Great Plains Post Acute

Inspectors wroteBased on interview and record review the facility failed to ensure Resident (R) 1 remained free from physical restraint when Certified Nurse Aide (CNA) M placed her hand over Resident (R) 1's mouth to keep her quiet.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide the services of a full-time certified dietary manager for the residents who resided in the facility and received their meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 106 residents in the facility, who receive their meals from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to resolve recurring issues reported by the Resident Council.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement alternative communication methods for one resident. Resident (R) 22, who spoke in Bengali.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide consistent bathing services as care planned for one sampled resident, Resident (R) 107.

Inspectors wroteBased on observation, interview, and record review, the facility failed to evaluate the effectiveness of fall interventions for two residents, Resident (R) 29 and R93, who had multiple falls, to prevent further falls.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to identify trauma-based triggers related to Resident (R)41 and R13 post-traumatic stress disorder (PTSD - a mental disorder characterized by an acute emotional response to a traumatic event or situation involving severe environmental stress) and failed to implement individualized interventions to prevent re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to label Resident (R) 46 and R89s' insulin (a hormone that lowers the level of glucose in the blood) flex pens with an opened date and the facility failed to label the tuberculin vial solution with an opened date.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure a communication process between the hospice provider and the facility for Resident (R)81, which included a plan of care and a description of the services provided, which included contact information, visit frequency, medications, and medical equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a sanitary and comfortable environment to help prevent the development and transmission of communicable diseases and infections when staff failed to wear appropriate Enhanced Barrier Precautions (EBP-infection control interventions designed to reduce transmission of resistant organisms, which employ targeted gown and glove use during high contact care) for one resident, Resident (R) 107.

Inspectors wroteBased on observation, record review, and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment in the laundry room.

Inspectors wroteThe facility reported a census of 105 residents with four residents included in the sample. Based on interview and record review the facility failed to ensure the staff administration of resident's medication met professional standards. The Certified Medication Aide administered Trazodone to Resident (R)2 at the incorrect time, and left R3's medication in her room, without observing the resident consume the medication and staff later found 15 medication cups with one gabapentin (medication used for nerve pain) and one tramadol (medication used for moderate to severe pain) in each cup and also found 19 tramadol pills in R3's drawer.

Inspectors wroteThe facility reported a census of 100 residents with eight residents sampled and one resident reviewed for proper discharge from facility. The facility failed to readmit Resident (R) 77 back into the facility. The likelihood for a serious adverse outcome existed, due to the threat to R77's continuity of care, feelings of insecurity to his safety in not having a place to discharge to after the facility had been providing his care for the past two years and four months. The negative psychosocial impact is significant and traumatic, with R77s history of having to live in a men's shelter. This placed R77 in immediate jeopardy. Findings Included: [...]

Inspectors wroteThe facility reported a census of 100 residents with eight residents sampled and one resident reviewed for fecal impaction (accumulation of hardened feces in the rectum that the individual was unable to move), and constipation (difficulty passing stools). Based on observation, interview, and record review the facility failed to have an adequate system in place to identify the known signs and symptoms of fecal impaction for Resident (R) 77, who was required to have a large stool ball removed from his upper rectum, under anesthesia on 02/25/25 at 10:30 AM at the local hospital. This deficient practice placed all residents at risk in immediate jeopardy. Findings Included: - Review of the Electronic Health Record (EHR) documented R77 had a diagnosis of constipation. [...]

Inspectors wroteThe facility reported a census of 102 residents. The sample included 21 residents. Based on interview and record review the facility failed to provide adequate supervision for Resident (R) 157 when a tourniquet was left on his arm from a blood draw on a Friday and not found until Monday, a total of 5 days.

Inspectors wroteThe facility identified a census of 102 residents with 21 sampled, which included one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observation, interview, and record review the facility failed to implement care plan interventions to prevent the development of facility-acquired, stage 3 pressure ulcers/injuries (full thickness pressure injury extending through the skin into the tissue below) for Resident (R)14.

