Above average — CMS composite of the measures below.
The next survey window likely opens around November 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 The Green Prairie Rehabilitation Center during CMS and state inspections, most recent first.
Delayed response to resident call lights: Multiple residents reported waiting 20 to 110 minutes for staff to answer call lights, including one resident with mild cognitive impairment who sometimes waited 45 minutes and another cognitively intact resident who filed grievances after waiting about 1 hour on separate occasions. Call light logs confirmed repeated extended waits for several residents, and staff acknowledged that hall screens only showed which rooms had call lights on while the nurses’ station computer showed the exact activation times.
A resident with no cognitive impairment reported that the transition strip between her room and bathroom floors was not secured and that she had caught her shoe on it while using the restroom. Staff entered a maintenance request, but the record was marked completed even though the strip remained unsecured, and the administrator confirmed the issue was known and unresolved.
A facility failed to complete a baseline AIMS for one resident on Seroquel and failed to document monthly orthostatic BP monitoring for two residents receiving antipsychotics. The residents had cognitive impairment and multiple medical diagnoses, and their care plans and MARs called for monitoring of psychotropic ADRs, including orthostatic BP checks and TD/AIMS screening. RN, DON, MD, and pharmacy interviews confirmed the missing monitoring and the lack of a baseline assessment.
Failure to develop a comprehensive fall care plan for a resident with repeated falls. The resident had intact cognition, used a walker, and was identified as a moderate fall risk with dementia-related debility and intermittent confusion. Incident notes showed multiple falls related to not using the walker and poor balance, including injuries such as a nosebleed, bruising, knee pain, and a back abrasion. Observation showed the resident ambulating without the walker and wearing socks without grippers, and staff and leadership confirmed the care plan lacked footwear, frequent checks, and other person-centered fall interventions.
Pharmacist reviews failed to identify missing orthostatic BP monitoring for 2 residents receiving antipsychotics. One resident had cognitive impairment, falls, orthostatic hypotension, HF, HTN, DM, and quetiapine orders, but the MAR, VS, and notes lacked evidence orthostatic BPs were attempted and the pharmacist did not address the missing baseline or monitoring. The other resident had cognitive impairment, CKD, delirium, and fall history, received Seroquel, and the TAR, VS, and notes also lacked orthostatic BP documentation, yet monthly pharmacy reviews did not flag the omission.
Incomplete and inaccurate behavior documentation was found for a resident with major depressive disorder and documented negative behaviors. The resident’s TAR repeatedly showed no behaviors and no interventions, while progress notes described isolation, sleeping all shift, not eating, verbal outbursts, racial slurs, profanity, refusal of cares, accusations toward staff, and yelling in the hall. NA-C, NA-D, RN-C, the DON, and MD-A confirmed target behaviors were expected to be documented in the TAR so providers could assess whether behavior medications were effective.
Improper PPE Use During EBP Care: A resident on EBP had chronic lower leg wounds, cellulitis, and urinary incontinence, and staff did not consistently follow PPE requirements during toileting and transfer care. During observation, one nurse wore a gown and gloves, but a nursing assistant entered without a gown and assisted with toileting and transfer care while her clothing made contact with the resident. Interviews showed mixed understanding among CNA, agency RN, and RN staff about when gowns were required, and the DON stated gowns and gloves were not expected for transfers despite the facility’s EBP policy listing transferring and toileting as high-contact care activities.
The facility did not provide a suitable and nourishing snack for residents when there was a 15-hour gap between dinner and breakfast. Although snacks and sandwiches were available, they were not consistently offered to all residents. The dietary manager, registered dietician, and other staff were unaware of the requirement for a substantial snack, which should include a protein and a carbohydrate. The facility's policy lacked specific meal times, and the responsibility to monitor adherence was not fulfilled.
The facility failed to consistently perform ROM exercises and ambulation for two residents, leading to deficiencies in their restorative therapy programs. One resident with hemiplegia had numerous missed ROM sessions, while another with rheumatoid arthritis reported infrequent ambulation despite a daily walking program. Staff interviews revealed inconsistencies in program execution and documentation, with the DON acknowledging the lack of routine checks unless concerns were reported.
A resident admitted with orders for physical and occupational therapy did not receive these services due to payor source concerns. The resident, who was nonverbal and dependent on staff, had specific therapy and PROM orders that were not entered into the EMR or initiated. Facility staff confirmed the orders were not executed, and no discontinuation orders were obtained.
