Inspection visit
Health inspection
5 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 5 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman,
before transfer or discharge, including appeal rights.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Findings include:
Record review of Resident #30's face sheet dated 06-24-2024 revealed a [AGE] year-old female resident
admitted to the facility on [DATE] with diagnoses to include cerebral infarction (occurs as a result of
disrupted blood flow to the brain due to problems with the blood vessels that supply it), pneumonia (lung
inflammation caused by a bacterial or viral infection), expressive language disorder (a condition in which a
person has lower that normal ability in vocabulary, saying complex sentences, and remembering words),
chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), hypertension (a
condition in which the force of the blood against the artery walls is too high), chronic atrial fibrillation (an
irregular, often rapid heart rate that commonly causes poor blood flow), atherosclerotic heart disease(a
buildup of fat, cholesterol, and other substances in the artery walls), psychotic disorder (severe mental
disorders that cause abnormal thinking and perceptions), and dementia. (a group of thinking and social
symptoms that interferes with daily functioning). Section-Miscellaneous Information-Date of
Discharge-05-13-2024. discharged to: Acute Care Hospital. Section-Contacts-Resident #30 is listed as the
Responsible Party. No other contacts are listed.
Record review of Resident #30's last MDS assessment completed 5-13-2024 reflected a discharge
assessment-return not anticipated listing Resident #30 with a BIMS that was not evaluated because
Resident #30 had memory problems and that Resident #30 had a functionality that ranged from
substantial/maximal assistance with activities of daily living such as dressing and footwear to independent
with eating. Section A marked the discharge as unplanned.
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 13
Event ID:
675327
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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 0623
Record review of Resident #30's discharge MDS completed 5-13-2024 also revealed the following:
Level of Harm - Minimal harm
or potential for actual harm
Section A:
Residents Affected - Few
At the time of discharge, did your facility provide the resident's current reconciled medication list to the
resident, family and/or caregiver? -there was no response.
Section O:
Is active discharge planning already occurring for the resident to return to the community? -the answer was
no.
Record review of Resident #30's care plan with admission date of 04-24-2024 revealed the following care
plan:
Focus-I wish to remain in the facility for long term care. Date Initiated: 05-10-2024.
Record review of Resident #30's chart to include Resident #30's progress notes dated 04-24-2024 to
05-25-2024 revealed the following:
The first documented progress note was 04-24-2024 and the last documented progress note was
05-13-2024.
-There was no documentation in the progress notes or any other area of Resident #30's chart for Resident
#30's transfer/discharge, the reason for Resident #30's transfer/discharge, no noted discharge summary, no
noted notification of the resident since Resident #30 was her own responsible party. There was no noted
notification of the Ombudsman of Resident #30's transfer/discharge or reason for the transfer/discharge.
During an interview on 06-24-2024 at 03:07 PM the DON verified that Resident #30 was discharged to the
ER on [DATE] after having behavioral issues with staff, Police, and the EMS and the plan was that Resident
#30 would not return due to being a risk to the other residents and staff. The DON reported that at the time
of this interview the facility did not know where Resident #30 was or what had happened to Resident #30.
The DON reported that the plan was for Resident #30 to go to a behavioral health unit but that she (the
DON) did not know if that had happened. The DON reported that no written notice of transfer or discharge
had been given to Resident #30 and to the DON's knowledge no notice had been sent to the ombudsman.
The DON also reported that no notice that Resident #30 would not be allowed to be readmitted to the
facility was given either but that that was the administrator's responsibility and that this surveyor would need
to ask the administrator for verification.
During an interview on 06/24/24 at 03:11 PM the Administrator reported that no written transfer or
discharge notice and no written notice that Resident #30 would not be readmitted to the facility had been
given to Resident #30 due to Resident #30 was a risk to the other residents and staff. The Administrator
stated, I honestly can't recall if we notified the Ombudsman of any of this due to Resident #30 was such a
threat and we knew Resident #30 would not be readmitted . The administrator checked her computer to
include Resident #30's chart and the Administrator's emails and could not find any notice of transfer or
discharge that was provided to Resident #30 or the Ombudsman.
During an interview on 06-24-2024 at 03:57 PM the Ombudsman for this facility checked her records
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 2 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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 0623
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
and verified that she has never received a notice of transfer or discharge for Resident #30. The
Ombudsman reported that she was supposed to receive a monthly list of transfers or discharges but this
facility is bad about not sending them.
