Below average — CMS composite of the measures below.
A standard survey is most likely before 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 Avir At Borger during CMS and state inspections, most recent first.
A resident with aggressive periodontitis, dental caries, and jaw necrosis had ongoing mouth pain documented over several months, including complaints of tooth and jaw pain, exposed necrotic bone, and foul taste. Although staff knew about the pain and an NP ordered PRN oral numbing gel, the MDS and care plan did not specifically address the resident’s mouth or dental pain, and the record showed continued pain complaints without clear incorporation into the pain management plan.
Surveyors identified multiple failures in food storage, labeling, dating, and sanitation practices, including improper storage of food on the floor, unlabeled and undated containers, unsanitary kitchen and bathroom conditions, and inadequate cleaning and hand hygiene by dietary staff. These deficiencies were observed through direct inspection and staff interviews, revealing lapses in adherence to facility policies and professional standards.
The facility failed to accurately code the MDS for three residents. One resident receiving O2 via NC for CHF was not coded for oxygen therapy, another resident with nicotine dependence reported smoking and chewing tobacco but was coded as not using tobacco, and a third resident with significant ongoing oral/dental pain and extensive dental disease was not coded for mouth or facial pain or chewing difficulty. Interviews and record review showed the MDS did not match the residents’ documented status.
A resident with severe dementia and dysphagia, requiring a pureed diet, was repeatedly served food that was watery, grainy, lumpy, and sometimes sweet due to the use of inappropriate liquids like apple juice. Dietary staff demonstrated inconsistent training and did not follow facility recipes or policies, resulting in meals that did not meet the resident's prescribed dietary needs. The resident also did not receive all required pureed items, such as bread, and was sometimes served food intended for others.
A DON did not wear a gown while performing wound care on a resident with a stage 4 pressure ulcer and colostomy, despite the resident's care plan and facility policy requiring enhanced barrier precautions (EBP) and PPE use during high-contact care activities. Staff interviews and record review confirmed this was a violation of infection control protocols.
Exposed Catheter Bag and Lack of Privacy: A resident with an indwelling catheter was observed in bed with the door open and curtain pulled back while her catheter drainage bag hung from the bed frame without a privacy bag. The bag remained exposed during a later observation, and two residents passed the room and could have seen it. Staff stated catheter bags should be covered to protect privacy and dignity, and facility policy required resident privacy and covered drainage bags.
Incomplete DNR Documentation: A resident with CHF, malnutrition, muscle wasting, anxiety disorder, and HTN had a DNR in the chart that was signed by the resident and physician, but the physician did not date the form. RN confirmed the missing date and said he did not know if the DNR was valid, while the DON and CN stated the DNR was not completed accurately and that they had missed it.
A resident's lunch tray was left in his room overnight and was still present the next morning with food exposed and about half the meal uneaten. The resident said staff sometimes leave his tray in his room overnight. The CN, RN, and DON all stated the tray should have been picked up much sooner and that leaving it for 18 hours was too long and could create an infection control concern or foodborne illness risk.
Delayed Significant Change MDS for Hospice Admission: A resident with CKD, COPD, hepatitis C, and cirrhosis was admitted to hospice and the significant change MDS was not completed within the required timeframe. The MDS coordinator, DON, and ADM acknowledged the assessment was not completed timely, even though the resident’s care plan later reflected terminal care from hospice.
A resident with aggressive periodontitis, dental caries, and jaw osteonecrosis had ongoing mouth and jaw pain, foul breath, and exposed necrotic bone, with notes showing repeated dental and oral surgery evaluations and treatment. However, the care plan only referenced acute pain in general and did not identify the resident’s mouth pain or need for oral surgery, despite staff awareness of the issue and documentation of continued complaints and treatment.
Respiratory care was not provided as ordered for two residents. One resident who was observed wearing O2 had no active physician order on the MAR, although staff said the order had been inadvertently discontinued and missed. Another resident with COPD had an order for O2 at 2 LPM via NC at HS, but staff observed her receiving O2 at 3 LPM and later 2.75 LPM. Staff stated nurses were responsible for setting O2 flow rates based on the physician’s order, and the facility policy required verification of the ordered flow rate and route.
A resident with aggressive periodontitis, dental caries, and necrotic jaw bone had ongoing oral pain, foul breath, and repeated dental issues, but the facility did not timely obtain oral surgery. Records showed multiple contacts with dentists, oral surgeons, and insurance sources over several months, while the resident continued to report pain and staff noted the surgery had still not been scheduled.
The facility did not obtain food from approved sources and failed to store, prepare, distribute, and serve food according to professional standards, resulting in a deficiency related to food safety and handling.
A resident did not receive food prepared in a form that met their individual needs, as the facility did not consistently modify meals to accommodate specific dietary requirements or physical abilities.
A resident with a stage 4 pressure ulcer and colostomy, who required enhanced barrier precautions per care plan and physician orders, received wound care from the DON without the use of a gown as required. Staff interviews and facility policy confirmed that PPE, including gowns, should be used during high-contact care activities such as wound care, but this protocol was not followed during the observed incident.
