Battle Mountain General Hospital

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure residents who received psychotropic medications had adequate monitoring for side effects, appropriate indication for usage, and required gradual dose reductions (GDR) for 2 of 5 residents selected for unnecessary medication review (Resident #5 and #22). This deficient practice had the potential to result in unnecessary medication use and adverse drug reactions.

Inspectors wroteBased on interview and document review, the facility failed to ensure accurate and complete submission of required staffing information to the Centers for Medicare & Medicaid Services (CMS). This deficient practice resulted in inaccurate federal reporting of staffing levels.

Inspectors wroteBased on interview, clinical record review, and document review the facility failed to ensure 4 of 5 residents sampled for pneumococcal vaccinations (Resident #2, #4, #16, and #17) were screened for eligibility to receive a pneumococcal vaccine, education regarding the vaccine was provided to the resident and/or the resident representative, and the indicated pneumococcal vaccine was offered and either administered or declined. This deficient practice had the potential to place residents at increased risk for preventable illness and complications associated with pneumococcal disease.

Inspectors wroteBased on interview, and document review the facility failed to ensure a Registered Nurse (RN) was screened annually for eligibility to receive a COVID-19 (COVID) vaccine, education regarding the vaccine was provided, and the vaccine was offered and either administered or declined. This deficient practice had the potential to affect compliance with vaccination requirements and increase the risk of disease transmission.

Inspectors wroteBased on interview, observation, and document review, the facility failed to ensure 1 of 12 sampled residents (Resident #5) maintained a dignified existence when the resident's bedroom door was left open and the resident's uncovered catheter bag containing urine was visible from the hallway. This deficient practice had the potential to compromise the resident's privacy and dignity.

Inspectors wroteBased on interview and record review, the facility failed to complete a required Minimum Data Set 3.0 (MDS) assessment when a resident passed away in the facility for 1 of 1 residents reviewed (Resident #20). This deficient practice had the potential to affect the accuracy of federally required reporting and compliance with MDS submission requirements.

Inspectors wroteBased on interview and record review, the facility failed to ensure Minimum Data Set 3.0 (MDS) assessments were completed accurately for residents receiving antipsychotic medications for 1 of 12 sampled residents (Resident #22). This deficient practice had the potential to result in inaccurate federal reporting, missed required monitoring, and incorrect classification of psychotropic medication use.

Inspectors wroteBased on interview, clinical record review, and document review, the facility failed to ensure prescribed chemotherapeutic medications were care planned for 1 of 12 sampled residents (Resident #17). This deficient practice had the potential to result in the resident not receiving the services and protections needed to keep the immunocompromised resident safe from infections, and ensure the resident was kept comfortable, medications administered correctly and safely, diagnostic labs were done timely, and the resident was monitored for signs and symptoms of adverse reactions to the chemotherapeutic medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise and update the comprehensive person centered care plan for 1 of 12 sampled residents (Resident #4) after the initiation of a new anticoagulant medication for a new diagnosis of atrial fibrillation. This deficient practice had the potential to result in unmet care needs, inadequate monitoring, and increased risk of adverse effects related to anticoagulant therapy.

Inspectors wroteBased on observation, interview, clinical records review, and document review the facility failed to ensure care was provided in accordance with professional standards of practice when staff provided feeding assistance to a sleeping resident. This deficient practice had the potential to result in physical and psychosocial harm to include aspiration, and an undignified existence.

Inspectors wroteBased on clinical record review, document review, and interview, the facility failed to ensure 1) the administration of intravenous (IV) medications was documented by the nurses who administered the IV medications and 2) the diagnoses of myelodysplastic syndrome and leukemia were not included on a residents Active Medical Diagnosis Record for 1 of 12 sampled residents (Resident #17). This deficient practice had the potential for the resident to not receive appropriate care and/or medications.

Inspectors wroteBased on observation, interview, record review, and document review, the facility failed to ensure 1 of 12 sampled residents had the appropriate isolation precautions in place. This lapse in infection control protocols jeopardized the safety of the immunocompromised resident by creating an unnecessary risk of infection Resident #17 Resident#17 was admitted to the facility on [DATE], with diagnoses including rheumatoid arthritis, unspecified. Resident #17's Active Medical Diagnosis record did not include the resident's diagnoses of myelodysplastic syndrome (a group of blood cancers) or leukemia (a cancer involving blood forming tissues. Dysfunctional white blood cells are produced by bone marrow and crowd out healthy white blood cells). On 04/21/2026 at 11:01 AM, an Enhanced Barrier Precaution (EBP) was posted on the door outside of Resident #17's room. [...]

Inspectors wroteBased on interview, personnel record review, and document review, the facility failed to ensure elder abuse prevention training was completed timely for 1 of 20 sampled employees (Employee #7). This deficient practice had the potential to place all residents at risk for abuse and neglect.

Inspectors wroteBased on interview and document review, the facility failed to maintain a complete and current facility assessment. This deficient practice had the potential to result in staffing levels and facility resources not matching resident needs.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteResident #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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteResident #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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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).

Inspectors wroteBased 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. [...]