During an interview on 06-25-2024 at 07:45 AM the Administrator reported that if a resident or the
ombudsman was not provided the information of a residents transfer or discharge then it could be a
violation of the resident's rights and the residents would not get the right to appeal the transfer or
discharge.
During an interview on 06-25-2024 at 08:14 AM the DON reported that if a resident was not given a transfer
or discharge notice and the information included with the transfer or discharge notice then that resident
would not have the information for the appeal process.
Record review of the facility provided policy titled, Transfer or Discharge, Facility-Initiated October 2022,
revealed the following:
Policy Statement: Once admitted to the facility, residents have the right to remain in the facility. Facility
initiated discharge, when necessary, must meet specific criteria and require resident/representative
notification and orientation, and documentation as specified in this policy.
-Notice of Transfer or Discharge (Emergent or Therapeutic Leave)
4. Notice of Transfer is provided to the resident and representative as soon as practicable before the
transfer and to the long-term care (LTC) Ombudsman when practicable (e.g. in a monthly list of residents .)
-Notice of Discharge after Transfer
2. If the facility does not permit a resident to return to the facility based on inability to meet the residents
needs, the facility will notify the resident, and/or his or her representative in writing of the discharge,
including notification of the appeal rights.
3. The facility will send a copy of the discharge notice to the representative of the Office of the State LTC
Ombudsman.
-Documentation of Facility-Initiated Transfer or Discharge
1, When a resident is transferred or discharge from the facility, the following information is documented in
the medical record.
a.
The basis for the transfer or discharge
b.
That appropriate notice was provided to the resident .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 3 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a
resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed
consent; and (4) Correctly install and maintain the bed rail.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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.
Finding include:
Resident #20
Record review of Resident #20's clinical record revealed an [AGE] year-old male admitted to the facility
originally on 01-4-2023 and readmitted on [DATE] with diagnoses to include cerebral infarction (occurs as a
result of disrupted blood flow to the brain due to problems with the blood vessels that supply it), Parkinson's
(a disorder of the central nervous system that affects movements to include tremors), hypertension (a
condition in which the force of the blood against the artery walls is too high), repeated falls, macular
degeneration (a degenerative condition affecting the central part of the retina), lack of coordination, muscle
weakness, and dementia (a group of thinking and social symptoms that interferes with daily functioning).
Record review of Resident #20's clinical record revealed his last MDS was a quarterly completed
03-12-2024 which indicated his BIMS was 15 indicating he was cognitively intact, and he had a functionality
of requiring substantial/maximal assistance with most activities of daily living. Resident #20 is listed as
requiring supervision or touching assistance when transferring from the bed to the chair.
Record review of Resident #20's Order Summary Report with active orders as of 06-24-2024 revealed the
following order:
Device: Side Rail: Three Fourth Side Rail - Active 01-04-2023
Record review of Resident #20's care plans with date of admit 07-08-2023 revealed the following care plan:
Focus - I use 1/4 side rails on both sides of my bed for increased bed mobility and positioning. - Date
Initiated: 04-24-2023.
Record review of Resident #20's clinical record revealed a Bed Rail Consent undated that was not
completed and had no signature for Resident #20 or his representative.
During an observation and interview on 06-23-2024 at 09:26 AM Resident #20 was in his wheelchair in
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 4 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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 0700
Level of Harm - Minimal harm
or potential for actual harm
his room. Resident #20 had bilateral 1/4 bedrails that were up and locked in place that he reported he uses
to move around in his bed, that he knew how to use the bedrails, but the facility had not addressed any
issues with his bed rails to include training him on their use. Resident #20 was noted to have a right-hand
contracture (a condition of shortening and hardening of the muscles and tendons, or other tissue, often
leading to deformity and rigidity of the joints).
