Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Powder River Manor during CMS and state inspections, most recent first.
The facility failed to protect residents from abuse when one resident without capacity to consent was found in a common area with another resident’s hand inside her brief, and the subsequent investigation did not include interviewing or assessing other residents who might have been affected. In a separate event, a resident shook his spouse’s head and later sprayed water in her face with a spray bottle when she was tired at dinner, causing her agitation, while both continued to share a room and she spent most of her time and slept in common areas due to ongoing behaviors between them, as reflected in her care plan.
Survey results completed by the State Survey Agency were not available in the designated, publicly accessible area. Observations found the labeled file holder empty on multiple occasions, and staff interviews revealed unawareness of the binder's location or absence.
A resident's POLST form was found incomplete, missing both the responsible party's and provider's signatures, as well as the date and provider's printed name. The form, which indicated No CPR and selective treatment, was not valid according to facility policy and state requirements, and staff could not explain why it was not properly completed.
A resident sustained a partial thickness facial burn after a CNA, without proper authorization or supervision, applied a hydrocollator heat pack to the resident's face for dental pain and left it on for 30-40 minutes without monitoring. Staff interviews revealed inconsistent training and understanding of heat pack use, and documentation failed to show appropriate assessment or monitoring before, during, or after the application.
A resident sustained a second-degree facial burn from a heat pack, resulting in pain, redness, swelling, and blistering. Staff observations and medical records documented the severity of the injury and the need for treatment, but the facility's reports to the State Survey Agency understated the extent of the injury and omitted key details, failing to provide accurate documentation of the event and investigative findings.
The facility failed to report and investigate allegations of neglect involving two residents. One resident was left unattended in a room without a call light, while another was found in a heavily saturated brief with a dried bowel movement. Staff members reported these incidents, but no action was taken due to a personal friendship between the involved staff members. The facility's policy requires such allegations to be reported and investigated, but this was not done, resulting in a deficiency.
Failure to Protect Residents From Sexual and Physical Abuse by Other Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, including sexual and physical abuse, by other residents. In one incident, a resident without capacity to consent was found in a common area with another resident’s hand inside her brief up to the wrist. Staff immediately separated the residents, and the incident was reported to the State Survey Agency; however, the facility’s investigation did not include interviewing or assessing other residents who might have been present or potentially affected by similar sexual abuse incidents. A staff member also reported that the incident was initially reported under the wrong license type because they were unaware the facility held both an adult day care and a skilled nursing facility license. In a separate incident, a resident became upset with his spouse, also a resident, during dinner and shook her head to wake her, then later sprayed water in her face with a spray bottle after staff had intervened and moved her to the nurses’ station. The spouse became agitated by these actions. Observations showed that the couple continued to share a room, with both residents’ nameplates and belongings present. Staff interviews indicated that the spouse who was the target of the behavior was usually kept out of the room and spent most of her time and slept in common areas or by the nurses’ station due to ongoing behaviors between the two. The care plan for the spouse reflected that she was not to be in the room when her husband was present unless both wanted to be there, and staff were to intervene if yelling occurred, based on the prior incident of head shaking and use of the spray bottle.
Survey Results Not Publicly Accessible
Penalty
Summary
The facility failed to ensure that the results of surveys completed by the State Survey Agency were readily available and located in a publicly accessible area. During observations on two separate occasions, the wall-mounted file holder labeled 'SURVEY RESULTS' at the facility's entrance did not contain any binder or documents for viewing. Staff interviews confirmed that the binder with survey results was not present in the designated holder, and staff were unaware of its location or why it had not been returned. This lack of accessible survey results would affect any person wishing to view them.