Inspectors wroteThe facility reported a census of 102 residents with 21 sampled. Based on observation, interview, and record review the facility failed to ensure staff assessed Resident (R) 409 after a fall on 01/27/25 and failed to document the fall and/or the resident's status after the fall until the resident transferred to a local hospital and was diagnosed with multiple fractures (broken bones).

Inspectors wroteThe facility identified a census of 102 residents, with 21 sampled, and one resident reviewed for weight loss. Based on observation, interview, and record review, the facility failed to monitor the weight loss and failed to develop care plan interventions to address the weight loss for cognitively impaired Resident (R) 14, who had an identified weight loss of 20.54% in one month. This deficient practice had the potential to negatively affect the resident's physical well-being.

Inspectors wroteThe facility identified a census of 102 residents, which included 57 residents with active trusts held by the facility. Based on observations, interviews, and record review, the facility failed to provide quarterly statements for the 57 residents with trust accounts in the facility.

Inspectors wroteThe facility reported a census of 102 with 21 residents in the sample. Based on observations, interview and record review the facility failed to ensure competent nursing staff when the LN did not apply a pressure dressing to R5's ruptured and heavily bleeding hematoma (collection of blood trapped in the tissues of the skin or in an organ, resulting from trauma) on the resident's right lower leg. The facility failed to maintain the quality of care for R409 which included lack of assessment, documentation from a fall on 01/27/25 which caused a fracture (broken bone) of the pelvic area.

Inspectors wroteThe facility reported a census of 102 residents. Based on observation, interview, and record review, the facility failed to conduct annual performance reviews for five of the five direct care staff reviewed, to ensure the residents receive adequate cares.

Inspectors wroteThe facility reported a census of 102 residents with 21 residents sampled for review. Based on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from the resident's bedside, toilet, and bathing facilities.

Inspectors wroteThe facility reported a census of 102 residents. Based on observation, interview, and record review, the facility failed to ensure the continuing competence of nurse aides included annual mandatory training for abuse, neglect, and exploitation training.

Inspectors wroteThe facility reported a census of 102 residents. Based on observation, interview, and record review, the facility failed to ensure the continuing competence of nurse aides but must be no less than 12 hours per year and Include dementia management training and resident abuse prevention training and address areas of weakness as determined in nurse aides' performance reviews which address the special needs of residents as determined by the facility staff.

Inspectors wroteThe facility had a census of 102 residents. The sample included 21 residents with seven residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice to seven residents, Resident (R) 14, R75, R79, R88, R92, R96, and R409 and/or their representative with a written notice specifying the duration of the bed-hold policy, at the time of the residents' transfers to the hospital.

Inspectors wrote- Review of the Resident (R)82's, Physician Orders, dated 05/18/22, revealed diagnoses which included anxiety disorder, muscle weakness, reduced mobility, obesity (severe overweight), and need for assistance with personal care. The Annual Minimum Data Set (MDS) dated [DATE], documentation included her Brief Interview for Mental Status (BIMS) score of 15, which indicated cognitively intact. She reported it was very important to choose what clothes to wear and type of bath. The resident was dependent on staff for partial to moderate for assistance with bathing and dressing. The Functional Abilities (Self-Care and Mobility) Care Area Assessment (CAA) dated 01/06/25 documentation included the resident remained in the facility for assistance with cares. [...]

Inspectors wroteThe facility reported a census of 102 residents which included 21 residents sampled and seven reviewed for ADL (activities of daily living such as walking, grooming, toileting, dressing and eating) care. Based on observations, interviews and record reviews, the facility failed to provide baths and/or showers to six residents who were dependent on staff for ADL care, Resident (R) 27, R80, R79, R76, R88 and R82. These deficient practices led to a failure to ensure the necessary services required for good personal hygiene were provided to the residents in the facility.

Inspectors wroteThe facility had a census of 102 residents. The sample included 21 residents. Based on observation, interview, and record review, the facility failed to serve the residents of the facility food, which was palatable, attractive, and served at the appropriate temperature.

Inspectors wroteThe facility reported a census of 102 residents. Based on observation, interview, and record review, the facility failed to store, prepare, and serve food in a sanitary manner to prevent possible food-borne illness to the residents of the facility.

