Powder River Manor

Inspectors wroteBased on observation and interview, the facility failed to label, date, and store food in a manner to maintain food safety and prevent foodborne illness by failing to ensure all open items were dated. This deficient practice had the potential to affect all residents who ate at the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect from sexual abuse 1 (#13) by resident #4; and failed to protect from physical abuse 1 (#5) by resident #8 of 12 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accuracy of MDS assessments for 2 (#s 1 and 7) of 12 sampled residents. Resident #1 had a history of pneumonia and resident #7 had limited range of motion to her left arm and shoulder. These were not accurately shown in the resident's MDS assessments. The deficient practice had the potential to affect resident care as the resident's current status was inaccurately documented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure direct care staff were aware of a resident's wandering behaviors and the need to increase monitoring when the weather warmed up for 1 (#6) of 12 sampled residents. This deficient practice increased the risk the resident would leave the facility unaccompanied.

Inspectors wroteBased on observation and interview, the facility failed to ensure readily available results of surveys completed by the State Survey Agency were located in a publicly accessible area. This failure would affect any person wishing to view the survey results.

Inspectors wroteBased on interview and record review, the facility failed to ensure a completed POLST form with physician signature was readily accessible in the hard chart and the electronic medical record for 1 (#5) of 5 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff were performing cares within their scope of practice; failed to ensure sufficient supervision; and failed to ensure nursing staff performed adequate pain assessment and ongoing monitoring for the application of a heat pack for 1 (#9) of 16 sampled residents. The facility's failures resulted in the development of a partial thickness facial burn for one resident and increased the risk of serious injuries for any resident in need of heat pack application.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure proper hand hygiene was used for 3 (#s 5, 12, and 18); failed to ensure clean medical equipment (lifts) between resident uses for 2 (#s 12 and 18); failed to properly clean blood glucose monitor for 1 (#5); failed to provide effective education related to enhanced barrier precautions (EBP) throughout the facility, and failed to implement the appropriate use of enhanced barrier precautions (EBP) for 1 (#9) of 16 sampled residents. The deficient practices increases the risks of infection for all residents receiving care within the facility.

Inspectors wroteBased on observations and interviews, the facility failed to ensure opened facility-wide use medications were labeled with an expiration date when stored in the medication cart; and expired products in the medication room were disposed of. This deficient practice increased the risk of adversely affecting any resident who was taking these medications or using an inaccurately calibrated glucose monitor.

Inspectors wroteBased on interview and record review, the facility failed to accurately document an event sent to the State Survey Agency regarding a resident-sustained facial burn and the resident had pain, due to the application of a heat pack, and failed to provide accurate documentation of the facility's investigative findings, for 1 (#9) of 16 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement equal practices during the admission process, by failing to complete admissions on residents entering the facility for respite care for 1 (#77) of 16 sampled residents. This deficient practice placed residents at risk for staff providing effective, person-centered care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to complete a baseline care plan for 1 (#77) of 16 sampled residents. This deficient practice put the resident at risk for bedside staff to be unaware of resident care needs and providing effective, person-centered care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to complete timely revisions to comprehensive fall care plans for 1 (#18) of 16 sampled residents. The failure to update the fall care plan caused staff confusion and increased the risk of additional falls resulting in injuries.

Inspectors wroteBased on observation, interview, and record review, facility staff failed to uphold professional standards by not following the physician orders to check the wanderguard function daily, for 1 (#20) of 16 sampled residents. The failure increased the risk for elopement and serious harm to the resident.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure fall interventions were followed by staff for 1 (#18); and failed to ensure staff followed needle safety techniques for 1 (#5) of 16 sampled residents. These deficient practices placed the resident at risk for increased falls for #18 and staff needle injuries. 1. During an observation on 3/11/25 at 7:32 a.m., resident #18 was in his bed wearing white crew socks, not non-skid socks. There were no grip strips on floors, the bedside table next to his bed, and the door to the hallway was closed. The ghost alarm (motion alarm) was turned off. No Falling Star magnet (visual tool for staff to know when a resident had frequent falls) was on the door. During an observations on 3/11/25 from 12:09 p.m. through 3:20 p.m., resident #18 was in his wheelchair without foot rests, by nurses' station, slumped over. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident in respiratory distress, who was coughing and unable to breathe, and afraid he was dying due to it, was provided respiratory care and assessed as needed, for 1 (#23) of 16 sampled residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure medication error rates were under 5% for 2 (#s 9 and 13) of 6 sampled residents for medication errors. The calculated medication error rate was 7.69%.

Inspectors wroteBased on interview and record review, the facility failed to provide COVID-19 vaccinations for residents requesting the vaccine for 2 (#s 9 and 10) of 5 residents sampled for vaccinations. This deficient practice increased the risk of COVID-19 infections for residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to ensure all allegations of neglect by staff were reported to the administrator and State Survey Agency within the required timelines for 2 (#s 1 and 4) of 7 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent the development and progression of a pressure wound, for 1 (#4) of 1 sampled resident with a Stage 3 sacral pressure wound.

Inspectors wroteBased on interview and record review, the facility failed to have an RN working at least eight consecutive hours per twenty-four-hour period, seven days per week. This deficient practice had the potential to affect all residents who received nursing services.

Inspectors wroteBased on observation and interview, the facility failed to maintain a safe environment free from chemicals for the residents. This deficient practice had the potential to adversely affect the well-being and safety of residents in the facility.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan, for residents receiving anticoagulant medication for 3 (#s 9, 18, and 22), and a resident receiving psychotropic medications for 2 (#s 10 and 22) of 20 sampled residents.

Inspectors wroteBased on interview and record review, the facility failed to meet professional standards of practice for the prevention, treatment, and documentation of pressure wounds for 1 (#4) of 1 sampled resident with a pressure wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications, failed to evaluate the medication effects, and failed to obtain consent for psychotropic medication use for 1 (#22) of 20 sampled. This deficient practice had the potential to adversely affect a resident's ability with maintaining highest practicable level of well-being.