Cross referenced with F656
NV00068139
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Comprehensive Care Plan
(Tag F0656)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a care plan was crea...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a care plan was created and implemented for 1) wound care for 1 of 12 sampled residents (Resident #17), 2) edema for 1 of 12 sampled residents (Resident #4), 3) misappropriation of funds for 1 of 12 sampled residents (Resident #11), 4) weight loss for 1 of 12 sampled residents (Resident #20), 5) the use of oxygen for 1 of 12 sampled residents (Resident #5), and 6) beds placed against the wall for 2 of 12 sampled residents (Resident #3 and #9).
Findings include:
Resident #17
Resident #17 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications and difficulty walking, not elsewhere classified.
The following physician orders were documented for Resident #17:
-04/06/23, apply Coban two or Unna Boot to right lower extremity (RLE) as needed for vascular issues to RLE.
-04/06/23, Physical Therapy evaluation and treatment.
Resident #17's care plan did not include instructions related to wound care such as wound care provided, interventions for non-pharmacological modalities, or monitoring for signs and symptoms of infection for the right lower leg.
On 01/08/24 at 3:04 PM, Resident #17 explained the resident had a chronic wound to the right lower leg for which the resident received wound care. The resident communicated the wound occurred at home and was present on admission to the facility.
On 01/10/24 at 2:04 PM, a Physical Therapist (PT) explained the healthcare provider would order PT to evaluate and treat the resident, the PT would evaluate the resident, create a treatment plan, and would perform the wound care per the treatment plan. The PT communicated the treatment plan was not documented in the electronic health record as the Therapy Department used a different database. The PT confirmed Resident #17 was provided wound care of the right lower leg twice weekly with the assistance of the Licensed Practical Nurse (LPN).
On 01/10/24 at 2:21 PM, an LPN explained Resident #17 had received wound care twice weekly by a PT. The LPN communicated the resident's wound had improved since admission and nursing was informed of the wound care through shift reporting.
The clinical record lacked any documentation of the resident's wound care.
On 01/11/24 at 7:06 AM, an LPN explained the care plan was part of the facility's standard of care and should include instructions on how to provide correct care of the resident. The LPN confirmed Resident #17's care plan did not include wound care and should have.
On 01/11/24 at 8:29 AM, the Chief Nursing Officer (CNO), also acting as the Director of Nursing (DON), explained wound care should be included on a resident's care plan. The DON confirmed PT provided wound care to Resident #17 and there had been an ongoing problem of the orders and treatment of wounds not entered by the PT into the clinical record. The DON confirmed Resident #17's care plan did not include wound care and should have.
A facility policy titled Wound Management, dated 06/08/21, documented wound care would be appropriately assessed and documented to ensure the continuity for wound management and care.
Resident #4
Resident #4 was admitted to the facility on [DATE], with diagnoses including chronic obstructive pulmonary disease, unspecified, and nutritional deficiency, unspecified.
The following physician orders were documented for Resident #4:
-11/09/21, hydrochlorothiazide tablet 25 milligrams (mg), give one tablet by mouth one time a day for edema.
-11/30/23, compression socks, put on during the day and off at bedtime two times a day for edema in the lower extremities.
-12/22/23, Lasix (furosemide) oral tablet 20 mg, give one tablet by mouth in the morning for edema in lower extremities.
A Nursing Progress Note dated 12/21/23, documented Resident #4 had reported to the physician the resident's lower extremities were swollen and wanted to know if anything could be done. Lasix 20 mg by mouth every morning was ordered to see if the medication would help. No other changes were made to the plan of care. Will continue to monitor resident.
Resident #4's care plan did not include instructions related to edema of the lower extremities such as interventions for non-pharmacological modalities, medications used for the edema, or monitoring for signs and symptoms of infection of the lower extremities.
On 01/08/24 at 3:39 PM, Resident #4 was observed to have swelling in both feet and ankles.
On 01/10/24 at 8:08 AM, an LPN confirmed Resident #4 took diuretic medication for edema. The LPN confirmed Resident #4's care plan did not include edema.
On 01/10/23 at 11:38 AM, the DON explained the nurses would let the DON know if an issue required care planning and was responsible to create the care plans for the residents. The DON confirmed edema was not care planned for Resident #4.
Resident #11
Resident #11 was admitted to the facility on [DATE], with diagnoses including pseudobulbar affect, hemiplegia and hemiparesis following cerebral infarction affecting left dominant side, and unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
Facility Reported Incident (FRI) #NV00068139 with an allegation of a resident missing money from their personal bank account was submitted to the State Survey Agency on 03/10/23.
Resident #11's care plan did not include instructions or monitoring of the resident for potential psychological effects of financial abuse.
On 01/10/24 at 11:13 AM, the DON confirmed Resident #11's care plan did not include instructions or monitoring of the resident for potential psychological effects of financial abuse.
Cross referenced with tag F610.
Resident #20
Resident #20 was admitted to the facility on [DATE], with diagnoses including heart failure and atrial fibrillation.
Resident #20's weights since admission documented the resident had been losing weight and was ordered interventions including high calorie protein drinks and a change in texture to minced and moist diet.
On 01/10/24 at 12:55 PM, the Registered Dietitian confirmed Resident #20 had a gradual weight loss since admission and had been monitoring the resident's weight each month.
Resident #20's care plan lacked documented evidence of the resident's weight loss, weight management or any interventions for the resident's weight loss.
On 01/11/24 at 9:21 AM, the DON confirmed Resident #20 had been losing weight since admission and the resident's care plan lacked documented evidence of any weight management or interventions for the resident. The DON confirmed the resident's weigh loss should have been documented on the resident's care plan.
Resident #5
Resident #5 was admitted to the facility on [DATE], with a diagnosis of multiple sclerosis.
On 01/11/24 at 6:53 AM, Resident #5 was in bed. An oxygen concentrator was next to the bed turned on and administering oxygen via nasal cannula to the resident. The oxygen concentrator flow read was four liters per minute.
Resident #5's care plan lacked documented evidence of the resident's use of oxygen.
On 01/11/24 at 9:08 AM, the DON confirmed Resident #5's use of oxygen and the resident's care plan lacked documented evidence of the use and administration of oxygen to the resident. The DON confirmed the resident's oxygen use should have been documented on the resident's care plan.
Resident #3
Resident #3 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified, other specified anxiety disorders, developmental disorder of scholastic skills, unspecified and epilepsy, unspecified, intractable, without status epilepticus.
Resident #9
Resident #9 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, single episode, unspecified, heart failure, unspecified and chronic obstructive pulmonary disease, unspecified.
On 01/08/24 at 1:27 PM, Resident #3 and Resident #9's beds were located against the wall with no spacing between the beds and the wall.
Resident #3 and #9's clinical record lacked care plans addressing the beds against the wall.
On 01/10/24 at 12:01 PM, the DON explained beds located against a wall were a safety concern for residents because it was an entrapment risk and concerns related to a possible restraint needed to be care planned. All nursing staff referred to the care plan for all care needs relating to the residents and a care plan would be important so staff knew possible interventions for each resident. The DON confirmed Resident #3 and Resident #9 lacked a care plan for the beds being placed against the wall causing an entrapment risk.
