Battle Mountain General Hospital

F-F656

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 15 295063 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295063 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Battle Mountain General Hospital 535 S. Humboldt Street Battle Mountain, NV 89820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0731 Request a waiver if it can't meet the nurse staffing requirements.

Level of Harm - Potential for 41848 minimal harm Based on interview and document review, the facility failed to ensure residents, resident representatives, and Residents Affected - Many resident's immediate family members were notified of the facility's waiver for the seven-day Registered Nurse (RN) requirement for 22 of 22 residents residing in the facility. This deficient practice had the potential for residents to not be aware of the staffing waiver indicating the facility did not have RN coverage in the facility seven days a week.

Findings include:

The facility waiver for the seven-day RN requirement, dated 04/16/2021, documented the facility would notify residents of the facility (or responsible guardians or legal representatives) and members of their immediate families of the waiver.

On 02/04/2025 at 11:48 AM, the Chief Nursing Officer verbalized the facility had not notified residents or their representatives and family members of the waiver.

The facility policy titled Resident Rights, revised 05/2021, documented the resident had the right to be notified of all services available.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 15 295063 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295063 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Battle Mountain General Hospital 535 S. Humboldt Street Battle Mountain, NV 89820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Potential for 41848 minimal harm Based on observation, interview, and document review, the facility failed to ensure the daily posted nurse Residents Affected - Many staffing information included the actual hours worked per shift for licensed and unlicensed staff responsible for resident care for 4 of 4 dates the posting was observed. This deficient practice had the potential for residents and visitors to not be aware of the most up to date information regarding staffing in the facility.

Findings include:

The staff posting on the bulletin board in the long-term care hallway did not include the actual hours worked by licensed and unlicensed staff on the following dates:

- 02/03/2025.

- 02/04/2025.

- 02/05/2025.

- 02/06/2025.

On 02/06/2025 at 9:08 AM, the Chief Nursing Officer confirmed the posted nurse staffing information did not include the actual hours worked by staff.

The facility policy titled Resident Rights, revised 05/2021, documented the resident had the right to be notified of all services available.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 15 295063 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295063 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Battle Mountain General Hospital 535 S. Humboldt Street Battle Mountain, NV 89820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

Level of Harm - Minimal harm or 40377 potential for actual harm Based on document review and interview the facility failed to maintain the required Quality Assurance and Residents Affected - Many Performance Improvement (QAPI)/Quality Assessment and Assurance (QAA) committee members to include

the Infection Preventionist, Chief Nursing Officer and the Medical Director.

Findings include:

The facility provided a list of QAPI Committee members. The list documented the QAPI committee was comprised of the Chief Executive Officer, the Chief Nursing Officer, the Medical Director or designee, the Infection Preventionist, and two other facility staff.

On 02/06/2025 at 11:03 AM, the Risk Manager verbalized the QAPI committee required at a minimum the Administrator, the Director of Nursing, Medical Director or designee, the Infection Preventionist and two other staff members.

The Risk Manager provided the QAPI sign in sheets for the following dates, the following noted QAPI members were not on the QAPI meeting sign-in sheet and were not in attendance:

February 14, 2024 - Medical Director (MD)

March 13, 2024 - Infection Preventionist (IP), MD

April 10, 2024- IP, MD

May 14, 2024 - Chief Nursing Officer (CNO), MD

June 19, 2024 - IP, MD

July 10, 2024 - CNO, MD

August 14, 2024 - CNO, MD

September 11, 2024 - CNO, MD

October 9, 2024 - MD

November 13, 2024 - Chief Executive Officer, CNO, MD

December 11, 2024 - MD

On 02/06/2025 at 11:23 AM, the Risk Manager confirmed the aforementioned members of QAPI had not been in attendance at the identified meeting dates.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 295063 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295063 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Battle Mountain General Hospital 535 S. Humboldt Street Battle Mountain, NV 89820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0868 On 02/06/2025 at 11:52 AM, the Chief Executive Officer confirmed the missing members of QAPI on the identified meeting dates. Level of Harm - Minimal harm or potential for actual harm The facility policy titled Long Term Care Quality Assessment and Assurance Plan (QAPI), reviewed 04/10/2024, documented the Quality Assessment and Assurance Committee would consist at a minimum of Residents Affected - Many the Director of Nursing Services, the Medical Director or his/her designee, at least three other members of

the facility's staff, at least one who must be the Administrator, Owner, a Board member or other individual in

a leadership role, and the Infection Preventionist. The QAA meetings would be held at least quarterly and with enough frequency to conduct required QAPI activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 295063

F-F684.

