Inspection·January 28, 2026

F 0605 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete could be negatively affected if a GDR was not considered for a psychotropic medication because they can get to where (the medication) is not effective.During an interview on 01/28/26 at 10:49 AM RNC stated, We rely on pharmacist consultant that comes in to review the charts to recommend GDRs. She stated a resident could be negatively affected by not receiving a GDR timely because we try to maintain medication at the lowest dose effective.During an interview on 01/28/26 at 10:52 AM DON stated the facility's pharmacy consultant was responsible for recommending GDRs for psychotropic medications. She stated she did not think a resident would not be negatively affected if a GDR was not addressed timely.Record review of facility policy titled, Tapering Medications and Gradual Dose Reduction and dated July 2022 revealed the following: . 1. After medications are ordered for a resident, the staf and practitioner shall see an appropriate dose and duration for each medication that also minimizes the risk of adverse consequences. 2. All medications shall be considered for possible tapering. Tapering that is applicable to psychotropic medications are referred to as gradual dose reductions. 3. Residents who use psychotropic medications shall receive gradual dose reductions and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. 1. Periodically, the staff and practitioner will review the continued relevance of each resident's medications. 10. Residents who use psychotropic medications shall receive gradual dose reductions, unless clinically contraindicated, in an effort to discontinue the use of such drugs. 11. Within the first year after a resident is admitted on a psychotropic medication or after the resident has been started on a psychotropic medication, the staff and practitioner shall attempt a GDR in two separate quarters (with at least one month between the attempts) unless clinically contraindicated. 15. Attempted tapering of psychotropic medications other than antipsychotics or sedatives and hypnotics shall be considered as a way to demonstrate whether the resident is benefiting from a medication or might benefit from a lower or less frequent dose. Tapering shall be done consistent with the following: a. During the first year in which a resident is admitted on a psychotropic medication . or after the facility has initiated such medication, the facility will attempt to taper the medication during at least two separate quarters (with at least one month between attempts), unless clinically contraindicated.Record review of facility policy titled Psychotropic Medication Use and dated July 2022 revealed the following: . 2. Drugs in the following categories are considered psychotropic medications . b. Anti-depressants . 11. Residents on psychotropic mediations receive gradual does reductions . unless clinically contraindicated, in an effort to discontinue these medications. Event ID: Facility ID: 675049 If continuation sheet Page 2 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Provide for the safe, appropriate administration of IV fluids for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure parenteral fluids were to be administered consistent with professional standards of practice and physicians orders for 1 of 12 residents (Resident #11) reviewed for physician orders. The facility failed to follow physician orders for completing central line care for resident #11. This failure could place residents at risk for not receiving needed care to maintain optimum health and injury and/or deterioration in their condition.Findings Included: Record review of Resident #11's face sheet dated 01/28/2026 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute and subacute infective endocarditis (inflammation of the inner lining of the heart's chambers and valves), bacteremia (presence of bacteria in the blood stream), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), heart disease (a range of conditions that affect the heart), occlusion and stenosis of bilateral carotid arteries (plaque blocks the normal flow of blood in the carotid artery), aneurysm of iliac artery (a ballooning or weakening area of an artery), peripheral vascular disease (blood circulation disorder). Record review of Resident #11's MDS, dated [DATE], revealed Resident #11 had a BIMS of 12 which indicated moderate cognitive impairment. Resident #11 required total dependency on staff for showering only, all other care areas Resident #11 was independent. Record review of Resident #11's Order Summary Report dated 01/26/2026 revealed the following orders: Dressing change to PICC site every 7 Days and PRN as needed for soiling or displacement related to ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS. Start date 11/16/2025, no end date noted. Haloguard Patch (antimicrobial IV disk designed to reduce catheter related blood stream infections); 1 in 4mm dressing; Amount to administer: 1; transdermal once a day on Monday in the morning related to BACTEREMIA. Start date: 11/12/2025, no end date noted. Record review of Resident #11's care plan dated 11/14/2025, included the following:Focus: I require enhanced barrier precautions due to the following: I am at increased riskof a MDRO acquisition due to have an indwelling medical device. Date Initiated: 11/06/2025 