Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Healthcare Center during CMS and state inspections, most recent first.
Surveyors found that the governing body did not ensure a licensed administrator was in place to manage the facility for an extended period after the prior administrator’s termination. An AIT reported she had completed training but had not passed the licensing exam and was planning to retest, while the facility continued to advertise for a full-time or interim administrator without securing a qualified candidate. The AIT, who served as regional BOM and intended to assume the administrator role once licensed, acknowledged that the absence of an administrator could lead to noncompliance with regulations, residents not feeling safe, families being uncomfortable, and poor outcomes in resident care.
The facility did not have a state-licensed administrator overseeing operations for several months after the previous administrator was terminated. The AIT, who had not passed the licensing exam, was acting in the administrator role without proper credentials, and staff interviews confirmed the absence of a licensed administrator responsible for management and oversight of care for all residents.
The facility did not have a state-licensed administrator in place after the previous administrator was terminated, with the AIT acting in the role without licensure and staff confirming the absence of a qualified administrator as required by policy.
Two residents admitted to the facility with surgical wounds did not receive appropriate wound care due to a lack of documented orders and assessments. One resident's dressing was not changed for 18 days, while another's dressing remained on for 13 days, leading to excoriation of the surrounding tissue. Staff interviews revealed a failure to communicate and obtain necessary wound care orders, resulting in inadequate care.
A facility failed to develop a baseline care plan for a resident with a surgical wound, omitting necessary wound care instructions. The resident's care plan did not include wound assessment or dressing change orders, and the dressing was not removed as per physician's orders. Despite the wound not being infected, the lack of adherence to care plan policies was noted.
A facility failed to implement a comprehensive care plan for a resident's post-surgical wound care. The resident, admitted with a hip fracture, had orders for wound care that were not documented or followed. The care plan lacked necessary dressing changes and wound assessments. Interviews revealed the resident's dressing was not removed as ordered, leading to skin excoriation. Despite no infection, the failure to follow orders increased infection risk.
A resident received four times the prescribed dose of Amitriptyline due to a transcription error in the EHR. The error was discovered after three days, highlighting lapses in the facility's medication administration and order review processes.
A resident was given 100 mg of Amitriptyline instead of the prescribed 25 mg for three consecutive nights, leading to hospitalization. The error was due to an LVN entering the incorrect order into the EHR, and the facility's review process for medication orders was not followed.
The facility failed to maintain an infection prevention and control program, as evidenced by a CNA and HA not performing proper hand hygiene and not using PPE during catheter care for a resident on Enhanced Barrier Precautions. The CNA had not received EBP training, and there were issues with PPE supply, increasing the risk of infection spread.
Failure to Maintain a Licensed Administrator for Facility Management
Penalty
Summary
The facility failed to ensure that its governing body appointed a state-licensed administrator who was responsible for managing the facility and accountable to the governing body. Record review showed that the former administrator was hired in early 2018 and terminated in mid-2025, and there was no administrator in place from that termination date through early 2026. The facility’s own policy, revised in March 2023, stated that a licensed administrator is responsible for the day-to-day function of the facility and that the governing body must appoint an administrator duly licensed in accordance with federal and state requirements, with a current license maintained on the premises. Interviews with the Administrator-in-Training (AIT) confirmed that she had completed administrator training and testing but did not pass the test on her first attempt and was planning to retest. She reported that the facility did not have a current administrator and had not had one since the former administrator left, and that the facility had advertised multiple times and was actively seeking a full-time or interim administrator, but had no qualified applicants and only one undecided interim candidate. The AIT, who had been the regional BOM since 2012 and intended to become the administrator upon passing her test, acknowledged that not having an administrator could result in the facility not following regulations and rules, residents not feeling safe, families not feeling comfortable, and potential bad outcomes with resident care.
Failure to Appoint Licensed Administrator for Facility Management
Penalty
Summary
The facility failed to ensure that its governing body appointed a state-licensed administrator to be responsible for the management of the facility, as required by policy and regulation. Record review showed that the previous administrator was terminated in mid-July, and since then, the facility had not had a licensed administrator in place. Interviews with staff, including the Administrator-in-Training (AIT), Interim DON, HRP Director, and Corporate Regional Director, confirmed that the AIT had not passed the licensing exam and was acting in the administrator role without a license. The facility's own policy requires a duly licensed administrator to oversee day-to-day operations, but this requirement was not met for several months. Staff interviews revealed that the absence of a licensed administrator was known to facility leadership, and the AIT was expected to assume the role upon passing the exam. In the interim, there was no full-time licensed administrator overseeing the facility. The lack of a licensed administrator was acknowledged by staff as a potential cause for regulatory citation, and concerns were raised that staff might not follow facility policies or rules in the absence of proper oversight. The deficiency affected all 50 residents in the facility, as there was no licensed administrator to ensure appropriate management and oversight of care.