The facility policy titled Baseline/Comprehensive Care Plan & Short Term Care Plan, last reviewed December 8, 2022, documented services provided to residents would be care planned and must include the minimum healthcare information necessary to properly care for and monitor a resident. The planning for care, treatment, and services would include the frequency of care and how the services and treatments would be provided.
Cross Reference with tag 689
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17
Resident #17 was admitted to the facility on [DATE], with diagnoses including unspecified atrial fibrillation, musc...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #17
Resident #17 was admitted to the facility on [DATE], with diagnoses including unspecified atrial fibrillation, muscle spasm of back, and difficulty in walking, not elsewhere classified.
On 01/08/24 at 3:16 PM, Resident #17's call light device was observed to have black tape loosely applied around the cord and residue from a previous tape application to the cord. Resident #17 explained the cord was broken and the facility put tape over the frayed edges to fix the cord instead of replacing the call light device and cord.
On 01/11/24 at 6:53 AM, an LPN explained the Maintenance Department would be contacted via a phone call or email to request a repair or replacement of something in a resident's room. The LPN confirmed Resident #17's call light device cord had been taped with black tape and had evidence of previous taping. The LPN explained the LPN did not know who would have taped the cord and had not previously noticed the taped cord. The LPN communicated the call light device should have been replaced and not used with tape over the cord as it could present a risk of electrical shock to the resident.
On 01/11/24 at 6:59 AM, Resident #17 explained the call light device had tape around the cord for months and did not know who had placed the tape on the cord. The call light device cord was observed to have new black tape wrapped tightly around the cord where the previous taping had been observed. Glue from the previous taping was visible on the cord.
On 01/11/24 at 7:01 AM, a CNA explained the CNA had not noticed tape on the call light device cord and did not know who taped the cord. The CNA confirmed Maintenance would be called for a call light device replacement or the CNA could swap out the call light device with an extra call light device kept in the storage closet on the unit.
On 01/11/24 at 7:45 AM, the Maintenance Manager explained the staff usually notified the department for a repair request through a verbal conversation in the hallway. The Maintenance Manager communicated there would never be an instance a call light device would be taped rather than replaced. A maintenance log for repairs was not kept by the Maintenance Manager.
The Maintenance Manager confirmed Resident #17's call light device cord was taped, had markings on it from previous taping, and was plugged into the wall. The Maintenance Manager communicated not knowing of the call light device was in need of repair and did not know who would have placed tape over the cord. The Maintenance Manager removed the tape from Resident #17's call light device cord and revealed frayed and exposed live electrical wiring on the cord.
A facility policy titled Maintenance Department, dated 02/2015, documented the Maintenance Department provided the routine and emergency maintenance services to all hospital and clinic grounds, buildings, equipment, fixtures, and furniture in a safe and courteous manner. The Maintenance Manager worked under the direction of the Administrator and directed employees in proper maintenance procedures, to schedule work, train employees, and maintain proper records.
Based on observation, clinical record review, interview and document review, the facility failed to 1) prevent falls with injury for 1 of 2 residents investigated for Facility Reported Incident (FRI) (Resident #2), 2) assess for entrapment and restraint for residents' beds against the wall for 2 of 12 sampled residents (Resident #3 and #9) and 3) maintain a call light device for safety for 1 of 12 sampled residents (Resident #17).
Findings include:
Resident #2
Resident #2 was admitted to the facility on [DATE], with diagnoses including muscle weakness, other specified disorders of bone density and structure, unspecified site, and history of falling.
On 01/11/24 at 8:36 AM, Resident #2 was in bed. The bed was in the low position. All four quarter bed rails were in the up position. No fall mattresses were located in the resident's room. A walker was at the foot of the resident's bed. The bed lacked a pressure alarm device.
An Incident Note dated 04/19/23, documented a nurse heard a resident yelling and found Resident #2 laying on the resident's left side on the floor by the resident's bed. X-ray orders were provided, and X-rays were taken. The X-rays determined the resident had a fracture of the left elbow.
A Morse Fall Scale assessment dated [DATE], documented Resident #2 as high risk for falls.
Resident #2's care plan dated 02/25/22, documented the resident as a high risk for falls related to generalized weakness. Bed in low position. Use of bed rails for sense of security.
A Nurse Progress Note dated 04/21/23, documented a nurse heard screaming for help and found Resident #2 on the floor with the resident's back against the nightstand. The resident was assessed and noted a new reddish-purple bruise and skin tear approximately two centimeters by one centimeter on the resident's upper left arm. The resident also had two small skin tears below the resident's left elbow.
A Nurse Progress Note dated 04/21/23, documented the resident had an X-ray taken and the resident had a fracture of the pubis.
Resident #2's clinical record lacked documented evidence a physician's order was obtained for the use of or discontinuation of fall mattresses.
On 01/11/24 at 9:25 AM, the Chief Nursing Officer/Director of Nursing (DON) confirmed Resident #2 did fall twice within a two-day period and sustained injuries from both falls. Fall mats were in place while the resident was recovering, but since the resident's recovery, fall mats were no longer used as the resident was ambulatory with the use of a walker. The DON confirmed no other interventions were in place at the time of the falls but would consider a bed alarm if the resident continued to have falls.
The facility policy titled, Falls Reduction Plan, dated 10/13/20, documented if a resident was identified as a high risk for falls, the following measures will be initiated to increase safety: provide 1 or 2 person assist for transfers and ambulation, as needed, teach resident the proper use of assistive ambulatory devices, and the use of fall mattresses on the floor and of a bed alarm if the resident demonstrated getting out bed without asking for help.
FRI #NV00068420 and FRI #NV00068443
Resident #3
Resident #3 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, recurrent, unspecified, other specified anxiety disorders, developmental disorder of scholastic skills, unspecified and epilepsy, unspecified, intractable, without status epilepticus.
Resident #9
Resident #9 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, single episode, unspecified, heart failure, unspecified and chronic obstructive pulmonary disease, unspecified.
On 01/08/24 at 1:27 PM, Resident #3 and Resident #9's beds were located against the wall with no spacing between the beds and the wall.
Resident #3 and #9's clinical record lacked care plans addressing the beds against the wall.
Resident #3 and #9's clinical record lacked documented evidence the risk and benefits were explained to the resident and the resident had been assessed for the risk of entrapment and restraint.
On 01/10/24 at 11:29 AM, a Certified Nursing Assistant (CNA) confirmed the beds for Resident #3 and #9 were against the wall.
On 01/10/24 at 11:43 AM, a Licensed Practical Nurse (LPN) confirmed the beds for Resident #3 and #9 were against the wall and posed an entrapment risk for both residents.
On 01/10/24 at 12:01 PM, the DON explained beds located against a wall were a safety concern for residents because it was an entrapment risk. The DON explained Resident #3 needed full assistance with all Activities of Daily Living (ADL), Resident #9 needed assistance with most ADL's, and both residents could not get out of bed on their own. The DON verbalized the beds against the wall would require and evaluation to be completed, a physician's order, and risks and benefits needed to be explained and completed and confirmed the risks and benefits were not reviewed with the residents, an assessment for entrapment was not completed nor was a consent signed to be able to place the beds against the wall for Resident #3 and #9.