A CNA failed to use a transfer belt while transferring a resident with severe cognitive impairment and multiple health issues, contrary to the facility's protocol. The resident required extensive assistance for mobility, and the care plan specified the use of a transfer belt for safety. Video evidence confirmed the improper transfer, and the facility was unaware of the reason for the CNA's deviation from protocol.
Two residents in the facility were observed multiple times with their catheter bags exposed without privacy bags, contrary to the facility's dignity policy. Despite the policy requiring catheter bags to be covered, observations showed that the bags were visible in various locations, including the dining room and hallways. Interviews with CNAs confirmed the importance of covering catheter bags to maintain resident dignity and prevent embarrassment.
The facility failed to provide a comprehensive activity program that met residents' needs and preferences. Residents reported boredom and a lack of engaging activities, with some not receiving activity calendars. Staff interviews revealed a lack of coordination, with the Activities Director and Assistant failing to ensure activities were conducted as planned. Care plans lacked documentation of activities, indicating non-compliance with facility policy.
The facility failed to properly label and date stored food, risking foodborne illness for residents. Observations revealed unlabeled and undated items in pantry #1, on the kitchen counter, and in refrigerator #2. Interviews confirmed that kitchen staff are responsible for following the facility's food storage policy, which requires all items to be labeled and dated to prevent contamination.
A medication cart on hall 600 was found unlocked and unattended, containing topical medications, with a resident nearby. A CNA and two nurses confirmed the cart is usually locked, acknowledging the risk of unauthorized access. The facility's policy requires all drugs to be stored in locked compartments when not in use.
A resident with severe dementia was found in a saturated bed, indicating neglect in incontinence care. Despite care plans requiring regular checks, the resident was not changed for an extended period. Interviews revealed inconsistencies in staff training and understanding of neglect, with the facility's administration unclear on what constitutes neglect.
A resident with respiratory issues was left unattended during a nebulizer treatment, contrary to facility policy requiring staff supervision. The LVN responsible was unaware of the importance of remaining with the resident, leading to potential risks of incomplete medication administration.
Two CNAs failed to adhere to hand hygiene protocols during resident care, leading to potential cross-contamination. They did not perform hand hygiene before donning gloves or after removing them while providing incontinent care to two residents. The facility's policy, which emphasizes hand hygiene as a primary means to prevent infection spread, was not followed.
A facility failed to ensure a resident's morphine was not misappropriated, leading to missed doses. The morphine was discovered missing at shift change, and the investigation revealed that the medication cart was not properly secured. The resident's family was informed, and a new bottle of morphine was eventually delivered.
A resident with severe cognitive impairment and multiple medical conditions was found with a bruise on her chest, which was not reported to the administrator and state within the required 24-hour window. The facility's policy on abuse and neglect was incomplete, and staff interviews revealed confusion and inconsistency in the reporting process.
The facility failed to lock the medication cart in hall 200, leaving it unattended and accessible to residents. Staff interviews confirmed it was the nurse's responsibility to keep the cart locked, as per facility policies.
Failure to Address Ongoing Mouth Pain
Penalty
Summary
The facility failed to ensure pain management was provided for Resident #14, who had ongoing mouth pain related to significant dental and jaw conditions. Her record showed diagnoses including aggressive periodontitis, dental caries, and myelodysplastic syndrome. The annual MDS completed in August 2025 documented mild pain and pain medication use, but it did not code mouth or facial pain, discomfort, or difficulty chewing. The care plan completed in August 2025 did not mention mouth or dental pain or issues, and instead only referenced acute pain without identifying the location. Resident #14’s record showed a prolonged history of oral problems and pain. In March 2025, an NP ordered oral numbing gel PRN to be kept at the bedside, and later that month the resident complained multiple times of tooth pain. In February 2025, she had two teeth extracted and was told more teeth needed extraction. In June 2025, she complained of pain radiating from the right side of her jaw to the front of her jaw, and the NP discontinued chlorhexidine mouthwash and ordered clindamycin and acidophilus. In July 2025, an oral and maxillofacial surgeon documented exposed necrotic bone in the resident’s right maxilla and mandible, along with pain and an occasional foul taste in her right jaw. During observations and interviews in August 2025, Resident #14 stated she was in pain all the time due to a pocket with pus in her mouth and said she regularly told staff about the pain. Staff interviews confirmed awareness of her mouth pain over a long period of time. The CC, CCM, LVN, ADM, and DON all acknowledged that the resident had ongoing mouth pain, with the DON stating the pain had been going on for a while and that the facility had been waiting for the oral surgeon. The facility policy required pain to be recognized, evaluated, managed, and incorporated into the care plan, but the resident’s mouth pain was not specifically addressed in the care plan or MDS documentation.
