Power County Skilled Nursing Facility

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure nurse staffing information was accurate and posted daily for each shift. This failed practice had the potential to affect all residents residing in the facility and their representatives, visitors, and others who wanted to review the facility's staffing levels.

Inspectors wroteBased on observation, interview, policy review, and review of the U.S. Food and Drug Administration 2022 Food Code, the facility failed to appropriately store, distribute, label foods, and clean cookware appropriately. This deficient practice had the potential to affect all residents who received meals prepared in the facility's kitchen. This placed residents at risk for potential contamination and use of spoiled foods, and adverse health outcomes including food-borne illnesses.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure controlled medications were tracked and kept secure from potential theft and/or diversion. This was true for 1of 1medication carts audited. This failure created the potential for undetected misuse and/or diversion of controlled medications and had the potential to affect all residents who received controlled medication in the facility.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control prevention practices were maintained to provide a safe and sanitary environment. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure residents were treated with dignity. This was true for 1 of 1 resident (Resident #3) reviewed for foley catheters. This deficient practice placed Resident #3 at risk of embarrassment and diminished sense of worth.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a written notice of transfer and bed hold policy was provided to the resident or their representative when residents were transferred to the hospital. This was true for 1 of 1 resident (Resident #4) reviewed for transfers. This deficient practice created the potential for psychosocial distress if residents and their representatives were not made aware of or able to exercise their rights related to transfers from the facility.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident's care plans were revised to reflect resident current code status. This was true for 1 of 2 residents (Resident #4) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed.

Inspectors wroteBased on observation, record review, and interview, it was determined the facility failed to ensure physician's orders were followed. This was true for 1 of 2 residents (Resident #11) whose physician's orders were reviewed. This had the potential for adverse effects and possible harm to resident's medical and physical status.

Inspectors wroteBased on staff interview and review of employee personnel files, it was determined the facility failed to ensure each CNA's annual performance reviews were completed at least once every 12 months for 3 of 3 CNAs (#2, #3, and #4) whose personnel records were reviewed for sufficient and competent CNA staffing. This failure created the potential for incompetent CNAs providing care and increased the risk for harm for all residents living in the facility.

Inspectors wroteBased on observation, interview, and U.S. Food and Drug Administration 2022 Food Code review, the facility failed to ensure garbage cans were properly closed with lids to minimize attracting pests and rodents into the kitchen. This deficient practice had the potential to affect all residents and staff in the facility.

Inspectors wrote5. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension. Resident #1's Quarterly MDS assessment, dated 1/20/25 was transmitted to the CMS database. but her Quarterly MDS assessment with ARD of 4/22/25 was not transmitted, it was 23 days overdue. 6. Resident #6 was admitted to the facility on [DATE], with multiple diagnoses including Huntington's disease (a neurological disorder that affects a person's movements, thinking ability, and mental health, with symptoms often including chorea, which are rapid, involuntary movements of the limbs and face). Resident #6's Quarterly MDS assessment, dated 1/23/25 was transmitted to CMS database, but her Quarterly MDS assessment with ARD of 4/25/25 was not completed, it was 20 days overdue. 7. Resident #13 was admitted to the facility on [DATE], with multiple diagnoses including dementia. [...]

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure person-centered comprehensive care plans were developed and implemented to address residents' needs. This was true for 6 of 12 residents (#1, #2, #9, #11, #15, and #120) whose care plans were reviewed. This failure created the potential for harm should residents receive inappropriate or inadequate care.

Inspectors wroteBased on staff interview, it was determined the facility failed to ensure there was a qualified dietary manager with required competencies and skills. This deficient practice had the potential to affect all the 20 residents residing in the facility who received food from the kitchen.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure kitchen staff wear their hair restraints appropriately and discard outdated food items in the kitchen. These deficiencies had the potential to affect the 20 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food borne illnesses.

Inspectors wroteBased on facility document review, and staff interview, it was determined the facility failed to ensure the Quality Assessment and Assurance (QAA) committee took actions to identify and resolve systemic problems. This failure affected 20 of 20 residents residing in the facility. The deficient practice resulted in failure to report resident assessments and comprehensive care planning which had the potential for adverse outcomes when residents' needs were not identified.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure residents' assessments accurately reflect their status. This was true 4 of 12 residents (#2, #11, #16, and #17) whose bedrails were assesed as a restraint. This created the risk for harm when residents' were not accurately assessed.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure resident's right to privacy was maintained during cares. This was true for 1 of 1 resident (Resident #6) observed during cares. This deficient practice placed Resident #6 to experience embarrassment and psychosocial distress if her body was exposed to others unnecessarily.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure residents' care plans were revised and updated as needed. This was true for 1 of 12 residents (Resident #16) whose care plan was reviewed. This created the potential for Resident #16 to experience harm if cares and services were not provided appropriately due to inaccurate information in his care plan.

