Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Power County Skilled Nursing Facility during CMS and state inspections, most recent first.
Incomplete Daily Nurse Staffing Postings: The facility failed to ensure daily staffing sheets were accurate and posted for each shift. Survey review found missing nurse data, CNA data, and resident census information on multiple dates, and the sheets did not document the actual hours worked by nursing staff. The DON stated the staffing sheets should have been completed correctly but were not.
Food storage, labeling, and sanitation deficiencies were observed in the kitchen. Surveyors found no handwashing sign at the sink, multiple opened food items without open dates, a skillet with encrusted black food residue, and missing refrigerator/freezer temp log entries. The FSS stated the sign had been removed and not replaced yet, and that opened foods should have been sealed and dated, temp logs completed daily, and cookware cleaned appropriately.
Controlled medications were not properly tracked because the narcotic accountability sheets in one medication cart had multiple entries without the required signatures from two nurses. During the audit, RN #1 and the DON both confirmed that two nurses should have signed the narcotic count sheets.
A facility failed to maintain infection control practices when residents in multiple rooms were served breakfast without being offered hand hygiene beforehand, despite a Dining Room policy requiring staff to encourage handwashing or sanitizing before each meal. A CNA later stated residents should have been offered hand hygiene and that staff are supposed to carry a large bottle of hand sanitizer to clean residents' hands.
A resident with a foley catheter was observed with the catheter bag hanging uncovered on the side of the bed while the room door was open. The resident had diagnoses including stroke-related hemiplegia/hemiparesis and UTI, and the care plan noted a foley catheter related to neurogenic bladder. CNA staff stated the bag should have been covered, and the DON acknowledged it was a privacy issue.
A resident with cerebral palsy and depressive disorder was transferred to the hospital, but the facility did not document completion of the required written bed hold notice for the resident or representative. The facility’s policy called for written bed hold notices at admission and again at transfer, and the SW confirmed the document was not completed.
A resident with cerebral palsy and depressive disorder had conflicting code status documentation in the medical record: the emergency care document showed full code, while the care plan listed DNR and no CPR. The DON stated the care plan was completed in error and should have been revised but had not been.
A resident with dementia and COPD had an order for continuous O2 via NC, with SpO2 to be maintained between 88% and 92% and not exceed 92%. The record showed SpO2 readings below 88% on room air and multiple readings above 92% while on supplemental O2, with no nursing interventions documented; the DON stated the resident’s SpO2 should have been better monitored and the physician’s O2 order more closely followed.
Missing Annual CNA Performance Reviews: The facility failed to complete annual performance reviews for 3 of 3 CNAs whose personnel files were reviewed. During file review, CNAs #2, #3, and #4 were found to have no performance review documentation since 2024, and the HR Director stated no CNA performance reviews had been done since 2024 because the process was being revised.
Uncovered Trash Can in Food Prep Area: A 50-gallon trash can in the food prep area was observed about half full and without a lid while not in use. The Food Service Supervisor stated she was not aware the garbage can required a lid but would get one.
The facility did not complete and transmit required MDS assessments within the mandated timeframe for several residents with complex medical conditions, resulting in overdue assessments and delayed reporting to CMS. The DON acknowledged the backlog and lack of timely reporting.
Several residents with complex medical, behavioral, and safety needs did not have individualized care plans that reflected their current conditions, physician orders, or observed behaviors. For example, residents on psychotropic medications were not monitored for side effects as required, and behaviors such as aggression, sadness, and fall risks were not documented in care plans despite being tracked elsewhere. Staff acknowledged these omissions during interviews.
The facility did not have a certified dietary manager overseeing food and nutrition services. The current dietary manager was not yet certified and was supervised by a Registered Dietitian who visited weekly, not full-time. This affected all residents receiving meals from the kitchen.
Kitchen staff did not consistently wear hair restraints as required, with one aide observed having hair exposed while working. Inspections also revealed several expired or undated food items, including syrups, tortillas, and seasonings, which remained in storage despite being past their best by or expiration dates. The dietary manager confirmed these practices did not meet food safety standards.
The QAA committee did not effectively identify or resolve systemic issues, as it lacked a method to measure or track improvements in performance improvement plans. The DON was unable to provide evidence of improved outcomes, relying only on incident counts, which led to failures in reporting resident assessments and comprehensive care planning for all residents.
Four residents were inaccurately assessed as using bedrails as restraints in their MDS documentation, despite care plans and assessments indicating the bedrails were used for mobility or independence. Staff interviews confirmed that the MDS coding did not match the actual use of bedrails, leading to inaccurate resident assessments.
A resident with Huntington's disease was exposed during wound care when an LPN left the window blinds open, resulting in a failure to maintain privacy as required. The LPN later acknowledged the oversight.
A resident with Alzheimer's disease and apraxia experienced two unwitnessed falls, after which a tab alarm was recommended and put in place for safety. Despite this intervention, the resident's care plan was not updated to include the use of the tab alarm, as confirmed by the DON during review.
A resident with SIADH and a physician-ordered fluid restriction was not properly monitored, resulting in repeated instances of fluid intake exceeding the prescribed daily limit. Despite a care plan and staff awareness of the restriction, intake records showed multiple days where the resident consumed more fluids than allowed, and the DON confirmed that monitoring was insufficient.
