Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Battle Mountain General Hospital during CMS and state inspections, most recent first.
Psychotropic medication use was not properly monitored for two residents. One resident with dementia, insomnia, and anxiety was receiving multiple meds for sleep, hallucinations, depression, and agitation, yet was observed asleep throughout the day for about two weeks, including during meals and a fire drill, and staff had not reported the change to the provider. Another resident with Parkinsons and dementia had orders for donepezil and memantine for hallucinations, but the side effect monitoring sheet only tracked trazodone and did not include those meds; the DON and RN confirmed the missing monitoring and that the indication for memantine was not appropriate.
Inaccurate CMS staffing data submission: The facility failed to ensure complete and accurate PBJ reporting of direct care staffing hours. The PBJ report showed multiple days with no RN hours reported, while LTC staffing hour sheets documented RN coverage on several of those same days. The HR Director stated the CASPER staffing summary was the only available document showing reported hours and could not produce a report identifying the specific staffing hours and staff submitted to CMS each day.
Pneumococcal Vaccine Screening and Documentation Deficiency: The facility failed to document eligibility screening, vaccine education, and offer/acceptance or refusal for pneumococcal vaccination for four sampled residents. One resident with MS had no documented pneumococcal vaccine history and a prior refusal noted without evidence of screening or education, while three other residents with diagnoses including COPD, dementia, and RA had prior pneumococcal vaccines documented but no record of follow-up screening or education regarding CDC-recommended PCV/PPSV options.
Failure to screen, educate, and offer COVID-19 vaccine to an RN and staff: An RN had a declination form on file, but the vaccine screening questions were left incomplete and there was no documented evidence of annual eligibility screening, vaccine education, or an offer to receive or decline the vaccine. The IP confirmed the RN had not been screened or educated, and that none of the facility staff had been offered the COVID vaccine or given an opportunity to accept or decline it during the reviewed period.
A resident with dementia, CKD, and DM2 was repeatedly observed asleep in the room with the bedroom door open and an uncovered urinary catheter bag containing urine visible from the hallway. A CNA confirmed the bag was not in a dignity bag, and the CNO stated CNAs had been trained to place catheter collection devices inside a dignity bag whenever visible to others.
A resident with dementia and nutritional deficiency died in the facility, but the required death MDS was not completed. The CEO, who served as the MDS Coordinator, stated MDS assessments were completed when assigned by the EHR, and the Administrator confirmed that admission, quarterly, annual, change of condition, death, and reentry MDSs were required.
Inaccurate MDS Antipsychotic Classification: A resident with Parkinson's disease and dementia had MDS Section N documented as showing zero antipsychotic meds, even though the chart included Aricept and Namenda ordered for hallucinations. The CEO stated the MDS was completed by reviewing orders, the MAR, and staff input, but confirmed the meds were not classified as antipsychotics because they were prescribed for Parkinson's-related hallucinations.
Failure to Care Plan Chemotherapy Medication: A resident with MDS received Inqovi, a chemotherapeutic medication, but the comprehensive care plan did not include the medication, administration precautions, side effects, lab monitoring, masking precautions, or handling of bodily fluids/excretions. The MAR showed the drug was administered routinely, and an oncology email outlined detailed directions for empty-stomach dosing, double-gloving, locked storage, weekly CBC/CMP monitoring, and transfusion thresholds, yet these items were not reflected in the care plan.
Care Plan Not Updated for New Anticoagulant Therapy: A resident with COPD, insomnia, and atrial fibrillation was started on Xarelto 20 mg daily, but the comprehensive care plan was not revised to reflect the new high-risk medication. The record lacked care plan updates for anticoagulant-related needs such as bleeding risk assessment or medication education, and staff confirmed the care plan remained unchanged while the MAR showed the medication was administered daily.
Feeding a Sleeping Resident: A CNA fed a resident while the resident was asleep and lying flat in bed, with food falling from the resident’s mouth onto the face and clothing. The resident had dementia, insomnia, and anxiety, and staff stated the resident had been sleeping through the day and night for about two weeks. The CNO confirmed residents should be awake and positioned upright when assisted with eating, and the care plan indicated the resident could eat independently with supervision and tray set-up/clean-up assistance.
