Health inspection·July 23, 2025

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few functioning) and Alzheimer's disease (a progressive disease that destroys memory and other important mental functions).Record review of Resident #12's quarterly MDS assessment completed on 05/29/25 revealed a BIMS score of 13 which indicated intact cognition. Resident #12 was coded to use a walker. She was independent across all ADLs except for bathing where she needed partial/moderate assistance and eating where she needed set up or clean up assistance.Record review of Resident #12's care plan completed 05/22/25 revealed no mention of personal food storage or a personal refrigerator.During an observation of Resident #12's room on 07/21/25 at 09:56 AM her personal refrigerator contained one, unopened bottle of soda, and a cheeseburger from a fast-food restaurant wrapped in the paper wrapper from the restaurant. The cheeseburger was hard to the touch.During an observation of Resident #12's room on 07/22/25 at 10:25 AM her personal refrigerator temperature log was up to date and signed every day of the month through 07/22/25. The cheeseburger was still in the refrigerator as was the unopened bottle of soda. The appearance of the cheeseburger when unwrapped from the paper wrapper was very dry, hard, and desiccated.During an observation of Resident #12 refrigerator on 07/23/25 at 08:53 AM her refrigerator temperature log was filled in for 07/23/25 and the cheeseburger was still in her refrigerator.During an observation and interview on 07/23/25 at 12:09 PM Resident #12 was seated in the dining room. She stated she knew the cheeseburger was in her refrigerator and she knew it was old and needed to be thrown away. She stated she was not going to eat the cheeseburger. Resident #12 stated, It's been in there a while.During an interview on 07/23/25 at 08:44 AM CNA B stated she had worked for the facility for a year and a half. She stated she worked for the facility previously as well. CNA B stated the facility policy regarding residents' personal food was that it was stored in their room and if it needed to be refrigerated it was stored in their personal refrigerator if they had one. She stated CNAs were responsible to ensure residents' personal food was stored according to the facility's policy. She stated CNAs checked residents' personal food and if it was expired or old they spoke to the resident and let them know it had to be thrown away. CNA B stated CNAs and nurses were responsible for checking residents' personal refrigerator temperatures and for cleaning old or expired food out of said refrigerators. She stated they did that twice a day. CNA B stated she was trained on her responsibilities regarding residents' personal food storage. She stated the training did not mention storing dry food in airtight containers. She stated with residents' chips, Sometimes we just fold them and put a clip. CNA B stated a possible negative outcome of residents' personal food not being stored properly and/or their personal refrigerators' temperatures not being checked daily was something might go bad and the resident can get sick.During an interview on 07/23/25 at 08:56 AM LVN A stated she had worked for the facility for 4 months. She stated the facility policy regarding residents' personal food stated food had to be sealed closed and have an expiration date. She stated residents' personal refrigerators were to be temperature checked every day by CNAs and nurses. She stated the CNAs usually did the checks, but it was the nurses' responsibility to ensure it was done. LVN A stated CNAs were responsible to ensure residents' personal food was properly sealed. She stated it was the nurses' responsibility to ensure that was done. She stated CNAs, nurses, and resident family members were all responsible for clearing old or expired food out of residents' personal refrigerators. She stated that was done daily or every other day. LVN A stated residents could get food poisoning or upset stomachs if their food was not stored properly or their refrigerator temperature was not checked daily.During an interview on 07/23/25 at 09:03 AM DON stated the facility's policy regarding residents' personal food stated residents had the right to have personal food. She stated residents were usually able to manage their own food and facility staff checked their refrigerator temperatures. She stated if staff smelled or saw something they would clean out the (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 2 of 7 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 07/23/2025 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete refrigerator. She stated of residents' personal dry food items, as long as it is not expired, they can have it, and we try to monitor and check it regularly. DON stated it was usually CNAs