Inspectors wroteThe facility reported a census of 102 residents with 21 residents sampled. Based on interview, observation, and record review the facility failed to protect the dignity of Resident (R) 80 and R27 when the staff failed to remove unwanted facial hair and/or trim resident fingernails as needed. The facility further failed to ensure staff knocked before entering resident rooms and blinds were closed to the outside when performing resident care activities. These practices had the potential to lead to negative psychosocial effects related to dignity.

Inspectors wroteThe facility reported a census of 102 residents with 21sampled, which included three residents reviewed for choices. Based on observation, interview, and record review, the facility failed to provide choices for dependent Resident (R) 82 related to her preferences for type and frequency of bath/shower.

Inspectors wroteThe facility reported a census of 102 residents. The sample included 21 residents. Based on interview and record review the facility failed to ensure the correct and complete Beneficiary Protection Notification Forms were issued to one of three residents reviewed, Resident (R)56.

Inspectors wroteThe facility had a census of 102 residents. The sample included 21 residents with eight reviewed for hospitalization. Based on observation, interview, and record review the facility failed to provide written notice for facility-initiated transfers for Residents (R) 79 or their representative when they were transferred to the hospital.

Inspectors wroteThe facility census totaled 102, with 21 residents in the sample. Based on observation, interview, and record review the facility failed to provide the necessary care for Resident (R) 88 related to obtaining ordered medications.

Inspectors wroteThe facility identified a census of 102 residents, with 21 sampled, one resident was reviewed for tube feeding (administration of nutritionally balanced liquefied foods or nutrients though a tube) management. Based on observation, interview, and record review, the facility failed to check for residual (the volume of fluid remaining in the stomach at a point in time during enteral nutrition feeding) or placement prior to a bolus feed (a method of administering liquid nutrition through a feeding tube). Additionally, staff failed to have head of bed elevated for at least 60 minutes after a bolus feed was completed. This deficient practice had the potential to negatively affect the resident's physical well-being.

Inspectors wroteThe facility reported a census of 102 residents with 21 residents sampled, including one resident reviewed for dialysis (the clinical purification of blood by dialysis, as a substitute for the normal function of the kidney). Based on observation, record review, and interview the facility failed to ensure coordination of care between the dialysis center and the facility, for one Resident (R) 85, regarding a lack of regular dialysis communication sheets, with the facility.

Inspectors wroteThe facility identified a census of 98 residents. The sample included three residents reviewed for misappropriation of property. Based on observation, record review, and interviews, the facility failed to ensure Resident (R) 1 remained free from misappropriation of medications when two tablets of Percocet (narcotic pain medication) were unaccounted for and never found by the facility. This deficient practice had the risk of missed medications and further misappropriation of medications for R1.

Inspectors wroteThe facility identified a census of 98 residents. The sample included three residents reviewed for falls. Based on observation, record review, and interviews, the facility failed to implement interventions to prevent falls for Resident (R) 2, who was at risk for falls. This deficient practice had the risk of further falls/injuries and unwarranted physical complications for R2.

Inspectors wroteThe facility reported a census of 107 residents with one resident reviewed for accidents. Based on observation, interview, and record review, the facility failed to ensure a safe environment on 12/10/23 when a facility staff member gave their personal vaping pen (an electronic device shaped like a pen that is used to inhale vapor when vaping), (which allegedly contained tetrahydro cannabinol [THC], an illegal psychoactive substance) to cognitively intact Resident (R) 1, who had a known history of substance abuse. R1 used the staff members vape pen (a device using marijuana that vaporize the active molecules in concentrated marijuana oil) and was found by staffR1 unable to function and required transfer to the emergency room for evaluation. This deficient practice placed R1 in immediate jeopardy.

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents. Based on observation, record review and interview, the facility failed to ensure Resident (R) 95, who was at risk for pressure ulcers (a localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction), received the proper care and treatments to avoid the worsening of a deep tissue injury (DTI - a purple or maroon localized area of discolored intact skin or blood?filled blister due to damage of underlying soft tissue from pressure and/or shear) and the new development of a stage three (full-thickness) pressure injury/ulcer to her sacral/coccyx (small triangular bone at the base of the spine) area. [...]

Inspectors wroteThe facility had a census of 104 residents. The sample included 23 residents. Based on observation, record review, and interview the facility failed to recognize, evaluate, manage, and treat Resident (R) 305's pain. This deficient practice resulted in uncontrolled pain which also placed the resident at risk for impaired mobility and diminished quality of life.

Inspectors wroteThe facility identified a census of 104 residents. The sample include 23 residents. Based on observation, record review, and interviews, the facility failed to implement a system to allow residents and/or their representatives to file grievances anonymously. This deficient practice placed the residents at risk for decreased psychosocial wellbeing. Findings Included: - An inspection of the facility revealed grievance form available in the front lobby on a table. The inspection revealed the facility had no labeled grievance boxes or other visible method in place to submit the form anonymously. On 06/27/23 at 01:30PM in a confidential interview, Resident Council members reported they were not aware if the facility provided a way to complete an anonymous grievance. The council reported they turned their complaints into Social Services X. [...]

Inspectors wrote- The facility identified a census of 104 residents. Based on observations, record review, and interviews, the facility failed to ensure proper infection control standards were followed related to hand hygiene during cares, disinfecting of shared equipment, monitoring of washing machine water temperature logs, and proper care for catheter (tube inserted into the bladder). The facility failed to ensure staff wore proper personal protective equipment (PPE) when care was provided for residents on enhanced barrier precautions. This deficient practice placed the residents at risk for complications related to infectious diseases. Findings Included: - On 06/26/23 at 07:36 AM review of the washing machine water temperature logs from 03/01/23 to 06/26/23 (118 days) revealed laundry water temperatures were assessed and documented on the following dates: [...]

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents. Based on observation, and interviews, the facility failed to provide a clean, home-like environment for all the residents who resided in the facility. This placed the affected residents at risk for impaired health and wellness.

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents with three residents reviewed for dignity. Based on observation, record review, and interviews the facility failed to ensure Resident (R) 88's urinary catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) drainage bag was placed in a privacy bag and a privacy curtain was provided during personal care. This deficient practice placed R88 at risk for impaired dignity and decreased psychosocial well-being.

Inspectors wroteThe facility had a census of 104 residents. The sample included 23 residents with two reviewed for accommodation of needs. Based on observation, record review and interview the facility failed to provide foot pedals for Resident (R)19's wheelchair. This placed the resident at risk for preventable accidents due to lack of necessary equipment.

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents with three residents reviewed for beneficiary notices review. Based on observation, record review, and interviews, the facility failed to provide Resident (R)307, who had Medicare Part A days remaining, with an Notice of Medicare Non-coverage (NOMNC CMS-form 10123) as required. This deficient practice placed R307 at risk for uninformed decisions and impaired ability to appeal. Findings Included: - A review of R307's Discharge Minimum Data Set (MDS) completed 04/06/23 indicated she had a Brief interview for Mental Status (BIMS) score of 15 indicating intact cognition. The MDS indicated she had a planned discharge with no return anticipated. The MDS indicated she discharged to the community on 04/06/23. [...]

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents. Based on observation, record review and interview that facility failed to ensure the residents were free from neglect when the facility failed to provide the necessary care and services for Resident (R) 90 and R19. This deficient practice placed the residents at risk for impaired health and decreased quality of life.

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents with four residents reviewed for abuse and neglect. Based on observation, record review, and interviews, the facility failed to identify as an allegation of abuse, and report to the appropriate abuse coordinator within the facility, when Resident (R)3 reported rough handling during cares to nursing staff. This placed R3 at risk for unidentified and ongoing abuse and /or neglect and related complications.

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 with two reviewed for transfer notifications. Based on record review, observations, and interviews, the facility failed to provide written notification of the reason and location for the facility-initiated transfer to the hospital for Resident (R)91 or her representative. This deficient practice placed R91 at risk of delayed care or uninformed choices. Findings Included: [...]

Inspectors wroteThe facility identified a census of 104. The sample included 23 residents with 23 reviewed for care plan revisions. Based on observation, record review, and interviews, the facility failed to complete care plan revisions for Residents (R)89. This deficient practice placed the residents at risk for ineffective treatment and unmet care needs. Findings Included: [...]

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents with one resident reviewed for communication. Based on observation, record review, and interviews, the facility failed to ensure Resident (R)70 received the necessary services to promote meaningful interaction and communication to support both physical and psychosocial needs in the presence of a language barrier. This deficient practice placed R70 at risk for unidentified care needs as well as risk for isolation and/or loneliness.

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents with six residents reviewed for activities of daily living (ADL) cares. Based on observation, record review, and interviews, the facility failed to ensure bathing was provided for Resident (R) 38 who required assistance from staff to complete the care. This deficient practice placed resident R38 at risk for further potential skin breakdown and/or skin complications from not maintaining good personal hygiene and bathing practices.

Inspectors wroteThe facility had a census of 104 residents. The sample included 23 residents with four residents reviewed for accidents. Based on observation, record review and interview, the facility failed to ensure Resident (R)19 had a safe/functionable shower chair to prevent avoidable accidents. This deficient practice placed the resident at risk for preventable accidents and injuries.

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents with six residents reviewed for bowel/bladder incontinence, catheter (a flexible tube inserted through a narrow opening into a body cavity, particularly the bladder, for removing fluid) and urinary tract infection (UTI-an infection in any part of the urinary system). Based on observation, record review, and interviews, the facility failed to provide appropriate treatment for Resident (R) 88 and R83 with indwelling catheters when the facility failed to prevent the catheter drainage bag from resting on the floor and the facility failed to maintain the catheter drainage bag below R88's bladder. The facility also failed to have an appropriate indication for R88's catheter and have an anchor for the catheter tubing to prevent pulling a d injury. [...]

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to ensure ongoing communication and collaboration with the dialysis (procedure where impurities or wastes were removed from the blood) facility regarding dialysis care and services and failed to obtain physician ordered weight for Resident (R) 305, who was on a fluid restriction and received dialysis. This deficient practice placed R305 at risk of physical complications related to dialysis.

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure the Consultant Pharmacist (CP) identified and reported the lack of pulse monitoring prior to the administration of a beta blocker (a medication used to slow down the action of the heart), for Resident (R)95. The facility failed to ensure the CP identified and reported an inappropriate indication for R93's antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel (antipsychotic) and R13's Vrylar (antipsychotic). The facility failed to ensure the CP identified and reported R13's blood glucose (the amount of sugar in the blood) levels that were outside of physician ordered parameters. [...]

Inspectors wrote- R13's electronic medical record (EMR) from the Diagnoses tab documented diagnoses of bipolar disorder (major mental illness that caused people to have episodes of severe high and low moods), diabetes mellitus (when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin), anxiety (mental or emotional reaction characterized by apprehension, uncertainty and irrational fear), major depressive disorder (major mood disorder), and constipation (difficulty passing stools). The Annual Minimum Data Set (MDS) dated [DATE] documented a Brief Interview of Mental Status (BIMS) score of 15 which indicated intact cognition. The MDS documented that R13 was dependent on two staff members assistance for activities of daily living (ADLs). [...]

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents with six residents sampled for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure Resident (R) 93's antipsychotic (class of medications used to treat psychosis and other mental emotional conditions) medication Seroquel and R13's antipsychotic Vrylar had an appropriate indication for use or a documented physician rationale which included the multiple unsuccessful attempts for nonpharmacological symptom management and risk versus benefits. This failure had the potential of unnecessary antipsychotic medication use and related side effects for R93 and R13.

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents with three reviewed for physician lab result notification. Based on observation, record review, and interviews, the facility failed to notify the medical provider of Resident (R)21's abnormal digoxin (medication used to treat heart failure and irregular heartbeats) lab result. This deficient practice placed R21 at risk for delayed treatment and/or toxicity.

Inspectors wroteThe facility identified a census of 104 residents. The sample included 23 residents. Based on observation, record review, and interviews, the facility failed to ensure physician ordered laboratory test results for Resident (R) 13 and R21 were included in the residents' clinical medical record. This deficient practice could result in unnecessary tests and delayed treatment.