Above average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pampa Nursing Center during CMS and state inspections, most recent first.
No Full-Time DON: The facility failed to designate an RN to serve as DON on a full-time basis. Staff interviews showed the facility had been without a DON for weeks to months after the previous DON left, and several staff stated residents no longer had someone available to hear concerns or provide the same nursing oversight. The facility policy stated the nursing services department is under the direct supervision of an RN and is managed by a full-time DON.
Bathroom Sink Draining Into Bucket: A shared bathroom sink for two residents and a third resident using the same bathroom area was found draining into a 5-gallon bucket, with wall damage and staining beneath the sink. One resident had severely impaired cognition, another used a wheelchair and needed set-up or clean-up help with hygiene, and the third had severely impaired cognition. Residents and family members reported the condition had been ongoing for weeks to months, and staff acknowledged the sink was in disrepair and that the bucket had to be emptied when full.
Unsafe and Unclean Bathroom and Shower Conditions: A shared bathroom sink for two residents was draining into a 5-gallon bucket for an extended period, with staff and residents giving differing accounts of how long the condition persisted and maintenance records not showing work orders or repair logs. Two showers also had missing or broken tiles and black discoloration along the floor and wall edges, and staff described the showers as dirty, chipped, and in need of reconstruction.
A resident with severe cognitive impairment and multiple neurologic diagnoses was identified as DNR on the face sheet, care plan, and physician orders, and had a Texas Out-of-Hospital DNR form signed and dated by the representative and physician. However, the DNR form’s witness section contained two signatures without dates, so the document was not fully executed as required. The MDS RN, who reported being responsible for verifying DNR accuracy, acknowledged the missing dates and could not explain how verification occurred without them. An LVN and the DON both stated that undated witness signatures rendered the DNR incorrect, with the DON confirming shared responsibility with the MDS RN for ensuring DNR documents were accurate.
A deficiency was cited for not ensuring a resident's right to a safe, clean, comfortable, and homelike environment, including the safe provision of treatment and daily living supports.
A resident with congestive heart failure and asthma was receiving oxygen therapy as ordered, but the care plan did not address this need. Despite documentation and staff awareness of the oxygen order, the care plan lacked measurable objectives and interventions for oxygen use, contrary to facility policy. Staff interviews confirmed responsibility for care plan updates and acknowledged the omission.
A resident with chronic heart and respiratory conditions was observed receiving oxygen at 4.5L/min, despite a physician's order for 2L/min to maintain appropriate O2 saturation. Staff interviews revealed a lack of monitoring and awareness of the oxygen flow rate, and the resident's care plan did not address oxygen therapy. Facility policy requiring verification of physician orders for oxygen administration was not followed.
The facility failed to meet food service safety standards, with issues in storage, labeling, and hygiene practices. Freezer and pantry items were improperly stored and labeled, and cleanliness was lacking. Personal items were found in the prep area, and staff did not follow proper hand hygiene and glove use protocols. The Dietary Manager acknowledged these deficiencies.
A resident with multiple medical conditions was transferred to a hospital without receiving the required notification, and the facility also failed to inform the Ombudsman. The resident's discharge was unplanned, and there was no documentation of a reconciled medication list or active discharge planning. Interviews with the DON and Administrator confirmed the lack of notification, and the Ombudsman verified not receiving any notice.
The facility failed to review the risks and benefits of bed rails with two residents or their representatives and did not obtain informed consent prior to installation. One resident, with multiple diagnoses including cerebral infarction and Parkinson's, had an unsigned consent form, while another resident, at high risk for falls, had no consent form. Both residents reported using bed rails without receiving proper training or information from the facility.
A medication cart in the North Hall was found unlocked and unsupervised, despite the presence of wandering and confused residents. The ADON confirmed the cart contained multiple resident medications, posing a risk of unauthorized access. LVN F, responsible for the cart, was unaware of how it was left unlocked, despite facility policy requiring carts to be locked when not in use.
CNAs in a facility failed to follow proper infection control practices during incontinent care for a resident. They did not perform hand hygiene or change gloves as required by facility policy, leading to potential cross-contamination. Interviews confirmed the risk of infection due to these lapses.
