Below average — CMS composite of the measures below.
The next survey window likely opens around June 2027
Estimate from public CMS data, current as of October 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.
Food service items were found improperly stored throughout the prep area, walk-in refrigerator, freezer, and pantry. Surveyors observed multiple items with no labels or dates, open-to-air containers, unreadable dates, and moldy grapes, while staff stated that everyone in the kitchen was responsible for labeling and dating food and that the facility policy required foods to be stored in closed containers or tightly wrapped packages and labeled with the common name and date.
An LVN used the same wrist BP cuff on multiple residents without cleaning it between uses, and CNAs performed peri-care and catheter care without changing gloves after preparing residents for care. A resident with a Foley catheter was also observed with the drainage bag on the floor and dragging under the wheelchair. The DON stated staff should remove gloves and perform hand hygiene after touching bedding, use clean gloves before peri-care, clean multi-use equipment after each resident, and keep catheter bags secured off the floor.
Care Plan Missing Compression Stocking Intervention: A resident with bilateral DVT, fluid overload, CHF, difficulty walking, and muscle weakness had a physician order for BLE above-the-knee compression stockings while awake, but the care plan did not include the stockings in any measurable goal, intervention, or timeframe. Observations showed the resident without the stockings while up in his wheelchair or recliner, and staff interviews showed CNAs commonly waited until he called for them rather than applying them when he got up.
A resident with bilateral DVT, fluid overload, and CHF was ordered to wear BLE compression stockings while awake each day shift, but observations showed the stockings were repeatedly not on during morning and midday hours. The resident stated staff usually waited until late morning or later to apply them, and staff interviews confirmed they often delayed application until the resident called for them rather than following the order when he got up.
Failure to Update Facility Assessment Annually: The facility failed to conduct and document an annual facility-wide assessment to determine resources needed to care for residents competently. Record review showed the Facility Assessment had not been updated since January 2025. The AIT and Interim ADM both stated they had not reviewed the assessment after assuming their roles and acknowledged it should be reviewed and updated annually or when significant changes occurred.
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.
Food Items Not Properly Labeled, Dated, or Stored
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during observation of the kitchen, walk-in refrigerator, freezer, and pantry. In the prep area, (3) clear bins containing individual cereal bowls were not labeled or dated. In the walk-in refrigerator, surveyors observed (1) box of vegetables with no label or date, (1) bag containing half of a cut lemon in a foam bowl with no label or date, (4) bags of fresh grapes open to air with 1 bag containing moldy grapes, (1) tray of fruit cups covered but with no label and an unreadable date, (1) box of cupcakes not sealed and with no label or date, and (1) box containing tortillas with no label or date. In the freezer, surveyors observed (4) large trays with individual foam bowls containing what appeared to be ice cream, all open to air and not labeled or dated, (1) bag of patties with no label or date, (1) bag of chicken patties open to air, and (1) bag of meat with an unreadable label and a date. In the pantry, (1) powdered Kool-Aid package was open to air, and (1) large clear container of rice had its lid off and the rice was open to air. Staff interviews stated that everyone working in the kitchen was responsible for labeling and dating food, and the facility policy required foods to be stored in closed containers or tightly wrapped packages and labeled with the common name and date.
Infection Control Lapses During Resident Care and Equipment Use
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for two residents and one staff member observed during survey. During medication pass observation, an LVN used the same wrist blood pressure cuff on multiple residents without cleaning it between uses. The cuff was placed on top of the medication cart after use, and the LVN later took blood pressures for two residents with the same cuff without cleaning it. The LVN later stated she cleaned the pulse oximeter but failed to clean the blood pressure cuff, and another LVN stated cloth blood pressure cuffs could not be cleaned. Resident #3 was an older male admitted with diagnoses including bilateral acute deep vein blood clot, fluid overload, acute on chronic diastolic CHF, difficulty walking, and muscle weakness. His MDS showed a BIMS of 13, and his care plan and physician orders documented that he required an indwelling Foley catheter with catheter care every shift. During observation, his catheter bag was seen on the floor in the dining room under his chair, and he was later observed wheeling himself down the hall with the catheter bag dragging on the floor under his wheelchair. Staff interviewed about the observation stated the bag should have been secured to the chair and not dragging on the ground. During incontinence care observation for Resident #3, two CNAs donned PPE and gloves, then removed the blanket, assisted the resident to turn, and opened the brief. One CNA began pericare without changing gloves, and the other CNA then performed catheter care without changing gloves. For Resident #2, an older female with heart failure, hypertension, dysphagia, Parkinson's disease with dyskinesia, and dementia, the MDS showed severe cognitive impairment and dependence for toileting hygiene. During incontinence care observation, a CNA washed hands and put on gloves, raised the bed, removed the blanket and brief, and then proceeded with pericare without changing gloves. The DON stated staff should remove gloves and perform hand hygiene after touching bedding and before starting pericare, and that staff should put on a clean pair of gloves prior to starting peri-care.
