Battle Mountain General Hospital

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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.Findings include: Resident #17 Resident #17 was admitted to the facility on [DATE], with diagnoses including rheumatoid arthritis, scoliosis, and fibromyalgia. Resident #17's physician's order dated 04/19/2026, documented: Piperacillin Sodium-Tazobactam Solution Reconstituted 3-0.375 milligrams (mg). Use 3.375 mg IV every six hours for pneumonia until 04/24/2026 at 4:00 AM. On 04/23/2026 at 9:07 AM, an emergency room (ER) nurse went to Resident #17's Long Term Care unit (LTC) room to transport the resident to the ER for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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. The sign did not include instructions for staff and/or visitors to wear a mask when entering the resident's room. Certified Nursing Assistants entered the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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. Findings include:Employee #7Employee #7 was hired as a Certified Nursing Assistant with a start date of 10/15/2023.Employee #7's personnel record documented annual abuse training completed on 01/17/2025 and 03/10/2026. The 2026 annual abuse training was completed late.On 04/23/2026 at 8:35 AM, the Human Resources (HR) Director explained all staff in the facility were required to complete abuse training upon hire and annually thereafter. The HR Director verbalized annual training was defined as completion every 12 months. The HR Director confirmed Employee #7 had not completed annual abuse training timely.The facility policy titled Training and Education, reviewed 01/05/2026, documented all employees were trained and competent to perform their assigned duties. All personnel would receive training on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 -…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.