The facility policy titled Mobility Devices & Physical Restraints, last reviewed 02/24/21, documented all residents would be assessed for physical mobility. Every resident had the right to be free from any physical restraint and a restraint would only be used to treat a specific medical condition. Prior to the using physical devises or physical restraints, an assessment would be completed, the resident would be monitored every shift, a physician's order would be obtained, consents would be obtained, and a care plan would be developed.
Cross Reference with tag 656
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Incontinence Care
(Tag F0690)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview and document review, the facility failed to obtain physician's orders fo...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview and document review, the facility failed to obtain physician's orders for the care of a suprapubic catheter for 1 of 12 sampled residents (Resident #5) and failed to obtain physician's orders for the care of a Foley catheter for 1 of 12 sampled residents (Resident #20).
Findings include:
Resident #5
Resident #5 was admitted to the facility on [DATE], with a diagnosis of neuromuscular dysfunction of the bladder, unspecified.
On 01/11/24 at 6:53 AM, Resident #5 was in bed. A catheter bag was hanging under the left side of the bed, covered.
A physician's order dated 05/11/23, documented 16 French, 10 cubic centimeters suprapubic catheter, change every two weeks one time a day on Wednesday, and as needed for neurogenic bladder.
Resident #5's clinical record lacked documented evidence of physician's orders for the routine care of the suprapubic catheter.
Resident #20
Resident #20 was admitted to the facility on [DATE], with a diagnosis of retention of urine, unspecified.
On 01/11/24 at 6:55 AM, Resident #20 was in bed. A catheter bag was hanging under the left side of the bed, covered.
A physician's order dated 01/04/24, documented 22 French, 30 cubic centimeters Foley catheter, to be changed monthly one time every four weeks on Thursday, and as needed for urinary retention.
Resident #20's clinical record lacked documented evidence of physician's orders for the routine care of the Foley catheter.
On 01/11/24 at 7:01 AM, the Long-Term Care Supervisor/Licensed Practical Nurse (LPN) confirmed Resident #5 and #20 lacked physician's orders for the care of catheters. The LPN verbalized having been unsure where to obtain the information on catheter care and had not reviewed the policy on catheter care in a long time. The LPN verbalized each resident's catheter care could be different and specific physician's orders should have been in place to administer the proper catheter care to each resident.
On 01/11/24 at 9:16 AM the Chief Nursing Officer/Director of Nursing (DON) confirmed Resident #5 and #20 each had catheters and the clinical records lacked documented evidence of physician's order for the care of the catheters. The DON confirmed physician's order should have been in place for the care of catheters for each resident.
The facility policy titled, Suprapubic Catheter Care, dated 05/02/22, documented the facility should follow the physician's orders for the care of the suprapubic catheter.
The facility policy titled, Indwelling Urinary Catheter (Foley) Care and Management, dated 07/20/15, lacked documentation physician's orders were required for the care of a Foley catheter.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview and document review, the facility failed to obtain a physician's order w...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview and document review, the facility failed to obtain a physician's order with the liters per minute (LPM) for the administration of oxygen for 2 of 12 sampled residents (Resident #5 and #20).
Findings include:
Resident #5
Resident #5 was admitted to the facility on [DATE], with a diagnosis of multiple sclerosis.
On 01/11/24 at 6:53 AM, Resident #5 was in bed. An oxygen concentrator was next to the bed turned on and administering oxygen via nasal cannula to the resident. The oxygen concentrator flow read was four LPM.
A physician's order dated 05/11/23, documented oxygen via nasal cannula two times a day for shortness of breath. The order lacked documented evidence of the LPM of oxygen to be administered to the resident.
Resident #20
Resident #20 was admitted to the facility on [DATE], with diagnoses including heart failure and atrial fibrillation.
On 01/11/24 at 6:55 AM, Resident #20 was in bed. An oxygen concentrator was next to the bed turned on and administering oxygen via nasal cannula to the resident. The oxygen concentrator flow read was two LPM.
A physician's order dated 02/20/23, documented oxygen via nasal cannula, titrate as needed to keep saturation above 90 percent as needed for heart failure and atrial fibrillation. The order lacked documented evidence of the LPM of oxygen to be administered to the resident.
On 01/11/24 at 6:56 AM, the Long-Term Care Supervisor/Licensed Practical Nurse (LPN) confirmed the physician's orders for oxygen for Resident #5 and #20 lacked documented evidence of the oxygen LPM flow. The LPN verbalized the orders should have been specific with the LPM as too much oxygen could kill a resident.
On 01/11/24 at 9:08 AM, the Chief Nursing Officer/Director of Nursing (DON) confirmed oxygen was considered a medication and the physician's orders for oxygen for Resident #5 and #20 lacked documented evidence of the oxygen LPM flow. The DON verbalized the orders should have been specific with the LPM as an inappropriate amount of oxygen could be detrimental to a resident.
The facility policy titled, Administration of Medications, last reviewed 06/04/21, documented a physician's order was required for all medications and should include the amount to be administered.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure unsecured medications...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review the facility failed to ensure unsecured medications were not left in a resident's room for 1 of 12 sampled residents (Resident #7).
Findings include:
Resident #7
Resident #7 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including hemiplegia and hemiparesis following cerebral infarction affecting right dominant side, major depressive disorder, shortness of breath and cerebral infarction, unspecified.
On 01/09/24 at 3:49 PM, Resident #7 pulled out an albuterol inhaler from a shirt pocket on the shirt the resident was wearing. The Resident communicated the inhaler was the resident's inhaler and was on the resident most times.
On 01/09/24 at 3:55 PM, the Licensed Practical Nurse (LPN) explained none of the residents in the facility had any orders to self-administer any medications and all medications were to be locked at all times. The LPN verbalized providing Resident #7 the inhaler earlier in the day to self-administer the medication. The LPN confirmed the albuterol inhaler was unsecured, accessible to all residents in the facility, and was inappropriate to leave the inhaler with the resident.
A physician's order dated 05/06/23, documented Albuterol Sulfate HFA Inhalation Aerosol Solution 10/ (90 base) microgram (MCG)/Actuation (ACT) (Albuterol Sulfate). Inhale two puffs orally every six hours as needed for shortness of breath.
On 01/10/24 at 12:03 PM, the Chief Nursing Officer/Director of Nursing (DON) verbalized once a resident was administered a medication, the medication was to be secured to avoid residents from having access to medications. The DON explained Resident #7 did not have an order to self-administer medications and nursing staff were to observe medication administration to residents and then lock the medications after the administration.
The facility policy titled Administration of Medications last reviewed 06/04/21, documented all medications were to be secured and not left unattended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to assist a resident to receive...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review and document review, the facility failed to assist a resident to receive assistance to attain dental services for 1 of 12 sampled residents (Resident #9).
Findings include:
Resident #9
Resident #9 was admitted to the facility on [DATE], with diagnoses including major depressive disorder, single episode, unspecified, heart failure, unspecified and chronic obstructive pulmonary disease, unspecified.
On 01/08/24 at 4:24 PM, Resident #9 explained the resident had asked multiple times to see a dentist for missing teeth on the left side of the mouth. The resident verbalized having a terrible time talking because of the lack of teeth and the facility found a place for the resident to obtain dental services, however, failed to make an appointment for the resident or go any further with the resident's request.
A Social Services progress note dated 07/27/23, documented Resident #9 verbalized wanting to see a dentist and the facility would contact a dentist, set an appointment, and get the resident's needs addressed.