No Full-Time DON
Penalty
Summary
The facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis. The report states the last day of the previous DON was 04/06/26, and during interviews on 06/11/26, the MDS RN stated the facility had not had a DON since the first week of April. Other staff members also stated the facility had been without a DON for about a month to 2-3 months, and one LVN stated the previous DON always had her door open and was available to listen to residents. During the same interviews, staff described the absence of nursing oversight and its effect on residents and nursing operations. An LVN stated residents did not have anyone to talk to about their concerns now that the previous DON was no longer employed. Another LVN stated residents could be negatively affected because there was no one to oversee nursing and ensure it was done the way it was supposed to be done. A CNA stated residents could be negatively affected because a DON had more control and could ensure nursing care was provided correctly, and another CNA stated residents felt not seen or heard since the DON left. Record review of the facility policy titled Director of Nursing Services stated the nursing services department is under the direct supervision of a registered nurse and is managed by the DON, who is a registered nurse employed full-time.
Bathroom Sink Draining Into Bucket
Penalty
Summary
The facility failed to ensure a safe, clean, comfortable, and homelike environment for three residents who shared a bathroom sink that was not functioning properly. The sink in the shared bathroom was observed and described as draining into a 5-gallon bucket, with a large hole in the wall underneath the sink and visible staining on the sheetrock. The condition was reported by family members, residents, and staff as having been present for an extended period of time, with accounts ranging from several days to several months. Resident #1 was a female with severely impaired cognition, a BIMS score of 5, and functional needs that included set up or clean up assistance with oral and personal hygiene. Her family member reported seeing the sink draining into a bucket and the wall damaged underneath it. Resident #1 stated the sink had been draining into a bucket for 4 months and that she shared the bathroom with Resident #2 and Resident #3. Resident #2 had intact cognition, used a wheelchair, and required set up or clean up assistance with oral and personal hygiene. During observation, her sink was seen draining into a pipe with a covering over the wall area beneath it. She stated the sink had been draining into a bucket for 3 months and that the bucket made it difficult for her to get to the sink in her wheelchair to wash her hands. Resident #3 had severely impaired cognition and was independent with oral and personal hygiene. She stated she had to use the bathroom next door for 2 to 3 days while the water in her bathroom was turned off, and she also reported the sink had been draining into a bucket for a while. Multiple staff members acknowledged awareness of the condition and gave differing timeframes for how long the sink had been in disrepair.
Unsafe and Unclean Bathroom and Shower Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents using a bathroom shared by three residents and for two showers reviewed during the survey. The shared bathroom sink for two residents was observed and reported to be draining into a 5-gallon bucket rather than through proper plumbing. Multiple interviews with residents, family members, and staff described the sink in that condition for varying lengths of time, with reports ranging from days to months. One resident with severely impaired cognition and wheelchair use stated the sink had been draining into a bucket for 4 months, while another resident stated she had difficulty reaching the sink with the bucket underneath it and had purchased hand sanitizer instead. A third resident stated she had to use another bathroom for 2 to 3 days while the water was turned off so the sink could be fixed. Staff interviews confirmed awareness of the condition. An LVN stated the sink had been draining into a bucket for more than 2 weeks and that staff emptied the bucket when it became full. Other staff gave differing estimates of how long the sink had been in disrepair, including a few days, a week, 2 to 3 weeks, a month, 2 and a half months, and 7 or 8 days. The maintenance staff member stated he and housekeeping dumped the bucket when it got full and said he did not have maintenance logs or work orders showing when repairs were requested or completed. The facility’s OM stated there was an open complaint case regarding dirty or moldy showers, and the complaint had been open since November 2025. The survey also found problems in both showers reviewed. Shower A had approximately 20 missing 2-inch tiles in one corner, with loose broken tile pieces on the bare concrete and chipped edges, along with black discoloration along the base and grout or caulk lines. Shower B had black discoloration around the bottom edge of all three walls extending onto the floor tiles and was missing one and a half 2-inch tiles in the corner. Staff interviews noted the showers had been chipped and black along the floor for an extended period, and one CNA stated the showers needed to be reconstructed and updated. Facility policies stated residents are to be provided a safe, clean, comfortable, and homelike environment and that maintenance is responsible for keeping plumbing fixtures and the building in good working order.