Three residents with complex medical histories were found to have bed rails in use without proper assessment, documentation, or informed consent as required by facility policy. Staff confirmed that assessments were either missing or incorrectly completed, and there was no evidence of quarterly reassessment or risk/benefit review with residents or their representatives.
A pharmacist recommended that a physician document the dose of citalopram for a resident with dementia, UTI, and chronic pain. The physician signed the report but did not provide the requested dosage information, and this omission was not identified by staff during a medication review meeting.
A resident receiving Apixaban and Aspirin for DVT prevention was not monitored for bruising or bleeding, as required for anticoagulant therapy. The DON confirmed that no daily assessments for bleeding were performed by licensed nurses, and the resident's record lacked documentation of monitoring for adverse outcomes.
Two residents experienced significant medication errors when a Med-Tech without documented insulin competency administered the wrong insulin to a diabetic resident, and another resident with chronic pain did not receive a prescribed dose of Oxycodone-Acetaminophen. Both incidents involved failures in verifying the MAR and following the five rights of medication administration.
A Novolog insulin pen remained in the medication cart past its expiration date and was administered by an LPN to a resident after it had expired. The expired medication was not removed from the cart as required.
A resident with osteoporosis and fractures did not receive a timely evaluation or provision of an appropriate wheelchair after a physician's order. The resident continued to use an ill-fitting wheelchair, and staff interviews revealed delays in arranging for a vendor evaluation and lack of documentation of the required assessment.
An LPN did not apply a mask or gown while administering a nasal medication to a resident on enhanced barrier precautions for MRSA, despite facility protocols requiring these PPE measures. The DON confirmed that a mask and gown should have been used.
A resident with a history of breast cancer was not offered or administered the pneumococcal vaccine according to CDC recommendations, as there was no documentation of the vaccine being offered upon admission and her immunization history was unknown. Staff only offered the vaccine months later after unsuccessful attempts to obtain her records, resulting in a deficiency related to timely and appropriate immunization practices.
A resident with dementia and anxiety reported missing laundry, but the facility failed to document the grievance or notify residents on how to file grievances. The DON and ADON were unaware of the issue, as grievances were only documented if unresolved.
The facility failed to employ sufficient staff with the necessary competencies in food and nutrition services, affecting 20 residents needing medical nutrition therapy. The DM lacked certification and an appropriate degree, and responsibilities were shared with the RD. The Food Services Manager had an engineering degree, not a nutrition-related one.
The facility failed to maintain proper hand hygiene, food storage, and cleaning practices in the kitchen. Staff did not wash hands appropriately, shelves were improperly placed on the floor, and personal food items were stored in the resident's refrigerator. Additionally, there was significant ice buildup in the freezer, dust on the refrigerator fan, and multiple food items were open and undated.
The facility did not meet the minimum member requirement for its QAPI committee because the Medical Director did not attend the meetings. This was identified during a review of the QAPI meeting minutes, and the DON confirmed the Medical Director's absence and her lack of awareness of the attendance requirement.
The facility did not provide timely meal assistance to two residents, affecting their dignity and dining experience. One resident waited 11 minutes for help with her meal, while another's tray was delayed due to random placement in the food cart. An LPN confirmed this practice, which led to the observed delays.
A resident with dementia and COPD was observed managing her oxygen supply independently without an assessment for self-administration, contrary to the facility's policy. The resident's care plan required continuous oxygen, but no evaluation for self-administration was documented, despite a previous determination that the resident was not a candidate for self-administration of medications. Staff acknowledged the oversight.
A facility failed to notify the State LTC Ombudsman of a resident's hospital transfer, as required by policy. The resident, with multiple diagnoses, was discharged to a hospital and later readmitted. The resident's record lacked documentation of the required notification. A social services employee admitted to not knowing about the notification requirement.
A facility failed to complete an annual comprehensive MDS assessment for a resident with multiple diagnoses, including shortness of breath and diabetes, before the required deadline. The DON confirmed that a quarterly assessment was submitted late, and an annual assessment was mistakenly not completed.
The facility failed to maintain comprehensive care plans for several residents, leading to potential risks. A resident with COPD was observed without oxygen, and her care plan lacked an assessment for self-administration. Another resident's dementia diagnosis was missing from her care plan. A third resident's care plan did not document side rail use, despite a preference for them. A resident with Huntington's disease was without a call light in the TV room, and her care plan did not address this need. Lastly, a resident's care plan did not reflect a hospice order for oxygen use or the discontinuation of CPAP use. The DON admitted the care plans were not updated as required.
The facility failed to update care plans for three residents, including those with Huntington's disease, Alzheimer's, and COPD, as required by their policy. The care plans were overdue for review, and the DON acknowledged the oversight, placing residents at risk of adverse outcomes.
A facility failed to obtain a physician's order to discontinue CPAP use for a resident. The resident had a physician's order for nightly CPAP use, but the MAR showed CPAP care was stopped without an order. The DON confirmed the resident no longer used CPAP and acknowledged the lack of a discontinuation order, despite discussions in an IDT meeting.
The facility failed to ensure medications were not expired, as observed in a medication storage room and cart. Expired vaccines and an Antacid liquid were found, with an LPN acknowledging the oversight and uncertainty about handling expired medications. The DON indicated that expired medications should be removed for destruction.
