Great Plains Post Acute

In the surveyor’s words

From the most serious findings on record at Great Plains Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF626Mar 5, 2025

  The 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. […]

• Immediate jeopardy, isolatedF675Mar 5, 2025

  The 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. […]

• Immediate jeopardy, isolatedF689Dec 21, 2023

  The 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. […]

• Actual harm, isolatedF600Feb 11, 2025

  The 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. Findings included: - R157's Electronic Health Record (EHR) revealed a diagnoses transient ischemic attack (TIA- temporary episode of inadequate blood supply to the brain), sepsis (life threatening systemic reaction that develops due to infections which cause inflammation throughout the entire body), and lactic acidosis (excessive accumulation of lactic acid produced by the muscle cells with the breakdown of carbohydrates for energy). […]

• Actual harm, isolatedF686Feb 11, 2025

  The 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. […]