Revision on: 11/14/2025Goal: I will have no signs or symptoms related to a MDRO infection Date Initiated: 11/06/2025Target Date: 02/03/2026Interventions- Discard PPE inside my room in the appropriate receptacle prior to leaving my room. Date Initiated: 11/06/2025 Revision on: 11/06/2025 Notify my physician and resident representative of any issues related to MDRO.Date Initiated: 11/06/2025 Revision on: 11/06/2025 Post a sign on my door that says please check with nurse before entering roomDate Initiated: 11/06/2025 Staff will wear PPE during high-contact activities such as dressing,bathing/showering, transferring, providing hygiene, changing linens, incontinent care,wound care of any type requiring a dressing, device care or use (central line).Date Initiated: 11/06/2025 There were no other care plans for PICC line dressing care. Record review of Resident #11's TAR dated 01/01/2026-01/31/2026 revealed she received her central line dressing change on 01/11/2026 by LVN D, 01/18/2026 by LVN A, and 01/25/2026 by LVN D. There were no signatures or initials for 01/04/2026 dressing change. Record review of Resident #11's TAR dated 01/01/2026-01/31/2026 revealed she did not receive a Haloguard change on 01/04/2026. Haloguard was not placed on 01/11/2026 by LVN D. Haloguard was placed by ADON on 01/25/2026. During an observation and record review on 01/27/2026 at 9:41 AM revealed the dressing to the PICC line for Resident #11 was not changed since 01/19/2026, record review revealed that the nurse changed the dressing on 01/25/2026. There was no Haloguard in place at the time of this observation. During an observation on 01/28/2026 at 9:52 AM PICC line dressing for Resident #11 had been changed and dated 01/27/2026, but no Haloguard was present under transparent dressing. During an interview on 01/28/2026 at 1:22 PM ADON stated the Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 If continuation sheet Page 3 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0694 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete negative outcome for not having a Haloguard over the insertion site for Resident #11's PICC line could lead to an increased risk for the resident, and the dressing would need to be changed more often. ADON stated the negative outcome for not following doctors' orders was it could lead to infection for the resident. During an interview on 01/28/2026 at 1:28 PM DON stated the negative outcome for not having a Haloguard over the insertion site for Resident #11's PICC line was increased infection risk. DON stated, It (Haloguard) is an added barrier to prevent infection. During an interview on 01/28/2026 at 1:37 PM RNC stated the negative outcome for not having a Haloguard over the insertion site for Resident #11's PICC line was, The resident is already on antibiotics for endocarditis (inflammation of inner lining of heart's chambers and valves) it (Haloguard) is an added barrier to prevent infection. During an attempted interview on 01/28/2026 at 1:48 PM the investigator called LVN D to ask about the dressing and documentation. There was no answer, and the investigator provided contact information to call back. During a phone interview on 01/28/2026 at 2:05 PM LVN A stated there was no reason that she did not place the Haloguard. LVN A stated the negative outcome for not placing one was the resident could pull out the PICC line. LVN A stated she did not remember charting that she placed the Haloguard on the resident. Record review of facility provided policy titled Peripheral and Midline IV dressing Changes dated 12/31/2025, revealed the following: PurposeThe purpose of this procedure is to prevent complication associated with intravenous therapy, including catheter-related infections.General GuidelinesPerform site care and dressing change at established intervals, or immediately if the integrity of the dressing is compromised. 4. Change the dressing if it becomes damp, loosened or visibly soiled and:At least every 7 days for TSM dressing; . 6. b. check expiration dates of infusion, dressing and administration set; . Record review of facility provided policy titled Medication Administration-Intravenous Therapy dated 11/01/2025, revealed the following: PurposeTo ensure safe, effective and standardized intravenous (IV) therapy and medication administration via Peripheral IVs, Midline Catheters and PICC Lines in accordance with facility standards and regulatory requirements.PICC Line .Follow central-line infection prevention practices . Event ID: Facility ID: 675049 If continuation sheet Page 4 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. Based on observation, interview, and record review 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 1 (Hall 100 and Hall 200) of 2 medication carts, and 1 of 1 OTC closet. -two bottles of Calcium Supplement with expiration dates that were not legible in the OTC closet.