High Plains Post Acute LLC

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Aug 14, 2023

  Based 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). […]

• Actual harm, isolatedF689Aug 11, 2025

  Based 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. […]

• Actual harm, isolatedF689Feb 27, 2025

  Based 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. […]

• Actual harm, isolatedF689Apr 1, 2024

  Based 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. […]

• Actual harm, isolatedF688Aug 14, 2023

  Based 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. […]