Powder River Manor

In the surveyor’s words

From the most serious findings on record at Powder River Manor, in the surveyor’s own words.

• Immediate jeopardy, patternF689Mar 2, 2023

  Based on observation, interview, and record review, the facility failed to have a proactive beneficial system in place for the prevention of falls for all residents, to include specifically those at heightened risk of falls, due to their past history of recurring falls, and: - failed to identify the direct root causes of falls for the implementation of individualized interventions; - failed to assess fall events and details comprehensively and ensure fall documentation was in place and consistent across disciplines; - failed to ensure staff had the necessary tools and knowledge to provide fall prevention interventions on an ongoing daily basis; - failed to ensure resident care plans were updated with interventions related to fall safety and address the resident's current medical,… […]

• Actual harm, patternF657Mar 2, 2023

  Based on observation, interview, and record review, the facility failed to revise interventions on the resident's plan of care after multiple falls for 8 (#s 4, 6, 7, 8, 9, 17, 19, and 22) of 8 sampled residents. This deficient practice affected half of the facility resident population, and had the potential to further increase the risk of falls, with or without injury, for the vulnerable or non vulnerable residents, and act proactively for preventing the falls vs being reactive and responding to the falls. Findings include: Refer to F689 - Free of Accident Hazards/supervision/devices for detailed fall information. 1. Review of resident #22's Brief Interview for Mental Status exam, dated 5/7/22, showed she scored a 0, for severe cognitive impairment. […]

• Actual harm, isolatedF726Mar 13, 2025

  Based 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. […]

• Actual harm, isolatedF686Mar 14, 2024

  Based 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. Findings include: During an observation and interview on 3/12/24 at 2:10 p.m., resident #4 was seated in a recliner in her room, leaning toward the left arm of the chair. A pressure relieving chair pad was observed on the chair. An air mattress was observed on resident #4's bed. Resident #4 stated she had a butt sore, which made it hard to sit up straight in the chair. Resident #4 stated, I got that new (air) mattress on the bed and this (pressure relieving chair pad) thing not too long ago, but I don't think they are helping much. […]

• No harm, potential for more than minimal, widespreadF880Mar 13, 2025

  Based 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. Findings include: 1. During an observation on 3/11/25 at 3:58 p.m., staff member E and F were toileting resident #18, using the sit-to-stand lift. […]