A resident’s IV antibiotic dose was documented on the MAR as given by an LPN even though an ER nurse administered it, and the resident’s active diagnosis record and MDS did not include myelodysplastic syndrome or leukemia despite orders and care plan references for those conditions.
Failure to Use Appropriate Isolation Precautions for an Immunocompromised Resident: A resident with cancer diagnoses and chemotherapy-related immune suppression did not have the correct isolation precautions in place. An EBP sign was posted outside the room, but it did not direct staff or visitors to wear masks, and CNAs entered without masks. The CNO confirmed the resident was immunocompromised and that reverse isolation precautions, including mask use by staff, visitors, and the resident when leaving the room, should have been followed.
A CNA did not complete required annual abuse training on time. Personnel records showed the employee completed abuse training upon hire and later completed the annual training late, and the HR Director confirmed the annual training requirement was every 12 months. Facility policy required staff training on the prevention, identification, and reporting of abuse, neglect, exploitation, and misappropriation of resident property upon hire and annually thereafter.
Incomplete Facility Assessment and Staffing Documentation. The facility failed to keep its facility-wide assessment complete and current. The assessment listed an average of nine nurses and twenty-one nurse aides, but the CEO stated it was not reviewed after a change in administration and did not include required staffing levels. The CEO confirmed the staffing numbers were not accurate and were not updated to reflect current operational needs or admin changes, including the CEO and CNO.
The facility did not maintain the required members for its QAPI committee, as key members like the Medical Director, Infection Preventionist, and Chief Nursing Officer were frequently absent from meetings throughout 2024. This was confirmed by the Risk Manager and Chief Executive Officer, indicating a failure to adhere to the facility's QAPI plan.
The facility failed to obtain informed consent for changes in psychotropic medications for two residents. One resident received an increased dose of lorazepam without a new consent, while another was administered Trazadone and Belsomra without documented consent. The facility's policy requires residents to be informed of treatment changes, which was not followed.
The facility failed to develop comprehensive care plans for three residents, resulting in deficiencies in addressing specific health needs. A resident with a coccyx wound lacked a care plan for wound care interventions, while another with a skin tear had no care plan for treatment goals. Additionally, a resident experiencing significant weight loss did not have a care plan to manage the issue, despite documentation by the dietitian. These oversights highlight a lack of communication and coordination among staff.
An LPN failed to adhere to professional nursing standards by not notifying a physician of a resident's skin tear, not obtaining a physician's order before administering wound care, and failing to document the care and treatment of the wound. The LPN applied steri-strips without a physician's order and did not document necessary measurements or notify the physician, which was outside the LPN's scope of practice.
A resident with multiple sclerosis and nutritional deficiencies had a pressure ulcer that was not properly assessed or documented according to facility policy. The wound lacked measurements and a care plan, leading to potential safety and healing issues. The LPN and CNO acknowledged the documentation failures, and the PT clarified their limited role in wound care.
The facility failed to transmit MDS 3.0 assessments to the State within the required timeframe for three months, affecting a significant percentage of assessments. The CNO, responsible for submitting these assessments, confirmed the delays, which had the potential to impact resident care by delaying care plans.
The facility failed to ensure that MDS assessments were certified by an RN for 13 residents, as required by policy. Instead, an LPN signed off on these assessments, which included Quarterly, Annual, and Admission assessments for residents with various medical conditions. The LPN confirmed signing these assessments over several months, and the CNO acknowledged the deviation from protocol, which requires an RN to verify the assessments.
The facility did not inform residents, their representatives, or family members about a waiver for the seven-day RN requirement, as admitted by the Chief Nursing Officer. This affected all 22 residents, despite the facility's policy on Resident Rights mandating such notifications.
The facility did not post the actual hours worked by licensed and unlicensed staff responsible for resident care on four observed dates. The Chief Nursing Officer confirmed the omission, which violated the facility's policy on Resident Rights requiring residents to be informed of all available services.
The facility failed to thoroughly investigate the misappropriation of property for a resident with severe cognitive impairment. The DON admitted that the investigation was incomplete, and no follow-up actions were taken. Additionally, an invalid DPOA was accepted, allowing the resident's son to withdraw money from the resident's account.