Delayed Response to Resident Call Lights
Penalty
Summary
The facility failed to ensure resident call lights were answered in a timely manner for multiple residents who reported prolonged waits for assistance. One resident with mild cognitive impairment stated she sometimes waited 45 minutes for staff to respond and reported having to search for staff when her urinary catheter bag was full. During a grievance review, the administrator checked the call light response screen and found the resident’s call light had been on for 12 minutes, and the call button remained on throughout the conversation until it was turned off after 26 minutes total. The resident also stated she wanted staff to acknowledge when they were busy and let her know they had seen her call light. Call light logs showed repeated extended response times for this resident, with 13 call light events ranging from 22 to 61 minutes over the reviewed period. Another resident, who was cognitively intact, filed grievances stating he waited about 1 hour for staff to answer his call light on two separate occasions. Facility review of the call bell report identified waits of 58 minutes on one grievance and a call light log showing a 110-minute wait on another. The resident’s call light logs also showed 13 events ranging from 21 to 71 minutes during the reviewed period. Additional resident interviews and call light logs showed similar delays for other residents. One resident reported call light waits of at least 30 minutes up to an hour and a half and said he sometimes had to stop waiting. Another resident said he took his cell phone to the bathroom and played games while waiting for staff, stating it could take two games of cribbage before staff entered. Call light logs for several other residents showed waits ranging from 20 to 80 minutes, and a nursing assistant stated the hall screens only showed which room numbers had call lights on, while the nurses’ station computer showed the exact time the lights were activated.
Unsecured Floor Transition Strip
Penalty
Summary
The facility failed to ensure a flooring transition strip was fixed and secure for one resident who had no cognitive impairment on the quarterly MDS assessment dated 8/28/25. During observation and interview on 12/1/25, the resident stated the transition strip between her room floor and bathroom floor was not secured to the floor, that she had caught her shoe on it while using the restroom, and that she had told the facility about the issue approximately 2 weeks earlier without receiving follow-up about when it would be fixed. Record review showed a maintenance request was submitted on 11/25/25 to repair or secure the transition strip, and the maintenance record later showed the request as completed on 12/1/25 even though the strip had not been repaired or secured. During interview on 12/4/25, the administrator stated she was aware the transition strip needed repair or securing and confirmed it remained unsecured.
Failure to complete baseline AIMS and monthly orthostatic monitoring for residents on antipsychotics
Penalty
Summary
The facility failed to ensure a baseline abnormal involuntary movement assessment was completed for one resident receiving antipsychotic medication and failed to ensure proper side effect monitoring was in place for two residents receiving Seroquel. One resident had diagnoses including auditory hallucinations, heart failure, repeated falls, orthostatic blood pressure, and depression, and the quarterly MDS showed moderate cognitive impairment with no behaviors. The resident’s care plan called for monitoring for psychotropic drug adverse reactions, including monthly orthostatic blood pressures and TD/AIMS screening per protocol, but the medical record lacked a baseline assessment. For that resident, the MAR showed Seroquel was ordered in varying doses over time, and the TAR, vital signs record, and progress notes did not document that orthostatic blood pressures were attempted or refused. A second resident with moderate cognitive impairment, delirium, a history of falling, depression, and a history of bladder and colon cancer also received Seroquel twice daily. That resident’s care plan and MAR required monthly orthostatic blood pressure monitoring while receiving antipsychotic medications, but the TAR, vital signs, and progress notes did not show orthostatic blood pressures were attempted or refused. During interviews, the RN stated orthostatic blood pressure monitoring was documented on the MAR/TAR and that staff would obtain vital signs if a resident had odd symptoms. The DON stated the facility obtained consent, monitored target behaviors and side effects, and completed a baseline AIMS assessment when initiating antipsychotics, and confirmed the two residents did not have orthostatic blood pressure monitoring in place and that one resident lacked a baseline assessment. The MD stated orthostatic measurements were expected at least monthly while residents were taking antipsychotic medications, and the pharmacist stated she reviewed side effect monitoring and vital signs during monthly pharmacy reviews but did not monitor to ensure monthly orthostatic measurements were being completed.
Failure to Develop a Comprehensive Fall Care Plan
Penalty
Summary
The facility failed to identify the root causes of repeated falls for a resident with intact cognition, independent eating, sit-to-stand movement, and ambulation with a walker. The resident’s MDS assessment showed fall risk, and the fall CAA noted prior falls and ongoing physical debility secondary to dementia. The care plan revised on 10/2/25 included only basic interventions such as keeping the call light within reach, keeping the room clean and free of clutter, and monitoring/documenting safety, but it did not include additional fall interventions after that date. The resident’s record also lacked analysis of each subsequent fall and did not show any new interventions after the falls occurred. Incident notes documented multiple falls in which the resident was ambulating without the walker, including trying to sit in a recliner too soon, turning and losing balance while trying to get something across the room, and falling while moving from bed to chair with feet tangled; one fall caused a nosebleed, left knee pain, and bruising above the left eye, and another caused a 4 cm abrasion to the mid back. During observation, the resident was seen sitting at the side of the bed in socks without grippers, walking without the walker, and being assisted to the bathroom without shoes being put on first. Staff interviews identified the resident as a moderate fall risk due to intermittent confusion and not using the walker, and the DON, ADON, and MD confirmed the care plan was not comprehensive and did not include appropriate footwear, frequent observations, or keeping the walker close.