A Social Services Progress note dated 11/29/23, documented Resident #9 verbalized wanting to see a dentist and the facility would contact a dentist, set an appointment, and get the resident's needs addressed.
A care plan initiated on 05/31/23, and last revised on 10/27/23, documented the resident had a potential for oral/dental health problems related to missing a lot of the resident's own teeth. Interventions included to coordinate arrangements for dental care, transportation as needed and as ordered.
On 01/11/24 at 7:41 AM, the Chief Nursing Officer/Director of Nursing (DON) explained the facility would arrange for residents appointments for doctor and dentist appointments once a resident had made a request to do so. The facility had several vehicles to transport residents all over the state if needed. Once a dentist was chosen, the facility would ensure the dental office accepted the resident's insurance and then the resident would be taken to the dentist as soon as possible and an appointment was made. The DON confirmed Resident #9 had requested to see a dentist, at least on two occasions and the resident was not made an appointment nor taken to a dentist. The DON expressed Resident #9 had the right to have the resident's needs and requests always met.
On 01/11/24 at 8:44 AM, the Licensed Social Worker (LSW) recalled Resident #9 making a few requests to see a dentist with the LSW. The LSW referred the request to a Licensed Practical Nurse (LPN) and did not follow up on the resident's request to see a dentist. The LSW explained not following up with the LPN because the LSW was unsure of the job duties assigned and whether the LSW was responsible for ensuring appointments were made by the LSW once requested by a resident. The LSW confirmed no attempts were made to make a dentist appointment for Resident #9 from the facility nor any family member.
The Job Description for the Licensed Clinical Social Worker documented the LSW was responsible for resident case management to include assisting residents in accessing community resources, coordinate transportation for medical services, and ensure residents personal needs were addressed.
The facility policy titled Patient Dental Services, effective on 10/02/10, documented the facility was to provide residents with routine dental care and emergency dental services. A physician's order would be obtained for a dental appointment once a resident indicated having dental pain, lose or broken teeth or other dental concerns.
The facility policy titled Residents Rights, last revised 08/2022, documented all residents had the right to be treated with consideration and respect.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0826
(Tag F0826)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) the clinical reco...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) the clinical record included an order for wound care provided by a Physical Therapist (PT), 2) documentation of a wound evaluation by a PT, and 3) documentation of wound care provided by a PT (Resident #17).
Findings include:
Resident #17
Resident #17 was admitted to the facility on [DATE], with diagnoses including type two diabetes mellitus without complications and difficulty walking, not elsewhere classified.
The following physician orders were documented for Resident #17:
-04/06/23, apply Coban two or Unna Boot to right lower extremity (RLE) as needed for vascular issues to RLE.
-04/06/23, Physical Therapy evaluation and treatment.
Resident #17's clinical record lacked a wound care order, treatment plan, or a PT wound assessment.
On 01/08/24 at 3:04 PM, Resident #17 explained the resident had a chronic wound to the right lower leg for which the resident received wound care.
On 01/10/24 at 2:04 PM, wound care was performed by the PT on Resident #17's RLE and with the assistance of a Licensed Practical Nurse (LPN). The PT explained once the healthcare provider ordered a PT evaluation, the PT would assess the resident, create a treatment plan, write a wound care order, and perform the wound care per the treatment plan. The PT communicated the treatment plan was not documented in the electronic health record as the Therapy Department used a different database. The PT confirmed Resident #17 was provided wound care of the right lower leg twice weekly with the assistance of an LPN.
On 01/10/24 at 2:21 PM, an LPN confirmed PT provided wound care to the RLE twice weekly for Resident #17.
On 01/11/24 at 8:29 AM, the Chief Nursing Officer/Director of Nursing (DON) confirmed PT provided wound care to Resident #17 and there had been an ongoing problem of PT orders and wound treatments missing in the clinical record. The DON confirmed Resident #17's clinical record did not include wound care orders or wound care documentation by the PT.
A facility policy titled Wound Management, dated 06/08/21, documented wound care would be appropriately assessed and documented to ensure the continuity for wound management and care. The wound assessment would include the etiology and duration, anatomical location, dimensions, wound appearance, tissue type, wound edges, skin condition surrounding the wound, exudate amount and type, odor, pain assessment, and signs of infection. Physician orders were required for all treatment, procedures, and medications administered in the facility and must be ordered by a physician. The physician order would include the patient's name, date of birth , order date and time, diagnosis, wound location, type, type of clean/irrigation solution, type of dressing, frequency of dressing change, and duration of dressing. Nursing and physical therapy would clarify any incomplete or questionable physician orders.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) an employee wore a face mask in the facility during a COVID-19 (Covid) outbreak and 2) vi...
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Based on observation, interview, clinical record review, and document review, the facility failed to ensure 1) an employee wore a face mask in the facility during a COVID-19 (Covid) outbreak and 2) visitors wore a face mask in the facility during a Covid outbreak.
Findings Include:
Employee
On 01/08/24 at 1:00 PM, a red colored sign was observed on the door of the facility's main point of entry that required staff and visitors to wear a face mask due to the facility's high positivity rate of Covid.
On 01/08/24 at 1:02 PM, the Chief Nursing Officer/Director of Nursing (DON) confirmed three staff and four residents had tested positive for Covid and the facility was in a Covid outbreak status. The DON confirmed the Infection Preventionist (IP) was responsible for the Infection Control Program, Infection Control education, and the Personal Protective Equipment (PPE) requirements during a Covid outbreak.
On 01/09/23 at 7:00 AM, an office employee came out of an office, down a hallway, and opened the door of the facility's point of entry to allow surveyors into the building without wearing a mask to cover the nose and mouth. The employee explained the employee was not able to see who was awaiting entrance to the facility and had forgotten to put on a mask. The staff confirmed the staff was aware of the facility's mask mandate due to a Covid outbreak of staff and Long-Term Care residents.
On 01/11/24 at 8:37 AM, the IP confirmed staff had been educated on PPE requirements and the mask mandate due to a Covid outbreak amongst residents and staff. The IP explained the IP tried to educate and re-educate staff regarding PPE requirements but could not be everywhere in the facility at all times. The IP communicated the request of facility leadership and nursing staff to assist in monitoring and reminding staff and visitors of the PPE requirements while in an outbreak status.
A facility policy titled Covid 19: Masking, PPE, and Testing, dated 06/01/23, documented when the facility was in outbreak status of SARS-CoV-2 infection, residents would mask in the communal areas of the facility and staff would use source control in all areas of the facility. Source control options were a National Institute for Occupational Safety and Health (NIOSH) approved particulate respirator with N95 filters or higher, a respirator approved under the standards used in other countries that were similar to NIOSH approved filtering facepiece respirators, a barrier face covering that meets American Society for Testing and Materials (ASTM) F3502-21 requirements, or a well-fitting facemask.
Visitors
On 01/09/24 at 3:40 PM, a resident's visitor was observed to visit in the resident's room without a mask.
On 01/09/24 at 3:43 PM, the visitor explained they visited the resident twice per day, every day, and had been informed of the Covid outbreak but had not been asked to wear a mask at any time. The visitor confirmed once the visitor entered the facility, the visitor would continue through three hallways until reaching the intended room and was not told about the mask requierement.