The facility failed to maintain infection control and prevention practices, including improper cleaning of resident equipment, inadequate hand hygiene by an LPN, and incorrect storage of oxygen supplies. Additionally, inappropriate detergent was used for residents' laundry, posing a risk of cross-contamination and infection.
Incomplete Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure nurse staffing information was accurate and posted daily for each shift. During review of the facility daily staffing sheets, the surveyor found missing nurse staffing data and census data on multiple dates, including missing resident census entries and missing nurse and CNA data for specific shifts. The daily staffing sheets also had not documented the actual hours worked by nursing staff. On 6/8/26 at 1:30 PM, the DON stated the daily staffing sheets should have been completed correctly and had not been.
Food Storage, Labeling, and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to appropriately store, distribute, label foods, and clean cookware in the kitchen. During observation on 6/8/26, the surveyor found no handwashing signage posted by the handwash sink, an opened unsealed bag of shredded cheese in the walk-in refrigerator with no open date, opened gallons of milk and Lactaid milk in the reach-in refrigerator with no opened dates, and two opened bags of chile pods in the dry food pantry with no opened dates. In the food prep area, a cleaned skillet was observed with encrusted black food on the inside. The sanitizer bucket log documented the bucket had been changed or refreshed every four hours in June 2026. The facility’s Refrigerator and Freezer temperature log was missing temperature data from June 5, 6, and 7, 2026. The facility’s policies stated opened food items are to be labeled and dated, prepared foods are to be kept covered, labeled, and dated, and refrigerator and freezer temperatures are to be recorded daily. On 6/9/26, the Food Service Supervisor stated the handwash signage had recently been removed and needed to be put back up but had not yet been, and also stated the opened food items should have been sealed correctly, labeled with the opened date, temperature logs should have been completed every day, and cookware cleaned appropriately and were not.
Incomplete Narcotic Count Documentation
Penalty
Summary
Controlled medications were not tracked and kept secure from potential theft and/or diversion because the facility failed to ensure the narcotic accountability sheets were properly signed by licensed nurses. During a medication cart audit, multiple dates were found on the narcotic accountability sheets without a documented on-coming or off-going licensed nurse signature, including several entries in late April, May, and early June. RN #1 stated that two nurses should have signed the narcotic accountability sheet and had not, and the DON also stated that two nurses should have signed off on the narcotic count sheets.
Failure to Provide Hand Hygiene Before Meals
Penalty
Summary
The facility failed to maintain infection control prevention practices to provide a safe and sanitary environment. The facility's Dining Room policy dated 1/1/24 stated staff are to encourage residents to wash hands in the sink or with a washcloth or sanitize prior to each meal. On 6/8/26 at 8:10 AM, breakfast was observed being served to residents in rooms 9, 14, 15, and 18, and the residents were not offered hand hygiene before eating their meals. On 6/8/26 at 10:14 AM, CNA #1 stated residents should have been offered hand hygiene before they ate and that staff are supposed to carry a large bottle of hand sanitizer to clean residents' hands.
Uncovered Foley Catheter Bag Observed With Door Open
Penalty
Summary
The facility failed to ensure a resident was treated with dignity when Resident #3’s foley catheter bag was observed hanging on the side of the bed without a cover while the room door was open. Resident #3 was admitted with diagnoses including hemiplegia and hemiparesis following a cerebral infarction affecting the left non-dominant side and a UTI, and his care plan documented that he had a foley catheter related to neurogenic bladder. The facility’s Promoting/Maintaining Resident Dignity policy stated that residents are to be protected and promoted in their rights and treated with respect and dignity. During interview, CNA #1 stated the catheter bag should have been covered since the door was open, and the DON stated she had never thought the catheter should have been covered in the room with the door open and acknowledged it was a privacy issue.
Failure to Provide Bed Hold Notice at Hospital Transfer
Penalty
Summary
The facility failed to ensure that a written notice of transfer and bed hold policy was provided to the resident or the resident’s representative when the resident was transferred to the hospital. The facility’s Bed Hold policy dated 2/1/18 stated that two written notices of the bed hold policy and procedures would be issued to the resident, family member, or legal representative, with the first notice given upon admission and the second notice given at the time of transfer for hospitalization. Resident #4 was admitted with multiple diagnoses including cerebral palsy and depressive disorder. Record review showed no documentation of a written bed hold form being completed when Resident #4 was transferred to the hospital on 2/23/26, and the Social Worker stated that she had not completed a bed hold document for the resident when she was transferred in February 2026 and that she should have.
Care Plan Not Updated to Match Current Code Status
Penalty
Summary
The facility failed to ensure a resident’s care plan was revised to reflect the resident’s current code status. The facility’s Care Plan policy stated that care plans would be reviewed quarterly, annually, and with a change of status to ensure they remained current. Resident #4 was admitted with multiple diagnoses including cerebral palsy and depressive disorder. The resident’s medical record contained a Plan for Emergency Care and Intensity of Treatment document showing full code status, while the resident’s care plan documented DNR status and no CPR. The DON stated that the care plan had been completed in error and should have been revised but had not been.