-one loose pill was in the bottom of Medication cart #1. These failures could place residents at risk for not receiving the intended therapeutic action of the medication.Findings Included:During an observation on 01/26/2026 at 9:59 AM one loose pill (unidentified) was discovered in the bottom of medication cart #1's drawer. During an interview on 01/26/2026 at 10:03 AM LVN F stated the negative outcome for having loose pills in the medication cart was that the medication could fall out of the cart and a resident could pick it up and take it. During an observation on 01/26/2026 10:08 PM OTC closet revealed two bottles of Calcium Supplement with expiration dates that were not legible. During an interview on 01/26/2026 at 10:11 AM ADON stated the negative outcome for having loose pills in the medication cart could lead to a resident missing a dose. ADON also stated the negative outcome of having expired medications was the medications would not have the efficacy that was needed for a therapeutic level for the resident. During an interview on 01/26/2026 at 10:17 AM LVN F stated the negative outcome for having expired medications was the medications would not be effective for the residents.During an interview on 01/28/2026 at 1:28 PM DON stated there was no negative outcome to the residents for having loose pills in the bottom of medication cart drawers. During an interview on 01/28/2026 at 1:37 PM RNC stated a possible negative outcome of a loose pill was a nurse might pick it up thinking it was dropped and give it to a resident. RNC stated the negative outcome for having expired medications was the medication would have lost its efficacy. Record review of policy titled, Medication Labeling and Storage, undated, revealed the following: .Medication Storage.2. The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.5. Medications are stored in an orderly manner in cabinets, drawers, carts, or automatic dispensing systems.Medication Labeling.2. The medication label includes, at a minimum: .d. expiration date, when applicable; .4. For over the counter (OTC) medications in bulk containers (if permitted by state law) the label contains: .f. expiration date.Record review of policy titled, Administering Medication, revised April 2019, revealed the following: .12. The expiration/beyond use date on the medication label is checked before administering. When opening a multi-dose container, the date opened is recorded on the container. Event ID: Facility ID: 675049 If continuation sheet Page 5 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based 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. The facility failed to ensure refrigerated, freezer, pantry and kitchen items were properly stored, labeled, and dated.This failure could place residents at risk of food-borne illnesses.Findings Included:During an observation of the pantry on 01/26/26 at 9:39 a.m. revealed the following:1. (1) clear container that contained what looked like rice, no lid on container, no label or date.2. (2) boxes of packets of jelly, no label or date.3. 1) container of sugar, lid not sealed.4. (1) box of potatoes, no label or date. During an observation of the freezer on 01/26/26 at 9:43 a.m. revealed the following:1. (1) box of frozen meat, no label or date.2. (1) box of what looked to be frozen bread, dated, no label.3. (1) box of what looked like tater tots, no label.During an observation of the refrigerator on 01/26/26 at 9:48 a.m. revealed the following:1. (1) box of tomatoes, no date.2. (1) box of single serve packs of sour cream - no label or date.3. (1) pitcher, 1/4 full of red liquid, no label or date. 4. (3) individual drinking cups filled with liquid, covered and dated, no label. 5. (1) Ziploc with dinner rolls, no label or date. 6. (1) Ziploc with what looks like cooked rice, dated, no label.7. (1) Ziploc containing deli meat, no label or date.8. (1) Ziploc containing cooked bacon, no label or date.9. (1) Ziploc with unidentified meat, no label or date.10. (2) open milk cartons, one 1/4 full, one 3/4 full, no label or date.11. (1) tray with 5 cups filled with white liquid, partially open to air, no label or date.During an observation of the kitchen preparation area on 01/26/26 at 9:53 a.m. revealed the following:1. (1) Ziploc bag of what looked like cookies on prep table, no label or date. 2. (1) clear container filled with cereal, no label or date. 3. (1) spice container of garlic powder, no label or date. During an interview on 01/26/26 at 9:56 a.m., [NAME] C stated she had worked at the facility since August 2025. She stated it was everyone's responsibility to label and date food and if this did not happen, food could get ruined, and residents could get sick. During an interview on 01/26/26 at 10:03 a.m., [NAME] B stated he had worked at the facility for three months and everyone who worked in the kitchen was responsible for labeling and dating food. He stated a possible negative outcome was residents could become sick. During an interview on 01/26/26 at 10:07 a.m., the DM stated it was everyone's responsibility to label and date food. She stated that she goes over this with new hires and trained them to label and date food as soon as it arrived. The DM stated that if this did not happen, there could be sickness related to food. Record review of facility policy, titled Food Storage dated 2023, revealed the following information in part:8. Plastic containers with tight-fitting covers or sealable plastic bags must be used for storing grain products and sugar. All containers or storage bags must be legible and accurately labeled ad dated. 12. Leftover food should be stored in covered containers or wrapped carefully and securely and clearly labeled and dated before being refrigerated. 13. Refrigerated food storage:f. All foods should be covered, labeled and dated. 