Inspectors wroteBased on record review, and staff and resident interview, it was determined the facility failed to ensure professional standards of care were followed for 1 of 12 residents (Resident #69) reviewed for quality of care. Resident #69's physician's order was to restrict his fluid intake to 1,500 ml was not followed. This deficient practice had the potential to adversely affect or harm Resident #69 when his fluid intake was not restricted or monitored.

Inspectors wrote3. Resident #1 was admitted to the facility on [DATE], with multiple diagnoses including dementia and hypertension. On 5/28/25 at 10:40 AM, Resident #1 was observed in bed with one side rail in raised position. Resident #1's Side Rails Assessment form, dated 10/10/22, documented the following assessment/questions and next to it was Yes and No column: 1. Will side rails be used to improve mobility? 2. Will side rails be used to improve independence? 3. Will resident be able to use the bed controls? 4. Will the side rails in good working order? 5. Are the side rails installed correctly and safely? 6. Does the resident request the side rails are up when they are in bed? 7. Is there any potential or risk of the resident their extremities caught in the side rails? 8. They have been assessed and are safe to be used with this resident? 9. [...]

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure pharmacist recommendation was addressed by the physician. This was true for 1 of 5 residents (Resident #2) whose medications were reviewed. This failure created the potential for Resident #2 to receive medications that were unnecessary, ineffective, or used in excessive duration.

Inspectors wroteBased on record review and staff interview it was determined the facility failed to ensure residents were properly assessed for anticoagulants. This was true for 1 of 5 residents (Resident #9) whose records were reviewed for unnecessary medications. This failed practice created the potential for harm when Resident #9 was not assessed for bleeding.

Inspectors wroteBased on review of Incidents and Accidents reports, and staff interview, it was determined the facility failed to ensure residents were free from significant medication errors. This affected 2 of 2 residents (#11 and #14) whose records were reviewed for medication error. This failure placed Resident #11 at risk for hypoglycemic episodes and even death and Resident #14 to experienced uncontrolled pain.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure medications available for residents were removed from the medication cart on expiration date. This was true for 1 of 1 medication carts inspected. This failure created the potential for residents to receive expired medications with decreased efficacy.

Inspectors wroteBased on resident interview, and staff interview, it was determined the facility failed to ensure rehabilitative services were provided. This was true for 1 of 1 resident (Resident #14) whose records were reviewed for rehabilitative services. This failure created the potential for poor quality of life and declined ability to perform activities of daily living. Findings Include: Resident #14 was admitted to the facility on [DATE], with multiple diagnoses including age-related osteoporosis and pathological fractures. A physician's order dated March 2025, documented Resident #14 was to be evaluated and treated for a wheelchair. On 5/27/25 at 11:22 AM, Resident #14 stated she has been waiting for physical therapy to get her a wheelchair that fits appropriately but they keep telling her its being ordered. On 5/27/25 at 11:28AM, Resident #14 was observed sitting in her wheelchair. [...]

Inspectors wroteBased on observation and staff interview it was determined the facility failed to ensure appropriate infection control measures were maintained. This was true for 1 of 1 resident (Resident #119) when LPN #3 failed to apply personal protective equipment while administering a nasal medication to Resident #119 who tested positive for methicillin-resistant staphylococcus aureus (MRSA - a bacterial infection). This failed practice created the potential for adverse outcomes including infection due to cross contamination.

Inspectors wroteBased on record review and staff interview, it was determined the facility failed to ensure pneumococcal immunizations were offered and administered with the current CDC recommendation. This was true for 1 of 5 residents (Resident #9) reviewed for pneumococcal immunizations. This failure increased Resident #9's risk for contacting pneumonia with potential negative outcome. The CDC website's article titled Pneumococcal Vaccine Recommendation, dated 10/26/24 and accessed on 6/2/25, documented for routine vaccination, administer PCV15, PCV20, or PCV21 for all adults 50 years or older. - Who have never received any pneumococcal conjugate vaccine. - Whose previous vaccination history was unknown. If PCV 15 is used, administer a dose of PPSV23 one year later. Their vaccination is complete. If PCV20 or PCV 21 was used, a dose of PPSV 23 is not indicated. [...]