Pharmacist Failed to Identify Missing Orthostatic BP Monitoring With Antipsychotic Use
Penalty
Summary
The facility failed to ensure the consultant pharmacist identified irregularities during monthly drug regimen reviews for 2 residents receiving antipsychotic medications. For one resident, the quarterly MDS showed moderate cognitive impairment with no behaviors, partial to substantial assistance needs, and diagnoses including debility/cardiorespiratory conditions, orthostatic hypotension, heart failure, high blood pressure, diabetes, auditory hallucinations, repeated falls, and depression. The care plan called for monitoring for psychotropic adverse drug reactions, including monthly orthostatic blood pressures and TD/AIMS screening, but the MAR, vital signs, and progress notes lacked documentation that orthostatic blood pressures were attempted, and the medical record lacked a baseline assessment. That resident’s MAR showed quetiapine orders beginning with 12.5 mg at bedtime, later changed to 12.5 mg at bedtime and 12.5 mg as needed, and then to 12.5 mg during the day and 25 mg at bedtime. The pharmacist’s recommendation forms dated 10/3/25 and 11/3/25 noted the active quetiapine orders but did not mention initiating orthostatic blood pressure monitoring or obtaining a baseline assessment. Although the pharmacist made recommendations on those dates, the 12/1/25 review found no irregularities. For the second resident, the quarterly MDS showed moderate cognitive impairment with no behaviors and partial to moderate assistance needs, with diagnoses including chronic kidney disease, delirium, history of falling, depression, and history of bladder and colon cancer. The care plan required monthly orthostatic blood pressure monitoring and TD/AIMS screening with antipsychotic use, and the MAR/TAR listed Seroquel 12.5 mg at 4 p.m. and 8 p.m. with monthly orthostatic blood pressure monitoring on the 3rd of each month. However, the TAR, vital signs record, and progress notes lacked documentation that orthostatic blood pressures were attempted or refused, and pharmacy reviews from July 2025 through December 2025 did not note the missing measurements or recommend that they be completed.
Incomplete and Inaccurate Behavior Documentation
Penalty
Summary
Medical records were not complete and accurately documented for one resident whose quarterly MDS dated 8/28/25 identified no cognitive impairment but did note behavior symptoms occurring 1 to 3 days. The resident’s care plan addressed altered mood and behavior related to major depressive disorder, including that the resident was known to make inappropriate racial jokes or comments, could be malcontent about care and environmental concerns, and could refuse care and later file grievances. The resident’s orders required target behaviors to be monitored every shift and documented in the nursing progress notes, with behaviors including isolation, depressive statements, crying, and feelings of helplessness, along with any non-pharmacological interventions used. Review of the TAR and progress notes showed multiple instances where the TAR documented no behaviors and no interventions for all shifts, while the progress notes described behaviors that matched the ordered target behaviors. On 10/17/25, the TAR showed no behaviors, but a progress note stated the resident stayed in her room all shift, slept all shift, and did not eat dinner. On 11/26/25, the TAR showed no behaviors, but a progress note documented verbal outbursts with staff, racial slurs, and profanities. On 11/28/25, the TAR again showed no behaviors, but progress notes documented refusal of cares, accusations toward staff, and yelling in the hall. Interviews with NA-C, NA-D, RN-C, the DON, and MD-A confirmed that target behaviors were expected to be charted as observed in the TAR so providers could determine whether behavior medications were effective, and the DON and MD-A both stated they would have expected the specific negative behaviors to be documented.
Improper PPE Use During EBP Care
Penalty
Summary
The facility failed to ensure proper use of PPE for a resident on enhanced barrier precautions (EBP) who had chronic lower leg wounds, cellulitis of the lower limb, urinary incontinence, and open lesions and skin tears. The resident’s MDS indicated the resident was cognitively intact, required assistance with multiple activities of daily living, and was dependent on staff for toilet hygiene. The care plan addressed altered nutrition related to wound healing, urinary incontinence, discomfort related to wounds and immobility, and alteration to skin related to wounds. Provider orders directed staff to follow EBP during wound care and other high-contact care activities, along with dressing changes to the resident’s open lower leg wounds. During observation, a sign outside the resident’s room indicated EBP and a supply cart with gloves and gowns was located nearby. One nurse sanitized hands, applied a gown and gloves before entering the room, but a nursing assistant entered shortly after, sanitized hands, and applied gloves only, without a gown. The resident was seated on the commode, and both staff assisted with toileting and transfer care. The nursing assistant and nurse reached behind the resident to hold the incontinence product in place while the resident sat down, and the nursing assistant’s clothing made contact with the resident. After the resident was seated, the nursing assistant removed the gait belt, removed gloves, performed hand hygiene, and left the room. Interviews showed inconsistent understanding of EBP requirements. The nursing assistant stated gowns and gloves were worn for residents on EBP when toileting or doing things with catheters, but said she would not wear a gown when transferring a resident on EBP. A staffing agency nurse stated she would apply PPE for cares but would not wear PPE just for transfers because there was no risk of spreading anything. Another nurse stated staff should wear gowns for dressing changes but not for transfers unless there was risk of exposing the wound. The DON stated staff receive online training and competencies, expects staff to read the signs on residents’ doors, and does not expect staff to wear gowns and gloves when transferring residents. The facility policy defined high-contact resident care activities to include transferring, toileting, dressing, bathing, and wound care.