40377

Resident #3

Resident #3 was admitted to the facility on [DATE REDACTED], with diagnoses including type 2 diabetes mellitus without complications, nutritional deficiency, unspecified, developmental disorder of scholastic skills, lactose intolerance, unspecified, and gastro-esophageal reflux disease without esophagitis.

Resident #3's clinical record documented Resident #3 had a -5.1% weight change from 12/13/2024 to 01/01/2025 and a -10.7% weight change from 11/04/2024 to 02/04/2025.

Resident #3's Quarterly Minimum Data Set 3.0 (MDS), Section K0300 - Weight Loss, dated 01/04/2025, documented Resident #3 was not on a weight loss regimen.

A Quarterly Nutritional assessment dated [DATE REDACTED], documented the Registered Dietitian noted Resident #3 had a significant weight loss of 5%.

A Dietary Progress Note dated 01/17/2025, documented Resident #3 had a weight change of -5.2% in the last 30 days. The resident's significant weight loss was attributed to pneumonia, medication change leading to decreased appetite and overall intake reduction.

The Comprehensive Care Plan for Resident #3 dated 01/08/2025, lacked a care plan addressing Resident #3's significant weight loss interventions and goals.

On 02/05/2025 at 8:13 AM, the LPN/LTC Coordinator confirmed Resident #3 had significant weight loss and lacked a care plan to identify the goals and interventions to address the weight change.

On 02/05/2025 at 9:33 AM, the CNO confirmed Resident #3 had significant weight loss and lacked a care plan to identify and direct the goals and interventions to address the resident's weight change.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 15 295063 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295063 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Battle Mountain General Hospital 535 S. Humboldt Street Battle Mountain, NV 89820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 A facility policy titled Baseline/Comprehensive Care Plan and Short Term Care Plan, reviewed 12/08/2017, documented the facility will provide an individualized, interdisciplinary plan of care for all residents that shall Level of Harm - Minimal harm or be appropriate to the resident's needs, strengths, results of diagnostic testing limitations and goals. The care potential for actual harm plan shall describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychological well-being as required. Care plans will be re-evaluated with a significant Residents Affected - Few change of condition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 15 295063 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295063 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Battle Mountain General Hospital 535 S. Humboldt Street Battle Mountain, NV 89820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 43311 potential for actual harm Based on interview, clinical record review, and document review, the facility failed to ensure a Licensed Residents Affected - Few 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 REDACTED], with diagnoses including wedge compression fracture of unspecified lumbar vertebrae, essential (primary) hypertension, and gout, unspecified.

A Physician Order dated 11/21/2024, documented for Resident #5 Nystatin External Powder 100000 unit/gram topical, apply to affected areas topically every 6 hours as needed for candidiasis. Start 11/21/2024.

A Skin assessment dated [DATE REDACTED], documented Resident #5 an LPN had inspected a large slit in the left abdominal fold area. The LPN placed steri-strips (wound closure strips made of porous surgical tape used to close small wounds in a manner which pulls the skin on either side of the wound together) over the area instead of the Nystatin powder which was normally used and would monitor closely.

A Nursing Progress Note dated 01/28/2025, documented Resident #5 was monitored closely for a large slit to the left abdominal fold, steri-strips remained intact, and would continue to monitor the resident.

A Nursing Progress Note dated 01/29/2025, documented Resident #5 had a slit under the left abdominal fold which had steri-strips in place.

A Nursing Progress Note dated 01/30/2025, documented Resident #5 had a slit to the left abdominal fold.

The area was red in color and new steri-strips were applied.

A Nursing Progress Note dated, 01/30/2025, documented the steri-strips on Resident #5's left abdominal fold were coming off and would be replaced the next morning before the resident left the facility for a couple of days to visit with family.

Resident #5's clinical record lacked the following documentation:

-measurements of the abdominal skin tear,

-physician notification of the abdominal skin tear,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 15 295063 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295063 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Battle Mountain General Hospital 535 S. Humboldt Street Battle Mountain, NV 89820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 -a physician order to treat the abdominal skin tear, and

Level of Harm - Minimal harm or -a care plan describing the care and interventions provided for the abdominal skin tear. potential for actual harm

On 02/05/2025 at 11:26 AM, the Chief Nursing Officer (CNO) explained Resident #5's clinical record did not Residents Affected - Few contain physician notification of a new wound or an order to provide wound care related to the LPN's skin assessment findings on 01/28/2025. The CNO confirmed the LPN's description of the left abdominal fold skin tear as a large slit and did not provide measurements of length, width, or depth or staging of the site. The CNO expected the LPN to document skin assessment findings consistent with nursing practice documentation, measure and document the skin tear, contact the physician with the assessment findings, and receive an order prior to wound care provided to the resident.

