Battle Mountain General Hospital
Inspection history, citations, penalties and survey trends for this long-term care facility in Battle Mountain, Nevada.
- Location
- 535 S. Humboldt Street, Battle Mountain, Nevada 89820
- CMS Provider Number
- 295063
- Inspections on file
- 15
- Latest survey
- February 11, 2025
- Citations (last 12 mo.)
- 0
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.
Latest citations in Nevada
A resident with multiple medical conditions, including ESBL resistance and neuromuscular bladder dysfunction, was injured when a roommate pushed or slammed a bedside table toward their face during an argument about television volume, causing a cut lip and a loose tooth. The incident occurred in a shared room, involved resident-to-resident physical contact, and required assessment and law enforcement notification, demonstrating a failure to protect the resident from physical abuse.
An unauthorized male intruder repeatedly gained access to the facility through unsecured or inadequately controlled entry points, including following someone into the kitchen, bypassing the front lobby visitor kiosk, and entering through a window that was not fully locked. On one occasion he entered a resident’s room, identified himself as kitchen staff, and stole the resident’s cellphone containing personal identification and financial cards; on other occasions he stole personal items from staff, including a cellphone, wallet, and keys. Door alarms did not sound when he entered during at least one event, and staff initially considered the resident’s report possibly delusional before connecting it to prior and subsequent thefts and video evidence showing the same individual inside the building and on the grounds.
Multiple residents with psychiatric and behavioral histories physically assaulted other residents, including those with impaired cognition and significant medical conditions, resulting in documented injuries such as facial redness, bleeding, skin tears, abrasions, swelling, and periorbital discoloration. In separate episodes, one resident was slapped and nearly burned with a lit cigarette in a smoking area, another was pushed to the floor and kicked after entering a room, and two different roommates were punched on consecutive nights by the same hostile, non-redirectable resident. Facility leadership acknowledged a high behavior population, confirmed these events met the definition of willful infliction of injury and physical abuse, and reported that the aggressors had intact cognition, prior psychiatric hospitalizations, refusal of psychotropic medications, and a history that included homicidal ideation and threats with a weapon.
The facility failed to provide necessary behavioral health services, including trauma evaluations and meaningful interventions, for several residents involved in physical altercations and with significant psychiatric histories. After two residents were physically assaulted by roommates and sustained injuries, psychiatric providers were notified but did not document trauma-focused evaluations or address contributing behaviors such as wandering. Two other residents with schizophrenia, schizoaffective disorder, violent behavior, and documented noncompliance with psychotropic medications were involved in repeated aggressive incidents toward peers and staff, yet records showed only routine refusals of medication without evidence of effective, individualized behavioral interventions. The facility acknowledged a high-behavior population and a pattern of resident altercations, along with dissatisfaction with the psychiatric NP’s limited and delayed evaluations.
Failure to report resident-to-resident physical abuse: A resident with Alzheimer's disease was documented slapping another resident, and the other resident slapped back. The on-call manager was notified, but the incident was not reported to the SA. The DON later stated it was probably mutual combat and the MDS Coordinator, who was the DON at the time, confirmed physical abuse includes hitting and slapping and denied the incident was reported.
A resident with MS and polyneuropathy developed new occasional urinary incontinence after previously being continent, but the care plan did not include a focused care area or interventions to address the change. The resident reported not recalling staff prompting toileting at timed intervals, and the DON confirmed the care plan lacked urinary incontinence interventions and that the facility did not have a bladder training or retraining policy.
Failure to address new urinary incontinence: A resident with MS and polyneuropathy, previously continent of bladder, began having occasional urine incontinence but did not recall staff prompting toileting at timed intervals. The MDS later documented occasional bladder incontinence, yet the care plan had no focused interventions for the change in condition. The CNA was unaware of any bladder training/retraining program, and the DON confirmed the care plan lacked related interventions and the facility had no bladder training/retraining policy.
The facility failed to complete a required annual CNA performance review for one CNA, Employee #8, whose personnel record had no documented evaluation. The HR Director stated CNA evaluations were done each year on Oct. 1 to review the prior year and confirmed this CNA was not reviewed 12 months after starting at the facility. The Facility Assessment stated weaknesses identified in CNA performance reviews and annual competency assessments would be addressed through in-service training.
Facility Assessment did not match actual night shift staffing. The assessment stated Harmony Manor and Quail Corner each required an LPN on nights, with consistent staffing prioritized in the memory care unit, but the April schedule showed both units sharing one licensed nurse on multiple nights. The DON confirmed one nurse was responsible for all 32 residents on those nights and acknowledged the assessment needed to reflect the staffing schedule.