Failure to Follow Oxygen Orders for Resident with COPD
Penalty
Summary
The facility failed to ensure physician orders were followed for Resident #11, who was admitted with multiple diagnoses including dementia and COPD. On 6/8/26, the resident had an order for oxygen via nasal cannula continuously and twice daily for COPD, with oxygen titrated to maintain SpO2 between 88% and 92% and not to exceed 92%. The resident’s medical record showed SpO2 readings below 88% on 5/23/26 at 4:27 PM and 5/16/26 at 10:20 AM while on room air, with no interventions documented. The record also showed multiple SpO2 readings above the ordered range while the resident was on supplemental oxygen, including readings of 95% to 98% on several dates, without any nursing intervention documented. Nursing progress notes likewise documented SpO2 of 97% and 98% on 2 L NC without documented intervention. On 6/9/26, the DON stated the resident’s SpO2 should have been better monitored and the physician’s oxygen order more closely followed by staff and was not.
Missing Annual CNA Performance Reviews
Penalty
Summary
The facility failed to ensure 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. During review of CNA employee personnel files on 6/9/26 at 11:00 AM, it was observed that CNAs #2, #3, and #4 had no performance review documentation since 2024. At 11:10 AM, the HR Director stated the facility had not conducted any CNA performance reviews since 2024 because the process was being revised.
Uncovered Trash Can in Food Prep Area
Penalty
Summary
The facility failed to ensure garbage cans were properly covered in the food prep area to minimize attracting pests and rodents. Based on observation, interview, and review of the U.S. Food and Drug Administration 2022 Food Code, a 50-gallon trash can in the food prep area that was not being used was observed about half full and had no lid. The FDA Food Code Section 5-501.113 requires receptacles and waste handling units to be kept covered when inside the food establishment if they contain food residue and are not in continuous use or after they are filled. The Food Service Supervisor stated she was not aware the garbage can required a lid but would get one.
Failure to Complete and Transmit MDS Assessments Timely
Penalty
Summary
The facility failed to ensure that Minimum Data Set (MDS) assessments were completed and transmitted to the State within the required 7-day timeframe for 7 out of 9 residents reviewed. Record review, staff interviews, and reference to the RAI manual revealed that multiple MDS assessments, including Admission, Quarterly, and Annual assessments, were either not completed or not transmitted on time. The Director of Nursing (DON) confirmed that the facility was behind in reporting assessments to CMS and offered no explanation for the delays. Specific examples included residents with diagnoses such as malnutrition, seizures, dementia, bipolar disorder, and diabetes mellitus, whose MDS assessments were overdue by periods ranging from 11 to 52 days. The failure to complete and transmit these assessments as required resulted in the potential for harm and inaccuracy in identifying and addressing residents' needs, as timely assessments are necessary for proper care planning and regulatory compliance.
Failure to Develop and Implement Comprehensive, Person-Centered Care Plans
Penalty
Summary
The facility failed to develop and implement person-centered, comprehensive care plans that addressed all identified needs for several residents. For multiple residents with complex medical and behavioral histories, care plans did not reflect current physician orders, observed behaviors, or required monitoring. For example, one resident with dementia and behavioral issues was being monitored for paranoia, hallucinations, delusions, and verbal aggression, but these behaviors were not included in her care plan. Another resident with depression and chronic pain was monitored for increased sadness, excessive sleeping, and overeating, yet these behaviors and specific side effects to monitor for her antidepressant were not documented in her care plan. Additional deficiencies were noted for residents with psychiatric and neurological conditions. One resident with aphasia and on psychotropic medication was monitored for behaviors such as being snappy, short-tempered, and experiencing air hunger, but these were not included in her care plan, nor was there documentation to monitor for adverse side effects of her medication. Another resident with bipolar disorder, anxiety, and depression did not have these diagnoses or related interventions and triggers documented in her care plan, despite being a trauma survivor. The facility also failed to address physical safety and equipment use in care plans. A resident with a history of falls and a recent fall incident did not have fall prevention interventions documented or updated in the care plan following the event. Another resident who used bed rails daily did not have this use reflected in her care plan. Staff interviews confirmed that these omissions were recognized and acknowledged as deficiencies in the care planning process.
Lack of Qualified Dietary Manager
Penalty
Summary
The facility failed to employ a qualified dietary manager with the required certification and competencies to oversee the food and nutrition service. The current dietary manager had been working in the role for about five weeks but had not yet obtained certification, although she was enrolled in classes to become a certified dietary manager. The dietary manager reported being supervised by a Registered Dietitian, who was not employed full-time at the facility but visited at least once a week. This deficiency had the potential to affect all 20 residents who received food from the facility's kitchen.
Improper Hair Restraint Use and Storage of Expired Food Items in Kitchen
Penalty
Summary
Kitchen staff failed to wear hair restraints appropriately, as observed when a dietary aide was seen in the kitchen with her hair not completely restrained, leaving her bangs and hair around her face exposed. The dietary manager confirmed that the aide should have worn her hair restraint to fully cover her hair, in accordance with FDA Food Code requirements for food safety. Additionally, multiple outdated and undated food items were found during two separate kitchen inspections. These included expired Hershey syrup, taco mix, flour and corn tortillas, and undated soup base and seasoning. The dietary manager acknowledged that these items should not have been present in the kitchen and should have been discarded.
Failure of QAA Committee to Identify and Resolve Systemic Problems
Penalty
Summary
The facility failed to ensure that its Quality Assessment and Assurance (QAA) committee effectively identified and resolved systemic problems, impacting all 20 residents in the facility. Document review and staff interviews revealed that while the QAPI plan required comprehensive monitoring, evaluation, and cross-departmental involvement, the committee did not have a method to measure or track improvements in performance improvement plans (PIPs). The Director of Nursing (DON) was unable to provide evidence of improved outcomes or measurements for the PIPs, instead relying on incident counts from the prior month without a system to track progress. This deficiency resulted in failures to report resident assessments and comprehensive care planning, as required, with the potential for adverse outcomes when residents' needs were not identified.