Psychotropic Medications Lacked Required Monitoring and Appropriate Use
Penalty
Summary
The facility failed to ensure that residents receiving psychotropic medications had adequate monitoring for side effects, appropriate indications for use, and required gradual dose reductions for 2 of 5 residents reviewed for unnecessary medication use. Resident #5, who had diagnoses including unspecified dementia, insomnia, and anxiety disorder, had orders for doxepin for insomnia, brexpiprazole for hallucinations, sertraline for depression, and hydroxyzine for agitation, yelling, and/or screaming. A provider note stated a gradual dose reduction was not indicated because the resident continued to have episodes of not sleeping for many days at a time and had improved with doxepin. However, during observations on 04/21/2026 and 04/22/2026, the resident was repeatedly found asleep in bed during the day, including while a CNA attempted to feed the resident and during a fire drill, and a CNA confirmed the resident had been sleeping all day for approximately the last two weeks without reporting it to the physician/provider. Resident #22, who had diagnoses including Parkinsons, dementia, and insomnia, had orders for donepezil and memantine documented as being given for hallucinations. The resident's April 2026 Side Effect Monthly Flow Sheet documented monitoring for trazodone side effects each shift, but did not include side effect monitoring for memantine or donepezil. The RN confirmed that behavior and side effect monitoring were completed each shift, that the flow sheet was created from a report of psychotropic medications, and that only trazodone side effects were being monitored for this resident. The CNO confirmed that side effects and behavior monitoring were required for all psychotropic medications and that memantine and donepezil side effects were not being monitored for April 2026; the CNO also stated memantine was used for hallucinations, which could represent a diagnosis or behavior, but this was not an appropriate indication because the resident did not have a diagnosis of hallucinations.
Inaccurate CMS Staffing Data Submission
Penalty
Summary
The facility failed to ensure accurate and complete submission of required direct care staffing information to CMS based on payroll and other verifiable and auditable data. Review of the PBJ Staffing Data Report 1705D for October through December 2025 showed multiple dates with no RN coverage reported, while review of the Long-Term Care Staffing Hours Sheets for the same period documented RN coverage on several of those dates that CMS reported as having no RN hours. On 04/23/2026 at 7:40 AM, the Human Resources Director provided the CASPER 1702S Staffing Summary for Quarter 1 and stated it was the only document available showing how many staffing hours were reported, and explained that a report could not be pulled showing what specific staffing hours and staff were reported to CMS for each day worked.
Pneumococcal Vaccine Screening and Documentation Deficiency
Penalty
Summary
Develop and implement policies and procedures for flu and pneumonia vaccinations. Based on interview, clinical record review, and document review, the facility failed to ensure 4 of 5 residents sampled for pneumococcal vaccinations were screened for eligibility to receive a pneumococcal vaccine, were provided education regarding the vaccine to the resident and/or resident representative, and were offered the indicated vaccine with documentation that it was either administered or declined. The residents involved were Resident #2, Resident #4, Resident #16, and Resident #17. Resident #2 was admitted with active primary progressive multiple sclerosis and had no documented pneumococcal vaccination in the State Immunization Record; the clinical record showed the resident declined a pneumococcal vaccine when admitted in 2015, but there was no documentation of eligibility screening, vaccine education, or an offer of the vaccine. Resident #4 had diagnoses including major depressive disorder and chronic obstructive pulmonary disease, and the State Immunization Record showed PCV13 and PPSV23 had been given, but the record lacked documentation of screening after the last PPSV23 dose, education about CDC-recommended vaccines, and an offer of PCV-15 or PCV-21. Resident #16, with unspecified dementia, had documentation of PCV13 and PPSV23, but the record lacked screening after 01/28/2020, education, and an offer of PCV-20 or PCV-21. Resident #17, with rheumatoid arthritis, had documentation of PCV13, but the record lacked screening after 01/28/2020, education, and an offer of PCV-20 or PCV-21.