Widespread Food Storage and Sanitation Failures in Dietary Services
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Observations revealed multiple instances of improper food storage, including unlabeled and undated containers, food stored directly on the floor, and open food items exposed to air. Dented cans were not separated for return, and leftover food was not discarded by the use-by date. The kitchen environment was found to be unsanitary, with dirty floors, walls, trashcans, and a bathroom that was not clean or sanitized. Dirty dishes were left overnight in sinks and on trolleys due to staff clocking out before cleaning could be completed. Further observations showed that food contact surfaces and equipment, such as prep tables and blenders, were not properly cleaned and sanitized between uses. Staff were seen using improper hand hygiene and glove use, such as touching ready-to-eat food after handling trays, utensils, and door handles without changing gloves or washing hands. Temperature logs for refrigerators and freezers were not maintained daily as required, and food items in cold storage were found to be unlabeled, undated, or past their use-by dates. The pantry and storage areas contained open, undated food items and visible dirt and debris on the floors. Interviews with dietary staff indicated inconsistent training and understanding of food labeling, dating, and cleaning responsibilities. Staff reported that cleaning schedules were not consistently followed or documented, and that hours had been cut, making it difficult to keep up with cleaning tasks. Review of facility policies and training materials confirmed that staff were instructed to label and date food, maintain cleanliness, and avoid bare hand contact with food, but these practices were not consistently implemented. No specific residents were identified as being directly affected in the report.
Inaccurate MDS Coding for Oxygen Use, Tobacco Use, and Dental Pain
Penalty
Summary
The facility failed to ensure the MDS accurately reflected Resident #2’s oxygen therapy status. Resident #2 was a female with diagnoses including generalized anxiety disorder, shortness of breath, and acute chronic congestive heart failure. Her annual MDS with an ARD of 08/07/25 was completed without coding her as receiving oxygen therapy, even though her care plan identified a need for PRN oxygen therapy related to heart failure and included an approach to administer oxygen at 2 L via nasal cannula. Her active orders also included continuous oxygen at 2 L/min every shift, and oxygen saturation notes documented oxygen use during the look-back period. Observation confirmed Resident #2 wearing oxygen via nasal cannula while in bed sleeping on two separate occasions. During interview, the CCM reviewed the annual MDS and acknowledged that the resident was not marked for oxygen use because oxygen was not documented on the MAR. After reviewing the oxygen assessments, the CCM stated the resident should have been marked for oxygen therapy and that she did not see the documentation. The CCM also stated that not addressing respiratory therapy needs on the MDS would affect the care plan and could affect resident care and reimbursement. The facility also failed to accurately code Resident #8’s tobacco use status. Resident #8 was a male with diagnoses including cerebral infarction, flaccid hemiplegia affecting the left non-dominant side, and nicotine dependence. His annual MDS completed 02/07/25 coded him as not using tobacco, and the smoking-related care plan, smoking risk form, smoking evaluation, and smoking list did not reflect chewing tobacco use. However, during interview the resident stated that he smoked and chewed snuff quite a bit and had not stopped. Staff interviews were inconsistent, with some stating he smoked or preferred dip and others unsure how long he had used tobacco. The CCM stated she was responsible for MDS completion and was not sure how long he had been smoking or why the annual MDS did not code him as using tobacco. The facility further failed to accurately code Resident #14’s dental status. Resident #14 was a female with diagnoses including aggressive periodontitis, myelodysplastic syndrome, and dental caries. Her annual MDS completed 08/25/25 did not code mouth or facial pain or difficulty chewing in the oral/dental section, and the care plan did not mention mouth or dental pain/issues. The record, however, contained extensive documentation of ongoing dental and oral problems, including tooth extractions, dental abscess treatment, oral numbing gel, repeated complaints of tooth pain, referrals to oral surgery, and notes describing exposed necrotic bone in the right maxilla and mandible with pain and foul taste. During observation and interview, the resident stated she had bone and blood cancer and was in pain all the time due to a pocket with pus in her mouth, and staff interviews confirmed her mouth pain had been an ongoing issue. The CCM stated she did not know why the mouth pain was not coded on the most recent MDS, and other staff acknowledged the resident’s mouth pain had been present for a long time.