Failure to Appoint Licensed Administrator
Penalty
Summary
The facility failed to ensure that its governing body appointed a state-licensed administrator to be responsible for the management of the facility. According to interviews and record reviews, the facility had not had a licensed administrator since the previous administrator was terminated on 07/16/2025. The acting administrator in training (AIT) was not licensed and had not received a formal offer for the administrator position. The AIT stated she was still in training and had not yet submitted the required hours to the licensing department or applied to take the licensing exam. Multiple staff interviews confirmed the absence of a full-time, licensed administrator, with the Director of Nursing and the Medical Program Director both acknowledging that the AIT was acting in the administrator role without the necessary licensure. Review of facility policy indicated that a licensed administrator is required to oversee the day-to-day functions of the facility, and a copy of the current license should be maintained on the premises. The lack of a licensed administrator was directly observed and confirmed through staff interviews and record reviews.
Failure to Provide Adequate Wound Care for Surgical Patients
Penalty
Summary
The facility failed to ensure that two residents received appropriate wound care upon admission, leading to a deficiency in quality of care. Resident #1, who was admitted with a surgical wound, did not have any wound care orders documented upon admission. The resident's surgical dressing was not assessed or changed for 18 days, and the dressing was found dried to the leg during a post-surgery check-up. Despite the lack of infection, the facility did not follow professional standards of practice by failing to obtain and implement wound care orders. Similarly, Resident #2 was admitted with a surgical wound and had orders to remove the bulky dressing after three days, leaving the Dermabond intact. However, the facility did not follow these orders, and the dressing remained on for 13 days, becoming soaking wet and causing excoriation of the surrounding tissue. The facility's staff did not document any wound assessments or changes, and the resident was given showers without removing or protecting the dressing, contrary to the physician's instructions. Interviews with staff revealed a lack of communication and understanding regarding wound care orders and procedures. The Director of Nursing (DON) and other nursing staff admitted that they did not receive or seek out wound care orders for the residents upon admission. The facility's policy required nurses to contact the attending physician for wound care orders if none were provided, but this was not done, leading to inadequate care and oversight of the residents' surgical wounds.
Removal Plan
- Chart reviews have been completed for all residents that have wounds to ensure that they have orders.
- Dressing changes and assessments have been documented in the resident's clinical record.
- Wound care has been completed and wound care orders for the residents were followed per the physician orders.
- Nursing staff has been re-educated and in-serviced on ensuring residents have wound orders for surgical wounds on admission, assessment, and documentation of wound/skin in PCC every shift, informing the physician of any changes as needed.
- IDT/Nursing staff has been re-educated and in-serviced on ensuring residents have wound orders for surgical wounds on admission, assessment, and documentation of wound/skin in PCC every shift, informing physician of any changes as needed.
- DON/Designee will monitor assessment of skin documentation and assist in physician notification of any changes and to ensure orders are obtained for any wounds.
- Administrator will have oversight.
- QAPI committee will monitor until compliance is assured.
Failure to Implement Baseline Care Plan for Surgical Wound
Penalty
Summary
The facility failed to develop and implement a baseline care plan for a resident that included necessary instructions for effective person-centered care, specifically regarding wound care. The resident, who was admitted with a surgical wound following hip surgery, did not have a baseline care plan that addressed wound assessment and dressing changes. Despite having a surgical wound, there were no wound care orders documented in the physician orders, and the nurses' notes did not record any wound assessments during the resident's stay. The baseline care plan also lacked information about the resident's primary reason for receiving skilled services, which was aftercare for hip surgery. Interviews revealed that the resident had orders to remove a bulky dressing after three days to assess the surgical site, but this was not done. The dressing remained on for 18 days, contrary to the physician's orders, although the wound was not infected. The Director of Nursing acknowledged that the baseline care plan should have included wound care orders and assessments, but these were missing. The facility's policy required a baseline care plan to be developed within 48 hours of admission, including necessary healthcare information, but this was not adhered to in this case.
Failure to Implement Comprehensive Care Plan for Post-Surgical Wound Care
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident, which included necessary wound care and assessments following hip surgery. The resident, who was admitted with an intertrochanteric fracture of the left femur, had orders for wound care that were not documented or followed in the clinical record. The care plan did not include dressing changes, wound assessments, or documentation of findings, which were essential for the resident's post-surgical care. Interviews revealed that the resident's bulky dressing was not removed as per physician orders, and the resident was given showers with the dressing still intact, leading to skin excoriation around the surgical site. The dressing remained on for 13 days, contrary to the orders to remove it after three days. Despite the wound not being infected, the failure to follow orders and document care increased the risk of infection. The facility's policy required comprehensive, person-centered care plans with measurable objectives and timeframes, which were not adhered to in this case.