Inaccurate Resident Assessments Related to Bedrail Use
Penalty
Summary
The facility failed to ensure that resident assessments accurately reflected the residents' status regarding the use of bedrails. For four residents, the Minimum Data Set (MDS) assessments were coded to indicate daily use of bedrails as restraints, despite documentation in care plans and side rail assessments that the bedrails were used for mobility, independence, or at the resident's discretion. In several cases, care plans and assessments noted that the bedrails were not used as restraints, and residents or their representatives were informed of the risks and had provided consent for their use. However, the MDS continued to be coded as if the bedrails were restraints. Staff interviews, including statements from the Director of Nursing (DON) and Licensed Social Worker (LSW), confirmed that the MDS coding did not accurately reflect the actual use of bedrails for these residents. The DON stated that the coding was based on daily use of the side rails, not on whether they functioned as restraints, and expressed concern about falsifying records. This inconsistency between the MDS coding and the documented purpose and use of bedrails resulted in inaccurate assessments for the affected residents.
Resident Privacy Not Maintained During Wound Care
Penalty
Summary
A deficiency occurred when a resident with Huntington's disease, who was admitted with multiple diagnoses, received wound care from an LPN while her privacy was not maintained. During the care, the resident was in bed with her shorts pulled down to her knees, exposing her periarea as she moved from her back to her side. The window blind in the room was left open throughout the procedure, allowing potential exposure. The LPN acknowledged that the blinds should have been closed before performing the wound care. This incident was observed directly by surveyors and confirmed through staff interview, demonstrating a failure to ensure the resident's right to privacy during personal care, as required by regulatory guidelines.
Failure to Update Care Plan After Fall and Implementation of Tab Alarm
Penalty
Summary
The facility failed to ensure that a resident's care plan was revised and updated as needed following significant events. A resident with Alzheimer's disease and apraxia experienced two unwitnessed falls, one of which resulted in a recommendation to implement a tab alarm for safety. Documentation showed that the tab alarm was in use after the second fall. However, review of the resident's care plan revealed that it did not include the use of a tab alarm, only instructions to leave the call button within reach. The Director of Nursing confirmed that the care plan should have been updated to reflect the addition of the tab alarm after it was implemented.
Failure to Adhere to Fluid Restriction Orders for Resident with SIADH
Penalty
Summary
A deficiency was identified when a resident with a diagnosis of Syndrome of Inappropriate Secretion of Antidiuretic Hormone (SIADH), which requires careful fluid management, was not provided care in accordance with physician orders. The resident had a physician's order for a fluid restriction of 1,500 ml per day, and the care plan specified that the kitchen would provide 1,200 ml, leaving 300 ml for other fluids. Despite these orders, the resident's fluid intake records showed that on multiple days within the review period, the resident consumed more than the prescribed 1,500 ml limit, with intake ranging from 1,510 ml to 2,220 ml on several days. Staff interviews revealed that the resident was aware of being on a fluid restriction but could not specify the allowed amount. The Director of Nursing (DON) acknowledged that the resident's fluid intake was not adequately controlled or monitored, and that closer monitoring should have been implemented to ensure compliance with the fluid restriction order. This failure to follow professional standards of care and physician orders resulted in the resident receiving more fluids than prescribed.
Failure to Properly Assess and Document Bed Rail Use
Penalty
Summary
The facility failed to properly assess residents for bed rail use, as required by its own policy and regulatory standards. Specifically, three residents with multiple diagnoses, including malnutrition, cancer, history of falls, bipolar disorder, major depressive disorder, muscle weakness, dementia, and hypertension, were observed with bed rails in use. For one resident, no documentation of a bed rail assessment or risk versus benefit review was provided upon request. Another resident's care plan allowed for bed rail use at their discretion, but the corresponding assessment was incomplete, with several required questions left unanswered or marked incorrectly, and no evidence that the resident or family had been informed of the risks. The third resident's assessment form was also improperly completed, with most questions marked 'No' or 'NA', and there was no documentation of quarterly reassessment as required by policy. Staff interviews confirmed that previous assessments were not documented correctly, and the facility was unable to provide evidence that the required risk assessments, informed consent, and ongoing evaluations were conducted for these residents. The lack of proper documentation and assessment created a situation where residents were not adequately evaluated for entrapment or other risks associated with bed rail use, contrary to facility policy and best practices.
Physician Failed to Address Pharmacist Medication Recommendation
Penalty
Summary
The facility failed to ensure that a physician addressed a pharmacist's recommendation regarding a resident's medication regimen. Specifically, for a resident with multiple diagnoses including dementia, urinary tract infection, and chronic pain, the pharmacist documented a recommendation to clarify the dose of citalopram on the Physician Action Report/Pharmacist Report form. Although the physician signed the form, they did not provide the requested information about the citalopram dosage. This omission was not identified by staff during a psychotropic medication meeting, resulting in the pharmacist's recommendation not being addressed as required by facility policy.
