Below average — CMS composite of the measures below.
The next survey window likely opens around December 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 Lamar Estates Nursing Center during CMS and state inspections, most recent first.
The facility failed to document education, consent, refusal, and administration of the updated COVID-19 vaccine for multiple residents who had said they wanted it, and several residents did not receive the vaccine before a COVID-19 outbreak began. Records showed residents with significant chronic conditions, including cognitive impairment, heart disease, kidney disease, diabetes, and respiratory illness, were not up to date on COVID-19 vaccination, and some EMRs had no documentation that the updated vaccine had been offered at all.
A resident with a missing filling reported a jagged tooth, tongue soreness, pain, and difficulty eating, but emergency dental care was not arranged promptly. Nursing and SSD notes showed repeated complaints and only an initial message left with a dental office, with no documented follow-up until the AD arranged an urgent appointment more than a month later. The dentist smoothed the tooth and the resident reported immediate relief.
Failure to complete annual CNA performance reviews and evaluation-based in-service education. Record review showed the facility could not provide annual performance evaluations for five CNAs, even though each had worked at the facility for more than one year. The DON said annual CNA evaluations had not been done for more than two years, and the facility’s 12 hours of annual in-service education was not based on completed evaluations.
Infection control practices were not maintained when staff posted incorrect precaution signage on resident room doors, entered a resident’s room requiring droplet precautions without the proper PPE, and performed wound care using the same gauze on separate wounds and ungloved hands during dressing preparation. A housekeeper did not perform hand hygiene after glove changes, an RN did not clean her hands after handling paperwork before preparing insulin, and a pulse oximeter probe was returned to a resident after being placed on the RN’s finger without being disinfected.
Failure to Include Medication-Related Care Plan Focuses: The facility failed to develop and implement comprehensive care plans for two residents’ medication needs. One resident with severe cognitive impairment, hospice status, chronic pain, and anxiety had orders for morphine and lorazepam, but the care plan did not address pain, anxiety, or related monitoring. Another cognitively intact resident with depression had an order for duloxetine, but the care plan did not include a focus for that medication.
Failure to Prime Insulin Pen Before Insulin Administration: An RN prepared and administered insulin glargine to a resident with diabetes but did not prime the insulin pen before giving the dose, contrary to manufacturer instructions. The RN said she did not know priming was required, and the DON stated priming is important to help ensure the correct insulin dose is delivered.
Improper medication storage was identified in a medication cart and medication room when an LPN and the DON observed a resident’s used Ozempic pen without an opening date, an expired Glutose gel tube, and an opened Aplisol vial without a date it was opened. The DON stated the Ozempic pen and Aplisol vial should have been dated when opened, and the expired gel should have been discarded.
Failure to document and provide updated COVID-19 vaccination
Penalty
Summary
The facility failed to maintain a system to ensure residents were educated about, offered, and documented for the updated COVID-19 vaccine before an outbreak began. Record review showed that on 5/6/25, 15 residents indicated they wanted the updated COVID-19 vaccine when it became available, but the residents' EMRs did not contain documentation that education about the vaccine's benefits and risks had been provided, that consent or refusal had been recorded, or that the vaccine had been administered or declined for multiple residents. The facility also did not have documentation in the EMRs for the remaining residents showing whether education about the updated vaccine had been provided before the outbreak. The facility confirmed a COVID-19 outbreak beginning when Resident #8 was hospitalized and diagnosed with COVID-19, and additional residents tested positive over the following days. By 1/28/26, 16 of 24 residents and nine staff members had tested positive. The report states that the facility had not provided the vaccination list to the pharmacist before the outbreak, and all residents who had said they wanted the updated vaccine on 5/6/25 had not received it by the onset of the outbreak. Six of the 10 residents who still lived at the facility and wanted the vaccine tested positive during the outbreak. Several resident records showed the same pattern of missing documentation and delayed vaccination. Residents with diagnoses including heart disease, kidney disease, diabetes, dementia, cerebral palsy, respiratory failure, and other chronic conditions were identified as not up to date on COVID-19 vaccination. Some residents had last received COVID-19 vaccines in 2021, 2022, or 2024, and their EMRs did not show education about the updated vaccine before the outbreak. Residents who had consented in May 2025, including residents who were cognitively intact and residents with severe or moderate cognitive impairment, did not receive the updated vaccine until after the outbreak began, and one resident's EMR did not reflect the vaccine dose that was reportedly given during the survey.
