Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Palo Duro Nursing Home during CMS and state inspections, most recent first.
Activities Program Not Followed and Resident Preferences Not Met: Surveyors found the facility did not follow the activity calendar and did not provide an ongoing activities program based on resident preferences. Residents were observed sitting in the day area with no activities occurring, no supplies out, and no calendars posted in rooms. Residents reported boredom, lack of morning exercise, no outings, and limited choices beyond Bingo, while staff confirmed weekend activities were essentially absent and activity supplies were locked away.
The facility failed to maintain RN coverage for at least 8 consecutive hours a day, 7 days a week, with multiple weekends lacking RN presence over several months. Record review and staff interviews showed the DON was not physically in the building on weekends, the ADON was an LVN, and staff were told to call the DON or ADON by phone when issues arose. The DON acknowledged the weekend RN coverage gap, and the Administrator was aware the facility did not have RN coverage on weekends.
A resident with an indwelling catheter and intact cognition was observed multiple times with his catheter drainage bag hanging from his wheelchair without a privacy cover, leaving urine visibly exposed. He stated he had not been offered a privacy bag despite wanting one. Facility leaders, including the ADON, MDS Coord, CNA, DON, and ADM, acknowledged that covering catheter bags was a nursing responsibility tied to resident dignity and privacy, and the facility policy required catheter drainage bags to be covered at all times.
Inaccurate MDS coding occurred when an MDS coordinator failed to capture a resident’s oxygen therapy on an annual assessment despite active O2 orders, daily treatment documentation, and care plan references to supplemental oxygen. The facility also failed to code significant weight loss on another resident’s quarterly MDS even though the chart showed substantial recent loss and the care plan identified nutritional risk and recent significant weight loss. The DON and MDS coordinator both acknowledged the assessments were inaccurate.
A resident with PTSD and anxiety disorder had no documented trauma screening or Trauma Informed Care Assessment in the chart, and the care plan contained no PTSD-related interventions or triggers. During observation, another resident yelled at him in the common area while he was trying to buy a drink, and the resident pulled back his money and declined to discuss whether he was upset. Staff stated trauma assessments should be completed on admission and documented, but the SW was not aware of the assessment form and believed triggers would be addressed in care plan meetings or progress notes.
Expired CNA Certification: A CNA worked multiple shifts with an expired certification after the BOM notified the DON that renewal was needed. The BOM tracked certifications but the facility had no specific policy for verifying staff licensure status, and the DON acknowledged she knew the certification was expired but did not complete the planned status change. The CNA said she was unaware the certification had expired until the facility informed her.
The facility did not ensure that two staff members, including a Marketing/Admissions Coordinator and a CNA, received mandatory training in areas such as abuse prevention, fall prevention, restraint reduction, bloodborne pathogens, emergency procedures, and dementia care before beginning work with residents. Record reviews and staff interviews confirmed that these trainings were not completed as required, and there was no policy in place to ensure compliance.
The facility failed to follow professional standards for food safety, as observed in the kitchen. The Dietary Manager (DM) did not perform appropriate hand hygiene while preparing pureed foods, leading to potential cross-contamination. The DM was seen handling food items without changing gloves or washing hands between tasks, despite acknowledging the risk of foodborne illness. The facility's policy requires hand washing and glove changes between tasks, which was not adhered to in this case.
The facility failed to complete quarterly MDS assessments for five residents within the required timeframe, affecting individuals with various medical conditions. The MDS LVN, a remote employee, did not complete the assessments timely, citing the need for accurate coding. The ADON, responsible for resident interviews, felt overwhelmed by her dual roles. Staff interviews revealed concerns about the impact on funding and resident care, as care plans are based on MDS information.
The facility failed to refer two residents for PASRR Level II reviews after new diagnoses of serious mental disorders. One resident was diagnosed with bipolar disorder shortly after admission, and another with a psychotic disorder years after admission. Despite these diagnoses, the facility did not conduct the necessary reviews, and staff interviews revealed confusion over responsibility for PASRR completion.
A facility failed to perform a PASRR for three residents, including one with major depressive disorder, until 27 days after admission. Miscommunication about responsibility for PASRR completion led to the delay, contrary to the facility's policy requiring immediate completion. Staff interviews highlighted concerns about potential inadequate care due to this oversight.
A facility failed to maintain accurate medical records for a resident with bipolar disorder and major depressive disorder, resulting in an incorrect PASRR Level 1 Screening that did not indicate mental illness. This oversight led to the resident not receiving a necessary PASRR Level II evaluation. Interviews revealed confusion over PASRR responsibilities, with the ADON unaware of the oversight. The facility's policy mandates mental disorder screening for new admissions, which was not followed in this case.
A facility failed to maintain an effective infection control program as staff did not use PPE gowns during wound and Foley catheter care for a resident with a pressure ulcer and Foley catheter. Observations showed PPE gowns were absent, and interviews revealed staff were unaware of Enhanced Barrier Precautions (EBP). The resident had multiple diagnoses, including a pressure ulcer, requiring daily care. The facility's Infection Preventionist and ADON admitted to not being informed about EBP, contributing to the deficiency.
Activities Program Not Followed and Resident Preferences Not Met
Penalty
Summary
The facility failed to provide an ongoing activities program based on resident preferences, including facility-sponsored group, individual, and independent activities, for 12 residents reviewed. Surveyors found that the activity calendar for August was not followed and that the calendar did not incorporate physical activities or community interaction into the activity program. The activity director stated she had completed training in May 2025, was still trying to figure out what to do, and was also working as a CNA and in the kitchen because of staffing shortages. During observations on multiple days, residents were seen sitting in the day area with no activities occurring, no activity supplies out, and no activity calendars posted in resident rooms. The activity of Current Events did not occur, crafts did not occur, and there were periods when no activities were occurring in the facility. On one day, the only activity completed was Bingo, and the activity director reported she did room visits for four residents who did not get out of bed, but she did not document the visits. She also stated she passed out snacks and had made chocolate dipped cookies and chocolate covered strawberries with an RCP, but did not involve other residents in the cooking activity. Several residents stated they were bored, did not like Bingo, and wanted activities such as morning exercise, going outside, van rides, shopping, eating out, or other outings. One resident stated he liked golf and working with his hands, including fixing things and working on cars. Another resident stated she had not gone to any activities and did not know what was offered. Staff interviews confirmed there were no weekend activities except church services, that activity supplies were locked in the activity director’s room and cabinets, and that staff did not know where the supplies were. The ADM stated he expected the activity calendar to be followed and that not providing activities could result in boredom.
RN Coverage Not Maintained on Weekends
Penalty
Summary
The facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week during multiple weekends from April 2025 through August 2025. Record review of the employee roster showed two RNs employed in April, and review of time sheets from 04/01/25 through 08/18/25 showed numerous dates without RN coverage for at least 8 hours, including weekends in April, May, June, July, and August. The report states the facility did not have RN coverage on most weekends since April. During interviews, the BOM stated the DON had provided a stack of time sheets that were filled out for weekends from April to the present and said it was unethical and that she had an issue putting the time into the system. The BOM also stated the DON was not in the building on those days. Staff interviews stated the DON had never worked in the building on weekends for RN coverage, that there had not been RN coverage in the building since April, and that when assistance was needed on a weekend the DON told staff to call the ADON, who was an LVN. The DON stated she was responsible for ensuring RN coverage, acknowledged the facility had not had adequate RN coverage on weekends since April, and said she and the ADON alternated being on call but she had not physically come to the facility on weekends when on call. The Administrator stated he was aware the facility had not had RN coverage on weekends and that the DON and ADON were available by phone if needed.
Uncovered catheter bag exposed resident’s urine
Penalty
Summary
The facility failed to ensure Resident #1 was treated with respect and dignity when his catheter drainage bag was left uncovered and the urine in the bag was visually exposed. Resident #1 was a male resident admitted to the facility with diagnoses including paraplegia, muscle weakness, chronic pain syndrome, and lack of coordination. His MDS reflected intact cognition with a BIMS score of 15 out of 15 and indicated he had an indwelling catheter. His physician orders directed catheter care every shift and required a Foley catheter privacy bag in place, and his care plan addressed long-term indwelling Foley catheterization with catheter and drainage bag changes per protocol or provider order. During observation and interview, Resident #1’s catheter bag was seen hanging from his wheelchair without a protective cover, with a small amount of amber liquid visible in the bag. He stated he had been in the facility for approximately a month, had not received a privacy cover for his catheter bag, and said he would like one but was not offered one. Additional observations showed the catheter bag uncovered while he was in the dining area and later while exiting his room in his wheelchair. Facility staff, including the ADON, MDS Coord, CNA B, DON, and ADM, stated nursing staff were responsible for ensuring catheter bags were covered because it was a dignity and privacy issue. The facility policy titled Catheter Care stated privacy bags would be available and catheter drainage bags would be covered at all times when in use, and the Resident Rights policy stated the resident has the right to a dignified existence.
