Pampa Nursing Center

Inspectors wroteBased on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility reviewed for a DON.The facility failed to have a full-time DON. The last day of the previous DON was 04/06/2026. This failure could place residents at risk of not having their needs met and/or feeling unheard due to no nursing oversight. Findings Included:During an interview on 06/11/26 at 06:22 AM MDS RN (who was standing in for ADM, who was on vacation) stated the facility had not had a DON since the first week of April. During an interview on 06/11/26 at 07:24 AM LVN E stated the facility had not had a DON for going on 2 months. She stated residents do not have anyone to talk to about their concerns now that the previous DON was no longer employed. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 3 (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for homelike environment. The facility failed to ensure the sink in the bathroom shared by Residents #1, #2, and #3 was plumbed properly and not draining into a 5-gallon bucket from at least 05/02/26 to 05/26/26. This failure could place residents at risk of feeling neglected and/or unimportant. Findings Included:1. Record review of Resident #1's admission record dated 06/11/26 revealed an [AGE] year-old female admitted to the facility on [DATE] and discharged from the facility on 05/29/26. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 3 (Resident #1, Resident #2, and Resident #3) of 5 residents and 2 (Shower A and Shower B) of 2 showers reviewed environment. The facility failed to ensure the sink in the bathroom shared by Residents #1, #2, and #3 was plumbed properly and not draining into a 5-gallon bucket from at least 05/02/26 to 05/26/26. The facility failed to ensure the floors of both showers were free of broken, chipped, or missing tiles and clean around the bottom edges where the floor met the walls of the showers. These failures could place residents at risk of feeling uncomfortable/neglected in their home. Findings Included:1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #1) of 5 residents reviewed for advanced directives. Resident #1's DNR form lacked dated witness acknowledgments and therefore was not fully executed. This failure could place residents at risk of receiving medical treatment inconsistent with their or their legal representative's expressed wishes.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 2 (Resident #4 and Resident #12) of 12 resident's reviewed for homelike environment.1. The facility failed to ensure Resident #4 stored her chips in an airtight, sealed container. The facility failed to ensure Resident #4's personal refrigerator temperature was checked daily.2. The facility failed to ensure Resident #12's personal refrigerator was cleared of old food. These failures could place residents at risk of pests and/or food borne illness. Findings Included:1. [...]

Inspectors wroteBased on observation, interview and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet residents' medical, nursing and mental and psychosocial needs for 1 of 12 residents (Resident #42) whose care plans were reviewed. The facility failed to ensure Resident #42's care plan addressed the resident's need for oxygen therapy. This deficient practice could result in residents not receiving the appropriate and necessary care and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of care for 1 of 12 residents (Resident #42) reviewed for respiratory care. The facility failed to administer oxygen at the correct dose for Resident #42. This failure could affect all residents on oxygen therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure freezer items were properly stored, labeled, and dated. 2. The facility failed to ensure personal items were not in the prep area. 3. The facility failed to ensure pantry foods were properly stored, labeled, and dated. 4. The facility failed to ensure proper hand hygiene and glove use was practiced. 5. The facility failed to ensure cleanliness in the kitchen. These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident or a representative of the Office of the State Long-Term Care Ombudsman of the transfer or discharge for 1 (Resident #30) of 3 residents reviewed for transfers/discharges. The facility failed to notify Resident #30 of her transfer to the hospital and pending discharge. The facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman of Resident #30's discharge. This failure could affect residents at the facility by placing them at risk of being transferred/discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on interview, and record review the facility failed to review the risks and benefits of bed rails with the resident or resident's representative and obtain informed consent prior to installation of bed rails for 2 (Resident #20 and #24) of 17 residents reviewed for bedrails. The facility failed to inform Resident #20 and #24 or their representatives for the use of bed rails and obtain consent for the use of bed rails. This deficient practice could place all residents with bed rails at risk for injuries such as abrasion, fractures, and entrapment.

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure medications were stored in accordance with currently accepted professional principles for 1 (North Hall Medication Cart) of 4 medication storage areas reviewed for medication storage. LVN F left the North Hall medication cart unlocked and unsupervised in the hallway. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a residents, visitors, or staff accessing the resident medications resulting in misappropriation of resident property, exacerbation of the resident's condition, overdose, and exacerbation of the resident's disease processes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 1 (Resident #23) of 17 Residents. -CNA A and CNA B failed to use proper hand hygiene before, during, and after incontinent care of Resident #23. These failures had the potential to affect residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedure that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility failed to ensure a criminal history check was conducted for the BOM prior to start 09/25/2023. This failure could place residents at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to review and revise the comprehensive care plan after each assessment, including both the comprehensive and quarterly review assessments for one(Resident #17) of 13 resident's reviewed for comprehensive care plans. - The facility failed to revise residents care plans timely to reflect residents' current status. This failure could affect residents by placing them at risk of having care plans that are not updated/accurate to their current identified needs.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week and to designate a registered nurse as the director of nursing on a full-time basis. The facility was without full-time RN coverage for 10 days during the month of April, 2023 and without full-time RN coverage for 8 days in May, 2023. The facility failed to ensure RN weekend coverage and did not have a DON designated for the facility. These failures have the potential to affect the residents in the facility and place them at risk of not having staff with advanced care skills available to assist in their care needs.

Inspectors wroteBased on observation, interview and record review; it was determined the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles to include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 2 medication carts. 3 loose pills were found in the North medication cart and 1 bottle expired medication, was found in the South medication cart. The facility's failure to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable could place all residents receiving medication at risk for drug diversion, drug overdose, and accidental or intentional administration to the wrong resident.

Inspectors wroteBased on observation and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods was properly labeled and dated. 2. The facility failed to ensure proper temperature of hot and cold food items. 3. The facility failed to ensure proper thawing procedures. This failure could place the residents at risk of foodborne illnesses. Findings Include: Observation of freezer one on 5/7/23 beginning at 9:01 AM revealed the following: 1. 1 box of 12 Vanilla Ice Cream Sandwiches with no expiration date. 2. 12 dozen tortillas not labeled or dated. 3. 1 dozen frozen breadsticks not labeled or dated 4. Box of flat dough sheets not labeled/dated 5. Box of sirloin tips not dated 6. Open box of Legend Chicken not dated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 (RN, LVN A, LVN B, LVN E, and CNA C) of 6 staff observed for infection control practices. -RN failed to change from surgical mask to sterile mask when providing dressing change of peripherally inserted central catheter line on Resident #9. -LVN A failed to use proper hand hygiene techniques when providing eye drops to Resident #20 -LVN B and LVN E failed to use proper hand hygiene techniques when providing wound care to Resident #9. CNA C failed to use gloves when providing care for residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized records for one (Resident #1) of 13 residents reviewed for medical records. The facility failed to accurately document Resident's #1 advanced directives in their medical records. This failure could place all residents at risk of not receiving appropriate care through inadequate documentation, possibly resulting in the deterioration in condition, exacerbation of disease process, and increased risk of harm or injury.