A facility policy titled Battle Mountain General Hospital Masking Guidelines, last revised 06/01/23, documented the use of well-fitting masks in healthcare settings were an important strategy to prevent the spread of respiratory viruses. If there was a positive case within the facility, masks would be required for all patients, staff, and visitors. Visitors would see a red Face Mask required sign at each facility entrance.
Nov 2022
13 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to ensure written acknowledgement of the Ad...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to ensure written acknowledgement of the Advance Directive notice was provided to the resident or the resident's representative for 1 of 12 sampled residents (Resident #22) and a copy of Advanced Directives was included in the clinical record for 3 of 12 sampled residents (Resident #22, #19, and #18).
Findings include:
Resident #22
Resident #22 was admitted to the facility on [DATE], and readmitted on [DATE], with diagnoses including unspecified mood (affective) disorder, anxiety disorder, and personal history of traumatic brain injury.
Resident #22's clinical record lacked documented evidence the resident was provided with information regarding Advanced Directives.
On 11/01/22 at 3:32 PM, the Chief Nursing Officer (CNO) confirmed Resident #22's clinical record lacked documented evidence information regarding an Advanced Directive was provided to the resident or resident representative. The CNO confirmed Resident #22's clinical record did not include an Advance Directive or documentation the resident declined to formulate an Advance Directive.
The facility policy titled Advance Directives, dated 05/17/22, documented information regarding Advance Directives and resident rights in regard to Advance Directives was provided to residents within 24 hours of admission. Advance Directive Acknowledgement forms always remained in residents' medical records.
Resident #19
Resident #19 was admitted to the facility on [DATE], with a diagnosis of neuromuscular dysfunction of bladder, unspecified.
A facility document titled Acknowledgement of Patient Information on Advance Directives, signed by Resident #19 on 02/20/21, documented Resident #19 had a Durable Power of Attorney (DPOA) for health care decisions.
Resident #19's clinical record (electronic and paper) lacked documented evidence of a DPOA for health care decisions.
On 11/01/22 at 3:24 PM, the CNO confirmed Resident #19's clinical record did not include a copy of the resident's DPOA for health care decisions and should have obtained a copy upon admission or shortly thereafter.
Resident #18
Resident #18 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.
A facility document titled Acknowledgement of Patient Information on Advance Directives, signed by Resident 18's representative on 11/24/20, documented Resident #18 had a DPOA for health care decisions and a copy was provided to the facility.
Resident #18's clinical record (electronic and paper) lacked documented evidence of a DPOA for health care decisions.
On 11/01/22 at 3:26 PM, the CNO confirmed Resident #18's clinical record did not include a copy of the resident's DPOA for health care decisions and should have.
On 11/01/22 at 3:46 PM, the CNO explained the documentation a resident needed to provide to the facility upon admission was discussed with the resident and/or the resident's representative prior to admission and included a DPOA for health care decisions. The expectation was when a resident had a DPOA, upon admission, a copy would be placed in the resident's chart. The CNO communicated the facility lacked a follow up process to ensure the documents were provided and placed in the resident's clinical record.
The facility policy titled Advance Directives, dated 05/17/22, documented the facility followed the known written Advance Directives of residents and a copy was placed in the resident's chart.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Assessment Accuracy
(Tag F0641)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to ensure a resident's diagnosis was accura...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review, the facility failed to ensure a resident's diagnosis was accurately documented in the resident's Minimum Data Set 3.0 (MDS) assessment for 1 of 12 sampled residents (Resident #2).
Findings include:
Resident #2
Resident #2 was admitted to the facility on [DATE], with a diagnosis of dementia without behavioral disturbance.
A physician note dated 11/18/21, documented Resident #2 had a diagnosis of dementia without behavioral disturbance.
Resident #2's MDS assessment dated [DATE], documented in Section I - Active Diagnoses, Neurological reporting: Non-Alzheimer's Dementia was not marked.
On 11/03/22 at 9:27 AM, the Chief Nursing Officer (CNO) verbalized Resident #2 had a diagnosis of dementia and confirmed Resident #2's MDS assessment was not marked for dementia and was signed by the CNO. The CNO confirmed the MDS was inaccurate.
The facility policy, MDS (Minimum Data Set), reviewed July 13, 2022, documented the nurse/MDS Coordinator completed all sections of the MDS and was responsible for the final submission of the MDS. Comprehensive and Quarterly assessment errors inaccurately reflect the resident's clinical status were considered significant errors.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and document review, the facility failed to ensure a Pre-admission Screening and Resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview and document review, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR) Level II review was submitted for determination for 1 of 12 sampled residents with a serious mental disorder or a related condition (Resident #2).
Findings include:
Resident #2
Resident #2 was admitted to the facility on [DATE], with a primary diagnosis of schizoaffective disorder, bipolar type.
A PASRR Level I Determination dated 08/06/19, documented dementia Alzheimer and no mental illness, intellectual disability, or related condition. Appropriate for skilled nursing placement.
A physician order dated 11/20/19, documented lithium carbonate 150 milligrams caplet, take one caplet orally in the morning related to schizoaffective disorder, bipolar type.
Resident #2's Minimum Data Set 3.0 (MDS), dated [DATE], Admission, Section I - Active diagnoses, documented Psychiatric/Mood Disorder: Schizophrenia.
A physician note dated 09/15/22, documented Resident #2 had an active diagnosis of chronic schizophrenia and bipolar disorder.
Resident #2's record lacked documented evidence a PASRR Level II had been submitted for determination.
On 11/02/22 at 11:38 AM, the Chief Nursing Officer (CNO) verbalized currently the facility did not have a Social Worker and the CNO and Assistant CNO were responsible for resident PASRR submissions for determination. The CNO confirmed a PASRR Level II request for determination was not submitted for Resident #2 and should have been, based on the resident's primary diagnosis, to ensure the resident was provided the necessary services.
The facility policy titled, PASRR (Pre-admission Screening Resident Review) Nursing Facility Responsibilities, reviewed July 13, 2022, documented a social worker would assess all residents on an ongoing basis to identify if a resident had indicators of mental illness, intellectual disability or a related condition indicating a need for a PASRR Level II.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with pain...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, clinical record review, and document review, the facility failed to ensure a resident with pain had a care plan to address interventions to maintain or improve the resident's pain for 1 of 12 sampled residents (Resident #12).
Findings include:
Resident #12
Resident #12 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, type II diabetes mellitus without complications, and pain in unspecified joint.
A physician order dated 08/19/21, documented oxycodone HCL tablet, 5 milligrams (mg), give one tablet by mouth every four hours as needed for pain. The order lacked an indication for administering the medication such as location, type, and/or severity of the pain.
Resident #12's Medication Administration Record (MAR) for November 2022, documented oxycodone HCL tablet, 5 mg, give one tablet by mouth every four hours as needed for pain with a start date of 08/19/21.
Resident #12's clinical record lacked documented evidence a care plan was developed for pain and/or the use or administration of oxycodone including monitoring of adverse side effects.
On 11/03/22 at 3:28 PM, the Chief Nursing Officer confirmed Resident #12's clinical record lacked a care plan related to pain and/or opioid medications and confirmed a care plan should have been developed and implemented for pain including monitoring opioid medications for efficacy and adverse outcomes.