Failure to Provide Properly Prepared Pureed Diet for Resident with Dysphagia
Penalty
Summary
The facility failed to ensure that a resident with a physician-ordered pureed diet consistently received food prepared in the correct form to meet her individual needs. The resident, an elderly female with severe dementia, dysphagia, and protein-calorie malnutrition, was dependent on staff for most activities of daily living and required a pureed diet to reduce the risk of choking and aspiration. Observations revealed that her pureed meals were not prepared according to facility recipes or dietary guidelines, resulting in food that was watery, grainy, lumpy, and sometimes sweet due to the inappropriate use of apple juice as a liquid for pureeing eggs and sausage. Additionally, regular oatmeal, which contained lumps, was served instead of a properly pureed version, and pureed bread was omitted from her meal despite being available for other residents. Interviews with dietary staff indicated inconsistent and incorrect training regarding the preparation of pureed foods. One dietary aide reported being trained to use water or apple juice as the liquid for pureeing, while another stated she had not received training at this facility and relied on practices from a previous job. The registered dietitian confirmed that the correct consistency for pureed food should be smooth, thick, and free of lumps, and that apple juice and water were not appropriate liquids for pureeing eggs or sausage. Facility recipes and policies also specified the use of milk, broth, or gravy as appropriate liquids and emphasized the importance of following recipes to ensure proper texture and nutritional value. Further observations documented that the resident's pureed food was sometimes delivered to the wrong tray, and that the texture of the food served remained incorrect even after being remade. Staff interviews consistently acknowledged that food not prepared to the correct consistency could pose a choking hazard. Despite in-service trainings and written policies outlining the correct procedures for preparing pureed diets, the facility did not ensure that staff consistently followed these guidelines, resulting in the resident receiving food that did not meet her prescribed dietary needs.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the Director of Nursing (DON) not wearing a gown while performing wound care on a resident with a stage 4 pressure ulcer and a colostomy. The resident's care plan and physician orders specified the need for enhanced barrier precautions (EBP), including the use of personal protective equipment (PPE) such as gowns, gloves, and goggles during high-contact care activities like wound care. The DON confirmed during an interview that she did not wear a gown during the procedure, acknowledging this was a violation of the EBP protocol and infection control policy. Interviews with other nursing staff further confirmed that EBP should be implemented for residents with wounds, catheters, or ostomies, and that appropriate PPE is expected to be used during high-contact care activities. The facility's policy on enhanced barrier precautions, implemented in June, also required PPE during wound care. The failure to follow these established protocols was directly observed and verified through staff interviews and record review.
Exposed Catheter Bag and Lack of Privacy
Penalty
Summary
The facility failed to treat Resident #29 with respect and dignity when her catheter bag was left without a privacy bag. Resident #29 was a new admission with diagnoses including major depression and neuromuscular dysfunction of the bladder. Her care plan included an indwelling catheter. During an observation, she was in bed with the light on, the curtain pulled up against the wall, and the door open, with her lower thighs and legs exposed while she attempted to move her catheter bag on the bed frame. The catheter bag was approximately half full of urine and was not in a privacy bag. During a later observation, Resident #29 remained in bed with the door open and the curtain still pulled up, and her catheter bag continued to hang from the bed frame without a privacy bag. Two residents passed her room and could have observed the exposed catheter bag. Staff interviews confirmed that catheter bags should be stored in a privacy bag to prevent them from being viewed by visitors and other residents, and that leaving the bag exposed was a dignity issue. Facility policies also stated that resident privacy and dignity must be maintained and that catheter drainage bags will be covered at all times while in use.
Incomplete DNR Documentation
Penalty
Summary
The facility failed to ensure that all residents had the right to formulate an advance directive for Resident #10. Record review showed the resident was admitted with diagnoses including CHF, malnutrition, muscle wasting, anxiety disorder, and hypertension. Her annual MDS indicated a BIMS of 15, showing she was cognitively intact, and she required partial or moderate assistance with most ADLs. Her care plan identified her code status as DNR, and the clinical record included an order summary listing her as Do Not Resuscitate with a start date. Record review of the resident’s DNR form showed it was signed by the resident and included the physician’s printed name and license number, but the physician did not date the form. During interview, RN E reviewed the resident’s electronic record and confirmed the physician had not dated the DNR, stating he did not know whether it was valid. The DON and CN both stated that an inaccurately completed DNR would be an issue, and the CN reported that she and the DON were responsible for ensuring DNRs were accurately completed and that they had missed this one.
Meal tray left in resident room overnight
Penalty
Summary
The facility failed to provide a safe and clean environment for Resident #9 when a dining tray was left in his room for 18 hours. Resident #9 was a male resident admitted with diagnoses including bipolar disorder, cognitive communication deficit, mild intellectual disabilities, mood disorder, and vitamin D deficiency. His most recent MDS showed a BIMS of 15, indicating he was cognitively intact, and he was independent with most ADLs. His care plan included monitoring meal percentages and addressed unintended weight gain related to increased access to food and snacks. During an observation, Resident #9 was not in his room, and his lunch tray from the previous day was found on his bedside table with approximately 50% of the food eaten. The tray ticket and a cup were left on top of the plate with food exposed. On interview, Resident #9 confirmed that staff sometimes leave his tray in his room overnight. The CN verified the tray was from the prior day and stated it should not have been left out because it could be an infection control issue and could make someone sick if eaten. RN E and the DON both stated that meal trays should be picked up in a timely manner and that leaving a tray in a room for 18 hours was too long and could result in foodborne illness. The facility policy stated food must be stored, prepared, distributed, and served in accordance with food safety standards, but no instructions were found for when a resident's meal tray should be retrieved once the meal was completed.