Failure to Screen, Educate, and Offer COVID-19 Vaccine to RN and Staff
Penalty
Summary
The facility failed to ensure an RN was screened annually for eligibility to receive a COVID-19 vaccine, was provided education about the vaccine, and was offered the vaccine with documentation showing it was either administered or declined. Employee #1 was hired as an RN on 02/28/2022, and a 2023-2024 COVID Vaccine Consent/Declination form dated 09/2023 documented that the employee declined COVID vaccines on 10/13/2023. However, the portion of the form containing screening questions was not completed, including questions about current illness, prior COVID vaccination, severe allergic reaction to vaccine components, bleeding disorder or blood thinner use, and pregnancy or breastfeeding status. On 04/23/2026, the facility was unable to provide documented evidence that Employee #1 had been screened for eligibility, educated regarding the vaccine, or offered and either administered or declined a COVID vaccine from 10/14/2023 through 04/23/2026. The Infection Preventionist confirmed that Employee #1 had not been screened, educated, or offered the vaccine. The Infection Preventionist also confirmed that none of the facility staff had been offered a COVID vaccine, provided education regarding the vaccine, or given an opportunity to receive or decline vaccination between 01/01/2024 and 04/23/2026.
Uncovered catheter bag visible from hallway
Penalty
Summary
The facility failed to ensure that 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. Resident #5 was admitted with diagnoses including unspecified dementia, chronic kidney disease, and diabetes mellitus type II without complications. During multiple observations on 04/20/2026, 04/21/2026, 04/22/2026, and 04/23/2026, the resident was found asleep in the room with the catheter bag attached to the side of the bed and not covered with a dignity bag, while the door remained open and the bag was visible from the hallway. On 04/22/2026 at 3:00 PM, a CNA confirmed that Resident #5’s catheter bag was not covered with a dignity bag and urine was visible from the hallway. On 04/23/2026 at 11:25 AM, the CNO confirmed CNAs had been trained to place catheter collection devices inside a dignity bag, and that the expectation was for each resident with a urinary catheter to have the urinary collection bag placed inside a dignity bag at all times when visible to others. The facility policy titled Resident Rights stated residents were to be treated with consideration and respect with full recognition of dignity and individuality.
Incomplete MDS Assessment After Resident Death
Penalty
Summary
The facility failed to complete a required MDS 3.0 assessment when Resident #20 died in the facility. Resident #20 was admitted with diagnoses including unspecified dementia and nutritional deficiency and later expired in the facility. During interview, the CEO stated he was the MDS Coordinator and acknowledged that MDS assessments were required when assigned by the EHR. The Administrator confirmed that residents required admission, quarterly, annual, change of condition, death, and reentry MDS assessments, and also confirmed that the MDS assessment for Resident #20, who passed away, was not completed. The facility policy titled MDS stated the nursing home was to maintain compliance with state and federal requirements for MDS data collection and transmission.
Inaccurate MDS Antipsychotic Classification
Penalty
Summary
The facility failed to ensure MDS 3.0 assessments were completed accurately for a resident receiving medications documented for hallucinations related to Parkinson's disease. Resident #22 was admitted with diagnoses including Parkinson's disease, unspecified dementia, anxiety, and insomnia. The physician ordered Aricept 10 mg in the morning for hallucinations due to Parkinson's on 12/19/2025, and Namenda 5 mg in the morning for hallucinations on 01/23/2026. The MDS assessment dated [DATE] in Section N, N0415 - High Risk Drug Classes: Use and Indication, documented zero antipsychotic medications. During interview on 04/21/2026, the CEO stated MDS assessments were being completed by the CEO and had previously been completed by the former DON, and that medication orders, the MAR, and nursing staff input were reviewed when completing the assessment. The CEO confirmed the assessment was inaccurate and did not classify Namenda and Donepezil as antipsychotics because they were ordered for Parkinson's-related hallucinations, and stated not realizing the medications should have been classified as antipsychotics due to drug classification requirements. The facility policy stated the nursing home was to maintain compliance with state and federal mandates for MDS data collection and transmission.
