Plainview Healthcare Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure the freezer, refrigerator, and pantry items were properly stored, labeled, and dated. This failure could place residents at risk of food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 12 residents (Residents #2 and #3), and 1 of 2 staff members observed for infection control. LVN C failed to ensure infection control with wrist blood pressure cuff and did not clean it between use of residents. The facility failed to ensure Resident #3's catheter bag was not dragging on the floor. C.N.A. E failed to ensure infection control by not changing gloves prior to starting pericare for Resident #3. C.N.A. F failed to ensure infection control by not changing glovers prior to catheter care for Resident #3. C.N.A. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that meet professional standards of quality and that included measurable objectives and time frames for 1 of 11 (Residents #3) Residents reviewed for care plans. A. The facility failed to ensure Resident #3's daily use of compression socks had been care planned. There was no documentation in the care plan of measurable objectives, interventions, or timeframes for how staff would meet this need. This failure to accurately develop and implement a care plan could result in staff not being aware of critical treatment-related risks and monitoring needs, placing residents at risk for delayed treatment and failure to provide necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 11 residents (Resident #3) reviewed for physician orders for treatments. The facility failed to follow physician orders and apply Compression socks as ordered for Resident # 3. The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition.

Inspectors wroteBased on record review and interviews, 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 its residents competently during day-to-day operations and review and update the assessment at least annually for 1 of 1 facility reviewed. The Facility Assessment had not been updated since January 2025. This failure could place residents at risk of their needs going unmet and result in a lack of services provided by the facility to competently care for all residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the governing body of the facility had appointed an administrator, who was licensed by the state, was responsible for the management of the facility, and was accountable the to the governing body for 1 of 1 facility reviewed for administration. The facility had not had an administrator from 07/16/2025 to 01/07/2026 This deficient practice could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of the facility and report to the governing body. The facility had not had an administrator since 07/16/2025. This deficient practice could place residents at risk of decreased quality of life and quality of care due to lack of staff oversight and monitoring of care for all 50 residents at the facility.

Inspectors wroteBased on interview and record review the facility failed to ensure the governing body of the facility had appointed an administrator, who is licensed by the state, to be responsible for the management of the facility and report to the governing body. The facility had not had an administrator since 07/16/2025. This deficient practice could place residents at risk of decreased quality of life and quality of care due to a lack of staff oversight and monitoring of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchens when they failed to: A. Ensure kitchen staff used proper hand washing and sanitation procedures when handling food. This failure could cause decreased meal satisfaction and decreased meal consumption due to using unsanitary practices in the facility's only kitchen and could affect all residents in the facility that receive meals from the facility kitchen.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 3 of 3 medication carts (NE Hall, NW Hall, and South side Hall) and 1 of 12 residents (Resident #15) reviewed for medication storage. -Medication cart for NW Hall revealed Fluticasone Propionate nasal spray 50mcg with no open date on the bottle or resident identifying information. -Breo Ellipta had a date of 06/11/2025, with no resident identifying information. -Medication cart for NE Hall had a pill in a medication cup in the top draw of the medication cart. -Medication cart for NE hall had 1 unidentified pill loose in the bottom of the medication cart drawers. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 12 residents (Resident #15, #24, #26, #27, #31, and Resident #36) reviewed for infection control. The facility failed to ensure that facility staff performed hand hygiene appropriately during medication preparation, medication administration and incontinent care. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 1 of 12 residents (Resident #43) reviewed for accuracy of MDS assessments. -The facility did not correctly identify oxygen therapy for Resident #43 on her MDS assessment. This failure to ensure accurate assessments could affect all the residents by placing them at risk for inaccurate and incomplete MDS assessment, which could result in the residents not receiving correct care and services.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest t practicable physical, mental, and psychosocial well-being for 1 (Resident #37) of 16 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan that accurately addressed Resident #37's oxygen therapy. This failure could place residents at risk of not receiving desired and necessary care and treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #43) of 12 residents reviewed for respiratory care. The facility failed to administer oxygen at the correct dose for Resident #43. This failure could affect all residents on oxygen therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition.

Inspectors wroteBased on observation, interviews, and record review, it was determined the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 2 of 5 residents (Residents #1 and #2) reviewed for Quality of Care. The facility failed to ensure Resident #1's surgical wound was assessed, and wound care orders were received from the hospital upon admission to the facility. Resident #1 had a post-surgery check up on 9/3/24, 18 days after admission and the bulky wound dressing from the surgery was still covering the wound and was dried to his leg but the incision was not infected. The facility failed to ensure Resident #2's surgical wound was assessed, and wound care orders were received from the hospital upon admission to the facility. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective person-centered care of the resident that meet professional standards of quality care for one of 5 residents (Resident #1) reviewed for baseline care plans. The facility failed to develop a baseline care plan for Resident #1 that included assessment and dressing changes for a surgical wound. This failure could place residents at risk of receiving care that is substandard, unable to meet their needs, or inadequate to prevent complications such as a serious wound infection, wound deterioration, sepsis, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to obtain or maintain the resident's highest practicable physical, metal, and psychosocial well-being for 1 of 5 residents (Resident #2) whose comprehensive care plans were reviewed. The facility failed to develop a comprehensive care plan for Resident #2 that included dressing changes, assessing the wound for any changes and documenting in the clinical record what was found. [...]