Delayed Significant Change MDS for Hospice Admission
Penalty
Summary
The facility failed to complete a significant change assessment within 14 days after determining that Resident #7 had a significant change in condition when he was admitted to hospice care. Resident #7 was a [AGE]-year-old male with diagnoses including chronic kidney disease, chronic viral hepatitis C, COPD, and cirrhosis of the liver. His record showed that hospice was his primary payer and that he was receiving hospice services. Record review showed Resident #7’s significant change MDS documenting the change to hospice care was completed on 03/21/25, after hospice admission on 03/01/25. The resident’s care plan later identified terminal care from hospice, with the problem area initiated on 03/01/25 and approaches initiated on 03/03/25. Staff interviews confirmed that the MDS coordinator was responsible for timely completion of MDS assessments and stated the assessment was not completed within the 14-day timeframe; the DON and ADM also stated that timely completion was the responsibility of the MDS coordinator and interdisciplinary team.
Care Plan Did Not Address Resident’s Oral Pain and Need for Surgery
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for Resident #14 that included her mouth pain and need for oral surgery. Resident #14 was admitted with diagnoses including aggressive periodontitis, myelodysplastic syndrome, and dental caries. Her annual MDS showed intact cognition with a BIMS of 15 and documented mild pain, but the oral/dental section did not code mouth or facial pain or difficulty chewing. Her care plan, completed on 08/20/25, did not mention mouth or dental pain or issues; it only noted acute pain without identifying the location. The record showed ongoing dental and oral problems. A dental visit report documented two teeth extracted and additional teeth needing extraction, and she was placed on amoxicillin. An oral and maxillofacial surgery note documented evaluation for osteonecrosis of the jaw related to prior cancer treatment drugs, with exposed necrotic bone in the right maxilla and mandible, pain, and an occasional foul taste. The surgeon noted the resident had a 2 cm area of exposed necrotic bone and planned to obtain x-rays and schedule surgery, usually involving excision of the affected bone with primary closure. Progress notes and interviews showed repeated complaints of oral pain and ongoing attempts to obtain specialty care, but the care plan still did not reflect the specific mouth condition. Notes documented tooth pain, oral pain, jaw pain, foul breath, and treatment with Orajel, chlorhexidine mouth rinse, clindamycin, and pain medication. Staff interviews confirmed they knew about the resident's mouth pain and stated that an inaccurate care plan could affect care and treatment, while the DON and CCM were identified as responsible for care plans.
Respiratory Care Orders Not Followed
Penalty
Summary
Safe and appropriate respiratory care was not provided for two residents who required oxygen therapy. Resident #2, a female with diagnoses including history of COVID-19, shortness of breath, diabetes, dementia, myocardial infarction, peripheral vascular disease, and rheumatoid arthritis, had an annual MDS showing moderate cognitive impairment and dependence for most ADLs. Her record showed a care plan identifying PRN oxygen therapy for heart failure, and staff observed her sleeping in bed wearing oxygen via nasal cannula on multiple occasions. However, her chart did not contain an active physician order for oxygen on the MAR for the reviewed periods, and the DON stated she could not find an oxygen order in the chart. The CN later stated the oxygen order had been inadvertently discontinued as a duplicate and that it had been missed since then. Resident #15, a female admitted with COPD, had an annual MDS showing severe cognitive impairment and substantial to maximal assistance with most ADLs. Her active order specified oxygen at 2 LPM via nasal cannula at bedtime, and her care plan stated she required oxygen therapy at times due to COPD. Despite this, staff observed her receiving oxygen at 3 LPM on multiple occasions and later at 2.75 LPM, including while lying in bed and while sitting up eating breakfast. The resident was not documented as receiving oxygen at the ordered rate during these observations. During interviews, multiple staff members stated nurses were responsible for setting oxygen flow rates and were to use the physician’s order to determine the correct rate. The CN, CCM, CNA, LVN, ADM, and DON all acknowledged that oxygen flow should match the order, and several stated that giving oxygen at a higher rate than ordered could negatively affect a resident with COPD. The facility policy titled Oxygen Concentrator also stated oxygen is administered under the attending physician’s orders and that the nurse shall verify the physician’s order for the rate of flow and route of administration.
Failure to Obtain Timely Oral Surgery for Resident With Ongoing Mouth Pain
Penalty
Summary
The facility failed to provide or obtain dental services for a resident with significant oral disease, including aggressive periodontitis, dental caries, and a history of myelodysplastic syndrome. The resident’s record showed intact cognition on the annual MDS, mild pain requiring medication, and no oral/dental pain coded on the assessment. The care plan did not specifically address mouth or dental pain, although it noted acute pain without identifying the location. The resident’s chart documented ongoing dental problems and repeated attempts to obtain specialty care. She had teeth extracted and was noted to need additional extractions. An oral and maxillofacial surgeon later evaluated her for osteonecrosis of the jaw related to prior cancer treatment drugs and documented exposed necrotic bone in the right maxilla and mandible, along with pain and an occasional foul taste. The surgeon stated he would obtain x-rays from the dentist and call with a surgery date, but the resident continued to have oral pain and halitosis documented in subsequent notes. Facility notes showed multiple contacts with dentists, oral surgeons, insurance sources, and outside offices over several months, including reports that some providers did not accept the resident’s age group, did not accept adult Medicaid, or did not have a referral on file. The resident continued to report mouth pain, and staff documented that the oral surgeon had not yet scheduled surgery. During survey observation, the resident stated she was in pain all the time due to a pocket with pus in her mouth and said the out-of-state doctor had told her he would set a surgery date, but it had not happened yet. Staff interviews confirmed the resident’s mouth pain had been ongoing for a long time.