Failure to Care Plan Chemotherapy Medication
Penalty
Summary
The facility failed to ensure prescribed chemotherapeutic medications were care planned for one resident. Resident #17 was admitted with rheumatoid arthritis and also had myelodysplastic syndrome (MDS), although MDS was not documented on the resident’s list of diagnoses. A physician order dated 01/26/2026 directed Inqovi oral tablet 35-100 mg (decitabine-cedazuridine) one tablet by mouth daily for 5 days on and 23 days off for MDS, and the MAR documented the medication was administered daily at breakfast from 01/26/2026 through 04/23/2026. A facility email titled Chemotherapy dated 01/22/2026 documented oncologist recommendations for the medication, including administration on an empty stomach at 6:00 AM, handling precautions such as double gloving and not touching the medication with skin, keeping the medication in the bottom locked drawer of the medication cart, and monitoring for side effects and lab values. The recommendations also included masking precautions for staff and the resident, weekly CBC and CMP draws with results faxed to the provider and oncologist, and specific transfusion parameters for PRBCs and platelets. On 04/23/2026, the CNO confirmed the Comprehensive Care Plan lacked a care plan related to Inqovi, including administration precautions, side effects, monitoring, protective isolation needs, and handling of bodily fluids/excretions. The report also states the CEO verbalized that care plans were written following the RAI manual, and the RAI manual required the care plan to be revised based on changing goals, preferences, needs, and current interventions.
Care Plan Not Updated for New Anticoagulant Therapy
Penalty
Summary
The facility failed to revise and update the comprehensive person-centered care plan for Resident #4 after a new anticoagulant medication was started for a new diagnosis of atrial fibrillation. Resident #4 was admitted to the facility and later readmitted from the hospital with diagnoses including COPD, insomnia, and atrial fibrillation. The medication regimen was updated to include Xarelto 20 mg by mouth daily in the morning for atrial fibrillation, and the MAR and MDS reflected the anticoagulant use. The resident’s clinical record did not show that the care plan was revised after Xarelto was initiated and administered. No care plan updates were found to address anticoagulant therapy needs such as bleeding risk assessments or medication education. The MAR for February, March, and April 2026 showed Xarelto 20 mg was given daily as prescribed, and staff confirmed the care plan had not been revised after the resident returned to the facility with the new high-risk medication. The CNO confirmed the care plan was initiated on 02/18/2026 with no indication that an anticoagulant was prescribed or monitored in the care plan, and stated that high-risk medications were expected to be care planned right away.
Feeding a Sleeping Resident
Penalty
Summary
The facility failed to ensure care was provided in accordance with professional standards of practice when staff fed a sleeping resident. Resident #5, who had diagnoses including unspecified dementia, insomnia, and anxiety disorder, was observed on 04/21/2026 lying flat in bed with eyes closed and mouth slightly open while a CNA scooped scrambled eggs into the resident’s mouth. The resident did not respond, and the eggs fell out of the resident’s mouth onto the resident’s face and clothing. The CNA asked if the resident wanted more food, and the resident moaned in response; the CNA then placed the spoon in the resident’s mouth and the resident stirred. The CNA stated that for about two weeks Resident #5 had been sleeping throughout the night and day and that sleeping residents were to be woken up for meals; if the resident could not be awakened, the tray would be left at bedside for a couple of hours. On 04/23/2026, Resident #5 was again found asleep and did not eat breakfast, with crumbs of food on the resident’s face and shirt. The CNO confirmed residents should be awake and positioned at a 30-to-45-degree angle when assisted with eating, and stated residents fed while asleep could be at risk of aspiration. The care plan documented the resident could eat independently with supervision and tray set-up and clean-up assistance, while a nurse progress note stated the resident had been more lethargic and needed to be fed by staff because too tired to eat.
Incomplete medication documentation and missing active diagnoses
Penalty
Summary
The facility failed to ensure that IV medication administration was documented by the nurse who actually administered the medication for Resident #17. The resident was admitted with diagnoses including rheumatoid arthritis, scoliosis, and fibromyalgia, and had a physician order for piperacillin sodium-tazobactam IV every six hours for pneumonia. On 04/23/2026, an ER nurse went to the resident’s LTC room to transport the resident to the ER for IV antibiotic administration, and later returned stating the IV antibiotics had been administered and that the resident needed an IV site change because the site was sore. However, the LTC MAR documented the 9:49 AM IV dose as administered by the LTC LPN, even though the LPN did not administer the medication. The facility also failed to include the resident’s diagnoses of myelodysplastic syndrome and leukemia on the Active Medical Diagnosis Record. The resident had a physician order for Inqovi for myelodysplastic syndrome, and the comprehensive care plan referenced chemotherapy for leukemia. The resident’s quarterly MDS assessment did not mark cancer with or without metastasis and did not list myelodysplastic syndrome or leukemia under additional active diagnoses. The CNO confirmed that the Active Medical Diagnosis List and quarterly MDS assessment did not include those diagnoses.