Inspectors wroteBased on record review and interview the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the eneds of each resident for 1 (Resident #1) of 5 residents reviewed for pharmaceutical services. The facility failed to transcribe Resident #1's order for Amitriptyline (an antidepressant medication) accurately. The dose was entered into the EHR as 100 mg per day rather than the ordered 25 mg per day. This failure could place residents at risk of receiving incorrect doses of medication resulting in overmedication. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from significant medication errors for 1 (Resident #1) of 5 residents reviewed for medication errors. The facility failed to follow physician's orders in that Resident #1 was given 100 mg of Amitriptyline (an antidepressant medication) rather than the 25 mg the physician ordered. This failure could place residents at risk for oversedation such as dizziness, drowsiness and fatigue. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 1 (Resident #2) of 5 Residents in that: - The facility failed to ensure CNA performed hand hygiene during foley catheter care for Resident #2. -The facility failed to ensure CNA and HA donned PPE before entering Resident #2's room who was on EBP's. (Enhanced Barrier Precautions). -The facility failed to provide staff with adequate PPE. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.

Inspectors wroteBased on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for one of one facility reviewed for nursing services The facility did not have an RN in the facility on 01/27/2024, 01/28/2024, 02/10/2024, 02/11/2024, 03/16/2024, and 03/17/2024. This failure placed residents at risk of not having supervisory coverage for RN specific nursing activities.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food service safety. The facility failed to ensure stored food was properly labelled and dated. The facility failed to ensure dented cans were placed in the specified area to be returned. The facility failed to discard expired food. The facility failed to discard leftover food by use by date on the label. The facility failed to store food at least 6 inches off the floor. These failures could place residents at risk of food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail and failed to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation and failed to ensure maintenance of bedrails for 4 (Resident #6, Resident #17, Resident #33, and Resident #53) of 20 residents reviewed for bedrails. Residents #6 and #33 had bedrails that were loose. Resident #17 had no consent for bedrails in his EHR or his paper chart. Residents #33 and #53 had bedrails the day they were admitted to the facility. These failures could place residents at risk of injury and/or entrapment. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Resident #26 and Resident #48) of 20 residents reviewed for privacy. Resident #26's catheter bag was left without a cover in full view of anyone who entered resident's room. Resident #48's catheter bag was left without a cover in full view of other residents during mealtimes. This failure could place residents at risk of a lack of dignified existence, lowered self-esteem, or a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents with the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 (Resident #17 and Resident #4) of 20 residents reviewed for advance directives. Resident #17 had a DNR undated by the physician. Resident #4 had a DNR lacking the physician's printed name. These failures could place residents at risk of having their end of life wishes dishonored and having CPR performed against their wishes. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to complete a significant change in status assessment within 14 days after the facility determined or should have determined that a resident has a significant change in the resident physical or mental condition for 1 (Resident #14) of 20 residents reviewed for comprehensive resident assessments. The facility failed to complete a significant change of condition assessment when Resident #14 was discharged from hospice. This failure placed residents at risk for not receiving an accurate assessment and could result in lack of care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 3 (Resident #17, Resident #37, and Resident #44) of 20 residents reviewed for preadmission screenings. 1. Resident #17 had a PASRR performed 36 days after he was admitted to the facility. 2. Resident #37 had a PASRR performed 12 days after he was admitted to the facility. 3. Resident #44 had a PASRR with no assessment date in her EHR. These failures could place residents at risk of receiving inadequate care that could lead to deterioration in their health condition. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #36 and #38) of 20 residents reviewed for comprehensive care plans. -The facility failed to include care plans for hospice for Resident #36. -The facility failed to include care plans for dialysis for Resident #38. This failure could place resident at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -LVN failed to don gloves before administering an injectable medication to resident. - Facility failed to keep foley catheter bag off of the floor. These deficient practices have the potential to affect all residents in the facility by exposing them to care that could lead to the spread of viral infections, secondary infections, communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative of the transfer or discharge for 1 (Resident #1) of 5 residents reviewed for transfers/discharges. The facility failed to notify Resident #1's representative of the resident's discharge to the hospital. This failure could affect residents at the facility by placing them at risk of being transferred/discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received treatment and care in accordance with professional standards of practice for 1 (Resident #2) of 5 residents reviewed for physician orders. The facility failed to follow physician orders for completing wound care for Resident #2. The deficient practice could affect residents receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition.