Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Plainview Manor during CMS and state inspections, most recent first.
A facility failed to obtain signed informed consent for psychotropic meds for multiple residents. Residents with dementia, confusion, delusions, anxiety, depression, and other behavioral symptoms were receiving antipsychotic, antidepressant, and antianxiety medications such as risperidone, quetiapine, sertraline, lorazepam, buspirone, trazodone, and alprazolam. RN-L said consent forms were not used and updates were given verbally or by phone, and the DON confirmed there was no evidence of resident or RP informed consent.
PRN psychotropic orders lacked required stop dates for three residents. Residents with diagnoses including dementia, anxiety, depression, and significant cognitive or behavioral symptoms had PRN lorazepam or alprazolam orders for anxiety, agitation, or anxiousness, and doses were administered, but the medical record did not show a stop date. The DON confirmed the orders did not have stop dates and should have per facility policy.
Undated Open Insulin Vials and Pens: Open insulin vials and pens for three residents were found without dates showing when they were opened. During a medication cart tour, 4 of 5 opened insulin products were undated, including Lantus, Humalog, and Basaglar. An RN confirmed the items were not dated, and the DON stated opened insulin required a date so staff could track how long it could be safely used.
Failure to timely report major injury fall to APS. A resident fell in the dining room and sustained a head laceration, was sent to the hospital by EMS, and was later found to have an acute on chronic brain bleed. The DON/Administrator was notified the same evening, but APS was not notified within the required 2-hour timeframe.
A resident’s care plan was not updated to reflect EBP during high-contact care, including wound care for a facility-acquired heel pressure ulcer. An LPN provided wound care without gown and glove use at the start of the procedure and stated being unaware the resident was on EBP, while the MDS/Care Plan RN confirmed the care plan had not been revised to include EBP for wound care.
Failure to complete neurological assessments after unwitnessed falls. A resident with non-traumatic brain dysfunction, dementia, and depression had multiple falls, including one with reported head impact and head pain. Although some neuro checks were documented after one fall, staff failed to fully assess and document required neuro findings at one point, and there was no evidence of neuro checks after two later unwitnessed falls when the resident was only oriented to person or person and time.
A resident with a recent hip fracture and marked mobility decline developed a facility-acquired heel pressure ulcer after the care plan was not updated to add heel protection or other skin integrity interventions. The resident was dependent on staff for bed mobility, transfers, and hygiene, and although the care plan addressed increased assistance needs, it did not include measures to keep the heels off the bed until after the heel blister had already appeared.
A resident with moderately impaired cognition, impaired memory, impaired balance, and a history of falls continued to fall, but the facility did not consistently revise fall-prevention interventions beyond education to call for help. After an unwitnessed fall, a PT eval found no new fall-prevention recommendations; later falls included the resident found on the bathroom floor with hypotension, rolling out of bed, and being found on the floor next to the bed while looking under it. Staff and the DON confirmed the resident did not always remember to call for assistance and that education alone was not an effective intervention.
A resident with obstructive uropathy, diabetes, and a suprapubic catheter remained on Macrobid 100 mg daily for UTI prophylaxis without a stop date or documentation supporting ongoing need. The resident was later treated for a UTI with Cipro while still receiving the antibiotic, and PCP and urology reviews did not address the continued Macrobid use.
Failure to use EBP during wound care for a resident with a heel pressure ulcer. An LPN removed the heel boot and performed wound care without a gown and initially without gloves, despite a door sign indicating EBP and a facility policy requiring gown and glove use for wound care and other high-contact care. The LPN said she was unaware the resident was on EBP, and the care plan was not updated to reflect EBP.
A resident with severe cognitive impairment and a history of wandering was found outside the facility alone. Despite being at high risk for wandering and falling, the resident was not wearing a wander guard. The facility failed to report the elopement to APS or the State Agency as required by their policy.
The facility failed to ensure that the Social Service Director (SSD-M), responsible for transporting residents, maintained current CPR certification. This deficiency was identified when SSD-M, who transported two residents requesting CPR in their Advanced Medical Directives, was found not to be CPR certified. The facility's policy required CPR training and certification for personnel, but SSD-M was not listed as a participant in the training roster and confirmed the lack of certification during an interview.
