CMS Inspection Results for POWDER RIVER MANOR

The Center for Medicare & Medcaid Services (CMS) contracts with each state to conduct inspections once every 9-15 months to assure that certified facilities meet the minimum Medicare and Medicaid quality and performance standards.

• 05/15/2008 Health Survey for POWDER RIVER MANOR

Pharmacy Service
Deficiency	Scope	Level of Harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Pattern	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make a complete assessment that covers all questions for areas that are listed in official regulations.	Isolated	Minimal harm or potential for actual harm
Develop a complete care plan that meets all of a resident's needs, with timetables and actions that can be measured.	Isolated	Minimal harm or potential for actual harm

 

• 05/12/2008 Fire Safety Survey for POWDER RIVER MANOR

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Potential for minimal harm
automatic sprinkler systems that have been maintained in working order.	Pattern	Potential for minimal harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
Exits and Egress
Deficiency	Scope	Level of Harm
exits that are accessible at all times.	Pattern	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved back-up procedure for a faulty fire alarm system.	Widespread	Potential for minimal harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
exits that are free from obstructions and can be used at all times.	Isolated	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
Interior Finish
Deficiency	Scope	Level of Harm
fire-resistant interior walls.	Isolated	Minimal harm or potential for actual harm

 

• 04/18/2007 Health Survey for POWDER RIVER MANOR

Mistreatment
Deficiency	Scope	Level of Harm
Write and use policies that forbid mistreatment, neglect and abuse of residents and theft of residents' property.	Widespread	Potential for minimal harm
Pharmacy Service
Deficiency	Scope	Level of Harm
At least once a month, have a licensed pharmacist check the drugs that each resident takes.	Widespread	Minimal harm or potential for actual harm
Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%.	Pattern	Minimal harm or potential for actual harm
Have drugs and other similar products available, which are needed every day and in emergencies, and give them out properly.	Pattern	Minimal harm or potential for actual harm
1) Make sure that residents who take drugs are not given too many doses or for too long; 2) make sure that the use of drugs is carefully watched; or 3) stop or change drugs that cause unwanted effects.	Isolated	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm
Resident Assessment
Deficiency	Scope	Level of Harm
Make a complete assessment that covers all questions for areas that are listed in official regulations.	Pattern	Minimal harm or potential for actual harm
Resident Rights
Deficiency	Scope	Level of Harm
Provide proof that all residents' personal money which is deposited with the nursing home, is secure.	Widespread	Potential for minimal harm

 

• 04/17/2007 Fire Safety Survey for POWDER RIVER MANOR

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
back-up procedures in place for a faulty automatic sprinkler system.	Widespread	Potential for minimal harm
automatic sprinkler systems that have been maintained in working order.	Pattern	Potential for minimal harm
portable fire extinguishers.	Pattern	Potential for minimal harm
Building Service Equipment
Deficiency	Scope	Level of Harm
properly protected cooking facilities.	Pattern	Potential for minimal harm
Electrical
Deficiency	Scope	Level of Harm
weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
properly installed electrical wiring and equipment.	Pattern	Potential for minimal harm
a separate and independent backup electrical power source.	Pattern	Potential for minimal harm
Exits and Egress
Deficiency	Scope	Level of Harm
corridors or aisles that are unobstructed and are at least 8 feet in width.	Pattern	Potential for minimal harm
Fire Alarm Systems
Deficiency	Scope	Level of Harm
an approved back-up procedure for a faulty fire alarm system.	Widespread	Potential for minimal harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Pattern	Minimal harm or potential for actual harm
Vertical Openings
Deficiency	Scope	Level of Harm
exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detectors.	Isolated	Minimal harm or potential for actual harm

 

• 04/05/2006 Health Survey for POWDER RIVER MANOR

Environmental
Deficiency	Scope	Level of Harm
Have a program to keep infection from spreading.	Widespread	Minimal harm or potential for actual harm
Provide needed housekeeping and maintenance.	Pattern	Minimal harm or potential for actual harm
Mistreatment
Deficiency	Scope	Level of Harm
1) Hire only people who have no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents.	Isolated	Minimal harm or potential for actual harm
Nutrition and Dietary
Deficiency	Scope	Level of Harm
Store, cook, and give out food in a safe and clean way.	Widespread	Minimal harm or potential for actual harm
Quality Care
Deficiency	Scope	Level of Harm
Give professional services that meet a professional standard of quality.	Pattern	Minimal harm or potential for actual harm

 

• 04/05/2006 Fire Safety Survey for POWDER RIVER MANOR

Automatic Sprinkler Systems
Deficiency	Scope	Level of Harm
an approved automatic sprinkler system connected to the fire alarm system.	Isolated	Minimal harm or potential for actual harm
have an adequate water supply for the sprinkler system.	Isolated	Minimal harm or potential for actual harm
automatic sprinkler systems that have been maintained in working order.	Widespread	Potential for minimal harm
Building Contruction
Deficiency	Scope	Level of Harm
approved construction type or materials.	Pattern	Potential for minimal harm
Building Service Equipment
Deficiency	Scope	Level of Harm
properly protected cooking facilities.	Pattern	Minimal harm or potential for actual harm
Electrical
Deficiency	Scope	Level of Harm
properly installed electrical wiring and equipment.	Pattern	Minimal harm or potential for actual harm
weekly inspections and monthly testing of generators.	Widespread	Potential for minimal harm
Emergency Plans and Fire Drills
Deficiency	Scope	Level of Harm
record of quarterly fire drills for each shift under varying conditions.	Widespread	Potential for minimal harm
Furnishings and Decorations
Deficiency	Scope	Level of Harm
restrictions on the use of flammable curtains.	Pattern	Minimal harm or potential for actual harm
Hazardous Area
Deficiency	Scope	Level of Harm
construction that can resist fire for one hour or an approved fire extinguishing system.	Isolated	Minimal harm or potential for actual harm
Medical Gases and Anesthetizing Areas
Deficiency	Scope	Level of Harm
proper medical gas storage and administration areas.	Isolated	Minimal harm or potential for actual harm
Smoke Compartmentation and Control
Deficiency	Scope	Level of Harm
proper construction of ducts through walls designed to prevent smoke passage.	Pattern	Minimal harm or potential for actual harm
Smoking Regulations
Deficiency	Scope	Level of Harm
posted No-smoking signs in areas where smoking is not permitted or did not provide ashtrays where smoking was allowed.	Pattern	Potential for minimal harm