Residents Affected - Few
Resident #24
Record review of Resident #24's clinical record revealed an [AGE] year-old male admitted to the facility on
originally on 11-30-2023 and readmitted on [DATE] with diagnoses to include acquired absence of right leg
below the knee (surgical amputation below the knee of the right leg), hypertension (a condition in which the
force of the blood against the artery walls is too high), diabetes (a chronic condition that affects the way the
body processes blood sugar (glucose), depression (a mental health disorder characterized by persistently
depressed mood or loss of interest in activities, causing significant impairment in daily life), chronic
obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath),
peripheral vascular disease (a circulatory condition in which narrowed blood vessels reduce blood flow to
the limbs), congestive heart failure (a chronic condition in which the heart dose not pump blood as well as it
should), and malaise (a general feeling of discomfort, illness, lack of well-being).
Record review of Resident #24's clinical record revealed his last MDS was a quarterly completed
03-15-2024 which indicated his BIMS was 13 indicating he was cognitively intact, and he had a functionality
of requiring partial/moderate assistance with most activities of daily living. Resident #24 is listed as
requiring supervision or touching assistance when transferring from the bed to the chair.
Record review of Resident #24's Order Summary Report with active orders as of 06-24-2024 revealed no
orders for his bedrails.
Record review of Resident #24's care plans with date of admit 01-02-2024 revealed the following care plan:
Focus - I am at high risk for falls r/t Gait/balance problems. - Date Initiated: 12-17-2023.
Interventions - The resident needs a safe environment with: (even floors free from spills and/or clutter;
adequate, glare-free light; a working and reachable call light, the bed in low position at night; Slide rails (bed
rails) as ordered, handrails on walls, personal items within reach) - Date Initiated: 12-17-2023.
Record review of Resident #24's clinical record revealed there was no bedrail consent completed for
Resident #24.
During an observation and interview on 06-23-2024 at 09:22 AM Resident #24 was in his room laying in his
bed under his covers. Resident #24 had bilateral 1/4 bedrails up and locked in place. Resident #24 reported
that he used his bed rails a little bit and that he did not know how to use them properly or how to get them
up and down if needed, that the facility had never discussed his bed rails with him to include training him on
their use.
During an interview on 06-25-2024 at 07:41 AM the Administrator reported that Resident #20 had a bedrail
consent in his chart that was never signed, and Resident #20 had a family representative that
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 5 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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 0700
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
was his responsible party, and that Resident #24 did not have any bedrail consent in his chart. The
Administrator reported that she was going to get the family to come in and sign Resident #20's consent and
that she would get Resident #24's consent signed immediately.
During an interview on 06-25-2024 at 07:49 AM the Administrator reported that if a resident was not offered
the consent information for bedrails and given the opportunity to accept or refuse the consent then it
violates a residents' right to choose self-preservation which could pose a risk to the resident of becoming
trapped in the rail or being injured.
During an interview on 06-25-2024 at 08:15 AM the DON reported that if a resident was not given the
opportunity to address a bedrail consent, then the resident might hurt themselves on the bedrail and their
safety would not be maintained.
Record review of facility provided policy titled Bed Safety and Bed Rails, revision August 2022, revealed the
following:
Use of Bed Rails
8. Before using bed rails for any reason, the staff shall inform the resident or representative about the
benefits and potential hazards associated with bed rails and obtain informed consent.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 6 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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 - Few
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 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.
Findings included:
During an observation on 06-23-2024 at 03:09 PM of the North Hall medication cart that was placed at the
front of the north hall in the hallway in front of the nurse's station, the cart was noted to be unlocked. This
surveyor noted on several occasions during this shift that resident have been present in this hallway to
include resident who are wondering and confused. No staff or residents were present at the time of this
observation.
During an observation and interview on 06-23-2024 at 03:11 PM ADON E was asked to exit her office and
check the North Hall medication cart. ADON E verified that the North Hall medication cart was unlocked,
and that multiple resident medication were present in the cart. ADON E reported that leaving a medication
cart unattended and unlocked can result in residents or family members accessing the medications, that if
that happened the person taking the medications could have a reaction, it could be dangerous, and they
could take too much of something and overdose.
During an interview on 06-23-2024 at 03:15 PM LVN F (the nurse responsible for the North Hall medication
cart this shift) reported that she never leaves her cart unlocked and that she did not know what happened
this time. LVN F reported that leaving a medication cart unlocked could result in resident medications
getting stolen, residents who wonder could access the meds, and that a resident could die if they took the
wrong medication or took too much medication. LVN F reported that it was the facility's normal protocol to
ensure all medication carts are locked when staff are not present and that she had been trained on this by
a previous DON.