A facility policy titled Baseline/Comprehensive Care Plan and Short-Term Care Plan, dated 12/08/21, documented the plan of care was individualized, based on the diagnosis, resident assessment, and personal goals of the resident. The plan of care, treatment, and services included regularly reviewing and revising the plan of care, documenting pain assessment and management, and monitoring the effectiveness of care planning and the provision of care treatment and services.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0727
(Tag F0727)
Could have caused harm · This affected 1 resident
Based on interview and document review the facility failed to have a full-time Director of Nursing (DON).
Findings include:
On 10/31/22 at 10:55 AM, the Administrator verbalized the following:
- Th...
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Based on interview and document review the facility failed to have a full-time Director of Nursing (DON).
Findings include:
On 10/31/22 at 10:55 AM, the Administrator verbalized the following:
- The Chief Nursing Officer (CNO) for the hospital acted as the DON for the Long Term Care Facility (LTCF) and oversaw the hospital and emergency department, and
- The facility had a waiver dated 10/18/22, in effect for Registered Nurses for eight hours a day, seven days a week.
On 10/31/22 the LTCF Personnel Report lacked documented evidence of a DON listed on the report.
The Battle Mountain General Hospital Long Term Care Staffing posting dated 10/27/22 through 11/02/22, lacked documented evidence of DON staffing and DON hours.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12
Resident #12 was admitted to the facility on [DATE], with a primary diagnosis of unspecified dementia, unspecified ...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Resident #12
Resident #12 was admitted to the facility on [DATE], with a primary diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, anxiety, and a diagnosis of major depressive disorder, recurrent, mild.
A physician order dated 11/12/19, documented sertraline HCL 50 mg tablets, give one tablet orally in the morning for major depressive disorder, recurrent, mild.
A physician order dated 06/03/22, documented doxepin HCL 6 mg tablets, give one tablet by mouth at bedtime for insomnia, and major depressive disorder, recurrent, mild.
A physician order dated 09/15/22, documented quetiapine fumarate (Seroquel) 50 mg tablet, give 1 tablet by mouth two times a day for anxiety disorder.
Resident #12's physician notes dated 01/20/22, 02/17/22, 04/08/22, 08/18/22, and 10/20/22, documented the following:
-Anxiety disorder, the resident did well on the medication, and had a trial off the medication and had hallucinations. The assessment notes did not identify the referenced medication. The assessment note documented sertraline would not have a GDR per family request as the resident had stopped the medication before and had severe adverse effects.
-Depressive disorder, the resident did well on the medication, and had a trial off of the medication and was having hallucinations. The assessment notes did not identify the referenced medication.
Resident #12's clinical record lacked documentation non-pharmaceutical modalities were attempted prior to starting and/or increasing sertraline, doxepin, and Seroquel.
On 11/03/22 at 3:55 PM, the CNO confirmed Resident #12's physician notes dated 01/20/22, 02/17/22, 04/08/22, 08/18/22, and 10/20/22, did not document the medications being addressed and should have included at a minimum the name of the medication. The CNO confirmed the documentation did not satisfy the requirements of GDR documentation. The CNO confirmed a family request not to do a GDR was an inappropriate reason not to attempt a GDR.
On 11/03/22 at 4:00 PM, the CNO confirmed Resident #12's physician notes appeared to be replicated from note to note and confirmed it was not an acceptable practice for clinical record documentation.
On 11/03/22 at 4:04 PM, the CNO was not able to explain how the facility ensured different non-pharmaceutical modalities were trailed prior to starting or increasing psychotropic medications. The CNO confirmed the facility lacked documented evidence non-pharmaceutical modalities were trailed prior to starting and/or increasing doses of psychotropic medications.
The facility policy titled Psychotropic Medication Use, dated 05/03/21, documented psychotropic drugs included any drug that affected brain activities associated with mental processes and behaviors. The residents' need for psychotropic medication was monitored including when the dose could be lowered or discontinued. Psychotropic drugs could be ordered by a physician after non-pharmaceutical interventions were tried. A GDR was attempted as follows:
-Within the first year after a resident was admitted on antipsychotic medications,
-During two separate quarters with at least one month between the attempts when the facility initiated an antipsychotic, unless clinically contraindicated with the goal of discontinuing the medication all together, and
-After the first year, a GDR was attempted annually, unless contraindicated.
Based on clinical record review, document review, and interview, the facility failed to ensure a resident on a psychotropic medication had a gradual dose reductions (GDR) review, a clinical rationale for the continuation of the medication, and/or non-pharmacological modalities attempted prior to administering a psychotropic medication for 3 of 5 residents reviewed for unnecessary medications (Resident #11, #2, #12).
Findings include:
Resident #11
Resident #11 was admitted to the facility on [DATE], with diagnoses including major depressive disorder and insomnia.
A physician order dated 07/20/21, documented quetiapine fumarate (Seroquel) 25 milligrams (mg), give one tablet by mouth at bedtime for major depressive disorder, recurrent.
Physician notes dated 12/16/21, and 09/15/22, documented an assessment/plan for persistent insomnia: Resident #11 had been weaned down to the minimum amount of Seroquel and Trazodone at night and became agitated and slept poorly, no GDR needed.
Resident #11's clinical record lacked documentation a GDR was attempted or a physician's clinical rationale for continuation of Seroquel was obtained for major depressive disorder.
On 11/01/22 at 5:35 PM, the Chief Nursing Officer (CNO) verbalized Resident #11 lacked documented evidence of a GDR attempt for Seroquel in the first year of the medication administration and the physician notes addressing the Seroquel did not provide a clinical rationale for Resident #11's major depressive disorder.
Resident #2
Resident #2 was admitted to the facility on [DATE] with diagnoses including schizoaffective disorder, bipolar type, and dementia.
A physician order dated 11/20/19, documented:
- Lithium carbonate 150 mg caplet, give one caplet orally in the morning related to schizoaffective disorder, bipolar type.
- Thioridazine 25 mg tablet, give one caplet orally at bedtime related to schizoaffective disorder, bipolar type.
A physician order dated 12/12/19, documented divalproex sodium 500 mg delayed release tablet, give 1 tablet orally two times a day related to schizoaffective disorder, bipolar type.
A physician order dated 06/17/21, documented Ativan 0.5 mg tablet, give 0.5 mg orally in the afternoon related to anxiety disorder.
A physician note dated 10/22/21, documented bipolar/schizophrenia: resident was on lithium, Thioridazine, Depakote, and lorazepam. Family communicated they did not want the medications weaned. The resident had a long history of mental illness and the family had witnessed the resident's destabilization off meds previously and did not feel it was in the resident's best interest. No GDR will be performed.
The physician note lacked the clinical rationale for no GDR. The physician note failed to address the lorazepam (Ativan) for anxiety and potential GDR.
On 11/03/22 at 3:57 PM, the CNO verbalized the family communication was not a substitution for a clinical rationale. The provider needed to have a clinical rationale to continue the medications. The CNO verbalized the physician note dated 10/22/21, did not meet the criteria for GDR review and did not address all the resident's psychotropic medications.
The CNO confirmed the facility lacked documented evidence a review for GDR was performed in 2021 for lithium, Thioridazine and Divalproex.