A resident with dementia, without behavioral or psychotic disturbances, was administered Quetiapine Fumurate daily without a supporting diagnosis. The facility's policy requires a review of antipsychotic medications to prevent unnecessary use, but this was not adhered to. The DON confirmed the absence of a diagnosis to justify the medication.
The facility did not verify the state nurse aide registry for two dietary aides before employment, contrary to its policy requiring such checks to prevent hiring individuals with a history of abuse. The Business Office Manager confirmed the oversight, affecting the facility's compliance with ensuring resident safety.
Missing informed consent for psychotropic medications
Penalty
Summary
The facility failed to obtain signed informed consent for the use of psychotropic medications for multiple residents. The deficiency was cited under 175 NAC 12-006.12 after record review and staff interviews showed no evidence of signed consent forms for residents receiving antipsychotic, antidepressant, and antianxiety medications. The facility policy stated psychotropic medications were to be used only after causes of behavioral symptoms were identified and addressed, and that residents and/or families were to be notified quarterly of the medication regimen. Resident 1 had forgetfulness, confusion, impaired decision making, and was receiving risperidone, lorazepam, and sertraline for bipolar disorder and anxiety-related symptoms. Resident 2 had severe cognitive impairment, Alzheimer’s dementia, delusions, hallucinations, and inappropriate behavior, and was receiving quetiapine fumarate for moderate psychotic disturbance related to Alzheimer’s disease. Resident 12 had non-Alzheimer’s dementia, major depression, anxiety disorder, delusions, mild cognitive deficit, confusion, and disorientation, and was receiving escitalopram, buspirone, and lorazepam. Resident 17 had severe cognitive impairment, confusion, forgetfulness, sexually inappropriate language and behaviors, non-Alzheimer dementia, and anxiety, and was receiving trazodone, lorazepam, and Seroquel. Resident 34 had restlessness, delusions, confusion, anxiety disorder, depression, and dementia, and was receiving sertraline and alprazolam. RN-L stated she was unaware of any signed consent forms for psychotropic medications and reported that residents or responsible parties were updated verbally or by phone for medication changes. The DON confirmed the facility had no evidence that resident or responsible party informed consent had been obtained for psychotropic medications.
PRN Psychotropic Orders Lacked Required Stop Dates
Penalty
Summary
The facility failed to have stop dates for PRN antianxiety medications for Residents 12, 17, and 34. The facility policy on psychotropic medication use stated that PRN psychotropic medications would not be given beyond 14 days unless the medication was needed to treat a specific condition documented in the clinical record, and that continued use beyond 14 days required evaluation by the health care provider and documentation of the specific reasons and duration. Review of the records showed that Resident 12 had diagnoses of Non-Alzheimer's Dementia, Anxiety, and Depression, had delusions and mild cognitive impairment, and had a PRN lorazepam order for anxiety with doses given on 8/2/25 and 8/5/25, but no stop date was documented. Resident 17 had diagnoses of Non-Alzheimer Dementia and Anxiety, severe cognitive impairment, hallucinations, delusions, and behavioral symptoms including hitting, public sexual acts, and screaming out. The resident had a PRN lorazepam order for agitation and received doses on 8/1/25, 8/2/25, 8/3/25, and 8/5/25, but the medical record did not show a stop date. Resident 34 had diagnoses of Non-traumatic Brain Dysfunction, Dementia, Anxiety, and Depression, with delusions, verbal behaviors, rejection of care, wandering, and mild cognitive impairment. The resident had a PRN alprazolam order for anxiousness, last received on 7/26/25, and the medical record also lacked a stop date. The DON confirmed on 8/7/25 that the PRN psychotropic medications for Residents 12, 17, and 34 did not have stop dates and should have per facility policy.
Undated Open Insulin Vials and Pens
Penalty
Summary
The facility failed to label open insulin vials and pens with the date they were opened for Residents 2, 13, and 14, so staff could not verify how long the insulin had been in use. The cited deficiency involved storage and labeling of drugs and biologicals, and the report states that all drugs and biologicals were to be stored in locked compartments and that discontinued, outdated, or deteriorated medications were to be returned to the dispensing pharmacy or destroyed. The facility policy on Insulin Administration did not address dating insulin once opened, based on practice standards to avoid use beyond its effectiveness. During a tour of the medication carts, 4 of 5 opened insulin vials/pens were found without an open date. The undated insulin products identified were Lantus 30 units nightly and Humalog 5 units three times daily and per sliding scale for Resident 2, Basaglar 22 units in the morning and 12 units in the evening for Resident 13, and Lantus 45 units nightly for Resident 14. An RN confirmed the insulin vials/pens were not dated when opened, and the DON confirmed that all insulin once opened required a date to alert staff of how long it could be safely used.