Record review of the facility provided polity titled, Storage of Medications revised November 2020, revealed
the following:
Policy:
The facility stores all drugs and biologicals in a safe, secure, and orderly manner.
Policy Interpretation and Implementation:
1.-Drugs and biologicals used in the facility are stored in locked compartments . Only persons authorized to
prepare and administer medications have access to locked medication.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 7 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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
6.-Compartments (including . carts .) containing drugs and biologicals are locked when not in used.
Unlocked medication carts are not left unattended.
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 8 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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 - Many
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.
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.
Findings include:
Observation of the freezer on 6/23/24 at 9:20 AM revealed the following:
1. (1) Ziplock bag of coconut with a use by date of 5/26/24.
2. (1) box of frozen vegetables , not sealed and open to air.
3. (1) box of frozen cookie dough, not sealed and open to air.
4. (1) box of frozen biscuit dough, not sealed and open to air.
5. (1) box of frozen omelets, not sealed and open to air.
6. (1) box of frozen sausage patties, not sealed and open to air.
7. (1) box of frozen bacon, not sealed and open to air.
8. Food crumbs were observed in the floor of the freezer.
Observation of the walk-in pantry on 6/23/24 at 9:26 AM revealed the following:
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 9 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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
1.
Level of Harm - Minimal harm
or potential for actual harm
(1) Ziplock bag of spaghetti noodles, no label or date.
2.
Residents Affected - Many
Food crumbs were observed on the floor of the pantry and under the food storage racks.
In an observation and an interview of the kitchen prep area on 6/23/24 at 9:30 am revealed the following:
1.
(1) ladies' purse on the lower shelf of the kitchen prep table with kitchen pots and paper products. [NAME]
A stated the purse was hers and she did not know she was not supposed to have personal items in the
kitchen prep area. She stated she did not know what the consequences would be if her purse was in the
kitchen prep area.
In an observation and interview on 6/23/24 at 12:05 pm [NAME] B was observed with gloved hands to
touch food trays, the rolling cart next to the prep table, the kitchen prep table, condiment packages and
picked up a dessert cup and placed it on a resident meal tray. [NAME] B picked up a dinner roll with one
hand and pulled other rolls away from the first roll with her other hand. [NAME] B placed the roll on the
plate of food. [NAME] B did not wash her hands or change her gloves. [NAME] B stated she did not use
tongs because she had gloves on.
In an observation on 6/24/ 24 of the freezer on 6/23/23 at 10:00 AM revealed the following:
1. (1) box of frozen vegetables, not sealed and open to air.
3. (1) box of frozen cookie dough, not sealed and open to air.
4. (1) box of frozen biscuit dough, not sealed and open to air.
5. (1) box of frozen sausage patties, not sealed and open to air.
7. Food crumbs were observed in the floor of the freezer.
Observation of the walk-in pantry on 6/24/24 at 10:06 AM revealed the following:
1.
(1) Ziplock bag of spaghetti noodles, no label or date.
2.
Plastic cup lids in floor of pantry and on top of the canned food in the canned food rack
In an interview on 6/24/24 at 2:20 PM, the DM stated of the opened food products she expects all staff to
close food items up after use and she expected all food to be labeled and dated. She stated
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 10 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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 - Many
if foods were not properly wrapped up or labeled and dated this could cause food contamination and
sickness to residents. She stated anything could fall into the opened food items. She stated expired food
items should be thrown out if expired and not used as this could make residents sick. The DM stated she
expects all staff to use tongs to serve bread and rolls. The DM stated s personal items are not supposed to
be in the kitchen prep area. She stated she had a hook on the back of the kitchen that staff should use for
personal items. She stated having personal items in the kitchen could cause cross contamination. The DM
stated she was responsible for training staff, and she would retrain them.
Record Review of the facility policy and procedure, dated 2009, titled Safe Food Handling documented
employees wash hands prior to handling food. Follow all local state and federal regulations when handling
food. Refrigerated foods are properly covered, labeled and dated. Food is served with clean sanitized
utensils. There is no bare hand contact. All foods removed from the original packaging are stored in a
closed container and labeled with the common name of the product and the date it was opened.