Unsanitary Kitchen Floor Drain: A kitchen floor drain was observed with a buildup of debris and grime, and the Kitchen Mgr confirmed it was dirty and could spread contamination. The Mgr stated floor cleaning was the responsibility of Maintenance, and the Maint Mgr later confirmed the drain had not been recently cleaned and was not sanitary. The facility policy required strict sanitary conditions in Dietary and Nutrition to prevent food contamination and growth of disease-producing organisms.
Failure to Protect Resident From Roommate’s Physical Abuse During Altercation
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by a roommate. The resident was admitted with diagnoses including local infection of the skin and subcutaneous tissue, ESBL resistance, and neuromuscular dysfunction of the bladder. On the evening of 04/10/2026, while in a shared room, the roommate pushed or slammed a bedside table toward the resident during a dispute about the television volume being too loud. The bedside table struck the resident in the face, resulting in a bleeding lip and a loose tooth. The resident reported that the roommate became angry about the television volume and then pushed the bedside table toward their face. Following the incident, the resident was observed with blood on the face and lip, and a loose tooth was noted. The resident declined transfer to the hospital. Law enforcement was contacted, and both residents provided statements to the responding officer, with the injured resident declining to press charges. The roommate later stated that the bedside table had been positioned on the side of the bed and that they were pushing it back toward the other side, claiming they were simply returning the bedside table to its proper place. The facility’s failure to prevent this resident-to-resident physical altercation and resulting injury constituted a failure to protect the resident from physical abuse.
Unauthorized Intruder Repeatedly Accesses Facility and Resident Room
Penalty
Summary
The deficiency involves the facility’s failure to ensure a safe environment for residents and staff when an unauthorized male intruder repeatedly gained access to the building and entered resident and staff areas, including a resident room. One resident, identified as R94, had been admitted with anxiety disorder, major depressive disorder, and left knee pain, and was alert and oriented at the time of the incident. Around 5:00 AM in December 2025, R94 observed an unknown man enter the resident’s room, state that he was kitchen staff checking the table for breakfast, and then take the resident’s cellphone, which contained a driver’s license, debit card, health insurance card, and bus card. R94 reported that the door alarms did not sound when the man entered the facility and that the resident typically heard alarms when someone entered without using the correct code. After the theft, there were two unauthorized charges on the resident’s debit card. Staff interviews revealed that this was not an isolated security breach. An LPN reported that in December 2025, R94’s report of a man entering the room and taking the cellphone was initially considered possibly delusional due to the resident’s history of seeing a person, but during the same IDT discussion another nurse reported that the day before R94’s report, a stranger had entered the kitchen and stolen a dietary staff member’s iPhone around 5:30 PM. Security camera footage showed the same man entering through a kitchen door by following someone from behind, indicating that he was able to bypass normal access controls. The same individual was later seen twice in the parking lot, and staff contacted police on those occasions. A CNA also recalled interacting with a man who claimed he was there to pick up belongings of a discharged resident and asked for the Wi‑Fi password, which the CNA provided; during the subsequent investigation, this man was identified as the same individual seen on video breaking into the building. The Administrator’s review of the January 24–25, 2026 incident documented that during a night shift, an unauthorized individual gained access by exploiting a window on the south side of the building that was not fully seated in the locked position, allowing him to shimmy the frame open and enter an unoccupied case management office. From there, he exited into the hallway, went to the nurse station, and took a nurse’s wallet and keys. As he attempted to exit through a west door, the door alarm sounded, but he was able to reach a vehicle and flee before staff arrived. The Administrator also confirmed a prior December 24, 2025 security breach in which an unauthorized male bypassed the front lobby visitor kiosk, entered the facility, and went into R94’s room, where he removed the resident’s cellphone and attached personal items from the bedside. Investigation of that December incident showed the individual was not an authorized visitor, family member, or vendor, and that he had been able to enter the building and a resident room without being stopped at the kiosk or by staff. The DON stated that R94’s report was handled as a grievance and resolved, but there were no IDT notes related to the incident, and the Administrator was not aware of the earlier kitchen theft when first discussing the December event.