Inaccurate MDS Coding for Oxygen Use and Weight Loss
Penalty
Summary
The facility failed to ensure that the MDS accurately reflected Resident #3’s use of oxygen on the 06/08/25 annual assessment. Resident #3 was a female resident with diagnoses including congestive heart failure, anemia, and a history of venous thrombosis and embolism. Her annual MDS listed her as cognitively intact with a BIMS of 15 and needing set-up/clean-up assistance with ADLs, but Section O did not include oxygen therapy. Record review showed that Resident #3 had an active order for oxygen at 2 L/min via nasal cannula PRN for SOB/hypoxia, and the treatment record documented oxygen administration daily from 05/26/25 through 06/08/25, which was within the 14-day look-back period for the annual MDS. The care plan also identified that she required supplemental oxygen to maintain adequate oxygenation, with oxygen at 2L NC initiated on 07/03/25. During observation, Resident #3 was seen with oxygen on via nasal cannula, and later was observed sleeping without it after stating she did not need it all the time. The MDS Coordinator reviewed the record and verified that oxygen use should have been addressed on the annual MDS and stated it was missed when reviewing the treatment administration record. The facility also failed to accurately assess Resident #30 for weight loss on the 07/24/25 quarterly MDS. Resident #30 was a male resident with diagnoses including traumatic brain injury, intermittent explosive disorder, dementia, muscle wasting, psychotic disorder with hallucinations, and injuries from a motor vehicle accident. His quarterly MDS showed a BIMS of 00 and total dependence for ADLs, but Section K0300 was coded as no or unknown for weight loss. The care plan documented recent significant weight loss with a 27-pound loss since January 2025 and identified nutritional risk related to diet restriction, total dependence for feeding, and dysphagia. The weight summary showed Resident #30 weighed 113.0 lbs on 06/22/25 and 101.0 lbs on 07/22/25, which reflected a 10.62% loss in one month, and 129.0 lbs on 01/02/25 compared with 101.0 lbs on 07/22/25, which reflected a 21.71% loss in six months. The MDS Coordinator verified that the resident did have weight loss that should have been addressed on the quarterly MDS and stated the assessment was inaccurate because the weight had not been documented in the chart in a timely manner before the MDS was completed.
Missing Trauma Screening and Care Plan Documentation for Resident with PTSD
Penalty
Summary
The facility failed to ensure that a resident with a history of PTSD received trauma-informed and culturally competent care, and there was no documented trauma screening or trauma-informed care assessment in the resident’s clinical record. The resident was a male admitted with diagnoses of PTSD and anxiety disorder, and the quarterly MDS showed a BIMS score of 07, indicating severe cognitive impairment. The comprehensive care plan, last revised on 07/02/2025, contained no documentation of the resident’s PTSD or any interventions or triggers related to that diagnosis. Record review of the resident’s clinical file dated 08/20/2025 revealed no Trauma Informed Care Assessment. During observation on 08/19/2025, the resident was in a wheelchair going to the soda machine when another resident yelled across the common area that he did not need a drink or help getting one. The resident was getting money from his wallet to buy a drink, and when the DON approached and asked if she could help, he yanked the money back and stated he did not need help. After a few minutes, the DON was able to help him get his money and his drink. The resident declined to answer whether he was upset by the other resident yelling at him. During later interview and observation, the resident stated he had PTSD from the war but did not want to discuss his diagnosis or what led to it. Facility staff, including the ADON, MDS Coord, ADM, SW, DON, Corp RN, and an LVN, stated trauma assessments should be completed on admission and documented in the clinical file and care plan, but the SW was not aware of what a Trauma Assessment form was and believed triggers would be discussed in care plan meetings or progress notes. The facility’s Trauma-Informed Care policy stated the facility would identify a resident’s trauma history and cultural preferences, ask about triggers, use screening and assessment tools, and add trigger-specific interventions to the care plan.