Care Plan Missing Compression Stocking Intervention
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #3 that included measurable objectives and time frames for his daily use of bilateral above-the-knee compression stockings. Resident #3 was admitted with diagnoses including bilateral deep vein thrombosis, fluid overload, acute on chronic diastolic congestive heart failure, difficulty walking, and muscle weakness. His MDS showed he was cognitively intact with a BIMS of 13 and required substantial to maximal assistance with toileting and transfers, and he was totally dependent on staff for putting on and taking off footwear. The care plan dated 3/24/26 addressed diuretic therapy and edema, but it did not mention the compression stockings in any task, goal, intervention, or timeframe. The physician’s order directed staff to wear BLE above-the-knee compression stockings while awake every day shift for edema, with a start date of 05/15/25 and no discontinue date. The TAR documented the stockings as being placed on the resident on 6/29/26, 6/30/26, and 7/1/26 in the morning, but multiple observations showed the resident without compression stockings while up in his wheelchair or recliner during the morning and later in the day. During interviews, the resident stated he was supposed to have the stockings on when he got up around 6:00 a.m., but staff usually did not put them on until he reminded them later in the morning or afternoon. CNA staff stated they knew he needed the stockings but usually waited until he called for them, and one CNA did not know the care plan or physician order. An LVN stated the stockings should have been put on when the resident got up in the morning and said the stockings should have been in the care plan. The DON stated she expected physician orders to be followed and expected the compression stockings to be listed in the care plan.
Failure to Apply Ordered Compression Stockings
Penalty
Summary
The facility failed to ensure a resident received treatment in accordance with physician orders when bilateral above-the-knee compression stockings were not applied during the day as ordered. The resident had diagnoses including bilateral lower-extremity DVT, fluid overload, and acute on chronic diastolic CHF. The quarterly MDS indicated a BIMS of 13 and that the resident required substantial to maximal assistance with toileting and transfers, and he was totally dependent on staff for putting on and taking off footwear. The care plan also documented that he was totally dependent on staff for transfers, toileting, dressing, and bathing. The physician order directed that the resident wear BLE compression stockings while awake every day shift for edema, with no discontinue date. However, observations on multiple days showed the resident sitting in his recliner, wheelchair, and dining room without compression stockings on his legs during the morning and midday hours. During interview, the resident stated he was supposed to have the stockings on when he got up around 6:00 a.m., but staff usually did not apply them until around 10:30 a.m. or later, and he could not apply them himself because he depended on staff assistance. Staff interviews confirmed the stockings were often delayed until the resident called for them, rather than being applied when he got up. A CNA stated she knew the resident needed the stockings but did not look at the orders or care plan, and an LVN stated the stockings should be applied when the resident got up in the morning. The DON stated she expected staff to follow physician orders and that the stockings should be listed in the care plan, but she was not aware the resident had not been wearing them in the mornings. The facility policy stated medication and treatment orders must be recorded on the physician's order sheet in the resident chart.
Failure to Update Facility Assessment Annually
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment for the past year to determine what resources were necessary to care for residents competently during day-to-day operations and to review and update the assessment at least annually for 1 of 1 facility reviewed. Record review showed the Facility Assessment had not been updated since January 2025. A facility policy titled Facility Assessment, revised October 2018, stated that a facility assessment is conducted annually to determine and update the facility’s capacity to meet resident needs and competently care for residents during day-to-day operations, and that the assessment is reviewed and updated annually and as needed. During an interview on 06/30/26 at 1:59 PM, the AIT stated she had served in that role since July 2025 and had not reviewed the Facility Assessment since assuming the position because she had not had time. She stated it had been updated before the previous survey and acknowledged it was her responsibility along with the ADM to update the Facility Assessment and that it should be reviewed and updated annually or whenever significant changes occurred. She stated the only changes since the last update had been administrative leadership changes and said she would update the assessment that day with assistance from the Interim ADM. During an interview on 06/30/26 at 2:55 PM, the Interim ADM stated she had been employed at the facility since February 2026, had not reviewed the Facility Assessment upon assuming her position, and was unsure when it had last been updated. She stated she believed it was her responsibility to update the assessment annually or when changes occurred and thought it had already been updated during 2026.
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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Illustrative
What surveyors actually found near you
We read the 29 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
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 | ★★★★★ | 23 | 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 October 2026) and official state health department websites.