Manor of the Plains

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe 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.

Inspectors wroteThe facility reported a census of 32 residents; 12 residents were sampled for advanced directives (a written document, which indicates the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed to ensure two resident's advanced directives were thoroughly completed when Resident (R) 38 had a do not resuscitate (DNR- or no code, a legal document or order that means the person does not desire resuscitative measures) order but not signed DNR form. Additionally, R4's DNR lacked a witness signature.

Inspectors wroteThe facility reported a census of 32 residents. There were 12 residents selected for review which included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure that Resident (R) 21's as-needed (PRN) antianxiety (a class of medications that calm and relax people) medication had the required 14-day stop date or a specified duration with a physician's rationale to support the extended use.

Inspectors wroteThe facility reported a census of 32 residents. The sample included 12 residents with one resident reviewed for activities of daily living (ADLs). Based on observation, interviews, and record review the facility failed to offer and provide assistance with grooming of facial hair for Resident (R) 25, who participated in her hygiene activities but needed staff assistance.

Inspectors wroteThe facility reported a census of 32 residents; the sample included 12 residents with four residents reviewed for accidents. Based on observation, interview, and record review, the facility failed to follow the care planned interventions to prevent falls for Resident (R) 1 and R7.

Inspectors wroteThe facility reported a census of 32 residents; the sample included 12 residents with one resident reviewed for tube feeding (administration of nutritionally balanced liquefied foods or nutrients though a tube). Based on observation, interviews, and record review, the facility failed to ensure Resident (R) 38,a resident who did not eat or drink, had a physician's order for the type of enteral feed formula to be administered through R38's gastrostomy tube (G-tube: tube surgically placed through an artificial opening into the stomach) and/or assessment and direction from the Registered Dietician (RD) until six days after admission.

Inspectors wroteThe facility identified a census of 32 residents. The sample included 12 residents including five residents reviewed for unnecessary medications. Based on record review, interview and observation, the facility failed to act upon blood sugar monitoring for Resident (R) 7 when staff administered insulin (a hormone that lowers the level of glucose in the blood) that should have been held per physician ordered parameters.

Inspectors wroteThe facility reported a census of 32 residents. Based on interview and record review, the facility failed to electronically submit accurate staffing information through Payroll-Based Journaling (PBJ).

Inspectors wroteThe facility census totaled 29 residents with 12 included in the sample with five reviewed for medications. Based on observation, interview, and record review, the facility failed to follow the physician orders directing the nursing staff to notify the physician for blood sugars (BS) below 70 and above 350, for Resident (R)24.

Inspectors wroteThe facility reported a census of 29 residents with 12 residents included in the sample, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to ensure the Consulting Pharmacist identified and reported blood sugars out of parameters ordered by the physician for Resident (R)24, and the lack of an end date for as needed (PRN) psychotropic medications administered past the 14-day regulatory requirement for R1.

Inspectors wroteThe facility census totaled 29 residents with 12 included in the sample, that included five residents reviewed for unnecessary medications. Based on observation, interview, and record review, the facility failed to have an appropriate end date for as needed anti-anxiety medication administered past the 14-day regulatory requirements for Resident (R1).

Inspectors wroteThe facility census totaled 29 residents with 12 included in the sample. Based on observation, interview, and record review, the facility failed to ensure a clean sanitary environment for residents of the facility by the failure to change gloves when going from dirty to clean, and the lack of hand hygiene while assisting an incontinent resident to use the toilet for Resident (R) 20.

Inspectors wroteThe facility reported a census of 29 residents. Based on interview and record review, the facility failed to submit complete and accurate staffing information to the federal regulatory agency through Payroll Based Journaling (PBJ,) when the facility failed to submit staffing hourly data for all nursing personnel by the required deadline.

Inspectors wroteThe 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 inflammatory 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. [...]

Inspectors wroteThe 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. This had the potential to affect all residents.

Inspectors wroteThe facility reported a census totaling 30 residents. Based on observation and interview, the facility failed to maintain all mechanical care equipment in safe operating condition, when the kitchen tour revealed a three-tub sink and a garbage disposal in a separate sink did not work, putting residents at risk for unsanitary conditions.

Inspectors wroteThe facility reported a census of 30 residents, with 12 sampled, including five for unnecessary medications. Based on interview and record review, the facility failed to ensure the physician responded to the multiple consultant pharmacist's recommendations for Resident (R)15.

Inspectors wroteThe facility reported a census of 30 residents, with 12 sampled, including five for unnecessary medications. Based on interview and record review, the facility failed to ensure residents were free from unnecessary psychotropic medications, when multiple pharmacist recommendations for a gradual dose reductions (GDR) recommendations were not addressed for Resident (R) 15.