High Plains Post Acute LLC

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#3, #8 and #11) of six residents reviewed for accidents out of 21 sample residents received adequate supervision to prevent accidents. Resident #3 was admitted to the facility on [DATE] with diagnoses of displaced intertrochanteric (upper thigh bone - hip fracture) fracture, acute pain due to trauma and orthostatic hypotension. The resident was known to be a fall risk upon admission due to her fall at home which resulted in the resident's left hip fracture. However, the fall assessment completed on 3/12/25 documented the resident had not fallen and was a low risk for falls. The facility implemented a fall care plan upon admission which included ensuring items were within the resident's reach. On 4/18/25 Resident #3 turned her call light on after using the bedside commode in her room. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to address and/or act promptly upon the grievances and recommendations during resident council on issues of resident care and quality of life in the facility that were important to the residents. Specifically, the facility failed to ensure resident council grievances were addressed to resolve resident concerns related to call light response times.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that four (#1, #14, #7 and #2 of seven residents reviewed for activities received an ongoing program of activities designed to meet needs and interests, and promote physical, medical, and psychosocial well-being out of 21 sample residents. Specifically, the facility failed to offer and provide a personalized activity program for four Residents (#1, #14, #7 and #2).

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#8) of two residents out of 21 sample residents. Specifically, the facility failed to ensure nursing staff followed the physician ordered pain parameters when administering as needed (PRN) pain medication to Resident #8.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received proper respiratory treatment and care for two (#9 and #16) of the three residents reviewed for oxygen use out of 21 sample residents. Specifically, the facility failed to:-Ensure Resident #9 and #16 did not run out of oxygen in their portable oxygen tanks; and,-Ensure staff used the appropriate personal protective equipment (PPE) when filling residents' portable oxygen tanks.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus met the resident's nutritional needs. Specifically, the facility failed to ensure residents were provided adequate food to ensure they were not hungry after meals and in between meals.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure three (#13, #17 and #5) of four residents reviewed for accidents out of 24 sample residents remained free from accidents. Resident #13, who was identified with osteoporosis after a pathological (fracture caused by disease processes rather than trauma) right femur fracture (thigh bone above the knee) that required hospitalization and surgery on 6/22/24, sustained a non-displaced [NAME] fracture (an ankle injury that involves a fracture of the proximal fibula) on 1/12/25. The facility failed to ensure and document a root cause analysis and implement timely person-centered interventions after Resident #13 sustained a right femur fracture on 6/22/24. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#30) of three residents reviewed for catheters out of 24 sample residents. Specifically, the facility failed to: -Obtain physician's orders for the use of Resident #30's catheter; and, -Maintain documentation for Resident #30's catheter care and maintenance.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#22) of six residents reviewed for unnecessary medications out of 24 sample residents was free from unnecessary medications. Specifically, the facility failed to: -Ensure staff monitored and documented Resident #22's behaviors consistently to justify the use of the resident's psychotropic medications; and, -Ensure the interdisciplinary team (IDT) reviewed Resident #22's use of antidepressant and antipsychotic medications, on at least a quarterly basis, to determine if the continued use of the medications was justified or if a gradual dose reduction (GDR) was indicated.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to ensure facility staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP).

Inspectors wroteBased on record review and interviews, the facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for two (#22 and #37) of six residents reviewed for antibiotic use out of 24 sample residents. Specifically, the facility failed to effectively track and monitor the use of long-term antibiotics for Resident #22 and Resident #37.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents/hazards. Resident #1 had a diagnosis of advanced Huntington's disease (inherited disease that causes degeneration of the nerve cells in the brain) and was identified as a fall risk. Interventions for Resident #1 included a low bed and a fall mat. Resident #1 needed the assistance of two staff for transfers. On the morning of [DATE], certified nurse aide (CNA) #1 was assisting Resident #1 to get ready for the day. CNA #1 had lifted the bed from a low position to a higher position and had removed the fall mat to prepare to transfer Resident #1. [...]

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure two (#7 and #25) of five residents out of 23 sample residents were free of significant medication errors. Resident #7 had several medications prescribed to treat a significant mental health condition (bipolar), a progressive chronic pain condition (fibromyalgia), and a blood clotting condition (deep vein thrombosis). Between 6/1/23 to 7/25/23, the facility repeatedly failed to ensure the resident received these medications on schedule and as ordered to prevent complications and worsening symptoms. Resident #25 had several medications prescribed to treat a progressive neurodegenerative brain disorder (Huntington's disease). Between 6/1/23 to 7/25/23, the facility repeatedly failed to ensure the resident received these medications on schedule and as ordered to prevent complications and worsening symptoms. [...]

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure two (#1 and #7) of five residents received services and assistance to prevent a reduction in range of motion out of 23 sample residents. According to diagnoses on admission, Resident #1 did not admit to the facility with a contracture to her left hand but based on observations and interviews on 7/24-7/26/23, the resident was unable to extend her fingers independently and/or without pain. The facility failed to provide the resident interventions to prevent a reduction in the resident's range of motion of her left hand. Further, the facility failed to provide the resident occupational therapy (OT) as ordered after the identification of a possible ligament injury to the left wrist on 1/16/23. [...]