Medication Transcription Error
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for a resident, leading to the incorrect transcription of an order for Amitriptyline. The resident, who was admitted with multiple diagnoses including atrial fibrillation, type 2 diabetes mellitus, and heart failure, was prescribed 25 mg of Amitriptyline per day. However, the order was incorrectly entered into the Electronic Health Record (EHR) as 100 mg per day. This error resulted in the resident receiving four times the prescribed dose for three consecutive days before the mistake was discovered by the Medical Director (MD). The MD identified the error during a review of the resident's medication list and confirmed that the Licensed Vocational Nurse (LVN) responsible for entering the order had made a mistake. The Director of Nursing (DON) acknowledged that the next shift charge nurse was supposed to review the orders but had not been doing so consistently, prompting her to implement a new review process. The resident's baseline care plan indicated that he was cognitively alert and able to communicate easily with staff, and he was receiving psychotropic medication. Despite this, the error went unnoticed until the MD's review. The facility's policies on medication administration and order accuracy were not effectively followed, as evidenced by the lack of a specific policy addressing the accuracy of medical records. The DON admitted that the facility did not have a policy in place to ensure the accuracy of medical records, which contributed to the oversight. Attempts to interview the LVN responsible for the error were unsuccessful.
Significant Medication Error
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, specifically for one resident who was given 100 mg of Amitriptyline instead of the prescribed 25 mg. This error occurred over three consecutive nights, leading to the resident being unresponsive and subsequently hospitalized. The resident had a history of various medical conditions, including atrial fibrillation, type 2 diabetes, and heart failure, and was admitted to the facility for short-term care following joint replacement surgery. The error was discovered when the resident's condition deteriorated, and he was found to be unresponsive by his family members, prompting an emergency hospital admission. The resident's medical records revealed that he was taking 25 mg of Amitriptyline prior to his admission to the facility. However, the facility's records showed an incorrect order for 100 mg of Amitriptyline, which was administered on three occasions. Interviews with the resident's family and hospital staff indicated that the resident exhibited signs of oversedation, such as confusion and sleepiness, during his stay at the facility. The resident's condition improved significantly after being admitted to the hospital, where he no longer required supplemental oxygen, and his vital signs normalized. The error was attributed to a mistake made by an LVN who entered the incorrect medication order into the electronic health record (EHR). The facility's Director of Nursing (DON) acknowledged that the charge nurse on duty was responsible for entering orders into the EHR and that the next shift charge nurse was supposed to review the orders for accuracy. However, this review process was not consistently followed, leading to the medication error. The facility's policies on medication administration and order reconciliation were not adhered to, resulting in the resident receiving an incorrect dosage of Amitriptyline.
Infection Control Deficiencies in Catheter Care and PPE Usage
Penalty
Summary
The facility failed to maintain an infection prevention and control program, as evidenced by multiple deficiencies observed during the care of a resident with a foley catheter. During an observation, a CNA and HA performed hand hygiene at the beginning of the care but failed to change gloves or perform hand hygiene after cleaning the resident's penis and foley catheter. The CNA then proceeded to place a brief back on the resident and pull up his shorts without changing gloves, and also pulled the blankets back up on the resident with the same gloves used during the catheter care. This lapse in protocol was acknowledged by the CNA during an interview, who admitted to forgetting to perform hand hygiene and glove changes, recognizing the increased risk of infection this posed to the resident. Additionally, the facility failed to ensure that staff donned appropriate PPE before entering the resident's room, who was on Enhanced Barrier Precautions (EBP). The CNA had not received training on EBP, as evidenced by the lack of a signature on the in-service training document. The HA, who had signed the in-service, also failed to wear PPE during the catheter care. Interviews with the DON and other staff members revealed that there was an issue with the supply of PPE, which contributed to the failure to follow protocol. The DON and other staff members acknowledged the increased risk of infection due to the lack of appropriate PPE and hand hygiene practices. Record reviews of the facility's policies on hand hygiene and catheter care, as well as CMS guidelines on EBP, highlighted the importance of these practices in preventing the spread of infections. The facility's failure to adhere to these policies and guidelines, combined with inadequate staff training and PPE supply issues, resulted in a significant deficiency in their infection prevention and control program. This deficiency had the potential to affect all residents in the facility by increasing their risk of contracting and spreading infections.
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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) |
|---|---|---|---|---|
| Prairie House Living Center | 1.3 mi | ★★★★★ | 0 | 0 |
| Runningwater Draw Care Center Inc | 23.5 mi | ★★★★★ | 6 | 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.