14. Frozen Foods:c. All foods should be covered, labeled and dated. Event ID: Facility ID: 675049 If continuation sheet Page 6 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized medical records for 1 (Resident #11) of 12 residents reviewed for medical records. The facility failed to ensure accurate and complete medical records in that:-PICC line dressing was dated 01/19/2026 with no Haloguard in place over insertion site.-Resident #11's TAR revealed that there was no documented dressing change on 01/19/2026.-Resident #11's TAR indicated that a dressing change took place on 01/25/2026. These failures could place residents at risk of not receiving appropriate care resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury.Findings Included:Record review of Resident #11's face sheet dated 01/28/2026 revealed she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including acute and subacute infective endocarditis (inflammation of the inner lining of the heart's chambers and valves), bacteremia (presence of bacteria in the blood stream), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it, stroke), heart disease (a range of conditions that affect the heart), occlusion and stenosis of bilateral carotid arteries (plaque blocks the normal flow of blood in the carotid artery), aneurysm of iliac artery (a ballooning or weakening area of an artery), peripheral vascular disease (blood circulation disorder). Record review of Resident #11's MDS, dated [DATE], revealed Resident #11 had a BIMS of 12 which indicated moderate cognitive impairment. Resident #11 required total dependency on staff for showering only, all other care areas Resident #11 was independent. Record review of Resident #11's Order Summary Report printed 01/26/2026 included the following orders: Dressing change to PICC site every 7 Days and PRN as needed for soiling or displacement related to ACUTE AND SUBACUTE INFECTIVE ENDOCARDITIS. Start date 11/16/2025, no end date noted. Haloguard Patch; 1 in 4mm dressing; Amount to administer: 1; transdermal once a day on Monday inthe morning related to BACTEREMIA. Start date: 11/12/2025, no end date noted. Record review of Resident #11's care plan dated 11/14/2025, included the following:Focus: I require enhanced barrier precautions due to the following: I am at increased riskof a MDRO acquisition due to have an indwelling medical device. Date Initiated: 11/06/2025 Revision on: 11/14/2025Goal: I will have no signs or symptoms related to a MDRO infection Date Initiated: 11/06/2025Target Date: 02/03/2026InterventionsDiscard PPE inside my room in the appropriate receptacle prior to leaving my room. Date Initiated: 11/06/2025 Revision on: 11/06/2025 Notify my physician and resident representative of any issues related to MDRO.Date Initiated: 11/06/2025 Revision on: 11/06/2025 Post a sign on my door that says 'please check with nurse before entering roomDate Initiated: 11/06/2025 Staff will wear PPE during high-contact activities such as dressing,bathing/showering, transferring, providing hygiene, changing linens, incontinent care,wound care of any type requiring a dressing, device care or use (central line).Date Initiated: 11/06/2025 There were no other care plans for PICC line dressing care. Record review of Resident #11's TAR dated 01/01/2026-01/31/2026 revealed she did not receive a dressing change on 01/04/2026. Resident #11 received her central line dressing change on 01/11/2026 by LVN D, 01/18/2026 by LVN A, and 01/25/2026 by LVN D. Record review of Resident #11's TAR dated 01/01/2026-01/31/2026 revealed she did not receive a Haloguard change on 01/04/2026. Haloguard was not placed on 01/11/2026 by LVN D. Haloguard was placed by ADON on 01/25/2026. During an observation and record review on 01/27/2026 at 9:41 AM revealed dressing to PICC line for Resident #11 had not been changed since 01/19/2026, record review revealed that the nurse that changed the dressing on 01/25/2026. There was no Haloguard in place at the time of this observation. During an (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 If continuation sheet Page 7 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete observation on 01/28/2026 at 9:52 AM PICC line dressing for Resident #11 had been changed and dated01/27/2026, but no Haloguard was present under the transparent dressing. During an interview on 01/28/2026 at 1:22 PM ADON stated the negative outcome for documenting falsely was an increased risk of infection. During an interview on 01/28/2026 at 1:28 PM DON stated the negative outcome for false documentation was he doesn't have that added protection there. During an interview on 01/28/2026 at 1:37 PM RNC stated that the negative outcome for false documentation was it could increase the risk of infection for our residents. During an attempted interview on 01/28/2026 at 1:48 PM The investigator called LVN D to ask about the dressing and documentation. There was no answer, and the investigator provided contact information to call back. During a phone interview on 01/28/2026 at 2:05 PM LVN A stated she does not remember charting that she placed the Haloguard on the resident. Record review of a facility policy titled Charting and Documentation, dated July 2017, revealed the following: .Policy Interpretation and Implementation.2. The following information is to be documented in the resident medical record: .c. Treatments or services performed; .7. documentation of procedures and treatments will include care-specific details, including:a. the date and time the procedure/treatment was provided. Event ID: Facility ID: 675049 If continuation sheet Page 8 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm Based 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 4 (Resident #6, #13, #30 and Resident #42) of 12 residents reviewed for infection control. The facility failed to develop and maintain an infection prevention and control program as attested to by: -LVN A did not don a gown or perform hand hygiene before donning gloves to administer a bolus feeding to Resident #6 via peg-tub.