Above 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 Avir At Pampa during CMS and state inspections, most recent first.
Medication storage and labeling were not maintained in accordance with policy in 1 of 2 med carts and 1 OTC closet. An unidentified loose pill was found in the bottom of a med cart drawer, and two bottles of Calcium Supplement in the OTC closet had illegible expiration dates. Interviews with an LVN, ADON, and DON addressed the concerns, and policy review showed meds must be stored in an orderly manner and labeled with expiration dates when applicable.
Food items in the pantry, freezer, refrigerator, and prep area were observed unlabeled, undated, uncovered, or improperly stored, including rice, jelly packets, sugar, potatoes, frozen meat, tomatoes, sour cream, milk cartons, deli meat, cooked bacon, and other prepared foods. Staff stated that everyone in the kitchen was responsible for labeling and dating food, and the DM said she trained new hires to do so as soon as food arrived. Facility policy required food to be covered, labeled, and dated.
An infection prevention and control deficiency was cited after an LPN failed to perform hand hygiene and use PPE during PEG tube feeding and glucose checks for multiple residents, and a CNA did not don a gown for urinary catheter care. The bedside table used for feeding supplies was also not cleaned, and interviews confirmed the missed hand hygiene and gown use were infection control issues.
Failure to Attempt GDR for Psychotropic Medication: A resident with Alzheimer's disease, severe cognitive impairment, anxiety, and insomnia was receiving trazodone 50 mg HS as a psychotropic medication. Record review showed no GDR documentation in the MRR book, and staff, including the DON, ADON, and RNC, stated they relied on the pharmacy consultant and medical director to address GDRs. Facility policy required psychotropic meds to receive GDRs unless clinically contraindicated.
PICC Line Care Not Performed as Ordered: A resident with a PICC line and diagnoses including endocarditis and bacteremia had ordered weekly dressing changes and a weekly Haloguard Patch, but records and observations showed missed or inconsistent dressing documentation and repeated absence of the Haloguard under the transparent dressing. The DON, ADON, and RNC acknowledged the missing Haloguard and stated it was an added barrier to prevent infection, while an LPN said there was no reason it was not placed.
Incomplete PICC line documentation was identified for a resident with endocarditis, bacteremia, stroke history, and a PICC order for weekly dressing changes plus a Haloguard Patch. The TAR and bedside observations did not match: dressing changes and Haloguard placement were inconsistently documented, and staff interviews confirmed concern about false charting and infection risk. The facility policy required treatment documentation to include the date and time provided.
The facility did not submit the required results of an investigation into suspected abuse, neglect, or theft for a resident within the mandated 5 working days. Although the initial incident was reported, the follow-up Provider Investigation Report was not filed on time, as confirmed by record review and the Administrator's admission.
During a meal service, three staff members, including a CNA, LVN, and RNRS, failed to follow proper hand hygiene protocols, risking cross-contamination. Observations showed lapses such as touching clothing and surfaces without re-sanitizing hands before serving residents. Interviews revealed varying awareness of these lapses, and the facility lacked a specific policy for hand hygiene during meal service.
The facility failed to address grievances raised by the resident council over seven months, including issues with missing clothes and insufficient snacks. Residents reported dissatisfaction, with some receiving incorrect clothing sizes and inadequate snack distribution. Staff acknowledged the issues but did not implement effective solutions, relying on donations and leaving snacks unattended. Observations confirmed these practices, and interviews with staff revealed a lack of urgency in addressing grievances, contrary to the facility's policy on prompt action.
The facility failed to ensure RN coverage for at least 8 consecutive hours a day, 7 days a week, over several months in 2024. The DON acknowledged the lapse, stating it "fell through the cracks" and an RN was not hired until July, leaving staff without necessary supervisory coverage.
The facility failed to maintain sanitary conditions in the kitchen, with staff not wearing hair restraints and food items improperly labeled, dated, or covered. Observations revealed uncovered and unlabeled food in the cooler and freezer, contrary to facility policies and the USDA Food Code. The supervising staff acknowledged these practices could lead to cross-contamination and food-borne illness.