Failure to Use Appropriate Isolation Precautions for an Immunocompromised Resident
Penalty
Summary
The facility failed to ensure appropriate isolation precautions were in place for one of 12 sampled residents, Resident #17, who was admitted with rheumatoid arthritis and had additional diagnoses of myelodysplastic syndrome and leukemia noted in a facility email. On 04/21/2026, an Enhanced Barrier Precaution sign was posted outside the resident’s room, but it did not include instructions for staff or visitors to wear a mask when entering the room. Certified Nursing Assistants entered the room without wearing masks. A facility email titled Chemotherapy documented oncologist recommendations for Resident #17 related to treatment with Inqovi and infection control measures because the medication would further suppress the resident’s immune system. Those recommendations included staff wearing masks in the room, the resident wearing a mask when leaving the room, use of red trash bags for certain waste, disposal of those bags in the biohazard trash can, cleaning the bathroom with bleach, and limiting use of the resident’s toilet to the resident only. On 04/23/2026, the CNO stated she was not aware of the email and confirmed the resident was immunocompromised, that EBP was not the correct level of isolation precautions, and that reverse isolation precautions requiring masks for staff, visitors, and the resident should have been used.
Late Annual Abuse Training for CNA
Penalty
Summary
The facility failed to ensure elder abuse prevention training was completed timely for 1 of 20 sampled employees, Employee #7, a CNA hired with a start date of 10/15/2023. Employee #7's personnel record showed annual abuse training completed on 01/17/2025 and again on 03/10/2026, with the 2026 annual training completed late. During an interview on 04/23/2026 at 8:35 AM, the HR Director stated that all staff were required to complete abuse training upon hire and annually thereafter, defined as every 12 months, and confirmed that Employee #7 had not completed annual abuse training timely. The facility policy titled Training and Education, reviewed 01/05/2026, stated that all employees were trained and competent to perform their assigned duties and that personnel would receive training on the prevention, identification, and reporting of abuse, neglect, exploitation, and misappropriation of resident property upon hire and annually thereafter.
Incomplete Facility Assessment and Staffing Resource Documentation
Penalty
Summary
The facility failed to maintain a complete and current facility-wide assessment to determine the resources needed to care for residents competently during day-to-day operations and emergencies. The assessment dated [DATE] documented an average of nine nurses and twenty-one nurse aides, but on 04/21/2026 at 3:55 PM the CEO stated the assessment was not reviewed when administration changed and did not include the amount of required staffing. The CEO confirmed the documented average staffing numbers were not accurate and had not been updated to reflect operational needs and current staffing resources, including changes in administration staff such as the CEO and the Chief Nursing Officer. The assessment dated [DATE] also stated the nursing facility would conduct, document, and annually review a facility-wide assessment that included the resident population and the resources needed to provide person-centered care and services.
Failure to Maintain Required QAPI Committee Members
Penalty
Summary
The facility failed to maintain the required members for its Quality Assurance and Performance Improvement (QAPI) committee, as outlined in their policy. The committee was supposed to include the Director of Nursing Services, the Medical Director or designee, the Infection Preventionist, and at least three other staff members, including someone in a leadership role. However, the sign-in sheets for QAPI meetings throughout 2024 showed consistent absences of key members such as the Medical Director, Infection Preventionist, Chief Nursing Officer, and Chief Executive Officer. These absences were confirmed by the Risk Manager and the Chief Executive Officer. The facility's policy required that the QAPI committee meet at least quarterly, but the documentation revealed that essential members were missing from multiple meetings. This lack of attendance by critical members, including the Medical Director and Infection Preventionist, indicates a failure to adhere to the facility's own QAPI plan, which could potentially impact the effectiveness of the quality assurance processes. The absence of these members was acknowledged by the facility's leadership, confirming the deficiency in maintaining the required committee composition.