Delayed Emergency Dental Care for a Resident With a Broken Tooth
Penalty
Summary
The facility failed to provide timely 24-hour emergency dental services for one resident who lost a filling and reported that the tooth had become jagged and was rubbing against her tongue. The resident, who was cognitively intact and had diagnoses including urinary retention, recurrent UTI, and bilateral lower extremity edema, reported pain, difficulty eating, and a sore on her tongue after the filling came out. She told nursing staff about the problem and later reported it multiple times to staff and social services while waiting for a dental appointment. Record review showed the resident first reported the missing filling to a nurse, and a social services note documented that a message was left with a dentist’s office about the missing filling and tongue irritation. However, there was no documentation of a follow-up call to secure care. After the resident returned from an unrelated hospital stay, social services again requested a dental appointment, and later nursing notes documented that the resident continued to complain that the tooth was cutting into her tongue and that a sore/lesion had developed. The activity director ultimately arranged the dental appointment because the resident had continued to complain for over a month without resolution. The resident was not seen by the dentist until 34 days after first reporting the missing filling. The dental note documented that the tooth was smoothed because it was causing a sore spot on the tongue, and the resident reported immediate relief afterward. The social services director stated that a missing filling with pain would be an urgent visit, but also stated she did not follow up after leaving the initial message and that there was no system in place to remind her of appointments.
Failure to Complete Annual CNA Performance Reviews and Evaluation-Based In-Service Education
Penalty
Summary
The facility failed to complete annual performance reviews for five of five CNAs identified in the report: CNA #1, CNA #3, CNA #4, CNA #5, and CNA #6. Record review showed that annual performance reviews were requested, but the facility was unable to provide evaluations for those CNAs. The facility also provided documentation showing that the CNAs completed 12 hours of annual in-service education, but the education was not based on annual evaluations because those evaluations had not been completed. During interviews, the NHA and DON stated that no records were available showing completion of CNA performance evaluations. The DON said a previous administrator instructed her not to complete annual CNA performance evaluations because the CNAs were not going to receive raises, and she stated that annual CNA performance evaluations had not been done since she began working at the facility more than two years earlier. The DON also stated that CNA #1, CNA #3, CNA #4, CNA #5, and CNA #6 had worked at the facility for more than one year, and both the DON and NHA stated that annual performance evaluations should be completed for every CNA.
Infection Control Failures in Precautions, PPE, Wound Care, Hand Hygiene, and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infection. During observations and interviews, surveyors found incorrect transmission-based precaution signage posted on resident room doors, including contact isolation signs where droplet precautions and enhanced barrier precautions were required. The infection preventionist stated the signage should have matched the resident’s required precautions and said incorrect signage could lead staff to wear the wrong PPE and increase the risk of disease transmission. At the time of interview, the facility was in a COVID-19 outbreak. Staff were also observed not using the appropriate PPE and infection control practices during resident care. Two CNAs entered the room of a resident requiring droplet precautions for COVID-19 wearing gowns, gloves, and surgical masks, but not N-95 masks or protective eye shields. The infection preventionist stated staff should have been wearing N-95 masks and face shields in the rooms of residents requiring droplet precautions. During wound care, RN #1 used the same gauze to pat dry two wounds that were approximately two inches apart on one resident, and during another dressing change used ungloved hands to handle gauze and then used the same gauze to clean the wound. The DON and infection preventionist stated the wounds should have been cleaned separately and gloves should have been worn when preparing the gauze. Additional infection control lapses were observed with hand hygiene and equipment cleaning. A housekeeper changed gloves twice while cleaning a room without performing hand hygiene between glove changes. During medication preparation, RN #1 handled paperwork from a transporter and then continued preparing insulin without performing hand hygiene. RN #1 also placed a pulse oximeter probe on her own finger to test it and then returned it to a resident’s finger without cleaning the probe first. The housekeeper, RN, housekeeping supervisor, and infection preventionist all acknowledged that hand hygiene or cleaning should have occurred in those situations.