Expired CNA Certification
Penalty
Summary
The facility failed to ensure that 1 of 5 CNAs was certified in accordance with state law. CNA A’s certification had expired, yet record review showed CNA A worked in the facility as a CNA for 7 days after the expiration date, including multiple night shifts. During record review, the expired certification and the corresponding time sheet entries were identified, confirming that CNA A continued to provide CNA services while the certification was no longer active. During interviews, the BOM verified that CNA A’s certification had expired and stated that she had emailed the DON before the expiration date to notify her that the certification would need to be renewed. The BOM reported that she tracks employee licenses and certifications and notifies the responsible supervisor, but the facility had no specific policy for verifying staff license or certification status. The DON stated she was aware the certification was expired and had planned to move CNA A to nurse aide status until renewal, but that was not completed. CNA A stated she had just learned her certification had expired and reported she was working on renewing it.
Failure to Provide Required Staff Training Prior to Resident Contact
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, as evidenced by the lack of required training for two out of five employees reviewed. Specifically, the Marketing/Admissions Coordinator and a CNA did not receive training in Abuse, Neglect and Exploitation, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures, and Dementia prior to or on their first day of employment. Record reviews confirmed that these trainings were not completed as required before the employees began working with residents. Interviews revealed that the BOM/HR was responsible for assigning trainings through a computer-based system but was not familiar with the content or timing of the trainings. The DON was unaware that the required trainings had not been provided before the employees started working with residents. The Administrator, new to the position, acknowledged the issue and indicated a lack of existing policy on required trainings at hire. No evidence was provided to show that a policy for required trainings at hire existed.
Failure in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen during food preparation. The Dietary Manager (DM) was seen preparing pureed foods without performing appropriate hand hygiene. The DM changed gloves but then touched various kitchen surfaces, including the prep table and blender, without washing hands or changing gloves again. This was followed by handling food items directly with gloved hands, such as removing chicken from the bone and placing it into the blender, without changing gloves or washing hands. The DM acknowledged the oversight, admitting to not washing hands or changing gloves between tasks, which could lead to cross-contamination. Further observations revealed that the DM continued to handle food items, such as corn and bread, without changing gloves or washing hands between tasks. The DM admitted to touching the bread with contaminated hands and recognized the potential for cross-contamination. During an interview, the DM confirmed awareness of the failure to wash hands between tasks and acknowledged the risk of foodborne illness due to improper hand hygiene. The facility's policy on preventing foodborne illness requires employees to wash hands and change gloves between tasks to prevent cross-contamination, which was not followed in this instance.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments for five residents within the required timeframe of every three months, as specified by state regulations and approved by CMS. The residents affected included individuals with various medical conditions such as chronic obstructive pulmonary disease, Parkinson's disease, traumatic brain injury, myocardial infarction, congestive heart failure, and cerebral infarction. The MDS assessments were either incomplete or not conducted at all, with the Assessment Reference Dates (ARDs) for these residents ranging from early May to mid-June 2024. The MDS LVN, who was responsible for completing the MDS assessments, was a remote employee and did not visit the facility. She acknowledged that several MDS assessments were past the 14-day completion mark after the ARD, as she was gathering information to ensure accurate coding. The ADON, who conducted the resident interviews, felt overwhelmed by her dual responsibilities and indicated that the MDS LVN should use her assessments to complete the MDS. The failure to complete these assessments timely was recognized as potentially affecting the facility's funding and, consequently, the care provided to residents. Interviews with facility staff, including the ADM, ADON, and LVN A, highlighted concerns about the impact of delayed MDS completion on funding and resident care. The ADM emphasized that resident care plans, which are based on MDS information, could be compromised, affecting the quality of care provided. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that MDS completion must occur no later than 14 days after the ARD, a requirement that was not met in these cases.
Failure to Conduct PASRR Level II Reviews for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer two residents for a PASRR Level II review following new diagnoses of serious mental disorders. Resident #5 was diagnosed with bipolar disorder one day after admission, but the facility did not initiate a PASRR Level II review. The resident's records indicated a history of bipolar disorder and major depressive disorder, with medications prescribed for these conditions. Despite these indicators, the initial PASRR Level 1 Screening noted no evidence of mental illness. Resident #11, who had been admitted to the facility several years prior, was diagnosed with a psychotic disorder with hallucinations. This diagnosis was made almost six years after admission, yet the facility did not conduct a PASRR Level II review. The resident's records showed a history of traumatic brain injury, anxiety, depression, and psychotic disorder, with various medications prescribed for these conditions. The initial PASRR Level 1 Screening also failed to identify any mental illness. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of PASRRs. The ADON believed the MDS LVN was responsible for PASRRs, but later took over the responsibility upon realizing they were not being completed. The ADON admitted to not being aware of Resident #5's mental illness and did not recognize the potential negative outcomes of not referring residents for a PASRR Level II review. The facility's policy stated that all new admissions should be screened for mental disorders, but this was not adhered to in these cases.