Failure to Obtain Informed Consent for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were fully informed and consented to changes in their psychotropic medication regimens. For Resident #1, who was admitted with diagnoses including unspecified dementia and schizoaffective disorder, the facility did not obtain a new informed consent when the physician increased the dose of lorazepam from 0.5 mg to 1 mg twice daily. The existing consent was for the lower dose, and the Long-Term Care (LTC) Coordinator confirmed that a new consent should have been obtained prior to administering the increased dose. Similarly, for Resident #3, who was admitted with diagnoses including major depressive disorder and insomnia, the facility failed to document informed consent for the administration of Trazadone HCL and Belsomra. The LTC Coordinator confirmed that Resident #3 was receiving these medications without documented evidence of informed consent. The facility's policy on Resident Rights, revised in May 2021, states that residents have the right to be notified in advance about changes in treatment decisions and the right to refuse medical treatment, which was not adhered to in these cases.
Deficiencies in Comprehensive Care Planning for Residents
Penalty
Summary
The facility failed to ensure that a comprehensive care plan was developed and implemented for three residents, leading to deficiencies in addressing their specific health needs. Resident #6, who was admitted with multiple sclerosis and nutritional deficiencies, had a wound on the coccyx area that was not included in the care plan. Despite having orders for wound care, there was a lack of communication among staff, as the LPN believed the wound was not open and the PT was not responsible for wound care. This miscommunication resulted in the absence of a care plan for wound care interventions and goals. Resident #5, admitted with a wedge compression fracture, hypertension, and gout, had a skin tear in the left abdominal fold that was not addressed in the care plan. The LPN applied steri-strips to the area and monitored it, but the comprehensive care plan did not include interventions or goals for the skin tear. The CNO and LPN/LTC Coordinator confirmed the lack of a care plan, which was necessary to provide a complete picture of the resident's care needs. Resident #3, with diagnoses including type 2 diabetes and nutritional deficiency, experienced significant weight loss over a period of time. The resident's care plan did not address this weight loss, despite documentation of the issue by the Registered Dietitian and in the Dietary Progress Note. The LPN/LTC Coordinator and CNO acknowledged the absence of a care plan to manage the resident's weight change, which was essential for directing care and interventions.
LPN Fails to Adhere to Nursing Standards in Wound Care
Penalty
Summary
The facility failed to ensure that an LPN adhered to professional standards of nursing practice in the care of a resident with a skin tear. The LPN did not notify the physician of the abdominal fold skin tear, did not obtain a physician's order before administering wound care, and failed to document the care and treatment of the wound. This deficiency was identified for one resident who had been admitted with diagnoses including a wedge compression fracture, hypertension, and gout. The LPN applied steri-strips to the skin tear without a physician's order and did not document the necessary measurements or notify the physician, which was not within the LPN's scope of practice. The Chief Nursing Officer confirmed that the clinical record lacked documentation of physician notification, a physician's order for wound care, and a care plan for the skin tear. The LPN admitted to assessing the skin tear and applying steri-strips without a physician's order, acknowledging that the description and documentation of the wound were inadequate. The Nevada Nursing Practice Standards were not followed, as the LPN did not act within the scope of practice, which requires substantial judgment, knowledge, and skill of a registered nurse for such tasks.
Failure to Document and Plan Pressure Ulcer Care
Penalty
Summary
The facility failed to ensure proper assessment and documentation of a pressure ulcer for Resident #6, who was admitted with diagnoses including multiple sclerosis and nutritional deficiencies. The resident had a wound on the backside, and an order was in place to apply specific dressings. However, the Skin Assessment Progress Notes lacked wound measurements and documentation of the ulcer's stage. The Comprehensive Care Plan also did not address the wound, interventions, or goals for the resident's wound care. This lack of documentation and care planning was confirmed by the Licensed Practical Nurse (LPN) and the Chief Nursing Officer (CNO), who acknowledged that the wound should have been measured and documented properly. The Physical Therapist (PT) was involved in assessing the wound but was not responsible for ongoing wound care, which was supposed to be managed by nursing staff. Despite the PT's involvement, there was a miscommunication regarding the responsibility for wound care, as the LPN believed the PT was handling it. The facility's policy on Wound Management required detailed documentation of wounds, including measurements and descriptions, which was not followed in this case. This deficiency in documentation and care planning had the potential to impact the resident's safety and wound healing process.
