Below average — CMS composite of the measures below.
A standard survey is most likely before around August 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 Caprock Nursing & Rehabilitation during CMS and state inspections, most recent first.
A resident with Type 2 DM and multiple comorbidities received 45 units of short-acting insulin instead of the ordered long-acting insulin when an LVN failed to follow facility medication verification procedures. The LVN could not locate the usual insulin pen, found a vial, and relied on an external AI tool rather than facility drug references or consulting the DON/ADON, and did not fully review the information before administering the dose. After realizing the mistake while giving insulin to another resident, the LVN checked the resident’s blood glucose, which decreased from 200 to 145, and the resident was subsequently sent to the hospital for observation following the insulin overdose.
A resident with multiple diagnoses, including severe dementia and mood disturbances, did not have their comprehensive care plan updated within 7 days following a completed MDS assessment. Staff interviews confirmed the care plan was not revised as required, and facility policy mandates timely updates after assessments.
A deficiency was identified when the facility did not honor a resident's right to a dignified existence, self-determination, communication, and the ability to exercise personal rights. The report does not provide further details about the specific circumstances or individuals involved.
A resident with multiple chronic conditions experienced a misappropriation of her prescribed Tylenol #3 tablets when 10 pills were found missing, and both the narcotic count sheet and medication card were unaccounted for. The discrepancy was discovered during a narcotic count verification, and the lack of documentation prevented clear identification of the cause of the loss.
A resident with dementia was emotionally and potentially physically abused by another resident in a secure unit. Despite staff witnessing the incident, it was not reported as potential abuse. The male resident continued inappropriate behavior, leading to his discharge to a psychiatric hospital. The deficiency was identified as past non-compliance, as the facility corrected the issue before the investigation began.
A resident with dementia was subjected to emotional and possible physical abuse by another resident, who entered her room and attempted to control her wheelchair, causing distress. Despite staff witnessing the incident, it was not reported as potential abuse according to the facility's policy. Miscommunication and confusion among staff led to a delay in addressing the situation, placing residents at risk of continued abuse.
A resident with dementia was not protected from potential abuse by another resident in a secure unit. The incident involved inappropriate touching and distress, but was not reported to the administrator or state agency as required. Staff cited the victim's dementia as a reason for not considering it abuse, despite visible distress.
A resident with multiple health conditions filed a grievance regarding food preferences and call light response times. The facility failed to provide a written decision, only verbally informing the resident, which led to communication lapses and potential feelings of being unheard. Staff interviews confirmed the lack of documentation, despite the facility's policy requiring written grievance decisions.
Significant Insulin Administration Error Due to Failure to Verify Medication Type
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a nurse administered the wrong type of insulin. The resident was an older female with multiple diagnoses, including Type 2 diabetes, dementia, Parkinson’s disease, pancreatic disease, malnutrition, hypothyroidism, hypertension, and atherosclerotic heart disease. Her MDS showed she was cognitively interviewable and independent with ADLs. Her care plan for diabetes included administration of diabetes medications as ordered and monitoring for side effects and effectiveness. Physician orders specified two long-acting insulin glargine (Lantus) regimens—one pen injector dose in the evening and one vial dose in the morning—and a short-acting insulin aspart (Flasp) pen on a sliding scale three times daily. On the day of the incident, the LVN assigned to the resident went to the medication cart after already taking the resident’s vital signs. The resident typically received insulin via a pen and preferred it at a certain time. The LVN reported that she was looking for two insulin pens for the resident, as she had seen two pens previously, but on this occasion found only one pen in the cart. She then located a vial of insulin, which she believed to be the long-acting insulin needed at that time. Instead of using facility-provided drug reference materials or consulting the DON, ADON, or a more experienced nurse, she used an external AI tool (ChatGPT) to verify the insulin type and admitted she did not read the full response. Based on this incomplete external check, she proceeded to administer the insulin. After administering the insulin, the LVN went on to give insulin to another resident and then realized that the insulin she had given the first resident was actually the short-acting insulin, not the long-acting insulin ordered for that time. This error resulted in the resident receiving 45 units of short-acting insulin instead of the prescribed long-acting insulin. The LVN then checked the resident’s blood glucose, which was 200, and rechecked it 10 minutes later, finding it at 145. The resident recalled receiving insulin via a regular syringe instead of her usual pen and later learned she had received the wrong insulin. The facility’s written policy required staff to familiarize themselves with medications using facility drug references, to verify the type of insulin and dosage, and to read the label three times and check it against the MAR and the order, as well as to follow the five rights of medication administration. The events described show that these established procedures were not followed, leading to a significant medication error and the resident’s transfer to the hospital for observation after an insulin overdose. The nurse practitioner reported being informed that the nurse was out of long-acting insulin and had used an internet search to determine if another insulin was equivalent, then administered 45 units of short-acting insulin in error. The NP emphasized that this was a very serious situation and stated that a nurse should not use internet searches to make nursing judgments but should instead consult the DON or ADON. The NP indicated that the resident’s blood sugars remained within a normal range for her and did not drop below 120. The resident expressed discomfort with new or PRN nurses and stated she trusted the older nurses who had been at the facility longer, and she was glad that someone was following up on the incident because she believed it should never have happened.
Failure to Timely Update Comprehensive Care Plan After Assessment
Penalty
Summary
The facility failed to develop a comprehensive care plan within 7 days after the completion of the comprehensive assessment for one resident. Record review showed that the resident, a male with diagnoses including severe dementia with mood disturbances, major depressive disorder, type 2 diabetes mellitus, hypertension, and generalized anxiety disorder, had an annual MDS assessment completed, but the care plan was not updated or revised within the required timeframe. The care plan on file had a start and completion date prior to the most recent MDS assessment, and there was no evidence of an update following the assessment. Interviews with facility staff confirmed that it was the responsibility of the MDS LVN to ensure care plans were timed correctly with MDS assessments, and that failure to update the care plan could result in the resident not receiving appropriate care. The DON also acknowledged that the care plan should have been updated within 7 days of the MDS completion and that not doing so leads to inaccurate care plans. Facility policy requires that comprehensive care plans be developed within 7 days after completion of the comprehensive assessment and be reviewed and revised after each MDS assessment.
Failure to Honor Resident Rights
Penalty
Summary
The facility failed to honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. The report identifies a deficiency related to the lack of respect for resident rights, but does not provide specific details about the actions, inactions, or events that led to this deficiency. No information is given regarding the residents involved, their medical history, or their condition at the time of the deficiency.
Failure to Prevent Misappropriation of Resident's Narcotic Medication
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from the misappropriation of her prescribed medication, specifically Tylenol #3 tablets. The resident, an older female with a history of malignant neoplasm of the breast, polyneuropathy, osteoarthritis, gout, and restless leg syndrome, was prescribed Tylenol #3 for pain management. Her medication administration record indicated an order for one tablet every six hours as needed for pain, with a recent fill of 30 tablets. Upon review, it was found that 10 tablets were unaccounted for, and both the narcotic count sheet and the medication blister pack/card were missing, making it impossible to verify the exact circumstances of the loss. The incident was discovered after a nurse received a call from Hospice to verify the narcotic count, which revealed a discrepancy in the number of pills remaining. The nurse confirmed that she had previously reported a count of 13 pills, but subsequent checks indicated that 10 pills were missing. The DON confirmed that, according to the medication administration record, only 20 pills had been administered, leaving 10 unaccounted for. The missing documentation and medication raised concerns about the potential diversion or misappropriation of the resident's medication. At the time of the incident, the resident reported no issues with her medications and did not appear to have missed any doses, as the facility was able to provide the necessary medication from an emergency kit until a refill was obtained. However, the lack of proper documentation and the disappearance of both the medication and the narcotic count sheet constituted a failure to ensure the resident's right to be free from misappropriation of property.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from emotional and potential physical abuse by another resident. The incident began when the resident, who had dementia and was residing in a secure unit due to a high risk of elopement, was emotionally abused by another resident. This resident, who also had dementia and was admitted to the facility with a history of anxiety and potential for physical behaviors, was seen entering the female resident's room, waking her, and touching her inappropriately. The female resident was visibly distressed, crying, and attempting to escape the situation. Despite the incident being witnessed by staff, it was not reported as potential abuse. The staff removed the female resident from the secure unit for her safety and attempted to manage the male resident's behavior with medication adjustments. However, the incident was not communicated to the facility administrator or reported as abuse, which is a requirement under the facility's policy. The male resident continued to exhibit inappropriate behavior, including kissing the female resident on the forehead, which was later reported and led to his discharge to a psychiatric hospital. The deficiency was identified as past non-compliance, as the facility corrected the issue before the investigation began. However, the failure to report the initial incident and protect the resident from further emotional abuse highlights a significant lapse in the facility's duty to safeguard its residents from abuse and neglect. The staff's inaction and miscommunication contributed to the deficiency, as they did not follow the established protocols for reporting and addressing potential abuse.
Failure to Report and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents, as well as the misappropriation of resident property. This deficiency was identified during a review of an incident involving two residents. Resident #1, a female with dementia and other mental health conditions, was reportedly subjected to emotional and possible physical abuse by Resident #2, a male with dementia and other diagnoses. The incident occurred when Resident #2 entered Resident #1's room, touched her inappropriately, and attempted to take control of her wheelchair, causing her distress. The facility's staff, including nurses and CNAs, witnessed the incident but failed to report it as potential abuse according to the facility's Abuse/Neglect policy. Despite being trained to recognize and report abuse, the staff did not inform the administrator or take immediate action to protect Resident #1. The incident was not documented in Resident #1's progress notes for the day it occurred, and the facility did not initiate a self-report protocol until a later incident involving the same residents was observed. Interviews with staff revealed confusion and miscommunication regarding the incident, with some staff members believing Resident #2's actions were protective rather than abusive. The DON and ADM acknowledged that the incident should have been reported as possible abuse, especially considering the distress exhibited by Resident #1. The facility's failure to report and address the incident in a timely manner placed residents at risk of continued and unrecognized abuse or neglect.
Failure to Report Resident-to-Resident Abuse
Penalty
Summary
The facility failed to report an incident of emotional and possible physical abuse involving two residents in a timely manner, as required by regulations. The incident occurred when one resident, who had a history of behaviors and was residing in a secure unit due to dementia and risk of elopement, was seen entering another resident's room, waking her up, and touching her inappropriately. This led to the female resident panicking and trying to get away, resulting in a situation where the male resident was grabbing the handles of her wheelchair and dragging her back. Despite the distress exhibited by the female resident, the incident was not reported to the administrator or the state survey agency as potential abuse. The female resident involved in the incident had a medical history that included dementia, major depressive disorder, and a psychotic disorder with hallucinations. She was residing in a secure unit due to her diagnosis and risk for elopement. The male resident, who was involved in the incident, also had dementia and was noted to have potential for physical behaviors. He was later discharged to a behavioral health hospital. The facility's staff, including the DON and ADON, did not report the incident as potential abuse, citing the female resident's dementia as a reason for not considering the situation as abuse. Interviews with staff revealed that the female resident was visibly distressed during the incident, crying and trying to avoid the male resident's advances. Despite this, the incident was not reported as potential abuse, and the facility's administrator was not informed until later. The facility's policy on abuse and neglect requires that any person having reasonable cause to believe an elderly or incapacitated adult is suffering from abuse must report it to the appropriate authorities, which was not done in this case.
Failure to Provide Written Grievance Resolution
Penalty
Summary
The facility failed to ensure that efforts were made to resolve resident grievances effectively, as evidenced by the case of a resident who did not receive a written decision after filing a grievance. The resident, a cognitively intact male with a history of cellulitis, diabetes mellitus, chronic kidney disease, and an acquired absence of the left leg below the knee, had a grievance filed on his behalf concerning food preferences and call light response times. Although the facility's administrator verbally informed the resident of the grievance outcome, there was no documentation of a written notification provided to either the resident or his representative. Interviews with the resident, his family representative, and facility staff revealed a lack of communication and documentation regarding the grievance process. The resident's family representative expressed that she did not receive any outcome of the grievance and was denied access to the resolution details. Facility staff, including the administrator, DON, and SW, acknowledged the absence of written notification and recognized potential negative outcomes, such as residents feeling unheard or forgetting the grievance resolution. The facility's grievance policy mandates that the grievance official, typically the administrator, issue written decisions, which was not adhered to in this instance.
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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 Borger
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Borger | 0.7 mi | ★★★★★ | 17 | 0 |
| Avir At Pampa | 24.8 mi | ★★★★★ | 12 | 0 |
| Pampa Nursing Center | 24.8 mi | ★★★★★ | 1 | 0 |
| Great Plains Nursing And Rehabilitation | 34.4 mi | ★★★★★ | 0 | 0 |
| Memorial Nursing And Rehabilitation Center | 35 mi | ★★★★★ | 0 | 0 |
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