Average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Manor Of The Plains during CMS and state inspections, most recent first.
The facility failed to complete annual performance evaluations for two of five CNA/CMA personnel files reviewed. Personnel records showed that one CNA and one CMA lacked required annual evaluations, and Administrative Staff A stated she expected 100% compliance with annual evaluations completed each year. The facility did not provide a policy on annual performance evaluations.
Unsanitary Food Handling in Satellite Kitchen: A dietary staff member handled lettuce, tomatoes, pickles, bowls, and salad dressing with the same gloves, touched kitchen surfaces and food items without changing gloves or performing hand hygiene, and reached into a pickle jar with a gloved hand. The CDM stated staff were expected to perform hand hygiene whenever gloves were removed and to use utensils when removing food from containers, while admin staff stated kitchen staff were expected to serve all food in a sanitary manner.
CNA In-Service Training Deficiencies: The facility failed to maintain an in-service training program for CNA staff with the required topics and at least 12 hours per year. Record review showed multiple CNAs lacked required ANE, social media, and dementia training, and annual training hours were not calculated. An admin staff member stated staff were expected to have the required education and annual hours, but no policy for CNA in-service and annual training was provided.
Incomplete DNR Documentation: Two residents had incomplete advance directive records. One resident’s DNR form was missing a witness signature, and another resident had a DNR order in the EMR but no signed DNR form on file. Staff confirmed the missing documentation, and red dots outside both rooms indicated DNR status.
A resident with dementia and depression received PRN compounded lorazepam cream for agitation, but the physician order lacked the required 14-day stop date or documented extended duration with rationale. The MDS showed severely impaired cognition, and the record also noted ongoing psychotropic use, a PRN psychotropic review process that was due, and an MRR identifying no stop date for the PRN Ativan order.
A resident with macular edema and Meniere's disease, and with MDS findings showing assistance needs for most ADLs and supervision for personal hygiene, was observed with several long facial hairs that staff had not removed. Her care plan addressed bathing and showering but did not document personal hygiene assistance or preferences, while the personal hygiene task record incorrectly listed her as independent with shaving and other hygiene tasks. Staff interviews showed inconsistent expectations about facial hair removal, and the facility did not provide an ADL policy.
Failure to follow fall prevention care plans for two residents. One resident with a femur fracture history, narcolepsy, and severe cognitive impairment had repeated falls, including a bed fall when a body pillow was not in use, and was later observed being transferred in a way that left him unsteady and falling into a recliner. Another resident with vascular dementia, weakness, and osteoarthritis had a fall risk care plan requiring the walker within reach and Dycem in the chair and wheelchair, but staff observed during transfer did not have Dycem in place and the walker was left against a wall.
A resident with a G-tube, colon cancer, partial intestinal obstruction, and severe malnutrition was admitted without a physician order specifying the enteral formula or an NPO order. Staff observed tube feeding connected to a pump with limited labeling, and the resident said she did not know how much feeding she would receive. The RD assessment documenting Jevity 1.5 at 45 ml/hr and NPO status was not completed until several days after admission, and staff interviews confirmed the order lacked the type and amount of enteral feed.
Insulin was administered to a resident with DM even when blood glucose readings were below the physician’s hold parameters. The resident had moderate to severe cognitive impairment and was ordered Humalog after meals, with instructions to hold it when blood sugar was under 100 mg/dl or meals were refused. Facility nurses stated staff were expected to check blood sugar as ordered and then give or hold insulin based on the physician’s parameters, but the MAR showed multiple instances where Humalog was still given despite low readings.
Inaccurate PBJ staffing reporting was cited after the facility’s PBJ Staffing Data Report showed no 24-hour LPN coverage on several dates, even though the Daily Nurse Staffing Form and payroll data showed the required coverage was present. Administrative Staff A stated that Regional Human Resources would complete the PBJ report and that it was expected to be reported accurately. The facility did not provide a PBJ policy.
