Average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 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.
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.
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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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
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