Failure to Follow Food Procurement and Safety Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Provide Food in Appropriate Form for Individual Needs
Penalty
Summary
The facility failed to ensure that each resident received food prepared in a form designed to meet their individual needs. This deficiency indicates that meals were not consistently modified or adapted to accommodate the specific dietary requirements or physical abilities of residents, such as those needing pureed, chopped, or otherwise altered food textures.
Failure to Follow Enhanced Barrier Precautions During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program as evidenced by the Director of Nursing (DON) not wearing a gown while performing wound care on a resident with a stage 4 pressure ulcer and a colostomy. The resident's care plan and physician orders specified the need for enhanced barrier precautions (EBP), including the use of personal protective equipment (PPE) such as gowns, gloves, and goggles during high-contact care activities like wound care. Despite these documented requirements, the DON did not don a gown during the procedure, which was confirmed during an interview immediately following the observation. Interviews with other nursing staff, including an RN and a CNA, confirmed that EBP should be implemented for residents with wounds, catheters, or ostomies, and that appropriate PPE is expected to be used during high-contact care. The facility's policy on enhanced barrier precautions, implemented in June, also outlined the necessity of PPE during wound care. The DON acknowledged that not following EBP during the wound care was a violation of infection control protocols.
Failure to Use Transfer Belt During Resident Transfer
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and provide adequate supervision and assistive devices for a resident. A certified nursing assistant (CNA) did not use a transfer belt while transferring a resident from bed to wheelchair, which was against the facility's protocol. The resident, who had severe cognitive impairment and multiple health issues, required extensive assistance for mobility and transfers. The resident's care plan specified the need for a transfer belt, but the CNA attempted the transfer without it, as confirmed by video evidence provided by the resident's power of attorney (POA). The resident's medical history included conditions such as congestive heart failure, dementia, and muscle weakness, which necessitated careful handling during transfers. Despite the resident's dislike for the transfer belt, it was deemed necessary for her safety. The CNA's competency checklist indicated she was trained to use a transfer belt, yet she did not follow this protocol during the transfer. The facility's administration was unaware of the reason for this deviation, and attempts to contact the CNA for clarification were unsuccessful.
Failure to Maintain Resident Dignity with Catheter Care
Penalty
Summary
The facility failed to treat residents with respect and dignity by not ensuring that catheter bags were covered with privacy bags for two residents, Resident #19 and Resident #89. Resident #19, a male with multiple diagnoses including cerebral infarction and schizoaffective disorder, was observed multiple times with his catheter bag exposed without a privacy bag. Despite being alert, Resident #19's responses were limited, and he was noted to have a behavior of removing the dignity bag from his catheter. Observations were made in various locations, including the hallway, nurse's station, and dining room, where the catheter bag was visible to other residents and staff. Resident #89, a male with diagnoses including heart failure and diabetes, was also observed with his catheter bag exposed without a privacy bag. He had not been in the facility long enough for a Minimum Data Set (MDS) assessment to be completed. Observations of Resident #89 occurred in his room, the dining room, and the day area, where his catheter bag was visible to others. Interviews with Certified Nursing Assistants (CNAs) confirmed that catheter bags should be covered, especially when residents are outside their rooms, to maintain dignity and prevent embarrassment. The facility's policy on dignity, revised in February 2021, states that residents should be cared for in a manner that promotes their well-being and self-esteem, explicitly mentioning the need to cover urinary catheter bags. Despite this policy, the facility did not consistently apply it, as evidenced by the repeated observations of uncovered catheter bags for both residents. This oversight could lead to feelings of discomfort and disrespect among residents, as noted by the CNAs and the Clinical Resource Nurse (CRN) during interviews.
Deficiency in Resident Activity Program
Penalty
Summary
The facility failed to provide an ongoing program of activities that met the interests and needs of residents, as observed over a three-day period. Several residents expressed dissatisfaction with the activities offered, noting a lack of variety and engagement. One resident mentioned not receiving an activity calendar and expressed a desire for more games. Another resident, confined to bed due to illness, reported not being offered any in-room activities, despite an interest in word puzzles. Observations revealed that activities were often limited to bingo sessions on a big screen TV, which some staff struggled to operate. Interviews with staff highlighted a lack of coordination and responsibility in the activities program. The Activities Director (AD) and Activities Assistant (AA) were identified as responsible for planning and executing activities, but there were instances where activities were not conducted as planned. For example, the Med Records/Transport staff member was tasked with running bingo due to the absence of the AA, despite lacking the necessary skills. Additionally, the AD admitted to not having time to cover for the AA, and the AA was observed not performing her duties during scheduled one-on-one activities. The facility's care plans did not include documentation of activities, and the AD acknowledged that activity assessments were missing from care plans. The facility's policy on comprehensive care plans emphasized the need for person-centered care plans that address residents' needs, including activities. However, the lack of proper documentation and execution of activities suggests a failure to adhere to this policy, potentially impacting residents' quality of life.