Improperly Executed DNR Order Due to Missing Witness Dates
Penalty
Summary
The facility failed to ensure a resident’s right to formulate an advance directive was fully honored when a Do Not Resuscitate (DNR) order was not properly executed. The resident was an elderly male with a history of cerebral infarction, frontal lobe and executive function deficit following cerebral infarction, and Parkinson’s disease without dyskinesia. His face sheet identified him as DNR, his quarterly MDS showed a Brief Interview for Mental Status (BIMS) score of 2/15 indicating severe cognitive impairment, and his care plan documented his choice of DNR status with a directive not to provide CPR. Active physician orders also included a DNR order. The clinical record contained a Texas Out-of-Hospital DNR document signed and dated by the resident’s representative and the physician. However, the DNR document’s “Two Witnesses” section contained two witness signatures that were not dated, meaning the form was not fully and properly completed. During interviews, the MDS RN, who stated she was responsible for verifying DNR document accuracy, acknowledged that the witness signatures were not dated and could not explain how verification occurred without those dates. An LVN stated that a DNR would not be valid if witness signatures were not dated and identified that the MDS RN and DON were responsible for ensuring DNR documents were correct. The DON also confirmed the DNR was not correct due to the missing witness dates and stated that she and the MDS RN were responsible for ensuring DNR documents were accurate. A blank Texas Out-of-Hospital DNR form reviewed by surveyors specified that only a fully and properly completed DNR order is sufficient evidence to be honored by health care professionals.
Failure to Ensure Safe and Homelike Environment
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a safe, clean, comfortable, and homelike environment. The report notes that this includes, but is not limited to, receiving treatment and supports for daily living in a safe manner. Specific actions or inactions leading to this deficiency are not detailed in the provided excerpt, nor are there direct observations or events described beyond the general statement of noncompliance with the requirement.
Failure to Include Oxygen Therapy in Resident Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive, person-centered care plan that addressed all of a resident's needs, specifically omitting the resident's requirement for oxygen therapy. Despite documentation in the resident's medical records and MDS assessment indicating an active order for oxygen therapy at specific flow rates to maintain oxygen saturation, the care plan did not include any interventions or objectives related to oxygen use. Multiple observations confirmed the resident was receiving oxygen via nasal cannula at varying flow rates, and interviews with the resident and staff confirmed ongoing oxygen therapy due to the resident's cardiac and respiratory diagnoses. Interviews with facility staff, including the MDS nurse and DON, revealed that they were responsible for updating care plans but acknowledged the omission and the potential for negative outcomes if care plans are not kept current. The facility's own policy requires that care plans include measurable objectives and timeframes for all identified needs, yet the resident's need for oxygen therapy was not reflected in the care plan, despite being a current and ongoing intervention.
Failure to Administer Oxygen at Prescribed Dose
Penalty
Summary
The facility failed to provide safe and appropriate respiratory care by not administering oxygen at the correct dose for a resident with multiple chronic conditions, including heart failure, asthma, and sleep apnea. The resident had a physician's order for oxygen at 2 liters per minute via nasal cannula to maintain oxygen saturation at or above 90% and/or for shortness of breath. However, observations on multiple occasions showed the resident receiving oxygen at 4.5 liters per minute, which was not consistent with the physician's order. The resident's care plan did not address oxygen therapy, and staff interviews revealed a lack of awareness and monitoring of the oxygen flow rate being delivered. Staff interviews indicated that it was not common practice to administer oxygen at 4.5 liters per minute, and there was confusion among staff regarding the appropriate response to changes in the resident's respiratory status. The LVN responsible for the resident's care admitted to not checking the oxygen concentrator settings, and the DON acknowledged that setting the oxygen too high could have negative outcomes. The facility's policy required verification of a physician's order for oxygen administration, but this was not followed, resulting in the resident receiving a higher dose of oxygen than prescribed.
Food Safety and Hygiene Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in their kitchen operations. The deficiencies included improper storage, labeling, and dating of freezer and pantry items. Specifically, several items in the freezer, such as frozen vegetables, cookie dough, biscuit dough, omelets, sausage patties, and bacon, were found unsealed and open to air, with some items not labeled or dated. Additionally, food crumbs were observed on the floors of both the freezer and pantry, indicating a lack of cleanliness. In the pantry, a Ziplock bag of spaghetti noodles was found without a label or date, and plastic cup lids were scattered on the floor and atop canned food racks. The facility also failed to maintain proper hygiene practices in the kitchen. Personal items, such as a purse, were found in the kitchen prep area, which could lead to cross-contamination. An employee was observed handling food trays and other items with gloved hands without changing gloves or washing hands between tasks, contrary to the facility's policy. The Dietary Manager (DM) acknowledged these issues, stating that all food should be properly wrapped, labeled, and dated to prevent contamination and that personal items should not be in the kitchen prep area. The DM also confirmed that staff should use tongs to serve bread and rolls, and that she was responsible for training staff on these procedures.