Failure to Monitor for Adverse Effects of Anticoagulant Therapy
Penalty
Summary
The facility failed to ensure that a resident's drug regimen was free from unnecessary drugs by not properly assessing for adverse effects related to anticoagulant therapy. A resident with multiple diagnoses, including a non-surgical wound, history of falls, and a right artificial hip joint, was prescribed Apixaban and Aspirin for DVT prevention. Despite these medications, the resident's record did not include any monitoring for bruising or bleeding, which are known potential adverse effects of anticoagulants. The Director of Nursing confirmed that there was no documentation of monitoring for adverse outcomes, and that while the physician assessed the resident every 60 days, licensed nurses did not perform daily assessments for bleeding.
Significant Medication Errors Due to Inadequate Verification and Competency
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, as evidenced by incidents involving two residents. One resident with diabetes and restless leg syndrome was administered the incorrect insulin by a Med-Tech who did not have documented competency in insulin administration. The error was discovered after the resident's blood sugar was closely monitored and various interventions were implemented to maintain safe glucose levels. The Med-Tech involved had not completed a skills check-off for insulin, and it was later acknowledged that oversight of the Med-Tech's competencies was lacking. Another resident with chronic pain, anxiety, and dementia did not receive a prescribed dose of Oxycodone-Acetaminophen as ordered for pain management. The omission was identified during a narcotic reconciliation, revealing that the resident had requested to take the medication at a later time but ultimately did not receive it. Both incidents were documented in the facility's incident and accident reports and involved failures in verifying the medication administration record (MAR) and adhering to the five rights of medication administration.
Expired Medication Administered from Medication Cart
Penalty
Summary
A medication cart inspection revealed that a Novolog insulin pen with an open date of 4/26/25 and an expiration date of 5/24/25 was still present in the cart after its expiration. During the inspection, it was confirmed by LPN #3 that the insulin pen was expired, and she acknowledged administering the expired insulin to Resident #11 earlier that morning. This indicates that the facility did not remove expired medications from availability for resident use as required.
Failure to Provide Timely Rehabilitative Services and Equipment
Penalty
Summary
The facility failed to provide specialized rehabilitative services as required for a resident with multiple diagnoses, including age-related osteoporosis and pathological fractures. A physician's order was issued for the resident to be evaluated and treated for a wheelchair, but the evaluation and provision of an appropriate wheelchair were delayed. The resident reported waiting for physical therapy to obtain a properly fitting wheelchair, and observation confirmed that the current wheelchair was not suitable, with the hand rest positioned at chest level, making it difficult for the resident to use. The physical therapist acknowledged receiving the order three weeks prior but stated that a vendor visit was delayed until there were three residents in need, although the facility could purchase a wheelchair sooner if necessary. The DON indicated that the facility could not purchase equipment for everyone and noted that the delay was attributed to physical therapy. Additionally, the LSW confirmed there was no documentation of a wheelchair evaluation for the resident.
Failure to Use Required PPE During Medication Administration for MRSA-Positive Resident
Penalty
Summary
LPN #3 failed to follow appropriate infection control measures while administering medication to Resident #119, who was on enhanced barrier precautions due to a positive MRSA nasal swab. During a medication administration observation, LPN #3 performed hand hygiene and applied gloves before entering the resident's room and administering oral medication. However, when administering a nasal medication, LPN #3 did not put on a mask or gown as required for residents on enhanced barrier precautions. The Director of Nursing confirmed that a mask and gown should have been used during the nasal medication administration.
Failure to Offer and Document Pneumococcal Immunization per CDC Guidelines
Penalty
Summary
The facility failed to ensure that pneumococcal immunizations were offered and administered in accordance with current CDC recommendations. Record review and staff interviews revealed that one resident, who was admitted with multiple diagnoses including breast cancer, did not have documentation indicating she was offered or received the pneumococcal immunization upon admission. The resident's immunization history was unknown, and although staff stated that immunizations are offered upon admission, there was no evidence in the resident's record to support that the pneumococcal vaccine was offered at that time. Staff reported that the resident was eventually offered the pneumococcal immunization several months after admission, but only after attempts to obtain her immunization history from her primary physician were unsuccessful. The lack of documentation and delay in offering the vaccine did not align with CDC guidelines, which require routine vaccination for adults of the resident's age group, especially when previous vaccination history is unknown.
Failure to Address Resident Grievances
Penalty
Summary
The facility failed to honor residents' rights to voice grievances without discrimination or reprisal, as evidenced by the lack of notification to residents on how to file a grievance and the absence of a functional process for filing grievances anonymously. Additionally, the facility did not provide written responses to grievances, detailing the date received, investigation steps, and corrective actions. This was highlighted by the case of a resident with dementia and anxiety, who reported missing laundry but was unaware of any grievance form being filled out. The facility's grievance log did not document this issue, and the Director of Nursing (DON) and Assistant Director of Nursing (ADON) were unaware of the concern, indicating that grievances were only documented if issues could not be resolved.