Inspectors wroteBased on resident and staff interview, review of grievances, and record review, it was determined the facility failed to ensure: - Residents were notified individually or through postings in the facility of how to file a grievance. - A functional process for filing a grievance anonymously was in place. - Residents received written responses to grievances which included the date the grievance was received, steps taken to investigate the grievance, and corrective action taken to resolve the grievance. This was true for 1 of 20 residents (Resident #3) interviewed regarding grievances and had the potential to impact all residents in the facility who may want to file a grievance. These failures impeded the ability of residents to file a grievance and to receive a resolution.

Inspectors wroteBased on staff interview, it was determined that the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of food and nutrition services, including resident assessments, individual plans of care and the number, acuity, and diagnoses of the facility's resident population. These deficiencies had the potential to affect the 20 residents requiring medical nutrition therapy, initial nutritional assessments, and appropriate supplementation and dietary interventions.

Inspectors wroteBased on observation and staff interview, it was determined the facility failed to ensure the kitchen equipment and environment was maintained, appropriate hand hygiene was performed, and food was stored in a safe and sanitary manner. These deficiencies had the potential to affect the 20 residents residing in the facility who consumed food prepared by the facility. This placed residents at risk for potential contamination of food and adverse health outcomes, including food-borne illnesses.

Inspectors wroteBased on policy review and staff interview, it was determined the facility failed to meet the minimum member requirement of a quality assurance and performance improvement (QAPI) committee. This failure placed all residents at risk of not receiving quality care.

Inspectors wroteBased on observations and interviews, it was determined that the facility failed to treat each resident with respect and dignity that promoted enhancement of his/her quality of life and dining experience. This was true for 2 of 13 residents (Resident #8 and Resident #9) who were observed eating in the dining room.

Inspectors wroteBased on policy review, observation, record review, and staff interview, it was determined the facility failed to ensure whether a resident had the ability to self-administer medications for 1 of 1 resident (Resident #14), reviewed for self-administration of medications. This failure created the potential for adverse effects if medications were self-administered inappropriately by the resident.

Inspectors wroteBased on record review, policy review, and staff interview, it was determined the facility failed to ensure a notices of transfer was provided to the State Long Term Care Ombudsman when transferred to the hospital. This was true for 1 of 1 resident (Resident #8) whose record was reviewed for hospital transfer. This deficient practice had the potential for harm if residents were not aware of or able to exercise their rights.

Inspectors wroteBased on staff interview, record review, and policy review, it was determined the facility failed to ensure an annual comprehensive MDS assessment was completed prior to the required completion date. This was true for 1 of 4 residents (Resident #4), whose records were reviewed for MDS accuracy. The deficient practice placed Resident #4 at risk of adverse outcomes if her preferences, goals, health status, and needs were not identified in the comprehensive MDS assessment. This failure created the potential for harm if Resident #4's care was not provided due to a delay in completion of the comprehensive MDS assessment.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to develop and implement comprehensive resident-centered care plans. This was true for 5 of 13 residents (#1, #3, #6, #14, and #17) whose care plans were reviewed. These failures placed residents at risk of negative outcomes if services were not provided, or provided incorrectly, due to lack of information in their care plan.

Inspectors wroteBased on observation, record review, policy review, and staff interview, it was determined the facility failed to ensure resident care plans were revised to reflect current needs and interventions. This was true for 3 of 13 residents (Resident #6, #15, and #17) whose care plans were reviewed. This placed residents at risk of adverse outcomes if care and services were not provided due to care plans not being revised as residents' needs changed.

Inspectors wroteBased on observation, record review, and staff interview, it was determined the facility failed to ensure CPAP use was discontinued with a physician's order. This was true for 1 of 1 resident (Resident #17) who used a CPAP machine. This failure created the potential for Resident #17 to experience increased respiratory problems if he did not receive treatment necessary to meet his respiratory needs.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure medications available for residents had not expired; this was true for 1 of 1 medication storage room inspected and 1 of 1 medication cart inspected. This failure created the potential for residents to receive expired medications with decreased efficacy.

Inspectors wroteBased on observation, policy review, and staff interview, it was determined the facility failed to ensure infection control and prevention practices were maintained to provide a safe and sanitary environment when staff did not clean resident equipment properly, store oxygen supplies in a sanitary manner, perform proper hand hygiene, or use appropriate detergent for residents' personal laundry items. These failures had the potential to impact all residents in the facility by placing them at risk for cross contamination and infection.