Failure to Notify Resident and Ombudsman of Transfer and Discharge
Penalty
Summary
The facility failed to notify a resident, identified as Resident #30, or a representative of the Office of the State Long-Term Care Ombudsman about the resident's transfer to a hospital and subsequent discharge. This deficiency was identified during a review of the resident's records and interviews with facility staff. Resident #30, a female with multiple medical conditions including cerebral infarction, pneumonia, and dementia, was transferred to an acute care hospital without receiving the required notification. The facility also did not inform the Ombudsman, which is a violation of the resident's rights and the facility's policy. The record review revealed that Resident #30's discharge was marked as unplanned, and there was no documentation of a reconciled medication list being provided to the resident or any active discharge planning for a return to the community. The care plan indicated that the resident wished to remain in the facility for long-term care. However, there was no documentation in the progress notes or any other part of the resident's chart regarding the transfer or discharge, the reasons for it, or any notification to the resident or the Ombudsman. Interviews with the Director of Nursing (DON) and the Administrator confirmed that no written notice of transfer or discharge was given to Resident #30 or the Ombudsman. The DON mentioned that the resident was discharged after behavioral issues and was not expected to return due to being a risk to others. The Administrator admitted to not recalling if the Ombudsman was notified and could not find any documentation of such notice. The Ombudsman confirmed not receiving any notice of the transfer or discharge, which is a recurring issue with the facility not sending monthly lists of transfers or discharges.
Failure to Obtain Informed Consent for Bed Rail Use
Penalty
Summary
The facility failed to review the risks and benefits of bed rails with two residents or their representatives and did not obtain informed consent prior to the installation of bed rails. This deficiency was identified during a survey that included interviews and record reviews. The facility's policy requires that residents or their representatives be informed about the benefits and potential hazards associated with bed rails and that informed consent be obtained before their use. Resident #20, a cognitively intact male with multiple diagnoses including cerebral infarction, Parkinson's, and dementia, was found to have 1/4 side rails on both sides of his bed for increased mobility and positioning. However, his clinical record contained an undated and unsigned bed rail consent form. During an interview, Resident #20 reported using the bed rails for mobility but stated that the facility had not provided any training or addressed issues related to the bed rails. Resident #24, also cognitively intact, had a history of multiple health conditions including an acquired absence of the right leg below the knee and was at high risk for falls. His care plan included the use of bed rails, but there was no bed rail consent form in his clinical record. During an interview, Resident #24 indicated that he used the bed rails but was not trained on their proper use, and the facility had not discussed the bed rails with him. The facility's failure to obtain informed consent and provide necessary information and training on bed rail use was acknowledged by the Administrator and the DON during interviews.
Medication Cart Left Unlocked and Unsupervised
Penalty
Summary
The facility failed to ensure that medications were stored in accordance with currently accepted professional principles, as observed with the North Hall medication cart. During an observation, the cart was found unlocked and unsupervised in the hallway in front of the nurse's station. This occurred despite the presence of residents, including those who are wandering and confused, in the area. The Assistant Director of Nursing (ADON) confirmed the cart was unlocked and contained multiple resident medications, acknowledging the potential risks of unauthorized access. Licensed Vocational Nurse (LVN) F, responsible for the cart during the shift, claimed she never leaves the cart unlocked and was unaware of how it happened this time. She acknowledged the risks associated with leaving the cart unlocked, including the possibility of medication theft and the danger to residents who might access the medications. The facility's policy, revised in November 2020, mandates that all drugs and biologicals be stored in locked compartments and that medication carts are not left unattended when unlocked.
Inadequate Infection Control Practices During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNAs during the care of a resident. During an observation, CNAs C and D did not perform hand hygiene before starting incontinent care for the resident, who had a bowel movement. CNA D cleaned the resident's buttocks and rectum without changing gloves or performing hand hygiene, then proceeded to handle the resident's clean brief, blankets, pillow, and clothing with the same gloves. Additionally, CNA D did not perform hand hygiene after removing gloves and handling waste. CNA C also failed to perform hand hygiene before providing the resident with a drink. Interviews with the CNAs and the Director of Nursing (DON) confirmed the potential for cross-contamination and infection due to the lack of hand hygiene and glove changes. The facility's policies on hand hygiene and perineal care, which emphasize the importance of handwashing before and after resident contact and after glove removal, were not followed. This non-compliance with established procedures posed a risk of spreading infections within the facility.
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Illustrative
What surveyors actually found near you
We read the 14 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
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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) |
|---|---|---|---|---|
| Avir At Pampa | 0 mi | ★★★★★ | 12 | 0 |
| Avir At Borger | 24.1 mi | ★★★★★ | 0 | 0 |
| Caprock Nursing & Rehabilitation | 24.8 mi | ★★★★★ | 2 | 0 |
| Mclean Care Center | 30.2 mi | ★★★★★ | 1 | 1 |
| Palo Duro Nursing Home | 37.3 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.