Missing Annual Performance Evaluations for CNA/CMA Staff
Penalty
Summary
The facility failed to complete annual performance reviews at least once every 12 months for two of five CNA/CMA personnel files reviewed. The facility reported a census of 32 residents and identified five Certified Nurse Aides employed over the 12-month period. Review of personnel records showed that CNA II, hired on 06/20/24, lacked an annual performance evaluation, and Certified Medication Aide R, hired on 11/17/23, also lacked an annual performance evaluation. During an interview on 09/11/25 at 12:09 PM, Administrative Staff A stated she expected 100 percent compliance with annual performance evaluations being completed annually. The facility did not provide a policy on annual performance evaluations.
Unsanitary Food Handling in Satellite Kitchen
Penalty
Summary
The facility failed to prepare and serve food under sanitary conditions to prevent the potential for food borne bacteria. During observation in the satellite kitchen, Dietary Staff DD handled food and kitchen surfaces with the same gloves, including removing lettuce from the refrigerator, opening a cabinet, removing bowls, taking lettuce from a container, rinsing it under the faucet, squeezing it, and placing it into bowls without changing gloves or performing hand hygiene. She also poured salad dressing into a container, rinsed the container in the sink, removed her gloves, and put on a new pair without performing hand hygiene. During a later observation, Dietary Staff DD again used gloved hands to remove tomatoes and a jar of pickles from the refrigerator, removed her gloves and put on new gloves without hand hygiene, cut tomatoes, reached into the pickle jar with the same gloved hand, and handled lettuce in the same manner by grabbing it from the container, rinsing it, squeezing out excess water, and placing it on the plate with the tomatoes and pickles. In interview, Dietary Staff DD stated she usually used hand sanitizer when removing gloves and confirmed she had not washed her hands or used hand sanitizer when she removed her gloves. The Certified Dietary Manager stated staff were expected to perform hand hygiene every time gloves were removed and to use utensils when removing food from containers, and Administrative Staff A stated kitchen staff were expected to serve all food in a sanitary manner.
CNA In-Service Training Deficiencies
Penalty
Summary
The facility failed to develop, implement, and permanently maintain an in-service training program for CNA staff that included the required topics and at least 12 hours per year. The facility had a census of 32 residents, and five CNA staff members who had worked in the facility for more than 12 months were reviewed for required in-service training. Record review showed that CNA P, hired on 09/13/22, lacked abuse, neglect, and exploitation training, social media training, and dementia training, and the total annual training hours were not calculated. CNA Q, hired on 02/14/24, lacked abuse, neglect, and exploitation training and social media training, and the total annual training hours were not calculated. CNA II, hired on 06/20/24, lacked abuse, neglect, and exploitation training and social media training, and the total annual training hours were not calculated. During interview, Administrative Staff A stated he expected staff to have the required education and the required 12 hours annually. The facility did not provide a policy for CNA staff required for in-service and annual training hours.
Incomplete DNR Documentation
Penalty
Summary
The facility failed to ensure that two residents’ advance directives were thoroughly completed. One resident had a physician order for DNR in the EMR, and the DNR form was signed by the resident and physician, but the form lacked a witness signature. Another resident also had a physician order for DNR in the EMR, but the EMR did not contain a signed DNR form. During observations, red dots were noted on the name tags outside both residents’ rooms, and the administrative nurse reported that a red dot indicated the resident was DNR. During interview, the administrative nurse stated that the Social Service Designee would complete the advance directive forms and a nurse would enter the order in the EMR once the paperwork was completed. The Social Service Designee confirmed that one resident’s DNR form was incomplete because it did not have a witness signature and stated that she could not locate a signed DNR form for the other resident in either the file or the EMR. The facility’s advance directive policy stated that residents are provided written information to exercise their rights to make health care decisions, refuse treatment, and make advance directives, and that advance directives and physician orders are reviewed at least annually.