Improper Food Labeling and Dating in Facility
Penalty
Summary
The facility failed to ensure that stored food was properly labeled and dated, which could place residents at risk for foodborne illness. During an inspection of pantry #1, several items were found without proper labeling or dating, including a bag of ground cinnamon, a large container of food thickener with an outdated label, a box of chili mix, and two bags of turkey gravy. Additionally, three containers of cereal on the kitchen counter and a bag of sliced watermelon in refrigerator #2 were also found without labels or dates. Interviews with the Dietary Manager (DM) and another staff member revealed that all kitchen staff are responsible for adhering to the facility's food storage policy, which mandates that all items must be labeled and dated to prevent contamination. The facility's food service policy, dated 2018, outlines the proper procedures for dating, labeling, and storing food items to ensure freshness and prevent contamination.
Medication Cart Left Unlocked in Hall 600
Penalty
Summary
The facility failed to store all drugs and biologicals in accordance with State and Federal laws by not locking the medication cart on hall 600. During an observation, the medication cart was found unlocked with all three drawers easily accessible and filled with what appeared to be topical medications. A resident was present in the vicinity, seated in a wheelchair, with no staff members in sight. This situation was confirmed by a CNA who acknowledged that an unlocked medication cart could lead to unauthorized access to medications by residents or staff. Further observations revealed that the medication cart remained unattended and unlocked for nearly 10 minutes before two nurses, including a Wound Care nurse and an RN, returned. The Wound Care nurse, who identified herself as a nurse practitioner, confirmed that the cart contained only topical wound medications and acknowledged the potential risk of residents accessing the supplies. The RN Charge Nurse also confirmed that the cart is typically locked and recognized the potential for negative outcomes if medications were accessed by unauthorized individuals. The facility's policy, dated November 2020, mandates that all drugs and biologicals be stored in locked compartments when not in use, which was not adhered to in this instance.
Neglect of Resident Due to Inadequate Incontinence Care
Penalty
Summary
The facility failed to protect a resident from neglect, as evidenced by the observation of the resident's bed being saturated with urine. The resident, a female with severe unspecified dementia and other health issues, was found in a state of neglect during an observation. The resident's care plan indicated she was at risk for pressure ulcers due to incontinence and required regular checks and changes to maintain skin integrity. However, during the observation, it was noted that the resident's bed was saturated, and she had not been changed for an extended period. Interviews with the Certified Nursing Assistants (CNAs) involved revealed inconsistencies in their training and understanding of neglect. CNA A, who had been working at the facility for only three days, stated that she had not received training on abuse or neglect since starting. However, records indicated she had been trained on the facility's abuse and neglect policy. CNA B, who assisted in the care, could not confirm recent training but was recorded as having received it at hire. Both CNAs acknowledged that leaving a resident in a saturated bed could be considered neglect. The facility's administration also showed a lack of clarity regarding what constitutes neglect. During an interview, the Administrator did not confirm that leaving a resident in a saturated bed was neglect, suggesting it depended on various factors such as the timing of the last care and any medication changes. The facility's policies on abuse, neglect, and residents' rights emphasize the importance of providing necessary care and maintaining residents' dignity, which was not upheld in this instance.
Resident Left Unattended During Nebulizer Treatment
Penalty
Summary
The facility failed to provide adequate pharmaceutical services for a resident who was receiving medication via a nebulizer. The resident, a cognitively intact male with a history of dementia, shortness of breath, pneumonia, and other respiratory issues, was left unattended during a nebulizer treatment. This occurred despite the facility's policy requiring staff to remain with residents during such treatments. The resident was observed in the activities room receiving the treatment without supervision, while the LVN responsible was at the nurses' station and later seen walking away from the area. Interviews with the LVN and other staff revealed a lack of awareness regarding the importance of remaining with the resident during the nebulizer treatment. The LVN admitted to not knowing it was an issue and acknowledged that the resident might not receive the full dose of medication if left unattended. The Regional RN and ADM also highlighted potential negative outcomes, such as adverse reactions or incomplete medication administration, due to the lack of supervision during the treatment.