Failure to Include Medication-Related Care Plan Focuses
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents reviewed for unnecessary medications. For one resident, who had diagnoses including depression, chronic pain syndrome, generalized anxiety disorder, type 2 diabetes mellitus, rheumatoid arthritis, long-term opiate use, dementia, and cellulitis of the right lower limb, the January 2026 physician orders included morphine sulfate 15 mg twice daily for pain and lorazepam 0.5 mg three times daily for anxiety. The resident’s 12/23/25 MDS showed severe cognitive impairment with a BIMS score of 4 out of 15, and she was admitted to hospice in June 2025 and required extensive assistance with bathing, dressing, personal hygiene, toileting, and transfers using a Hoyer lift. Review of the resident’s comprehensive care plan, revised on 11/14/25, did not show a care plan focus for pain or anxiety, and it did not include side effects or behaviors to monitor related to anxiety. For the second resident, who had diagnoses including anxiety disorder, Parkinsonism, depression, systemic erythematosus lupus, low back pain, and sequelae of periprosthetic osteolysis of the internal prosthetic right knee joint, the January 2026 physician orders included duloxetine 60 mg daily for depression. The resident’s 1/8/26 MDS showed she was cognitively intact with a BIMS score of 14 out of 15 and required assistance with bathing, dressing, grooming, feeding, and toileting. Review of the comprehensive care plan did not reveal a care plan focus related to duloxetine use.
Failure to Prime Insulin Pen Before Administration
Penalty
Summary
Resident #22, who was admitted with diagnoses including respiratory failure, kidney disease, heart failure, and diabetes, was reviewed after a January 2026 MDS assessment found the resident cognitively intact with a BIMS score of 15 out of 15 and requiring varying levels of assistance with activities of daily living. The resident had a physician order for insulin glargine 23 units subcutaneously twice daily. During observation, RN #1 prepared the insulin glargine pen by cleaning the pen tip, applying a new needle, and dialing the dose to 23 units, then entered the resident’s room and administered the injection. RN #1 did not perform the required safety test or prime the insulin pen before administration, contrary to the manufacturer’s instructions. RN #1 stated she did not know the pen should be primed and had not learned that it was necessary during her eight months at the facility. The DON stated priming was important to ensure the resident received the correct dose and that failure to prime could affect blood sugar levels.
Improper Storage and Dating of Medications
Penalty
Summary
Proper medication storage was not maintained for one medication storage room and one medication cart. During observation of the medication cart with an LPN and the DON, a used Ozempic (semaglutide) injectable pen for Resident #11 was found without the date it was opened. An unopened Glutose 15 gel tube was also found on the cart with an expiration date that had passed. The LPN stated the Ozempic pen should be labeled with the date opened, and the DON stated the Glutose gel should have been discarded when it expired. During observation of the medication storage room with the DON, a used vial of tuberculin purified protein derivative (Aplisol) was found without the date it was opened. The DON stated the vial should have been labeled with the opening date and discarded 28 days after opening. The DON also stated the tuberculin purified protein might not be as effective if used after the recommended discard date.
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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 Lamar
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Holly Care Center | 27.3 mi | ★★★★★ | 0 | 0 |
| Bent County Healthcare Center | 32.7 mi | ★★★★★ | 0 | 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.