Inspectors wroteBased on record review and interviews, the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to unavailable and missed medications that rose to the scope and severity of immediate jeopardy during the survey on 7/24/23 to 8/14/23. Due to the missed medications, it caused distress and decline to Resident #7 and Resident #25.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure appropriate hand hygiene by food service staff.

Inspectors wroteBased on observation and staff interview, the facility failed to provide a safe, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure a backflow prevention device was installed on all hand held showers in four of four showers rooms, increasing the risk of contamination to the facility's main water supply.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure an effective program of pest management. Specifically, the facility failed to ensure the main kitchen was free from flies.

Inspectors wroteBased on observations and interviews, the facility failed to ensure care for residents was provided in a manner and in an environment that maintained or enhanced the residents' dignity and respect in full recognition of their individuality. Specifically, the facility failed to: -Ensure an adequate system was in place to provide meal services in a timely fashion to residents waiting to be served in the assisted dining room; and, -Ensure staff knocked before entering resident rooms.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 15 of 30 resident rooms in three hallways. Specifically, the facility failed to ensure walls, ceilings and doors were properly maintained.

Inspectors wroteBased on observations, record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible. Specifically, the facility failed to ensure safe water temperatures.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that self-administration of medications was clinically appropriate for one (#13) resident out of 23 sample residents. Specifically, the facility failed to ensure Resident #13 had a physician order an assessment and interdisciplinary team documentation stating it was appropriate for Resident #13 to self-administer medication.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan, consistent resident rights, that included measurable objectives and timeframes to meet medical, nursing, mental and psychosocial needs for one (#14) of five residents reviewed for comprehensive care plans out of 23 sample residents. Specifically, the facility failed to timely develop a care plan for the use of oxygen, timely develop a care plan for visual impairment, develop a care plan for hospice and develop a care plan for activity services for Resident #14.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#23 and #38) of five residents reviewed for activities out of 23 sample residents. Specifically, the facility failed to ensure Resident #23 and Resident #38 were invited and encouraged to attend activities of her preference.

Inspectors wroteBased on resident observations, record review and staff interviews, the facility failed to ensure residents received proper respiratory treatment and care for one (#13) of four residents reviewed for supplemental oxygen use out of 23 sample residents. Specifically, the facility failed to administer oxygen in accordance with the physician's order for Resident #13.

Inspectors wroteBased on record review and interviews, the facility failed to provide services that met professional standards of quality according to accepted standards of practice for one (#9) of five residents reviewed of 24 sample residents. Specifically, the facility: -Failed to ensure Resident #9 had been assessed to self administer medications when morning medications were left at her bedside; -Failed to accurately document said medication administration for Resident #9; and, -Failed to follow accepted standards of practice for medication administration by setting up several medications prior to administration.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure two (#13 and #8) out of 24 sample residents remained free from resident to resident abuse. Specifically, the facility failed to ensure Resident #13 was safe from resident-to-resident altercation with Resident #8. Resident #8 was observed to shake Resident #13's wheelchair and struck him in the back with his hand. Resident #13 was observed to swing with his right hand and struck Resident #8.

Inspectors wroteBased on resident observation, record review and interviews, the facility failed to ensure two (#22 and #5) of three residents out of 24 sample residents were repositioned and toileted in a timely manner for residents who were at risk for skin impairment. Specifically, the facility failed to provide repositioning and incontinence care according to professional standards of practice for Resident #22 and Resident #5.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that one (#32) of two residents reviewed with limited range of motion received appropriate treatment and services, out of 24 sample residents. Specifically, the facility failed to ensure Resident #32 received range of motion to the left upper extremity and received restorative services on a regular basis.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide person-centered dementia care services to one (#34) of five residents reviewed out of 24 sample residents. Specifically, the facility failed to develop and implement person-centered interventions of dementia care services to address the behaviors for Resident #34.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, in one of two medication carts and one of one medication storage rooms. Specifically, the facility: -Failed to date an insulin when opened; -Failed to date tuberculin when opened; and, -Failed to discard expired insulins.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure adequate fluid intake for the identified needs of two (#22 and #5) of five residents out of 24 sample residents. Specifically, the facility failed to ensure Resident #22 and Resident #5 received encouragement, cueing and assistance to meet their hydration needs.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#16) of one resident reviewed for hospice services out of 24 sample residents. Specifically, the facility: -Failed to orientate hospice aides to the facility including the policies and procedures; and, -Failed to develop a system to ensure aide visit notes were available in Resident #16's chart. II. Resident #16 A. Resident status Resident #16, age [AGE], was admitted on [DATE]. According to the May 2022 computerized physician orders (CPO), diagnoses included cerebral infarction, adult failure to thrive, and chronic atrial fibrillation. [...]