The CNO confirmed Ativan had not been reviewed for a GDR twice in the first year of administration from 06/17/21 to 06/16/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview and document review the facility failed to ensure a resident's medicatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, interview and document review the facility failed to ensure a resident's medication labels included an expiration date for 1 of 12 sampled residents (Resident #21).
Findings include:
Resident #21 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety.
A physician order dated 06/23/22, documented potassium tablet, 20 milliequivalents (MEQ), give 20 MEQ by mouth in the morning for hypokalemia.
A physician order dated 03/12/22 documented quetiapine fumarate (Seroquel) 25 milligrams (mg), give one tablet by mouth one time per day for mood swings.
A physician order dated 05/13/21, documented verapamil HCL extended release (ER) 120 mg, give one tablet by mouth in the morning for essential (primary) hypertension.
On 11/02/22 at 9:31 AM, during the inspection of a medication cart, the following medications belonging to Resident #21 were found with incomplete labels as follows:
-Potassium Chloride 20 MEQ tablets, the label did not include an expiration date for the medication,
-Seroquel 25 mg tablets, the label did not include an expiration date for the medication, and
-Verapamil 120 mg ER, the label did not include an expiration date for the medication.
On 11/02/22 at 9:33 AM, a Registered Nurse (RN) confirmed the labels on Resident #21's medication bottles for potassium, Seroquel, and verapamil lacked an expiration date and confirmed all medications should include an expiration date. The RN communicated the nurse could not ensure the resident was not given expired medications when an expiration date was not included on the label. The RN explained resident may not receive the proper or necessary dosage required for the intended treatment when residents were administered expired medications. The RN acknowledged expiration dates could not be checked when not included on the label or bottle. The RN confirmed safe medication administration included checking expirations dates each time a medication was given.
On 11/02/22 at 2:56 PM, the Chief Nursing Officer (CNO) confirmed the expectation was the nurse accepting medication deliveries, would review medication labels to ensure all requirements were met, including expiration dates. The CNO confirmed when medication labels lacked an expiration date, a nurse administering medications would not be able to ensure a resident was not given expired medications.
The facility policy titled Administration of Medications, dated 06/02/21, documented before administering any medication, the nurse checked the container for an expiration date of the contents. If any discrepancy existed, the medication was withheld, and the pharmacist was notified.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and document review the facility failed to ensure Protected Healthcare Informatio...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, interview and document review the facility failed to ensure Protected Healthcare Information (PHI) was secured from view for 1 of 23 residents residing in the facility (Resident #23).
Findings include:
Resident #23
Resident #23 was admitted to the facility on [DATE], with a diagnosis of unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety.
On 11/02/22 at 7:20 AM, the computer terminal on a medication cart in the resident hallway displayed PHI for Resident #23. A nurse was not located in the hallway at or near the medication cart. The computer terminal was open to Resident #23's physician order page and included the resident's name, photograph, diet, and medication orders.
On 11/02/22 at 7:22 AM, a Registered Nurse (RN) returned to the cart and confirmed the computer terminal was open to Resident #23's physician order screen and the resident's PHI and was in view of anyone in the hallway, including other residents and visitors. The RN explained the expectation was when the nurse walked away from the computer terminal, the nurse would log out of the system.
The facility policy titled Physical Safeguards - Workstation Security, dated 04/21/05, documented employees were responsible for providing physical security for their workstations and must make every effort to ensure written and/or electronic information was not accessible to anyone not authorized to use it. Employees were not to leave screens unattended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0865
(Tag F0865)
Could have caused harm · This affected 1 resident
Based on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the facility lacked a process to ensure 1) gradual dose reductio...
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Based on interview and document review the facility's Quality Assurance and Performance Improvement (QAPI) committee failed to identify the facility lacked a process to ensure 1) gradual dose reductions (GDR) were correctly completed for residents with psychotropic medications (see tag F758), 2) Preadmission Screening and Resident Review (PASRR II) screenings for determination were completed (see tag F644).
Findings include:
Gradual Dose Reductions
On 11/03/22 at 4:36 PM, the Quality Risk Manger (QRM) confirmed the QAPI committee had not identified concerns related to the facility's process for conducting GDRs for psychotropic medications and did not initiate a Performance Improvement Project (PIP) related to the process for conducting GDRs.
On 11/03/22 at 4:39 PM, the QRM communicated the Chief Nursing Officer (CNO) had identified concerns related to the facility's GDR process, but the concerns were not discussed in a QAPI meeting. Discussing concerns related to the GDR process during a QAPI meeting would have included the Medical Director and ensured communication with providers regarding GDR was followed through and enforced.
PASRR
On 11/03/22 at 4:38 PM, the QRM confirmed the QAPI committee did not identify concerns regarding the facility's lack of a process to ensure PASRR II screenings for determination were completed and confirmed a PIP was not developed.
On 11/03/22 at 4:41 PM, the QRM explained the Social Worker (SW) was responsible for ensuring PASRR screenings and determinations were completed, and the facility did not currently have a SW. The QRM communicated when the SW left the facility the QAPI committee could have ensured the SW's responsibilities were met by determining what processes the SW was responsible for and identifying staff capable of taking over the task.
The facility policy titled Long Term Care Quality Assessment and Assurance Plan (QAPI), dated 07/21/22, documented the goal of the QAPI committee was to provide a comprehensive, facility-wide program to ensure resident safety and provide efficient and effective quality care to residents in accordance with accepted professional standards and federal, state, and local requirements. All services related to patient care were evaluated.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0868
(Tag F0868)
Could have caused harm · This affected 1 resident
Based on interview, and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee was attended by the necessary members during one of three quart...
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Based on interview, and document review the facility failed to ensure the Quality Assurance and Performance Improvement (QAPI) committee was attended by the necessary members during one of three quarters reviewed for compliance.
Findings include:
On 11/03/21 at 4:21 PM, the Quality Risk Manager (QRM) communicated a sign in sheet was not used to keep track of attendance at QAPI meetings. The QRM explained the QRM wrote the first names of attendees on a copy of an email invitation to the meeting. The QRM confirmed attendance was not documented elsewhere and attendance was not formally kept and should have been.
On 11/03/21 at 4:26 PM, the QRM communicated the required members of the QAPI committee included the Chief Nursing Officer (CNO) and the Medical Director or designee. The QRM confirmed the facility lacked documented evidence the Medical Director or a designee and the CNO attended a meeting during the third quarter (August, September, and October) of 2022.
The facility policy titled Long Term Care Quality Assessment and Assurance Plan (QAPI), dated 07/21/22, documented the QAPI committee, at a minimum, consisted of the DON, the Medical Director or designee, the IP, and three other staff members, one of which must be the administrator, owner, board member or other individual in a leadership role. The facility maintained documentation and could demonstrate evidence the program met Centers for Medicare and Medicaid Services (CMS) requirements.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on document review and interview, the facility failed to ensure a policy related to COVID-19 (COVID) vaccination for residents was developed and implemented with the potential to cause harm to t...
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Based on document review and interview, the facility failed to ensure a policy related to COVID-19 (COVID) vaccination for residents was developed and implemented with the potential to cause harm to the facility's entire resident census of 23.
On 11/03/22 at 9:26 AM, the designated Infection Preventionist communicated the facility did not have a policy regarding COVID vaccination for residents.