Failure to Complete PASRR Prior to Admission
Penalty
Summary
The facility failed to perform a Pre-Admission Screening and Resident Review (PASRR) for individuals with mental disorders or intellectual disabilities prior to admission for three residents, including Resident #31. Resident #31 was admitted to the facility with diagnoses including cerebral infarction, major depressive disorder, and hemiplegia. Despite these conditions, the PASRR Level 1 Screening for Resident #31 was not completed until 27 days after admission, which is contrary to the facility's policy that requires PASRRs to be completed immediately. Interviews with facility staff revealed a misunderstanding regarding the responsibility for completing PASRRs. The Assistant Director of Nursing (ADON) initially believed that the MDS Licensed Vocational Nurse (LVN), who was a remote employee, was responsible for completing the PASRRs. Upon discovering that the MDS LVN was not completing them, the ADON resumed responsibility for the task. The ADON acknowledged that PASRRs should be completed immediately but did not recognize any potential negative outcomes from the delay in completing Resident #31's PASRR. The facility's policy, dated 2019, states that all new admissions and readmissions must be screened for mental disorders, intellectual disabilities, or related disorders as part of the PASRR process. The failure to adhere to this policy could place residents at risk of receiving inadequate care, as noted by other staff members who expressed concerns about the potential harm to residents if PASRRs are not completed prior to or at the time of admission.
Failure to Maintain Accurate Medical Records and PASRR Compliance
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident #5, who was admitted with a diagnosis of bipolar disorder and major depressive disorder. Despite these diagnoses, the Pre-Admission Screening and Resident Review (PASRR) Level 1 Screening completed by an acute care facility employee indicated no evidence of mental illness. This oversight resulted in the resident not receiving a PASRR Level II evaluation, which is necessary for residents with mental health conditions to ensure their needs are adequately met. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of PASRRs. The Assistant Director of Nursing (ADON) admitted to being responsible for PASRRs but was unaware of the oversight concerning Resident #5's mental illness at the time of admission. The facility's policy requires that all new admissions be screened for mental disorders, but this was not adhered to in this case. The failure to recognize and document the resident's mental illness could potentially place residents at risk of harm and not having their mental health needs met.
Inadequate Infection Control Practices Due to Lack of PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of four staff members, including an LVN and three CNAs, who did not don PPE gowns during wound care and Foley catheter care for a resident with an unstageable pressure ulcer and a Foley catheter. Observations revealed that PPE gowns were not present in the resident's room or in the hallway, indicating a lack of adherence to infection control protocols. The resident involved was a male with multiple diagnoses, including hypertension, diabetes, and a pressure ulcer in the sacral region. The resident required daily wound care and Foley catheter care, as outlined in his care plan and active order summary. Despite these requirements, staff members failed to use appropriate PPE, which is crucial for preventing the spread of infections, especially in residents with chronic wounds or indwelling medical devices. Interviews with the staff, including the facility's Infection Preventionist and ADON, revealed a lack of awareness and training regarding Enhanced Barrier Precautions (EBP). Staff members admitted to not being informed about the necessity of wearing gowns during certain care activities, and the Infection Preventionist acknowledged not having taught the staff about EBP. This lack of knowledge and training contributed to the deficiency in infection control practices, as highlighted by the CMS guidelines and the facility's own policies.
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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 Claude
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ware Memorial Care Center | 27.9 mi | ★★★★★ | 9 | 0 |
| Georgia Manor Nursing Home | 28.5 mi | ★★★★★ | 11 | 0 |
| Clarendon Nursing Home | 29.1 mi | ★★★★★ | 5 | 0 |
| Legacy Rehabilitation And Living | 29.6 mi | ★★★★★ | 5 | 1 |
| Heritage Convalescent Center | 31.3 mi | ★★★★★ | 9 | 0 |
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