Failure to Prevent Resident-on-Resident Physical Abuse in High-Behavior Population
Penalty
Summary
The facility failed to protect residents from physical abuse when multiple residents with known psychiatric and behavioral histories physically assaulted other residents on several occasions. In the first incident, one resident with fibromyalgia and an unspecified intracranial injury reported being slapped, cursed at, and nearly struck in the face with a lit cigarette by another resident in the smoking area, resulting in redness to the mandible area and involvement of law enforcement. The aggressor stated the victim was being annoying and deserved the assault. In a separate incident, a resident with moderately impaired cognition and no documented aggressive or wandering behaviors was pushed to the floor and kicked by another cognitively intact resident with schizophrenia and paranoid personality disorder after entering that resident’s room, causing a bleeding nose, a skin tear to the left forearm, and redness of the left forehead. Additional incidents involved a resident with moderately impaired cognition who reported being punched by a roommate, resulting in mild forehead swelling, and another resident with chronic obstructive pulmonary disease, heart failure, and schizoaffective disorder who was punched by the same aggressor after being moved into the room, sustaining discoloration around the left eye socket, a nose bridge abrasion, and a skin tear to the left forehead. Documentation showed that the aggressive resident was screaming violently, hostile, physically aggressive, and non-redirectable toward both residents and staff. The wound care team’s head-to-toe assessments confirmed the physical injuries sustained by the assaulted residents. Interviews with the DON, SSD, and DSD confirmed that these incidents met the facility’s own definition of willful infliction of injury and were classified as physical abuse. The DON stated that the aggressors had intact cognition, histories of inpatient psychiatric stays, and, in one case, a history of homicidal ideation and prior psychiatric hospitalization for chasing a person with a knife and threatening police. Facility leadership acknowledged a high behavioral population, an average of 45 residents with behavioral issues, and identified a pattern of resident altercations and physical abuse. They reported that the aggressors were refusing psychotropic medications and that concerns about psychiatric support, admission screening, and limitations on use of IM psychotropics had been communicated to the psychiatric provider and medical director, but these issues remained unresolved at the time of the incidents.
Failure to Provide Trauma Evaluations and Effective Behavioral Health Interventions
Penalty
Summary
The deficiency involves the facility’s failure to provide necessary behavioral health care and services, including trauma evaluations, following resident-to-resident physical abuse incidents. One resident with psychosis, schizophrenia, and major depressive disorder was found on the floor with a bleeding nose, a skin tear, and forehead redness after being pushed and kicked by another resident. A psychiatry progress note documented that the psychiatric NP saw the resident per staff request, but the record lacked documentation that the altercation or physical abuse incident was discussed or that the resident’s newly identified wandering behavior, which led to the altercation, was addressed. Another resident with COPD, heart failure, and schizoaffective disorder was punched by a roommate, resulting in discoloration around the eye, a nose bridge abrasion, and a forehead skin tear. Although the care plan for emotional distress included a psychiatry evaluation and the NP was informed of the incident, there was no documented evidence that a psychiatric trauma evaluation was completed. The facility also failed to implement meaningful behavioral health interventions for residents with psychiatric histories, aggressive behaviors, and refusal of psychotropic medications. One resident with schizophrenia and paranoid personality disorder, intact cognition, and a history of violent behavior and homicidal ideation, including chasing a person with a knife and threatening police, was involved in multiple physical altercations. This resident punched another resident in the smoking area and later admitted to pushing and kicking a different resident who entered the room. The care plan identified behavioral problems such as irritability, anger, violent behavior, homicidal ideations, mood swings, and a tendency to push and kick other residents, with interventions including attempts to identify underlying causes. However, the medical record showed the resident routinely refused medications, and there was no documentation of effective, meaningful interventions addressing this ongoing refusal and associated behaviors. Another resident with neuroleptic-induced Parkinsonism, schizoaffective bipolar type, and psychosis, recently transferred from a psychiatric hospital after an exacerbation of schizophrenia symptoms and noncompliance with psychotropic medications, was also involved in a physical altercation. Progress notes documented that this resident punched a roommate, was screaming violently, hostile, physically aggressive, and non-redirectable toward residents and staff. A social services note indicated that when staff attempted to discuss the altercation, the resident became agitated, screamed, yelled, and used inappropriate language, preventing further information gathering. A refusal of treatment form showed the resident had declined medications after being informed that refusal could affect mood stabilization and worsen behaviors. Despite the facility’s acknowledgment of a high-behavior population and multiple resident altercations, the report describes a pattern of inadequate psychiatric support and lack of thorough evaluations and timely, effective behavioral interventions for these residents.
Failure to Report Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to ensure an incident of resident-to-resident physical abuse was reported to the State Agency for 1 of 12 sampled residents. Resident #10, who was admitted with diagnoses including Alzheimer's disease and episodic tension-type headache, was documented in a nursing progress note as having been seen by a CNA slapping another resident, after which the other resident slapped Resident #10 back. The on-call manager was notified and directed staff to keep the residents apart and maintain them in eyesight if together. A physician progress note later documented that Resident #10 had been involved in a behavioral disturbance in which a heated exchange led to physical aggression between the two residents, with each resident physically striking the other. The DON stated the incident would probably not be considered resident-to-resident abuse because it was mutual combat and said the DON did not know whether either resident had been assessed for pain, injury, or mental anguish. The MDS Coordinator, who was the DON at the time of the incident, confirmed physical abuse includes hitting and slapping, denied being aware of the incident at the time, and denied that it was reported to the SA.