The facility failed to ensure call lights were within reach for two residents, one with severe cognitive impairment and another with moderately impaired cognition. Observations showed call lights were not accessible, contrary to care plans and facility policy, potentially delaying care.
The facility failed to implement its policies to prevent abuse, neglect, and exploitation by hiring RN F without conducting a required background check. RN F began working before the Employee Misconduct Registry check was completed, contrary to the facility's ANE policy, which mandates screening for potential employees. This oversight could place residents at risk.
Medication Storage and Labeling Deficiencies
Penalty
Summary
Drugs and biologicals were not stored and labeled in accordance with currently accepted professional principles in 1 of 2 medication carts and 1 of 1 OTC closet. During an observation on 01/26/2026 at 9:59 AM, one loose unidentified pill was found in the bottom of medication cart #1's drawer. During an interview at that time, LVN F stated a loose pill in the medication cart could fall out of the cart and a resident could pick it up and take it. Later that morning, an observation of the OTC closet revealed two bottles of Calcium Supplement with expiration dates that were not legible. During interviews, ADON stated that loose pills in the medication cart could lead to a resident missing a dose and that expired medications would not have the efficacy needed for a therapeutic level. LVN F also stated expired medications would not be effective for residents. Record review of the facility's Medication Labeling and Storage policy showed medications are to be stored in an orderly manner and medication labels must include an expiration date when applicable, and the Administering Medication policy stated the expiration/beyond use date must be checked before administering and the date opened must be recorded on multi-dose containers.
Food items were left unlabeled, undated, and improperly stored in kitchen areas
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety during a kitchen sanitation review. On 01/26/26, observation of the pantry found a clear container of what appeared to be rice with no lid, label, or date; two boxes of jelly packets with no label or date; a container of sugar with the lid not sealed; and a box of potatoes with no label or date. Observation of the freezer found a box of frozen meat with no label or date, a box of frozen bread that was dated but had no label, and a box of tater tots with no label. Observation of the refrigerator found a box of tomatoes with no date, single-serve sour cream packs with no label or date, a pitcher partially filled with red liquid with no label or date, three covered and dated drinking cups with no label, a Ziploc bag of dinner rolls with no label or date, a Ziploc bag of cooked rice that was dated but had no label, Ziploc bags containing deli meat, cooked bacon, and unidentified meat with no label or date, two open milk cartons with no label or date, and a tray with five cups of white liquid partially open to air with no label or date. In the kitchen preparation area, a Ziploc bag of cookies, a clear container of cereal, and a spice container of garlic powder were observed with no label or date. Staff interviews stated that everyone in the kitchen was responsible for labeling and dating food, and the DM stated she trained new hires to label and date food as soon as it arrived. The facility policy titled Food Storage stated that grain products and sugar must be stored in tight-fitting or sealable containers and that all containers or storage bags must be legibly labeled and dated; it also stated leftover, refrigerated, and frozen foods should be covered, labeled, and dated.
Infection Control Lapses During Resident Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program for 4 of 12 residents reviewed for infection control. During an observation on 01/26/2026 at 10:37 AM, LVN A administered a bolus feeding to Resident #6 via PEG tube without performing hand hygiene before donning gloves and without using PPE; the bedside table was also not cleaned before the syringe and supplies were placed on it. During an observation on 01/26/2026 at 11:03 AM, there were no supplies in any drawer of the PPE cabinet outside Resident #6's room. During observations on 01/27/2026, LVN A did not perform hand hygiene before donning gloves to clean the glucometer and complete a glucose check for Resident #42 at 6:27 AM, and did not perform hand hygiene before or after a glucose check for Resident #30 at 6:42 AM. During an observation on 01/27/2026 at 2:26 PM, CNA E did not don a gown before performing urinary catheter care for Resident #13. Interviews with CNA E, LVN A, the ADON, the DON, and the RNC confirmed that the missed hand hygiene and gown use were infection control issues. Record review showed the facility's policies required hand hygiene before resident contact and before aseptic tasks, and required gown and glove use for high-contact care activities involving feeding tubes and urinary catheters.
Failure to Attempt GDR for Psychotropic Medication
Penalty
Summary
The facility failed to ensure that a resident who was receiving a psychotropic medication received a gradual dose reduction, or documentation that such a reduction was clinically contraindicated, during the first year after the medication was started. Resident #2 was admitted with diagnoses including Alzheimer's disease with early onset and an anxiety disorder, and the quarterly MDS showed a BIMS score of 4, indicating severely impaired cognition. The resident's care plan stated she received antidepressant medication related to depression and insomnia and that she would be prescribed the lowest effective dose of medication. Record review showed the resident was receiving traZODone HCl 50 mg at bedtime for insomnia, with consent for psychotropic medication dated 04/21/25. Review of the facility's MRR book from April 2025 through January 2026 showed no mention of a GDR for the resident's antidepressant medication. The DON stated she did not remember a GDR being addressed for the resident and later stated hospice had started trazodone at 50 mg at bedtime in October 2024, adding that if there had been a recommendation for a GDR after admission it would have been in the MRR book. During interviews, facility staff stated the medical director and pharmacy consultant were responsible for ensuring GDRs for psychotropic medications were addressed timely. The ADON, RNC, and DON all stated the pharmacy consultant was responsible for recommending GDRs, and staff acknowledged that a resident could be negatively affected if a GDR was not considered timely. Facility policy required residents on psychotropic medications to receive GDRs and behavioral interventions unless clinically contraindicated, and required two separate taper attempts during the first year after admission or initiation of the medication.
PICC Line Care and Ordered Antimicrobial Dressing Not Followed
Penalty
Summary
The facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and physician orders for one resident with a PICC line. Resident #11 was admitted with diagnoses including acute and subacute infective endocarditis, bacteremia, cerebral infarction, heart disease, bilateral carotid artery occlusion and stenosis, iliac artery aneurysm, and peripheral vascular disease. Her MDS indicated a BIMS score of 12, showing moderate cognitive impairment, and she was otherwise independent except for showering. The resident’s orders included a PICC site dressing change every 7 days and PRN for soiling or displacement, and a Haloguard Patch to be applied once daily on Monday mornings. Record review showed the PICC dressing changes were documented on 01/11/2026, 01/18/2026, and 01/25/2026, with no initials or signature for the 01/04/2026 dressing change. The TAR also showed the Haloguard was not changed on 01/04/2026, was not placed on 01/11/2026, and was later placed by the ADON on 01/25/2026. During observation on 01/27/2026, the PICC dressing had not been changed since 01/19/2026 and there was no Haloguard in place. During observation on 01/28/2026, the PICC dressing was dated 01/27/2026, but no Haloguard was present under the transparent dressing. Interviews confirmed the missing Haloguard and inconsistent line care. The ADON, DON, and RNC each stated that not having a Haloguard over the PICC insertion site increased infection risk, and the ADON stated the dressing would need to be changed more often. LVN A stated there was no reason she did not place the Haloguard and did not remember charting that she placed it. Facility policy required dressing changes at established intervals and PICC line care in accordance with central-line infection prevention practices.
Incomplete PICC Line Dressing and Haloguard Documentation
Penalty
Summary
Resident #11, a female admitted with diagnoses including acute and subacute infective endocarditis, bacteremia, cerebral infarction, heart disease, bilateral carotid artery occlusion and stenosis, iliac artery aneurysm, and peripheral vascular disease, had a PICC line with orders for dressing changes every 7 days and a Haloguard Patch. Her MDS indicated a BIMS of 12, showing moderate cognitive impairment. Record review showed the PICC dressing was documented as changed on 01/11/2026, 01/18/2026, and 01/25/2026, but the TAR also showed no dressing change on 01/04/2026 and no Haloguard change on 01/04/2026. The record further showed Haloguard was not placed on 01/11/2026, and there were no other care plans for PICC line dressing care. During observation on 01/27/2026, the PICC dressing was noted to have not been changed since 01/19/2026, yet the record indicated the dressing had been changed on 01/25/2026. At that time, there was no Haloguard in place over the insertion site. On 01/28/2026, the PICC dressing was observed again, dated 01/27/2026, and no Haloguard was present under the transparent dressing. Interviews with the ADON, DON, and RNC acknowledged that false documentation could increase infection risk, and an LVN stated she did not remember charting that she placed the Haloguard on the resident. The facility policy required documentation of treatments and procedures, including the date and time provided.
Failure to Timely Report Investigation Results of Suspected Abuse/Neglect
Penalty
Summary
The facility failed to report the results of an investigation into suspected abuse, neglect, or theft within the required 5 working days, as mandated by state law. Specifically, for one incident involving a resident, the Provider Investigation Report (Form 3613-A) was not filed in the TULIP system within the required timeframe. The initial Facility Reported Incident and CII Self-Report Template were submitted, but the follow-up investigation results were not reported as required. Record review confirmed that the 5-day report was not completed until several weeks after the incident. During an interview, the Administrator acknowledged not remembering to complete the 5-day report and attributed the oversight to being preoccupied with other matters in the facility. The facility's own policy requires the Administrator to confirm receipt of the initial report and to submit the results of the investigation within 5 working days. The failure to complete this process was confirmed through both record review and the Administrator's statements.
Inadequate Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the improper hand hygiene practices of three employees during a lunch meal service. CNA A, LVN B, and RNRS C were observed not following proper hand hygiene protocols. CNA A used alcohol-based hand rub (ABHR) but then placed her hands in her pockets and later picked up a butter pat from the floor, placing it back on a resident's tray without re-sanitizing her hands. LVN B used ABHR upon entering the dining room but then touched her clothing and served a resident without re-sanitizing her hands. RNRS C was observed resting her hand on an ice machine before assisting a resident with their meal without sanitizing her hands. Interviews with the staff revealed varying levels of awareness and acknowledgment of the lapses in hand hygiene. RNRS C acknowledged the lapse and the potential for cross-contamination, while LVN B denied any lapse despite the observations. CNA A realized her lapse after handling the resident's tray. The facility's policy on hand hygiene was reviewed, which outlined the use of ABHR and handwashing procedures, but it was noted that there was no specific policy regarding hand hygiene while serving resident meals.
Failure to Address Resident Council Grievances
Penalty
Summary
The facility failed to adequately address and respond to grievances raised by the resident council over a period of seven months. The resident council meetings consistently highlighted issues such as missing clothes and insufficient snacks for residents, yet there was no documented feedback or response from the facility staff to these concerns. Interviews with residents revealed ongoing dissatisfaction, with reports of missing clothing items and inadequate snack distribution, which were repeatedly brought up in council meetings without resolution. Residents expressed frustration during interviews, indicating that their concerns were not being taken seriously by the staff. Specific issues included residents receiving incorrect clothing sizes after laundry, and snacks not being distributed fairly, leading to some residents going without. One resident, who was diabetic, noted that the available snacks were unsuitable for her dietary needs, and another resident reported going to bed hungry due to the lack of available snacks. The facility's Assistant Director (AD) and other staff members acknowledged these issues but did not implement effective solutions, relying instead on donated clothing to address missing items and leaving snacks unattended at the nurse's station. Observations by the State Surveyor confirmed the unattended snack cart and the mixing of donated clothing with lost and found items, which could lead to further confusion and dissatisfaction among residents. Interviews with staff, including the Director of Nursing (DON) and the Administrator (ADM), revealed a lack of urgency in addressing these grievances, with the ADM admitting that residents might feel their concerns were unimportant. The facility's policy on grievances mandates prompt action on resident concerns, yet this was not reflected in the facility's handling of the issues raised by the resident council.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to maintain the required registered nurse (RN) coverage for at least 8 consecutive hours a day, 7 days a week, over a period of several months in 2024. Specifically, there was no RN coverage on multiple dates in April, May, June, and July, and on one date in October, the RN coverage was insufficient, lasting only 5.63 hours. This deficiency was identified through interviews and record reviews, including the facility's time sheets and the CMS PBJ Staffing Data Report. During an interview, the Director of Nursing (DON) acknowledged the lack of RN coverage, stating that it had "fallen through the cracks" and that an RN was not hired until July. The DON admitted that the absence of an RN left the staff without supervisory coverage necessary for coordinating events such as emergency care. Despite a request for the facility's policy on RN coverage, it was not provided by the DON.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in the kitchen, as observed during a survey. Staff members did not wear appropriate hair restraints, which is a requirement to prevent hair from contaminating food and food contact surfaces. Specifically, a housekeeper was seen in the kitchen without a hairnet, and she was unaware of the necessity to wear one. This oversight was acknowledged by the supervising staff, who stated that the housekeeper should not have been in the kitchen without a hairnet. Additionally, the facility did not properly label, date, or cover stored food items, which is essential to prevent cross-contamination and ensure food safety. Observations in the walk-in cooler revealed several items, including cooked chicken, strawberries, and milk, that were either uncovered or not labeled and dated. Similarly, in the freezer, an opened box of beef fritters was found unsecured and exposed to air. These practices are contrary to the facility's policies and the USDA Food Code, which require proper labeling and covering of food items. The facility's policy on food storage and employee sanitation was not adhered to, as evidenced by the uncovered and unlabeled food items and the lack of hair restraints. The supervising staff admitted that the nursing staff preferred not to cover food served in the dining room, which led to uncovered puddings and milk. This practice was recognized as a potential cause of cross-contamination, posing a risk of food-borne illness to residents consuming the food.
Failure to Ensure Call Light Accessibility for Residents
Penalty
Summary
The facility failed to ensure that residents had reasonable accommodation for their needs and preferences, specifically regarding the accessibility of call lights for two residents. Resident #3, a legally blind and hearing-impaired elderly female with severe cognitive impairment, was observed multiple times with her call light out of reach while she was seated in her recliner. Despite being located near the nurse's station to compensate for her inability to use the call light, this arrangement did not align with her care plan, which specified that the call light should be within reach. Similarly, Resident #13, who had moderately impaired cognition and required extensive assistance, was found with her call light out of reach on several occasions. Observations revealed that the call light was placed on a dresser instead of being attached to her blanket as per her care plan. Interviews with staff indicated that the call light was not consistently placed within reach, and the resident resorted to pounding on the wall to seek help. The facility's policy required call lights to be within easy reach, but this was not adhered to, leading to potential delays in care.
Failure to Implement Abuse Prevention Policies
Penalty
Summary
The facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents. Specifically, the facility did not ensure that a potential employee, RN F, who would be working directly with residents, was free of criminal charges before hiring. RN F's employee file showed a hire date of July 4, 2024, but the Employee Misconduct Registry (EMR) check was conducted on July 9, 2024, after the hire date. During an interview, the Human Resources Director (HRD) acknowledged that RN F was supposed to start later in the month, but began working on July 4, 2024, without the necessary background check. This oversight could place residents at risk of abuse or neglect by an employee with a documented history of such behaviors. The facility's Abuse, Neglect, and Exploitation (ANE) policy, dated October 2023, mandates that potential employees be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. It also requires background, reference, and credentials checks for potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants. The failure to adhere to these policies resulted in a deficiency in ensuring resident safety.
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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 Pampa
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Pampa Nursing Center | 0 mi | ★★★★★ | 1 | 0 |
| Avir At Borger | 24.1 mi | ★★★★★ | 17 | 0 |
| Caprock Nursing & Rehabilitation | 24.8 mi | ★★★★★ | 2 | 0 |
| Mclean Care Center | 30.2 mi | ★★★★★ | 1 | 1 |
| Palo Duro Nursing Home | 37.3 mi | ★★★★★ | 10 | 0 |
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