Inadequate Hand Hygiene Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by improper hand hygiene practices observed among staff members during resident care. Specifically, CNA A and CNA B did not perform hand hygiene before donning gloves or after removing them while providing incontinent care to two residents. During the care of one resident, CNA B did not change gloves or perform hand hygiene after handling a dirty brief and before touching clean items, such as clothing and linens. Similarly, while assisting another resident, both CNAs failed to change gloves or perform hand hygiene between handling soiled and clean items, leading to potential cross-contamination. Interviews with the involved CNAs revealed a lack of adherence to hand hygiene protocols, with one CNA admitting to nervousness during the survey and the other unable to provide a reason for the oversight. The facility's policy on hand hygiene, which emphasizes its importance in preventing infection spread, was not followed. The policy clearly states that hand hygiene must be performed before donning and after doffing gloves, as well as after removing personal protective equipment. Despite being re-educated on these procedures, the CNAs did not comply with the established guidelines during the observed incidents.
Misappropriation of Resident's Morphine
Penalty
Summary
The facility failed to ensure that a 15 ml bottle of morphine prescribed to a resident was not misappropriated. The resident, an elderly female with heart disease, dementia with anxiety, and type 2 diabetes, did not receive her scheduled doses of morphine due to the medication being unavailable. The morphine was discovered missing at the change of shift, and the facility's investigation revealed that the bottle and the narcotics book sheet documenting the medication counts were also missing. The local police department was called to investigate the missing morphine. Interviews with staff members indicated that the morphine was last seen by an LVN the day before it was found missing. The night nurse, who was suspected of taking the morphine, was already on suspension for a previous incident. The facility's policies on controlled substances and medication storage were not followed, as the medication cart was not properly secured, and the sign-in and out sheet was missing, making it impossible to determine who had the morphine last. The resident's family members were informed about the missing morphine and reported that the resident did not show signs of being in pain despite missing doses. The hospice nurse eventually delivered a new bottle of morphine to the facility. The facility's policies on abuse, neglect, and exploitation, as well as controlled substances and medication storage, were reviewed and found to be inadequate in preventing the misappropriation of the resident's morphine.
Failure to Report Injury of Unknown Origin in a Timely Manner
Penalty
Summary
The facility failed to report an injury of unknown origin (bruising to a resident's chest) to the administrator and to the state within 24 hours. The resident, a female with severe cognitive impairment and multiple medical conditions including congestive heart failure, atrial fibrillation, dementia, chronic obstructive pulmonary disease, and chronic kidney disease, was found with a bruise on her chest. The bruise was first noticed by two CNAs and one LVN on the evening of 04/13/24, but it was not reported or documented until the following day by LVN H. The facility's investigation revealed that the bruise was reported to state authorities on 04/15/24 at 01:32 PM, which was beyond the required 24-hour reporting window. Additionally, the facility's policy on abuse and neglect was found to be incomplete, missing critical information regarding the reporting of such incidents. Staff interviews indicated that there was confusion and inconsistency in the reporting process, with some staff members receiving in-service training over the phone and others being unsure of the proper procedures. The facility's failure to report the injury in a timely manner could place residents at risk of not having incidents of possible abuse and neglect reviewed and investigated promptly. This deficiency highlights the need for clear and consistent reporting procedures to ensure the safety and well-being of residents. The facility's policy on abuse and neglect was found to be incomplete, missing critical information regarding the reporting of such incidents. Staff interviews indicated that there was confusion and inconsistency in the reporting process, with some staff members receiving in-service training over the phone and others being unsure of the proper procedures. The facility's failure to report the injury in a timely manner could place residents at risk of not having incidents of possible abuse and neglect reviewed and investigated promptly. This deficiency highlights the need for clear and consistent reporting procedures to ensure the safety and well-being of residents.
Failure to Lock Medication Cart
Penalty
Summary
The facility failed to store all drugs and biologicals in accordance with State and Federal laws by not locking the medication cart in hall 200. During an observation, the medication cart was found unlocked with all three drawers easily opened and full of medications. The double-locked drawers were unlocked on the first lock but still locked on the second lock. This occurred while a resident was awake and seated in his room in line of sight of the medication cart, with no staff members present. Subsequent observations confirmed the medication cart remained unlocked and unattended. Interviews with various staff members, including LVNs, CNAs, the ADON, and the DON, revealed a consensus that it was the nurse's responsibility to keep the medication cart locked to prevent unauthorized access to medications. The facility's policies on controlled substances and storage of medications, dated April 2019 and November 2020 respectively, were reviewed and confirmed the requirement for drugs and biologicals to be stored in locked compartments. The failure to adhere to these policies could lead to residents obtaining medications not prescribed to them, posing a risk of adverse reactions.
What surveyors are citing around you — mapped
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Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 15 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
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Borger
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Caprock Nursing & Rehabilitation | 0.7 mi | ★★★★★ | 2 | 0 |
| Avir At Pampa | 24.1 mi | ★★★★★ | 12 | 0 |
| Pampa Nursing Center | 24.1 mi | ★★★★★ | 1 | 0 |
| Great Plains Nursing And Rehabilitation | 35.1 mi | ★★★★★ | 0 | 0 |
| Memorial Nursing And Rehabilitation Center | 35.7 mi | ★★★★★ | 0 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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.