Insufficient Staffing in Food and Nutrition Services
Penalty
Summary
The facility failed to employ sufficient staff with the appropriate competencies and skills to carry out the functions of food and nutrition services. This deficiency was identified during staff interviews and had the potential to affect 20 residents requiring medical nutrition therapy, initial nutritional assessments, and appropriate dietary interventions. On July 10, 2024, it was noted that the documentation for the Dietary Manager (DM) certification was requested but not provided. Both the Registered Dietitian (RD) and DM admitted to sharing responsibilities for resident nutritional assessments, interventions, progress notes, and care plan development for about 18 months. It was revealed that the Food Services Manager held an engineering degree and lacked a degree in food and nutrition. Furthermore, the DM, who had worked as a kitchen aide for one year before being hired, confirmed she did not possess a DM certification or an associate degree or higher in food or nutrition services, although she planned to take the certification exam later in the year.
Deficiencies in Kitchen Hygiene and Food Storage Practices
Penalty
Summary
The facility failed to maintain proper hand hygiene practices in the kitchen, as observed during a tray-line inspection. Staff members, including the Dietary Manager (DM) and kitchen assistants, did not wash their hands between glove use, when changing tasks, or when entering the kitchen. Despite acknowledging the requirement for handwashing between these activities, the facility could not produce a specific policy on handwashing practices within the kitchen environment. Additionally, the annual handwashing safety training conducted by the facility was not specific to food services. The facility also did not adhere to proper food storage standards. During a kitchen inspection, it was observed that shelves in the dry pantry area were directly on the floor, contrary to the requirement that they be at least six inches above the floor. Items such as cherry pie filling, plastic cups, and tray liners were stored on these lower shelves. Furthermore, personal food items for a staff potluck and a personal container of food were improperly stored in the resident's nourishment refrigerator, despite the availability of a designated employee refrigerator. Cleaning and date marking practices were also found to be deficient. There was significant ice buildup in the deep freezer, and dust accumulation on the cooling fan in the refrigerator, with unboxed yogurt containers stored directly underneath. The cleaning schedule did not include the refrigerator fan. Additionally, multiple food items in the kitchen refrigerators and freezers were open and undated, including ice cream, bread, vegetables, frosting, and pies. Spice containers were also open and undated, with some dated as far back as early 2023. The DM acknowledged these issues and mentioned plans to address them, but the deficiencies remained uncorrected at the time of the inspection.
QAPI Committee Member Requirement Not Met
Penalty
Summary
The facility failed to meet the minimum member requirement for its Quality Assurance and Performance Improvement (QAPI) committee, as the Medical Director did not attend the QAPI meetings. This was discovered during a review of the QAPI monthly meeting minutes for the prior six months. The Director of Nursing (DON) confirmed that the Medical Director had not been present at these meetings and was unaware of the requirement for his attendance.
Failure to Provide Timely Meal Assistance
Penalty
Summary
The facility failed to treat residents with respect and dignity, impacting their quality of life and dining experience. This deficiency was observed in two residents during meal times. One resident, with diagnoses including hypertensive heart disease, hypothyroidism, and type 1 diabetes, was seen with her meal tray untouched for 11 minutes before receiving assistance. Another resident, with hypertension and mild cognitive impairment, was left without her meal tray while others at her table were served, and her tray was only discovered in the food cart 5 minutes later. An LPN confirmed that meal trays are placed randomly in the cart, leading to delays in serving meals to residents at the same table.
Failure to Assess Resident for Self-Administration of Oxygen
Penalty
Summary
The facility failed to ensure that a resident was appropriately assessed for the ability to self-administer medications, specifically oxygen, as per their policy. The policy required a basic evaluation by the charge nurse, a review by the IDT, and a physician's order if self-administration was deemed safe. However, Resident #14, who had multiple diagnoses including dementia and COPD, was observed managing her oxygen supply independently without having been assessed or care planned for self-administration. This oversight was noted when the resident was seen without her nasal cannula and oxygen turned off, and later independently applied the nasal cannula and turned on the oxygen. The resident's care plan indicated a need for continuous oxygen at 2 Liters/minute due to COPD, yet there was no documented assessment for self-administration of oxygen. An evaluation from the previous year had determined that the resident was not a candidate for safe self-administration of medications. Despite this, the resident was managing her oxygen without staff assistance, which was not aligned with the facility's policy or the resident's care plan. The LPN and DON acknowledged the lack of assessment and care planning for the resident's self-administration of oxygen.
Failure to Notify Ombudsman of Hospital Transfer
Penalty
Summary
The facility failed to provide a notice of transfer to the State Long Term Care Ombudsman when a resident was transferred to the hospital. This deficiency was identified during a review of the records for a resident who was admitted to the facility with multiple diagnoses, including hypertensive heart disease, hypothyroidism, and diabetes. The resident was discharged to a hospital with an anticipated return and was later readmitted to the facility. However, there was no documentation in the resident's record indicating that a Notification of Transfer was provided to the State Ombudsman regarding the hospitalization. During an interview, a social services employee stated that she was unaware of the requirement to notify the Ombudsman of such transfers.
Failure to Complete Annual MDS Assessment on Time
Penalty
Summary
The facility failed to complete an annual comprehensive Minimum Data Set (MDS) assessment for a resident prior to the required completion date. This deficiency was identified through staff interviews, record reviews, and policy reviews. The facility's policy, revised in December 2018, mandates that a comprehensive assessment be completed for Medicare recipients at admission and annually. The resident in question was admitted with multiple diagnoses, including shortness of breath, gastroesophageal reflux disease, and diabetes. A review of the resident's MDS history revealed that a quarterly MDS was transmitted late, and there was no record of an annual comprehensive assessment being completed within the required timeframe. During an interview, the Director of Nursing (DON) confirmed that a quarterly assessment was submitted late and acknowledged the mistake of completing a quarterly MDS instead of an annual one.