Failure to Timely Report Major Injury Fall to APS
Penalty
Summary
The facility failed to report a fall with major injury within the required time frame for one resident. The facility policy on Resident Abuse and Neglect stated that any injury resulting in possible fracture, laceration, or stitches must be notified to the Administrator within 2 hours and reported to Adult Protection Services (APS). On 8/11/25 at 7:20 PM, Resident 17 fell in the dining room and sustained a laceration to the top of the head, and emergency services transported the resident to the hospital. The Administrator was notified at 7:35 PM that evening of the fall with major injury and transfer to the hospital, and later at 9:42 PM was notified that the resident would be admitted and had an acute on chronic brain bleed. APS was not notified until 8/12/25 at 8:42 AM, and the Administrator confirmed in interview that APS was not notified within 2 hours of being notified of the injury.
Care Plan Not Updated for Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to ensure Resident 7’s care plan was reviewed and revised to reflect the use of Enhanced Barrier Precautions during high-contact care activities, including wound care. The facility policy stated that EBP required gown and glove use during high-contact resident care, and that EBP was indicated for residents with wounds. During an observation of wound care, an LPN entered Resident 7’s room and removed the heel boot and dressing from the resident’s right foot before putting on gloves, and no gown was used. The LPN then cleansed the wound, changed gloves, and applied betadine to a facility-acquired pressure ulcer on the resident’s heel. The LPN later confirmed the area being treated was a facility-acquired pressure ulcer. During interviews, the LPN stated being unaware that Resident 7 was on EBP and acknowledged that residents on EBP require gown and glove use during wound care. A nurse aide stated awareness that Resident 7 was on EBP and that gown and gloves were required during care such as toileting, dressing, and transfers. The MDS/Care Plan RN confirmed that Resident 7’s care plan was not updated to reflect the use of EBP during high-contact care activities such as wound care.
Failure to Complete Neurological Assessments After Unwitnessed Falls
Penalty
Summary
The facility failed to complete neurological assessments after unwitnessed falls for one resident. The resident had diagnoses of non-traumatic brain dysfunction, non-Alzheimer's dementia, and depression, with moderately impaired cognition, urinary incontinence, a history of falls with injury, and use of a wander/elopement alarm. The facility's neurological assessment policy required assessments after an unwitnessed fall, after a fall with suspected head injury, or when indicated by the resident's condition, and the procedure included checking orientation, speech, pupil reaction, motor ability, sensation, and facial drooping. After a fall on 9/17/24 at 7:25 PM, the resident reported trying to go after a spider, losing balance, hitting their head on the floor, and having head pain. Neurological checks were documented at 9:00 PM, 11:00 PM, and 1:00 AM, but at 5:00 AM staff failed to assess or document skin condition, hand grasps, pupil reaction, level of orientation, speech, motor response, and level of consciousness, with no indication of refusal. After an unwitnessed fall on 4/7/25 at 6:00 AM, when the resident was only oriented to person and time, there was no evidence neurological checks were completed. After another unwitnessed fall on 4/15/25 at 11:32 AM, when the resident was only oriented to person, there was again no evidence neurological assessments were completed.
