Grand Plains Skilled Nursing By Americare

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

to separate the residents and redirect them as appropriate to ensure a safe environment. Staff would then alert other staff to notify the nurse, then follow instructions the nurse provided, and provide a written report and/or witness statement for the nurse. CMA R reported she was aware of the incident between Resident R1 and Resident R2 but was not directly involved in the event.During an interview on 10/01/25 at 01:15 PM, CNA P reported when she came to work on the morning of 09/03/25, Resident R2 had bruising on his face near his eye. CNA P said Administrative Staff A spoke with staff to convince them nothing happened to Resident R2.During an interview on 10/01/25 at 02:15 PM, LN H said if staff observe or suspect resident-to-resident abuse, they should separate the residents to ensure safety and alert other staff to let the nurse know or notify the nurse directly. When the nurse arrived in the area, the nurse would perform assessments and provide aid if needed, and document any injuries in the report and in the EHR progress notes. LN H said the nurse would collect written statements by any staff directly involved, notify administration and law enforcement, and fill out an incident report, including the witness statements from staff. LN H said she was aware of the incident between Resident R1 and Resident R2 but was not directly involved in the incident.During an interview on 10/01/25 at 02:40 PM, Administrative Staff A said that if resident-to-resident abuse was observed or suspected, the expectation was for staff to separate, ensure the safety of the residents, provide aid as necessary, and notify the nurse. The nurse was expected to call the building administration, the resident's physician, LEO, EMS, and the residents' representatives. If there was any suspicion that any resident struck another resident, the nurse should also collect written witness statements from the staff. If the incident was willful abuse, then a report would be filed with the State Agency (SA). Administrative Staff A stated on the morning of 09/03/25, she received a call from the nurse who reported Resident R1 entered Resident R2's room and struck Resident R2 and hit Resident R2's wife. Administrative Staff A confirmed LEO and EMS were notified. Administrative Staff A reported Resident R1 was placed on one-on-one observation by Administrative Staff A until 08:00 AM, when Resident R1's wife arrived and assumed one-on-one observation until she left at 06:00 PM. Staff then provided one-on-one observation if Resident R1's wife was not present until Resident R1 was transferred to a BHU. Administrative Staff

A stated she had not reported the incident to the SA as required.The facility's Abuse, Neglect and Exploitation Policy and Procedure policy, dated 05/2023, documented that the facility prohibited abuse from any perpetrator that included but was not limited to staff, volunteer, contracted staff, vendor, family member, visitor, or any other resident.This deficient practice was cited at a scope and severity of G (actual harm, isolated) to reflect fear and anxiety because of the noncompliance using the reasonable person concept due to Resident R2's impaired cognition.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grand Plains Skilled Nursing by Americare

331 NE State Road 61 Pratt, KS 67124

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

necessary, and notify the nurse. The nurse was expected to call the building administration, the resident's physician, LEO, EMS, and the residents' representatives. If there was any suspicion that any resident struck another resident, the nurse should also collect written witness statements from the staff. If the incident was willful abuse, then a report would be filed with the State Agency (SA). Administrative Staff A stated on the morning of 09/03/25, she received a call from the nurse who reported Resident R1 entered Resident R2's room and struck Resident R2 and Resident R2's wife. Administrative Staff A confirmed LEO and EMS were notified. Administrative Staff A stated

she had not reported the incident to the SA as required. The facility's Abuse, Neglect and Exploitation Policy and Procedure policy, dated 05/2023, documented that the Administrator would notify the SA within 24 hours of the incident unless the incident met the definition of a crime against a person or resulted in serious bodily injury, then the report would be made to LEO and SA no later than two hours after the incident.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/01/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Grand Plains Skilled Nursing by Americare

331 NE State Road 61 Pratt, KS 67124

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

resident will be removed from contact with the resident during the course of the investigation. The resident suspected of elder-to-elder abuse will be provided supervision by staff until the physician, family, and facility management staff assess and provide treatment options to stop any further aggressive, abusive behavior by the elder. The accused resident's condition shall be immediately evaluated to determine the most suitable therapy, care approaches, and placement, considering his or her safety, as well as the safety of other residents and employees of the facility.

Event ID:

Facility ID:

If continuation sheet