Deficiencies in Resident Care Plans
Penalty
Summary
The facility failed to develop and implement comprehensive resident-centered care plans for five residents, leading to potential risks of negative outcomes. Resident #14, diagnosed with dementia and COPD, was observed without her prescribed oxygen, and her care plan lacked an assessment for self-administration of oxygen. Resident #1's care plan did not include her dementia diagnosis, and the Director of Nursing (DON) was unaware of this condition. Resident #3's care plan did not document interventions for the use of side rails, despite an assessment indicating the resident's preference for them. Resident #6, diagnosed with Huntington's disease, was observed without a call light in the TV room, and her care plan did not address this need, despite multiple falls from the chair in that area. Resident #17, diagnosed with Alzheimer's disease, had a hospice order for oxygen use that was not reflected in the care plan, and the discontinuation of CPAP machine use was not documented. The DON acknowledged the care plans were not updated as required, contributing to these deficiencies.
Failure to Update Resident Care Plans
Penalty
Summary
The facility failed to ensure that resident care plans were revised to reflect current needs and interventions, as required by their Care Plans policy. This deficiency was identified for three residents whose care plans were reviewed. The policy, dated January 1, 2024, mandates that care plans be reviewed quarterly, annually, and with any change of status to ensure they are current. However, the care plans for Resident #6, Resident #15, and Resident #17 were not updated as scheduled, placing these residents at risk of adverse outcomes. Resident #6, diagnosed with Huntington's disease, had a care plan initiated on January 8, 2021, which was due for review on January 15, 2024, but was not updated. Similarly, Resident #17, with Alzheimer's disease, had a care plan that was supposed to be reviewed on February 23, 2024, but this was not done. Resident #15, who has multiple diagnoses including dementia and COPD, had a care plan that was overdue for review since January 18, 2024. The Director of Nursing (DON) acknowledged the oversight in updating these care plans, which were overdue for review.
Failure to Obtain Physician's Order for Discontinuing CPAP
Penalty
Summary
The facility failed to ensure the discontinuation of CPAP use for a resident was accompanied by a physician's order. This deficiency was identified for a resident who had a physician's order dated February 2, 2024, to use a CPAP machine nightly. The Medication Administration Record (MAR) indicated that CPAP equipment care was initiated on May 12, 2024, and discontinued on June 1, 2024. However, on July 8, 2024, a CPAP machine was not observed in the resident's room, and on July 9, 2024, the Director of Nursing (DON) confirmed that the resident no longer used a CPAP machine. The DON also stated that there was no order on file to discontinue CPAP use, although the cessation of CPAP was discussed in an Interdisciplinary Team (IDT) meeting.
Expired Medications Found in Storage Room and Cart
Penalty
Summary
The facility failed to ensure that medications available for residents had not expired, as observed during an audit of the medication storage room and a medication cart. In the medication storage room, four syringes of Tetanus Toxoid reduced Diphtheria Toxoid and Acellular Pertussis vaccine were found with an expiration date of March 2024, and three doses of Influenza vaccine were found with an expiration date of June 30, 2024. An LPN acknowledged that these vaccines were expired and should have been removed from the refrigerator, but she was unsure of the procedure for handling expired medications. The Director of Nursing (DON) stated that expired liquid medications are sent upstairs to be destroyed by the pharmacy, and other expired medications should have been removed from the medication room for destruction. Additionally, during a medication cart audit, a bottle of Antacid liquid was found with an expiration date of June 2024. The same LPN stated that she had opened the Antacid liquid bottle the previous day without noticing its expiration. She acknowledged that expired medications should have been removed from the medication cart. This oversight created the potential for residents to receive expired medications with decreased efficacy.
Infection Control and Prevention Failures
Penalty
Summary
The facility failed to maintain proper infection control and prevention practices, as evidenced by several observations. A Hoyer lift and a Sit to Stand device were found with visible dirt and dust, and the cleaning log for these devices lacked documentation of regular cleaning. Additionally, a glucometer used by an LPN was not disinfected according to the recommended dry time, and the LPN was unaware of the proper procedure. This lack of adherence to cleaning protocols poses a risk of cross-contamination and infection among residents. Further deficiencies were noted in the handling and storage of oxygen and respiratory supplies. An oxygen concentrator in a common room had an undated water bottle and a nasal cannula on the floor, while a resident's nebulizer and tubing were undated and uncovered. The DON admitted there was no policy for storing respiratory supplies. Additionally, an LPN was observed not performing hand hygiene after blowing her nose and before dispensing medication. In the laundry room, inappropriate detergent was used for residents' personal laundry, as the machines were connected to a rinse aid meant for dishwashers.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 14 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near American Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Quinn Meadows Rehabilitation And Care Center | 21.1 mi | ★★★★★ | 6 | 0 |
| Gateway Transitional Care Center | 22.1 mi | ★★★★★ | 0 | 0 |
| Monte Vista Hills Healthcare Center | 22.6 mi | ★★★★★ | 8 | 0 |
| Idaho State Veterans Home - Pocatello | 23.1 mi | ★★★★★ | 0 | 0 |
| Bingham Memorial Skilled Nursing & Rehabilitation | 38.1 mi | ★★★★★ | 9 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.