Failure to Provide Substantial Snack Between Meals
Penalty
Summary
The facility failed to provide a suitable and nourishing snack for residents when there were more than 14 hours between the evening and morning meals. The facility's meal schedule indicated dinner at 5:00 p.m. and breakfast at 8:00 a.m., resulting in a 15-hour gap. During observations, a wicker basket with snacks and a refrigerator with half sandwiches were noted, but it was unclear if these were offered to all residents. Interviews with dietary staff revealed that peanut butter sandwiches were available, but there was no consistent offering of a substantial snack to all residents. The dietary manager and registered dietician were unaware of the 15-hour gap and the requirement for a substantial snack, which should include a protein and a carbohydrate. The director of nursing and administrator acknowledged the gap but were not aware of the need for a substantial snack. The facility's Meal Times policy, dated 9/2012, stated that meals should meet standards with no more than 14 hours between dinner and breakfast, but the policy lacked specific meal times. The hospitality services manager was responsible for monitoring adherence to this schedule, but the deficiency indicates a lapse in this responsibility.
Deficiencies in Restorative Therapy Programs for Two Residents
Penalty
Summary
The facility failed to perform range of motion (ROM) exercises and ambulation as ordered for two residents, leading to deficiencies in their restorative therapy programs. Resident R14, who had a history of stroke and hemiplegia, required maximal assistance for mobility and was on a ROM program for her left lower extremity. Despite the program being established and communicated to nursing staff, documentation revealed numerous instances where the ROM exercises were not performed or recorded, with staff marking 'not applicable' or leaving entries blank. Interviews with staff indicated a lack of awareness and accountability for ensuring the program was consistently executed. Resident R6, diagnosed with rheumatoid arthritis and requiring assistance for ambulation, was supposed to walk daily as part of their care plan. However, the resident reported only being able to ambulate once a week, and documentation showed frequent instances of missed opportunities for walking, with entries marked as 'not applicable' or left blank. Staff interviews revealed inconsistencies in the execution of the walking program, with some staff attributing missed sessions to time constraints or the resident's mood. The Director of Nursing (DON) acknowledged the lack of documentation and stated that completion of ROM and walking programs was expected but not routinely checked unless concerns were raised. The therapy director confirmed that communication forms were used to relay therapy programs to nursing staff, but the execution of these programs was inconsistent, potentially leading to increased weakness in residents. The facility's policy on restorative/maintenance therapy programs was requested but not provided, indicating a possible gap in procedural adherence.
Failure to Provide Ordered Therapy Services Due to Payor Source Concerns
Penalty
Summary
The facility failed to provide necessary physical and occupational therapy services for a resident who was admitted with specific therapy orders. The resident, who was nonverbal and had impairments in both upper and lower extremities, was dependent on staff for all care. Upon admission, the resident had orders for occupational therapy (OT) and physical therapy (PT) evaluations and treatments, as well as a passive range of motion (PROM) program for the left ankle, knee, and hip. However, these orders were not entered into the resident's electronic medical record (EMR) and were not initiated due to concerns about the payor source. Interviews with facility staff, including the occupational therapist and the director of nursing (DON), confirmed that the therapy orders were not executed because of the payor source issue, and no orders were received to discontinue the therapy. The administrator expected that all new admission orders would be entered into the EMR and followed until new orders were obtained. Despite this expectation, the orders were not followed, and the facility's therapy policy was not provided upon request.
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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 Plainview
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Whitewater Health Services | 14.6 mi | ★★★★★ | 3 | 0 |
| Gundersen St Elizabeth's Care Center | 16.4 mi | ★★★★★ | 2 | 0 |
| Rochester Rehabilitation And Living Center | 16.6 mi | ★★★★★ | 7 | 1 |
| Samaritan Bethany Home On Eighth | 17 mi | ★★★★★ | 8 | 0 |
| Rochester Restorative Care Center | 17.2 mi | ★★★★★ | 36 | 1 |
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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.