Record Review of the facility policy and procedure, dated 2009, titled Indications for Glove Use documented
employees must wash hands before putting on gloves, when changing into fresh gloves and immediately
after removing gloves. Change gloves when an unsanitary item is touched. Examples include opening a
drawer, touching a dirty plate, turning on a faucet .Change gloves when beginning a different task.
Record Review of the facility policy and procedure, dated 2009, titled Safe Food Preparation documented
Avoid touching ready to eat foods with bare hands. Use tongs or other utensils instead.
Record Review of the facility policy and procedure, dated 2009, titled Food Safety in Receiving and Storage
documented Refrigerated food items are properly covered, labeled and clearly marked to indicate a use by
date 2 months from the date opened.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 11 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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 1 (Resident #23) of 17
Residents.
Residents Affected - Few
-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.
Findings included:
Observation on 06/24/24 at 12:56pm of incontinent care for Resident #23 was performed by CNA C and
CNA D. Hand hygiene was not performed before the start of incontinent care for Resident #23 by either
CNA. Resident #23 had a BM and CNA D turned resident away from her towards the wall to clean Resident
#23's buttocks and rectum. CNA D then proceeded to take a clean brief and place it under the resident. No
hand hygiene or glove change took place during this observation. CNA D then with the same dirty gloves
that she performed incontinent care with, touched residents' blankets, pillow, and clothing of resident. No
hand hygiene was performed by CNA D after removal of gloves in room. CNA D was observed taking waste
to the dirty linen closet and did not perform hand hygiene after taking trash to the dirty linen closet. CNA C
removed gloves and provided Resident #23 with a drink of coke. No HH was performed until after the drink
was provided to resident.
Interview on 06/24/24 at 01:27pm CNA D stated that there was no negative outcome by not performing HH
or a glove change. CNA D was asked if there was any chance for infection if she did not perform HH or
glove change, CNA D stated yes.
Interview on 06/24/24 at 01:30pm CNA C stated that a negative outcome for not performing hand hygiene
before administering the drink to Resident #23 would lead to cross contamination.
Interview on 06/25/24 at 8:18am DON stated that a negative outcome for not performing hand hygiene and
glove changes during incontinent care could lead to cross contamination.
Record review of facility provided policy, titled Handwashing/Hand Hygiene, revised August 2019, revealed
the following:
Policy Statement
This facility considers hand hygiene the primary means to prevent the spread of infections.
Policy Interpretation and Implementation
1. All personnel shall be trained and regularly in-serviced on the importance of hand hygiene in preventing
the transmission of healthcare-associated infections.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 12 of 13
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
675327
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
06/25/2024
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Pampa Nursing Center
1321 W Kentucky
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
2. all personnel shall follow the handwashing/hand hygiene procedures to help prevent the spread of
infections to other personnel, residents, and visitors.
.7. Use an alcohol-based hand rub containing at least 62% alcohol; or, alternatively, soap (antimicrobial or
non-anti-antimicrobial) and water for the following situations: .
Residents Affected - Few
.b Before and after direct contact with residents; .
.h. Before moving from a contaminated body site to a clean body site during resident care; .
.m After removing gloves; .
.o. before and after eating or handling food;;;;
p. Before and after assisting a resident with meals; .
.8. Hand hygiene is the final step after removing and disposing of personal protective equipment.
.Applying and removing gloves:
1. Perform hand hygiene before applying non-sterile gloves .
.5. Perform hand hygiene.
Record review of facility provided policy, titled Perineal Care, revised February 2018, revealed the following:
Steps in procedure .
.2. Wash and dry your hands thoroughly.
.7. Put on gloves.
.10. Remove gloves and discard into a designated container.
11. wash and dry your hands thoroughly.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675327
If continuation sheet
Page 13 of 13
Reading this as a family member? Your long-term care ombudsman is a free advocate for residents and families.
Back to topCitations
5 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F880 - Infection Control
Provide and implement an infection prevention and control program.
F623 - Transfer and discharge-
Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.
F700 - Bed Rails
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
F761 - Labeling of Drugs and Biologicals
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.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the June 25, 2024 survey of PAMPA NURSING CENTER?
This was a inspection survey of PAMPA NURSING CENTER on June 25, 2024. The surveyor cited 5 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at PAMPA NURSING CENTER on June 25, 2024?
Yes, 5 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide and implement an infection prevention and control program."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.