On 11/03/22 at 9:27 AM, the Chief Nursing Officer confirmed the facility did not have a policy regarding COVID vaccination for residents and communicated the facility followed the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) guidance related to COVID-19 including vaccination requirements for residents.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0882
(Tag F0882)
Could have caused harm · This affected 1 resident
Based on interview and document review the facility failed to ensure the designated Infection Preventionist (IP) completed an approved IP training course prior to assuming the role of IP.
Findings in...
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Based on interview and document review the facility failed to ensure the designated Infection Preventionist (IP) completed an approved IP training course prior to assuming the role of IP.
Findings include:
On 10/31/22 at 11:31 AM, the Administrator communicated employee #12 was the facility's IP and was responsible for the Infection Control Program, the Antibiotic Stewardship Program (ASP), and COVID-19 vaccination and testing efforts.
On 11/02/22 at 12:24 PM, Employee #12 communicated the employee began working in the role of IP on 08/11/22 and confirmed the employee had not completed an approved IP training course.
On 11/02/22 at 12:34 PM, the Chief Nursing Officer confirmed Employee #12 had not completed an approved IP training course and confirmed the facility had not had a trained IP since 08/11/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0887
(Tag F0887)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review the facility lacked documented evidence 3 of 23 residents residi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, interview, and document review the facility lacked documented evidence 3 of 23 residents residing in the facility were screened for eligibility to receive a COVID-19 (COVID) vaccine, provided education related to COVID vaccines, and offered an opportunity to receive or decline vaccination with a COVID vaccine (Resident #17, #20, and #2).
Findings include:
Resident #17
Resident #17 was admitted to the facility on [DATE], with diagnoses including unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety, essential (primary) hypertension, chronic obstructive pulmonary disease, unspecified.
Resident #20
Resident #20 was admitted to the facility on [DATE], with diagnoses including unspecified atrial fibrillation, and type II diabetes mellitus without complications.
The facility's Resident Vaccination Matrix (RVM), undated, documented Residents #17 and #20 were not vaccinated for COVID.
Resident #17 and #20's clinical records lacked documented evidence the residents were screened for eligibility to receive COVID vaccines, education regarding COVID vaccines was provided to the resident or the resident's representative, a primary or booster dose of a COVID vaccine was offered to the resident, and primary and/or booster doses of a COVID vaccine were administered or declined by the resident or the resident's representative.
On 11/02/22 at 11:49 AM, the CNO confirmed the facility lacked documented evidence the Resident #17 was offered a COVID vaccine, screened for eligibility to receive a COVID vaccine, provided education regarding COVID vaccines, and either a primary and/or booster doses of COVID vaccine were provided or declined.
On 11/03/22 at 3:33 PM, the Chief Nursing Officer (CNO) confirmed the facility lacked documented evidence the Resident #20 was offered a COVID vaccine, screened for eligibility to receive a COVID vaccine, provided education regarding COVID vaccines, and either a primary and/or booster doses of COVID vaccine were provided or declined.
Resident #2
Resident #2 was admitted to the facility on [DATE], with a diagnosis of schizoaffective disorder, bipolar type.
The facility's RVM, undated, documented Resident #2's last booster dose of a COVID vaccine was administered on 10/17/21.
Resident #2's clinical record lacked documented evidence the resident was screened for eligibility or offered a second booster dose of a COVID vaccine, education regarding a COVID vaccine was provided to the resident or the resident's representative, and a second booster dose of a COVID vaccine was administered or declined by the resident or the resident's representative.
On 11/03/22 at 3:34 PM, the CNO confirmed Resident #2's clinical record lacked documented evidence the resident was screened for eligibility to receive a secondary booster, a secondary booster was offered, education regarding the vaccine was provided to the resident or the resident's representative, and a COVID vaccine was either administered or declined by the resident or the resident's representative. The CNO confirmed the facility's COVID-19 policies lacked guidance regarding COVID vaccinations for residents.
On 11/03/22 at 9:27 AM, the Chief Nursing Officer confirmed the facility did not have a policy regarding COVID vaccination for residents and communicated the facility followed the Centers for Disease Control and Prevention (CDC) and the Centers for Medicare and Medicaid Services (CMS) guidance related to COVID-19 including vaccination requirements for residents.
The facility policy titled Resident Immunization, dated 02/18/04, documented an immunization history was obtained upon every admission of every long-term care resident. The history and all subsequent immunization activity was recorded in the resident's immunization record and was permanently located in the resident's medical record.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Grade B+ (80/100). Above average facility, better than most options in Nevada.
- • No major safety red flags. No abuse findings, life-threatening violations, or SFF status.
- • No fines on record. Clean compliance history, better than most Nevada facilities.
Concerns
- • 31 deficiencies on record. Higher than average. Multiple issues found across inspections.
Bottom line: Generally positive indicators. Standard due diligence and a personal visit recommended.
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About This Facility
What is Battle Mountain General Hospital's CMS Rating?
CMS assigns BATTLE MOUNTAIN GENERAL HOSPITAL an overall rating of 5 out of 5 stars, which is considered much above average nationally. Within Nevada, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Battle Mountain General Hospital Staffed?
CMS rates BATTLE MOUNTAIN GENERAL HOSPITAL's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes.
What Have Inspectors Found at Battle Mountain General Hospital?
State health inspectors documented 31 deficiencies at BATTLE MOUNTAIN GENERAL HOSPITAL during 2022 to 2025. These included: 27 with potential for harm and 4 minor or isolated issues.
Who Owns and Operates Battle Mountain General Hospital?
BATTLE MOUNTAIN GENERAL HOSPITAL is owned by a government entity. Government-operated facilities are typically run by state, county, or municipal agencies. The facility operates independently rather than as part of a larger chain. With 25 certified beds and approximately 23 residents (about 92% occupancy), it is a smaller facility located in BATTLE MOUNTAIN, Nevada.
How Does Battle Mountain General Hospital Compare to Other Nevada Nursing Homes?
Compared to the 100 nursing homes in Nevada, BATTLE MOUNTAIN GENERAL HOSPITAL's overall rating (5 stars) is above the state average of 3.0 and health inspection rating (4 stars) is above the national benchmark.
What Should Families Ask When Visiting Battle Mountain General Hospital?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Battle Mountain General Hospital Safe?
Based on CMS inspection data, BATTLE MOUNTAIN GENERAL HOSPITAL has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 5-star overall rating and ranks #1 of 100 nursing homes in Nevada. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Battle Mountain General Hospital Stick Around?
BATTLE MOUNTAIN GENERAL HOSPITAL has not reported staff turnover data to CMS. Staff turnover matters because consistent caregivers learn residents' individual needs, medications, and preferences. When staff frequently change, this institutional knowledge is lost. Families should ask the facility directly about their staff retention rates and average employee tenure.
Was Battle Mountain General Hospital Ever Fined?
BATTLE MOUNTAIN GENERAL HOSPITAL has no federal fines on record. CMS issues fines when nursing homes fail to meet care standards or don't correct problems found during inspections. The absence of fines suggests the facility has either maintained compliance or corrected any issues before penalties were assessed. This is a positive indicator, though families should still review recent inspection reports for the full picture.
Is Battle Mountain General Hospital on Any Federal Watch List?
BATTLE MOUNTAIN GENERAL HOSPITAL is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.