Care Plan Missing Interventions for New Urinary Incontinence
Penalty
Summary
The facility failed to develop a care plan with interventions to assist Resident #24 in maintaining continence after the resident, who had previously been continent, began experiencing occasional urinary incontinence. Resident #24 was admitted and later readmitted with diagnoses including multiple sclerosis and unspecified polyneuropathy. On 04/20/2026, the resident stated they had recently started having occasional urinary incontinence but could still get to the bathroom once they realized they were urinating, and the resident could not recall staff prompting them to toilet at timed intervals. An MDS assessment dated 07/07/2025 documented the resident was always continent of bladder, while an MDS assessment dated 04/06/2026 documented the resident was occasionally incontinent of bladder. The care plan did not include a focused care area or interventions related to the resident’s new urinary incontinence. On 04/22/2026, the DON stated the resident had become increasingly incontinent over the last several months and believed it was related to the resident’s multiple sclerosis. The DON also stated the facility could try offering assistance with a toileting schedule and confirmed the care plan did not include a care area or interventions related to the resident’s urinary incontinence, and that the facility did not have a policy for a bladder training or retraining program.
Failure to Address New Urinary Incontinence
Penalty
Summary
The facility failed to ensure a previously continent resident received assistance or interventions to maintain or improve urinary continence after the resident began experiencing occasional urinary incontinence. Resident #24 was admitted with diagnoses including multiple sclerosis and unspecified polyneuropathy. The resident stated that the resident had recently started having occasional urinary incontinence but could still reach the bathroom once the resident realized the resident was urinating, and the resident could not recall staff prompting bathroom use at timed intervals. Record review showed an MDS dated 07/07/2025 documented the resident was always continent of bladder, while an MDS dated 04/06/2026 documented the resident was occasionally incontinent of bladder. The care plan did not include a focused care area or interventions related to the new urinary incontinence. The CNA stated the resident had begun experiencing incontinence several months earlier and was not aware of any bladder training or retraining program, while the DON stated the resident had become increasingly incontinent over the last several months and that the facility could try a toileting schedule; the DON also confirmed the care plan lacked interventions related to the resident's new urinary incontinence and that the facility did not have a policy for a bladder training or retraining program.
Missing Annual CNA Performance Review
Penalty
Summary
The facility failed to ensure a nurse aide performance review was completed at least once every 12 months and that areas of weakness were identified and addressed for 1 of 2 sampled CNAs, Employee #8. Employee #8 was hired as a CNA on 10/21/2024, and the personnel record lacked documented evidence of a nurse aide performance evaluation. During interview on 04/22/2026, the HR Director stated CNA performance evaluations were completed every year on October 1st to review the prior year and explained that, because of the date of hire, Employee #8 was not reviewed for performance. The HR Director confirmed Employee #8's nurse aide performance review was not completed 12 months after starting at the facility. The Facility Assessment, updated 03/2026, documented that areas of weakness identified in nurse aide performance reviews and annual competency assessments would be addressed through in-service training.
Facility Assessment Did Not Match Night Shift Staffing
Penalty
Summary
The facility failed to ensure its Facility Assessment accurately reflected current staffing needs. The Facility Assessment, updated 03/26/2026, stated the staffing plan included one licensed nurse on night shift for Harmony Manor and one licensed nurse on night shift for Quail Corner, and that consistent staffing would be prioritized in the memory care unit, with staffing levels not adjusted for low census or low acuity so resident needs would be met during call-ins and other staffing shortages. However, the April 2026 staffing schedule showed Quail Corner and Harmony Manor sharing a licensed nurse during night shift on multiple nights. During an interview on 04/24/2026, the DON stated that on Saturday, Sunday, Monday, and Tuesday nights, both units shared one licensed nurse during night shift, and that the nurse was responsible for all 32 residents in the facility. The DON confirmed the Facility Assessment indicated each unit required a licensed nurse during night shift and stated the Facility Assessment needed to be updated to reflect the staffing schedule.
Unsanitary Kitchen Floor Drain
Penalty
Summary
The facility failed to ensure staff maintained sanitary floor drains in the kitchen. On 04/20/2026 at approximately 10:45 AM, a kitchen floor drain was observed with a buildup of debris and grime. At approximately 10:50 AM the same day, the Kitchen Manager confirmed the drain had buildup of grime and acknowledged the potential spread of contamination, and stated that cleaning of the floor was the responsibility of the Maintenance Department. On 04/23/2026 at approximately 9:15 AM, the Maintenance Manager confirmed the kitchen floor drain had not been recently cleaned, was not sanitary, and acknowledged the potential spread of contamination. The facility policy titled, Maintenance of Strict Sanitary Conditions, dated 07/12/2022 and reviewed 07/08/2024, stated that maintaining strict sanitary conditions was of paramount importance in the Dietary and Nutrition Departments to eliminate food contamination and prevent growth of disease producing organisms, and to ensure maximum cleanliness and sanitation in the department.
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