Manor of the Plains

In the surveyor’s words

From the most serious findings on record at Manor of the Plains, in the surveyor’s own words.

• Immediate jeopardy, isolatedF803Dec 16, 2021

  The facility census totaled 30 residents, which included seven residents who required a mechanically altered diet (foods that can be safely and successfully swallowed by being whipped, blended, ground, chopped or mashed). Based on observation, interview, and record review the facility failed to provide the appropriate mechanically altered diet to Resident (R) 82, who subsequently developed aspiration pneumonia (an [CONDITION(S)] condition of the lungs caused by inhaling foreign material or vomit) and admitted to the hospital, requiring oxygen on 12/14/21 (after the noon meal) which she did not require prior to this incident. R82 underwent an esophagogastroduodenoscopy (EGD, a procedure to examine the throat, stomach and small intestine) to remove a piece of pork. […]

• No harm, potential for more than minimal, widespreadF730Sep 11, 2025

  The facility reported a census of 32 residents. The facility identified five Certified Nurse Aides (CNA) employed over the 12 the month period. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for two of the five CNA reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. Findings included:- Review of CNA personnel files revealed the following:CNA II, hired on 06/20/24, lacked an annual performance evaluation. Certified Medication Aide (CMA) R hired 11/17/23lacked an annual performance evaluation. […]

• No harm, potential for more than minimal, widespreadF812Sep 11, 2025

  The facility reported a census of 32 residents, one main kitchen and one satellite kitchen. Based on observation, record review, and interview, the facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. Findings included:- During a second tour of the satellite kitchen on 09/10/25 at 04:40 PM, observation revealed Dietary Staff DD removed a container of lettuce from the refrigerator with gloved hands. Wearing the same gloves, Dietary Staff DD opened a cabinet door, removed bowls from the shelf, and closed the door. […]

• No harm, potential for more than minimal, widespreadF947Sep 11, 2025

  The facility reported a census of 32 residents. Five Certified Nurse Aide (CNA) staff who worked in the facility for more than 12 months were reviewed for the required in-service training. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for CNA staff with the required topics and no less than 12 hours per year. Findings included:- Review of CNA personnel files revealed the following:CNA P, who was hired for the facility on 09/13/22, lacked abuse, neglect, and exploitation (ANE), social media training, and dementia (progressive mental disorder characterized by failing memory, confusion) training. […]

• No harm, potential for more than minimal, widespreadF812Dec 16, 2021

  The facility reported a census of 30 residents. Based on observation, interview, and record review the facility failed to store food in a safe, sanitary manner and in accordance with professional standards for food service safety. The facility failed to monitor the refrigerator and freezer temperatures to ensure proper food storage and temperatures, failed to monitor the quaternary (chemical used to clean and sanitize surfaces) levels to ensure efficacy of the sanitizer used to clean tables and surfaces, and failed to monitor food temperatures to ensure all foods were prepared/cooked to the safe temperatures. […]