PRN Psychotropic Medication Lacked Required Stop Date
Penalty
Summary
The facility failed to ensure that Resident 21’s PRN antianxiety medication had the required 14-day stop date or a documented extended duration with a physician’s rationale. Resident 21 had diagnoses of dementia and depression, a BIMS score of 3 on the annual MDS and later 0 on the quarterly MDS, and required total assistance with most ADLs. The resident’s records showed use of antipsychotic, antidepressant, and antianxiety medications, and the psychotropic drug use CAA identified the resident as having psychotropic medication use related to a psychiatric condition, with monitoring for side effects and medication review noted in the care plan. Resident 21’s physician order for compounded lorazepam cream, given topically every four hours PRN for dementia with agitation, did not include a stop date. The MRR later documented that there was no stop date for the PRN Ativan, and the MAR reflected a PRN psychotropic medication review process that was due but not initialed as completed. The practitioner’s concern and assessment noted that PRN compounded lorazepam required a 14-day review separate from the prescription, and that an extended end date could be used only if the review was completed and the rationale for extended use was documented; the stated rationale was progressive dementia with behaviors.
Failure to Assist With Facial Hair Grooming
Penalty
Summary
The facility failed to offer and provide assistance with grooming facial hair for a resident who participated in her hygiene activities but needed staff assistance. The resident had diagnoses of macular edema and Meniere's disease, and her admission MDS documented a BIMS score of 14 with maximal assistance needed for most ADLs and supervision for personal hygiene. The CAA identified that she required assistance with ADLs, had impaired balance and transition during transfers, and had functional impairment in activity, with generalized weakness and decreased safety awareness noted as contributing factors. Her care plan, revised later, directed staff to provide one-person assistance with bathing and showering, but it did not include documentation for personal hygiene assistance or preferences. The resident's personal hygiene task record documented her as independent with personal hygiene, including combing hair, shaving, applying makeup, and washing and drying her face and hands. During observation, she was in her room self-propelling in her wheelchair and had several long facial hairs on her face, about one-half inch long; she stated she did not know she had facial hair and did not like it, and she appeared somewhat confused and repeated questions. A later observation showed the facial hair was still present. Staff interviews reflected differing expectations about facial hair removal, with some stating preferences should be care planned and others stating staff should remove unwanted facial hair on shower days or as needed. The facility did not provide a policy for ADLs.
Failure to Follow Fall Prevention Care Plans
Penalty
Summary
The facility failed to follow care planned interventions intended to prevent falls for two residents. One resident had diagnoses including a right femur fracture, HTN, and narcolepsy, and the admission MDS documented severe cognitive impairment, prior falls, and a fall with fracture before admission. The falls CAA noted the resident needed assistance with ADLs, had impaired balance during transfers, generalized weakness, decreased safety awareness, and risk for further ADL decline, falls, and pain. The care plan identified the resident as a fall risk and was later updated after falls to require two staff for all transfers and to use a body pillow on the bed to prevent falls. Despite those interventions, the resident fell off the bed onto the floor when the body pillow was not in use and was on another bed in the room. During observation, CNA M assisted the resident with a transfer in a manner that included removing wheelchair foot pedals, applying a gait belt, positioning a walker in front of the resident, and pulling the resident forward to stand; the resident was unsteady and began falling before being lowered into a recliner. The CNA stated she was not aware of any special instructions on the care plan for transferring the resident, and an administrative nurse stated staff were expected to follow the care plan after falls were reviewed and interventions were added. A second resident had diagnoses including vascular dementia, generalized muscle weakness, and osteoarthritis, with MDS assessments showing moderate to severe cognitive impairment, multiple noninjury falls, and one nonsevere injury fall. The falls CAA documented impaired balance during transfers, generalized weakness, decreased safety awareness, and risk for further ADL decline, falls, and pain. The care plan identified the resident as a fall risk and instructed staff to keep the walker within reach; after a prior fall, it was updated to include Dycem in the chair and wheelchair. During observation, two CNAs assisted the resident with a transfer, but the recliner and wheelchair did not have Dycem in them, and the walker was placed against another wall rather than kept within reach. One CNA stated she was not aware the care plan required Dycem in the wheelchair and recliner or that the walker should be kept within reach.