Incomplete POLST Form Lacking Required Signatures and Provider Information
Penalty
Summary
The facility failed to ensure that a completed Physician Orders for Life-Sustaining Treatment (POLST) form was readily accessible and properly executed for one of five sampled residents. During record review, it was found that the resident's POLST form indicated selections for No CPR and selective treatment, and was filled out by the resident's responsible party. However, the form was missing the responsible party's signature, the provider's signature, the date, and the printed name of the provider. This incomplete documentation meant the POLST was not valid according to facility policy and state requirements. During an interview, a staff member stated that admission forms, including POLST forms, are typically reviewed by staff, the resident, or the responsible party, and sometimes provided to the responsible party to complete before admission. The staff member was unable to explain why the POLST for this resident was not fully completed with all required signatures and information. Facility policy and provided guidance clearly require both the provider's and the legal decision-maker's signatures for the POLST to be valid.
Resident Burn Injury Due to Improper Heat Pack Application and Inadequate Staff Supervision
Penalty
Summary
Nursing and nurse aide staff failed to perform care within their scope of practice, did not provide sufficient supervision, and did not conduct adequate pain assessment or monitoring during the application of a heat pack for one resident. A certified nursing assistant (CNA) obtained a hydrocollator heat pack from the physical therapy department without permission and applied it to a resident's face for dental pain. The CNA left the heat pack on for 30-40 minutes without monitoring, resulting in redness and subsequent blistering on the resident's face. The CNA reported the redness to a nurse but did not recognize the severity of the injury until the following day, when blistering was observed and reported to the nurse on duty. Interviews revealed inconsistent staff understanding and training regarding the use of heat packs, with some staff stating that only therapy or charge nurses were permitted to use the hydrocollator, while others reported that CNAs occasionally used heat packs. The facility's policy specified that only physical therapy, occupational therapy, or charge nurses were allowed to use the hydrocollator and moist heat packs. Nursing progress notes did not document any assessment, application, monitoring, or follow-up for the heat pack application on the day of the incident, and there was no evidence of pain assessment or prn medication request prior to the injury.
Failure to Accurately Document and Report Resident Burn Incident
Penalty
Summary
The facility failed to accurately document and report an incident involving a resident who sustained a facial burn due to the application of a heat pack. The resident reported experiencing pain and visible injury, including redness, inflammation, and blistering from the left cheek to the jawline. Multiple staff interviews confirmed the presence of significant redness, blistering, and swelling, with one staff member initially suspecting shingles due to the severity of the injury. Nursing progress notes and the resident's electronic medical record documented the use of topical aloe vera and an order for oral antibiotics, as well as ongoing pain and swelling. Despite these findings, the facility's report to the State Survey Agency minimized the extent of the injury, describing it as a red area with no need for medical treatment and only a couple of small blisters. The facility's investigative findings submitted to the agency also understated the injury, failing to accurately reflect the documented clinical observations and the need for treatment. This discrepancy between the actual condition and the reported information constitutes a failure to provide accurate documentation of the event and the facility's investigative findings, as required by facility policy.
Failure to Report and Investigate Allegations of Neglect
Penalty
Summary
The facility failed to report allegations of neglect involving two residents to the administrator and State Survey Agency within the required timelines. Staff member B witnessed staff member H pushing a resident down the hall and leaving him unattended in his room without a call light, leading to the resident yelling for help. Staff member G, who was working with staff member H, confirmed the incident and reported it to staff member I, expecting an investigation. However, no action was taken, and the incident was not reported to the proper authorities. Additionally, staff member J reported finding another resident in a heavily saturated brief with a dried bowel movement, indicating neglect during staff member H's shift. This incident was also reported to the nurse on duty but was not escalated further. The facility's policy on abuse prevention and reporting requires all allegations of neglect to be investigated and reported to the proper authorities. However, staff members A and K indicated that complaints about staff member H were referred back to staff member I, who failed to act due to a personal friendship with staff member H. Staff member A was unaware of the incidents until the survey identified them and noted that staff member I did not maintain any documentation related to the incidents. The facility's failure to report and investigate these allegations of neglect resulted in a deficiency being cited during the survey.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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