-LVN A did not ensure bedside table was clean before setting up supplies for Resident #6's bolus feeding via her peg-tube.-LVN A did not perform hand hygiene before donning gloves to perform a glucose check for Resident #42.-LVN A did not perform hand hygiene before donning gloves to perform a glucose check for Resident #30.-CNA E did not don a gown before performing foley catheter care for Resident #13. These failures could place residents at risk of contracting, spreading, and/or being exposed to bacterial or viral infections leading to the spread of communicable diseases.Finding Included:During an observation on 01/26/2026 at 10:37 AM LVN A did not perform hand hygiene before donning (putting on) gloves and no PPE was utilized during the administration of Resident #6's bolus feeding via her peg-tube. Observation revealed LVN A did not clean the bedside table before placing syringe and supplies on bedside table, During an observation on 01/26/2026 at 11:03 AM revealed there were no supplies in any of the drawer of the PPE cabinet outside Resident #6's room.During an observation on 01/27/2026 at 06:27 AM LVN A did not perform hand hygiene before donning gloves to clean glucometer, and no hand hygiene was performed before donning gloves to perform the glucose check for Resident #42. During an observation on 01/27/2026 at 6:42 AM LVN A did not perform hand hygiene before or after performing a glucose check for Resident #30. During an observation on 01/27/2026 at 2:26 PM CNA E did not don (put on) a gown to perform urinary catheter care for Resident #13. During an interview on 01/27/2026 at 2:37 PM CNA E stated the negative outcome for residents was that she could spread bacteria to other residents in the facility. During an interview on 01/27/2026 at 3:04 PM LVN A stated the negative outcome for not performing hand hygiene and donning a gown could lead to an issue with infection control. During an interview on 01/28/2026 at 1:22 PM ADON stated the negative outcome for not performing hand hygiene and not donning gowns was an infection control issue. During an interview on 01/28/2026 at 1:28 PM DON stated the negative outcome for not performing hand hygiene and not donning gowns could lead to the transfer of germs. During an interview on 01/28/2026 1:37 PM RNC stated that the negative outcome for not performing hand hygiene and donning gloves could lead to an increase in the spread of infection. Record review of policy titled, Enhanced Barrier Precautions, revised February 2025, revealed the following: Policy Statement Enhanced barrier precautions (EBPS) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities.Policy Interpretation and Implementation.3. Examples of high-contact resident cared activities requiring the use of gown and gloves for EBP's include: .g. device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator, etc.); and .5. EBPs are indicated (when contact precautions do not otherwise apply) for residents with wounds and/or indwelling medical devices regardless of MDRO colonization.b. Indwelling medical devices include central lines, urinary catheters, . Record review of policy titled, Handwashing/Hand Hygiene, undated, revealed the following: Policy StatementThis facility considers hand hygiene the primary means to prevent the spread of healthcare-associated infections.Indications for Hand HygieneHand Hygiene is indicated:Immediately before touching a resident;Before performing an aseptic task (for example, placing an indwelling device or handling an invasive medical Residents Affected - Some (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675049 If continuation sheet Page 9 of 10 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675049 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/28/2026 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Avir at Pampa 1504 W Kentucky Ave Pampa, TX 79065 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete device);After contact with blood, body fluids, or contaminated surfaces;After touching a resident;After touching the resident's environment; .g. immediately after glove removal. Record review of policy titled, Insulin Administration, revised September 2014, revealed the following: .Steps in the Procedure (insulin Injections via syringe)Wash hands.Check blood glucose per physician order or facility protocol.21. Wash hands.Record review of policy titled, Perineal Care, revised February 2018, revealed the following: PurposeThe purpose of this procedure is to provide cleanliness and comfort to the resident, to prevent infections and skin irritation, and to observe the resident's skin condition.Steps in the procedure.b. Gloves and PPE (gown, gloves, face mask as indicated). Event ID: Facility ID: 675049 If continuation sheet Page 10 of 10