Missing enteral feeding order and delayed RD assessment
Penalty
Summary
The facility failed to ensure a resident with a G-tube had a physician order specifying the type of enteral formula to be administered and/or RD assessment and direction until six days after admission. The resident had diagnoses including partial intestinal obstruction, malignant neoplasm of the colon, and severe calorie protein nutrition, and the admission BIMS score was 12, indicating moderately impaired cognition. The base line care plan documented staff were to provide tube feeding of Jevity 1.5, but the hospital discharge orders lacked a tube feeding or diet order, and the physician orders lacked an order for Jevity 1.5 or any enteral feeding solution as well as an NPO order. The RD nutrition assessment completed on 09/09/25 documented a diet order for enteral feedings at 45 ml/hour gravity with Jevity 1.5 and noted the resident was NPO and receiving tube feedings via gravity. During observation, the resident had a tube feeding bag connected to a feeding pump with only a date and time written on the bag, and the resident stated she did not know how much enteral feeding she would receive. Staff interviews confirmed the physician order did not state the type or amount of enteral feed to be administered, and administrative staff stated the RD assessment should have been completed before admission while the consultant RD stated she expected the nutritional assessment within 72 hours after admission.
Insulin Given Despite Blood Sugar Below Ordered Hold Parameters
Penalty
Summary
The facility failed to act on blood sugar monitoring for a resident with diabetes mellitus when Humalog insulin was administered even though the resident’s blood glucose was below the physician-ordered hold parameters. The resident’s EMR documented diabetes mellitus, and MDS assessments showed the resident had moderate to severe cognitive impairment and received insulin daily. The physician’s order directed staff to give Humalog eight units after meals, but to hold the insulin for blood sugars under 100 mg/dl or if meals were refused, and to notify the physician for blood sugar over 350 mg/dl or less than 60 mg/dl. The August 2025 MAR showed multiple instances in which the resident’s blood sugar was below 100 mg/dl and Humalog was still administered, including fasting or post-meal readings of 94, 91, 92, 88, 99, 97, and 98 mg/dl. Administrative Nurse F stated staff checked blood sugars fasting and two hours after meals and used those readings to decide whether to hold or give insulin after the resident ate. Administrative Nurse D stated staff were expected to check blood sugar as ordered and then give or hold insulin according to the physician’s parameters. The facility’s medication administration policy stated medications are to be administered as prescribed in accordance with good nursing principles and practices.
Inaccurate PBJ Staffing Reporting
Penalty
Summary
The facility failed to electronically submit accurate direct care staffing information through Payroll-Based Journaling (PBJ) based on payroll and other verifiable and auditable data. For FY 2025 Quarter 1, the PBJ Staffing Data Report documented that the facility did not have Licensed Nurse coverage 24 hours a day on 10/13/24, 10/20/24, 12/1/24, 12/8/24, and 12/24/24. However, review of the Daily Nurse Staffing Form and Payroll Data Sheets showed those dates were covered with the required Licensed Nurse coverage for 24 hours each day. During interview on 09/11/25 at 10:14 AM, Administrative Staff A stated that the Regional Human Resources staff would complete the PBJ report and that she expected the PBJ to be reported accurately. The facility did not provide a policy for Payroll Based Journal.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Dodge City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Trinity Manor | 0.7 mi | ★★★★★ | 0 | 0 |
| Kansas Soldiers Home | 1.3 mi | ★★★★★ | 5 | 0 |
| Sunporch Of Dodge City | 2.9 mi | ★★★★★ | 1 | 0 |
| Southwind At Spearville | 14.9 mi | ★★★★★ | 19 | 0 |
| The Shepherd's Center | 18.8 mi | ★★★★★ | 24 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.