Delayed MDS 3.0 Assessment Transmissions
Penalty
Summary
The facility failed to ensure timely transmission of Minimum Data Set (MDS) 3.0 assessments to the State for three out of eleven months, beginning in February 2024. Specifically, in September 2024, 23.1% of assessments were transmitted late, with 3 out of 13 assessments affected. In November 2024, 45.5% of assessments were transmitted late, impacting 5 out of 11 assessments. In December 2024, 15.7% of assessments were transmitted late, with 1 out of 3 assessments affected. The Chief Nursing Officer (CNO) was responsible for submitting these assessments and confirmed that they were filed late. This deficiency had the potential to impact resident care by delaying the resident care plan.
Failure to Ensure RN Certification of MDS Assessments
Penalty
Summary
The facility failed to ensure that the Minimum Data Set 3.0 (MDS) assessments were certified as complete by a Registered Nurse (RN) for 13 residents. Instead, a Licensed Practical Nurse (LPN) signed off on these assessments, which is against the facility's policy that requires an RN to verify the completion of MDS assessments. This practice was identified during interviews, clinical record reviews, and document reviews, highlighting a significant deviation from the required protocol. The report details that the LPN signed the MDS assessments under Section Z - Assessment Administration, which is designated for the RN Assessment Coordinator's signature. This occurred for various types of MDS assessments, including Quarterly, Annual, and Admission assessments, for residents with a range of medical conditions such as edema, nutritional deficiency, multiple sclerosis, glaucoma, and dementia, among others. The LPN confirmed having signed these assessments over several months, acknowledging that an RN should have been responsible for verifying the assessments. The Chief Nursing Officer (CNO) confirmed that the LPN had signed all MDS assessments as the RN Assessment Coordinator for a specific period. The CNO acknowledged that while the LPN could collect data for individual assessments, the RN was required to sign off to ensure accuracy and completeness. The facility's policy, effective since 2015, clearly states that the RN/MDS Coordinator is responsible for completing all sections of the MDS and for the final submission, which was not adhered to in this case.
Failure to Notify Residents of RN Staffing Waiver
Penalty
Summary
The facility failed to notify residents, their representatives, and immediate family members about a waiver for the seven-day Registered Nurse (RN) requirement. This waiver, dated 04/16/2021, indicated that the facility did not have RN coverage seven days a week. Despite the facility's policy on Resident Rights, which mandates that residents be informed of all available services, the Chief Nursing Officer admitted on 02/04/2025 that no notifications had been made to the residents or their families regarding this waiver. This oversight affected all 22 residents residing in the facility.
Incomplete Nurse Staffing Information Posting
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing information included the actual hours worked per shift for both licensed and unlicensed staff responsible for resident care. This deficiency was observed on four consecutive dates, where the staff posting on the bulletin board in the long-term care hallway did not reflect the actual hours worked by the staff. On the last observed date, the Chief Nursing Officer confirmed that the posted nurse staffing information was incomplete. The facility's policy on Resident Rights, revised in May 2021, states that residents have the right to be notified of all services available, which includes accurate staffing information.
Failure to Investigate Misappropriation of Resident Property
Penalty
Summary
The facility failed to ensure a thorough investigation into the misappropriation of property for a resident. Resident #11, who was admitted with diagnoses including pseudobulbar affect, hemiplegia, hemiparesis, and unspecified dementia, had money missing from their personal bank account. An initial Facility Reported Incident (FRI) was submitted, but the final report lacked a conclusion and documentation of whether the incident was substantiated. The Director of Nursing (DON) admitted that the investigative notes were incomplete because the former Long Term Care (LTC) Coordinator had kept the documents. The only documentation available was a timeline note from the LTC Coordinator. The DON confirmed that the investigation was incomplete and that no follow-up actions, such as reporting to local law enforcement, were taken. Additionally, the facility accepted an invalid Durable Power of Attorney (DPOA) for Healthcare Decisions, which was not signed by the resident but only by the resident's son, who had been withdrawing money from the resident's account. The DON confirmed that the facility did not have a Social Worker or LTC Coordinator to review the validity of the DPOA at the time of the resident's admission, and the responsibility fell on the DON, who failed to check the document's validity. The facility's policy on abuse, neglect, and exploitation was not followed, as the misappropriation of the resident's property was not thoroughly investigated, documented, or reported to the appropriate authorities. The facility's failure to protect the resident and complete the investigation led to the deficiency identified in the report.
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