Failure to Update Pressure Injury Prevention After Mobility Decline
Penalty
Summary
The facility failed to implement new measures to prevent pressure ulcer development for a resident after a significant condition change. The resident was dependent on staff for bed mobility, transfers, and hygiene, had functional limitations to both lower extremities, and had a surgical wound but no pressure ulcers on the 6/27/25 MDS. After the resident returned from the hospital on 6/24/25 following a hip fracture and surgical repair, the care plan was updated for increased assistance with hygiene, dressing, toileting, bed mobility, and ambulation, but the skin integrity interventions were not revised to address the resident’s changed mobility status. The resident’s care plan had identified skin impairment risk and included monitoring and a pressure relief mattress, but no additional interventions were added after the hip fracture to keep the heels off the bed or otherwise protect the heels until after a heel blister had already developed. On 7/7/25, the resident was found to have a fluid-filled blister on the heel, approximately 4 cm by 4 cm, secondary to left lower extremity weakness related to the hip fracture. During wound care observation on 8/7/25, the heel area was described as a golf ball sized area of blackened skin on the left heel, and the LPN confirmed it was a facility-acquired pressure ulcer. The DON and MDS/Care Plan RN confirmed the care plan had not been updated to include support surface changes or heel protection due to loss of mobility until after the pressure area developed.
Failure to Revise Fall Prevention Interventions for a Resident with Recurrent Falls
Penalty
Summary
The facility failed to develop and/or revise interventions for the prevention of ongoing falls for one resident with a history of falls. The resident was admitted with diagnoses of non-traumatic brain dysfunction, non-Alzheimer's dementia, and depression, and was assessed as having moderately impaired cognition, frequent urinary incontinence, impaired memory, impaired balance, and use of a wander/elopement alarm. The resident had an unwitnessed fall after reporting going after a spider and losing balance, and the only intervention identified was education to call staff for assistance and a PT evaluation. A PT progress note later documented no new recommendations related to fall prevention. The resident had additional falls after that event, including being found on the bathroom floor with a blood pressure of 67/39 and difficulty arousing, which led to discontinuation of a blood pressure medication, then rolling out of bed and onto the floor, which resulted in an assist bar being placed on the bed. The resident later fell again after staff heard the resident calling out and found the resident on the floor next to the bed while the resident was looking for something under the bed. The report identified the resident as oriented to person only at that time, and the only intervention listed was education to seek staff assistance. Nursing staff and the DON confirmed the resident had a history of falls, did not always remember to call for help, had impaired cognition, and that education alone was not an effective intervention to prevent further falls.
Unnecessary Long-Term Antibiotic Use Without Stop Date or Clinical Support
Penalty
Summary
The facility failed to ensure a resident’s drug regimen was free from unnecessary drugs related to long-term use of Macrobid 100 mg daily for prophylaxis. The resident was admitted with diagnoses including obstructive uropathy and diabetes and had a suprapubic catheter due to prostate catheter and obstructive uropathy. The admission order summary showed Macrobid 100 mg once daily with no stop date, and the care plan identified the medication as prophylactic use for prevention of UTI. The resident continued to receive Macrobid without documentation supporting ongoing clinical need based on symptoms or laboratory results. Nursing progress notes showed the resident was treated for a UTI with Cipro while still on Macrobid prophylaxis. Health status progress notes reflected PCP review of the record and medication use, but there was no evidence the PCP addressed the continued Macrobid use. A urology visit note also failed to assess the continued use of Macrobid, and the resident was still receiving the medication without a stop date at the time of review. The Infection Preventionist confirmed there was no evidence the urologist or PCP addressed the need for a stop date or continued indication for the antibiotic.
Failure to Use Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions during wound care for Resident 7. The facility policy stated that EBP required targeted gown and glove use during high contact resident care activities, including wound care, for residents with wounds and that EBP remained in place for the duration of the resident's stay or until wound resolution or discontinuation of an indwelling medical device. On 8/6/25, a sign on Resident 7's door indicated the resident was on Enhanced Barrier Precautions. During wound care on 8/7/25, an LPN entered the room, told the resident she was going to change the foot dressing, and removed the resident's left heel boot without first putting on a gown or gloves. The LPN then put on gloves, removed and disposed of a foam dressing from the left heel, exposed a golf ball sized area of blackened skin on the heel that was not open or draining, cleaned the wound, changed gloves, painted the area with liquid betadine, and replaced the heel boot. The LPN completed the wound care without wearing a gown and later stated she was unaware the resident was on EBP, while confirming that residents on EBP require a gown and gloves during wound care. The care plan RN confirmed the care plan was not updated to reflect EBP during high contact care, and the DON confirmed that EBP, including gowns and gloves, was required during wound care for Resident 7.