The CNO confirmed the facility's standard of practice followed the Nevada Nurse Practice Act and explained

the LPN was not acting within the LPN's scope of practice.

On 02/05/2025 at 12:42 PM, an LPN explained the LPN had assessed Resident #5 for a large skin tear of

the abdominal fold after receiving a shower on 01/28/2025, and had mistakenly described the skin tear as a large slit. The LPN confirmed applying steri-strips to the left abdominal fold skin tear after the skin assessment and without a physician's order on 01/28/2025. The LPN explained the description of the skin tear as a large slit was not a properly documented wound observation, had not provided measurements of

the skin tear, and had not documented physician notification of the skin tear.

On 02/05/2025 at 1:12 PM, the LPN confirmed Resident #5's clinical record did not contain a physician's order for wound care and would require a physician's order prior to any wound care. The LPN confirmed the LPN did not receive a wound care order from the physician and performed wound care without an order from 01/28/2025 through 01/31/2025. The LPN explained it was not within an LPN's scope of practice to provide wound care without a physician's order.

The Nevada Nursing Practice Standards documented an LPN may not independently carry out those duties which require the substantial judgment, knowledge and skill of a registered nurse. An LPN shall determine

before the performance of any task that he or she has the knowledge, skill and experience to perform the task competently. An LPN shall contribute to the plan of care established for a patient by recording and reporting to the appropriate person his or her observations by conducting a focused nursing assessment.

A job description titled Licensed Practical Nurse, undated, documented the LPN would:

-effectively communicate with all health care members regarding resident symptoms, reactions, and progress,

-demonstrate knowledge and application of job duties within the scope of practice for an LPN,

-note and initiate physician orders, verifying and clarifying conflicting or questionable orders when necessary, and

-perform any and all professional nursing duties within the LPN's scope of practice.

Cross referenced to

F-F686

43311

Resident #5

Resident #5 admitted to the facility on [DATE REDACTED], with diagnoses including wedge compression fracture of unspecified lumbar vertebrae, essential (primary) hypertension, and gout, unspecified.

A Skin assessment dated [DATE REDACTED], documented an LPN had inspected a large slit in the left abdominal fold area for Resident #5. The LPN placed steri-strips (wound closure strips made of porous surgical tape used to close small wounds in a manner which pulls the skin on either side of the wound together) over the area instead of the Nystatin powder which was normally used and would monitor closely.

A Nursing Progress Note dated 01/28/2025, documented Resident #5 was monitored closely for a large slit to the left abdominal fold, steri-strips remained intact, and would continue to monitor the resident.

A Nursing Progress Note dated 01/29/2025, documented Resident #5 had a slit under the left abdominal fold which had steri-strips in place.

A Nursing Progress Note dated 01/30/2025, documented Resident #5 had a slit to the left abdominal fold.

The area was red in color and new steri-strips were applied.

A Nursing Progress Note dated, 01/30/2025, documented the steri-strips on Resident #5's left abdominal fold were coming off and would be replaced the next morning before the resident left the facility for a couple of days to visit with family.

The Comprehensive Care Plan for Resident #5 lacked a care plan addressing Resident #5's wound care treatments, interventions, and goals of the left abdominal skin tear.

On 02/05/2025 at 11:31 AM, the CNO explained the Comprehensive Care Plan was used to direct the resident's care. The CNO confirmed Resident #5 had a skin tear to the left abdominal fold and lacked a care plan to identify goals and interventions to address the skin tear. The CNO explained the expectation of nursing to care plan a wound, the interventions used, and goals.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 15 295063 Department of Health & Human Services Printed: 09/09/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 295063 B. Wing 02/06/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Battle Mountain General Hospital 535 S. Humboldt Street Battle Mountain, NV 89820

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 On 02/05/2025 at 12:42 PM, the LPN/Long Term Care (LTC) Coordinator confirmed Resident #5 had a skin tear to the left abdominal fold and lacked a care plan to identify goals and interventions to address the skin Level of Harm - Minimal harm or tear. The LPN/LTC Coordinator explained the Comprehensive Care Plan gave nursing the whole picture of potential for actual harm the resident and how to provide care to the resident and should have included the care and treatment of the left abdominal skin tear. Residents Affected - Few

The Nevada Nursing Practice Standards documented an LPN shall determine before the performance of any task that he or she has the knowledge, skill and experience to perform the task competently. An LPN shall contribute to the plan of care established for a patient by recording and reporting to the appropriate person his or her observations by conducting a focused nursing assessment.

Cross referenced to