Failure to Report Resident Elopement
Penalty
Summary
The facility failed to report an elopement incident involving a resident with severe cognitive impairment and a history of wandering. The resident, who was admitted with diagnoses including high blood pressure, arthritis, and dementia, was found outside the building alone. Despite being identified as high risk for wandering and falling, the resident was not wearing a wander guard at the time of the incident. Upon being found, the resident was assisted back inside, and a wander guard was subsequently placed on their wrist. The facility's policy required that such incidents be reported to Adult Protective Services (APS) within 24 hours, or within 2 hours if injury and medical treatment were needed. However, there was no documentation indicating that the Director of Nursing (DON), Administrator, Provider, or APS had been notified of the elopement. An interview with the Administrator confirmed that the incident was not reported to the State Agency, highlighting a failure to adhere to the facility's elopement emergency policy.
Failure to Ensure CPR Certification for Transport Personnel
Penalty
Summary
The facility failed to ensure that the Transportation Personnel maintained current Cardiopulmonary Resuscitation (CPR) credentials, which had the potential to affect two residents out of a total of 23 sampled residents. The facility's policy required personnel to have completed CPR training and to initiate CPR for victims of sudden cardiac arrest unless a Do Not Resuscitate (DNR) order was in place. The policy also stated that if a resident's DNR status was unclear, CPR should be initiated until the status was determined. Training was to be provided biannually, and staff were required to provide the facility with a current CPR card upon completion. The deficiency was identified when it was found that the Social Service Director (SSD-M), who was responsible for transporting residents in the facility van, did not have current CPR certification. This was confirmed through a review of the CPR training roster, which did not list SSD-M as a participant, and an interview with SSD-M, who confirmed the lack of certification. The Director of Nursing (DON) indicated that a CPR-certified staff member should always be available for residents who have requested CPR in their Advanced Medical Directives. Both residents involved had requested CPR for witnessed cardiac or respiratory arrest, yet were transported by SSD-M, who was not certified in CPR.
Lack of Supporting Diagnosis for Antipsychotic Medication
Penalty
Summary
The facility failed to have a supporting diagnosis for the use of an antipsychotic medication for Resident 25. The facility's policy on psychotropic medication review and gradual dose reduction mandates that all antipsychotic medications be reviewed upon admission and quarterly to minimize unnecessary drug use and adverse reactions. However, a review of Resident 25's records revealed that the resident, who had a diagnosis of dementia without behavioral, psychotic, or mood disturbances, was taking Quetiapine Fumurate 25 milligrams daily at bedtime without a supporting diagnosis for its use. The Minimum Data Set (MDS) for Resident 25 indicated severe cognitive impairment with symptoms of inattention and disorganized thinking, yet there was no documented diagnosis justifying the antipsychotic medication. During an interview, the Director of Nursing confirmed the absence of a diagnosis to support the use of the antipsychotic medication for this resident. This oversight indicates a failure to adhere to the facility's policy and regulatory requirements regarding the use of psychotropic medications.
Failure to Verify State Nurse Aide Registry for Dietary Aides
Penalty
Summary
The facility failed to ensure that residents were free from potential abuse by not verifying the absence of negative findings in the state nurse aide registry for two dietary aides, identified as F and K, out of five employee records reviewed. The facility's policy required all employees to have license verifications completed via the state board of licensure/registry and prohibited the employment of individuals with a history of documented resident abuse. However, upon review of the employee records for Dietary Aide F, hired on February 13, 2024, and Dietary Aide K, hired on February 15, 2024, there was no evidence that the state nurse aide registry had been checked for adverse findings prior to their employment. An interview with the Business Office Manager confirmed the lack of documentation verifying the registry checks for these employees, who had been working since their respective hire dates in February 2024. The facility census at the time was 34 residents.
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What surveyors actually found near you
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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) |
|---|---|---|---|---|
| Avera Creighton Care Centre | 10 mi | ★★★★★ | 7 | 0 |
| Accura Healthcare Of Pierce | 17.7 mi | ★★★★★ | 2 | 0 |
| Good Samaritan Society - Bloomfield | 18.5 mi | ★★★★★ | 8 | 0 |
| Accura Healthcare Of Neligh | 19.5 mi | ★★★★★ | 2 | 0 |
| Alpine Village Retirement Center | 20.6 mi | ★★★★★ | 0 | 0 |
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