who were responsible for the storage of residents' personal food. She stated she had not trained staff on that responsibility. DON stated it was CNAs who were responsible for checking residents' personal refrigerator temperatures. She stated nurses were ultimately responsible to ensure it was done. DON stated if residents' dry food was not stored properly it can bring critters around. She stated if residents' refrigerators were not temperature checked and cleared of old or expired food residents could get sick.During an interview on 07/23/25 at 09:10 AM ADM stated she was familiar with the facility policy regarding residents' personal food storage. She stated CNAs were responsible for ensuring residents stored their personal food properly. ADM stated improperly stored dry food would not attract bugs because the facility had a monthly pest control program. She stated improperly stored refrigerated food might make them (residents) sick.Record review of a staff in-service presented by ADM on 04/15/25 revealed the following: All refrigerator [sic] in the facility will have a temperature sheet to be checked and written down once a day.Record review of facility policy titled Foods Brought by Family/Visitors and dated March 2022 revealed the following: . Facility staff will strive to balance resident choice and a homelike environment with the nutritional and safety needs of residents. 5. Food brought in by family/visitors that is left with the resident to consume later is labeled and stored in a manner that is clearly distinguishable from facility-prepared food. Non-perishable foods are stored in re-sealable containers with tightly fitting lids. Perishable foods are stored in re-sealable containers with tightly fitting lids in a refrigerator. Containers are labeled with the resident's name, the item, and the use by date. 6. The nursing staff will discard perishable foods on or before the use by date. 7. The nursing and/or food service staff will discard any foods prepared for the resident that show obvious signs of potential foodborne danger.Record review of facility policy titled Homelike Environment and dated February 2021 revealed the following: Residents are provided with a safe, clean, comfortable and homelike environment.Record review of facility policy titled Guidelines for Resident's Use of Personal Refrigerators and dated 2009 revealed the following: Our Facility strives to provide all residents with a comfortable, yet safe, living environment. The storage of perishable and non-perishable foods in resident rooms pose the risk and danger for spreading of infection and disease. All food items must be in clear, airtight containers, labeled with the resident's name, its contents, a prepared date and an expiration date. Facility staff will monitor temperatures of the refrigerators on a daily basis and discard any items deemed unsafe/hazardous by Facility staff . Event ID: Facility ID: 675327 If continuation sheet Page 3 of 7 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 07/23/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings included: Record review of Resident #42’s Face Sheet dated 7/22/2025, revealed an [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses including but not limited to: Congestive Heart Failure (is a long term condition where the heart cannot pump blood effectively leading to fluid build up in the lungs), asthma (long term inflammatory disease of the lungs). Record review of Resident #42's MDS, dated [DATE], revealed that Resident #42 was to receive oxygen therapy. The ARD date for MDS was 07/09/2025. The MDS did reveal that Resident #42 had a BIMS score of 13, which indicated Resident #42 did not have any cognitive impairment. Resident #42 required substantial/maximal assistance was required for shower/bathing. Resident #42 required setup/clean-up assistance with oral and personal hygiene and eating. Record review of Resident #42's active medication orders, dated 07/22/2025, revealed Resident #42 had an oxygen order that reflected: “May use oxygen @ 2 L per NC to maintain sats @ =/> 90% and/or SOB. every shift for SOB Verbal Active ordered date: 04/03/2025, start date 04/04/2025” Record review of Resident #42’s care plan, dated 03/26/2025, revealed nothing regarding Resident #42 receiving oxygen therapy. During an interview and observation on 07/22/2025 at 11:30 AM Resident #42 stated that she had been on oxygen for a long time due to being a heart patient. Resident #42 looked over the side of her bed and stated, “Yeah, it is on the right amount”. During an observation on 07/22/2025 at 11:35 AM revealed Resident #42 had a NC on and the oxygen concentrator was delivering oxygen on 4.5L/min. to Resident #42. During an observation on 07/22/2025 at 01:15 PM revealed Resident #42's oxygen concentrator was set at 4.5L/min and Resident #42 had a NC on and was receiving oxygen at time of observation. During an interview on 07/22/2025 at 02:45 PM MD stated that if a resident was having out of the ordinary issues such as pneumonia, there could be a change in treatment strategy. MD stated if the resident had advanced COPD the O2 could be at a 4.5L/min depending on residents current status. Otherwise, it would be titrated to manage a O2 saturation at 92% or greater. During an observation on 07/23/2025 at 08:57 AM Resident #42 had a NC on and oxygen concentrator (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 4 of 7 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 07/23/2025 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 0656 was delivering oxygen on 4.5L/min. to Resident #42. Level of Harm - Minimal harm or potential for actual harm During an interview on 07/23/2025 at 9:01 AM Interview with MDS Nurse stated that she and the DON were responsible for updating the Care plans. MDS nurse stated that the negative outcome for not having an updated care plan would be that the resident would not be receiving the appropriate care that they need. Residents Affected - Few During an interview on 07/23/2025 at 9:24 AM Interview with DON stated that she and the MDS nurse were responsible for updating the CP's. DON was responsible for changes and updates and MDS nurse performs the initial CP. DON stated the negative outcome for not updating the CP to mirror the MDS assessment puts the Residents at risk for not receiving the care that they need. During an interview on 07/23/2025 at 9:48 AM Interview with LVN A stated she rarely ever looks at the CP. LVN A stated a negative outcome for not having an updated CP, LVN A stated it could lead to not knowing what the patient needs in the way of their care. Record review of the facility provided policy titled, “Care Plans, Comprehensive Person-Centered”, revised March 2022, revealed the following: “Policy Statement A comprehensive, person-centered care plan that includes measurable objectives and timetables to meet the resident’s physical, psychosocial and functional needs is developed and implemented for each resident. … …3. The care plan interventions are derived form a thorough analysis of the information gathered as part of the comprehensive assessment. … …7. The comprehensive, person-centered care plan; a. Includes measurable objectives and timeframes; b. Describes the services that are to be furnished to attain or maintain the resident’s highest practicable physical, mental, and psychosocial well-being, including: … …(3) which professional services are responsible for each element of care; … …e. Reflects currently recognized standards of practice for problem areas and conditions. …” FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 5 of 7 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 07/23/2025 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 0695 Provide safe and appropriate respiratory care 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 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. Residents Affected - Few 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. Findings included: Record review of Resident #42's face sheet, dated 07/22/2025, revealed Resident #42 was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include type 2 diabetes mellitus without complications (a condition where blood sugar levels are persistently high due to either the body's inability to use insulin effectively (insulin resistance) or the pancreas doesn't produce enough insulin, or both), essential hypertension (a condition in which the force of blood against the walls of the arteries is consistently elevated above normal levels), chronic combined systolic (congestive) and diastolic (congestive) heart failure, rheumatoid arthritis, sleep apnea, unspecified asthma, and heart failure. Record review of Resident #42's MDS, dated [DATE], revealed that Resident #42 was to receive oxygen therapy. The ARD date for MDS was 07/09/2025. The MDS did reveal that Resident #42 had a BIMS score of 13, which indicated Resident #42 did not have any cognitive impairment. Record review of Resident #42's active medication orders, dated 07/22/2025, revealed Resident #42 had an oxygen order that stated: “May use oxygen @ 2 L per NC to maintain sats @ =/> 90% and/or SOB. every shift for SOB Verbal Active ordered date: 04/03/2025, start date 04/04/2025” Record review of Resident #42’s care plan, dated 03/26/2025, revealed nothing regarding Resident #42 receiving oxygen therapy. During an interview and observation on 07/22/2025 at 11:30 AM Resident #42 stated that she had been on oxygen for a long time due to being a heart patient. Resident #42 looked over the side of her bed and stated, “Yeah, it is on the right amount”. During an observation on 07/22/2025 at 11:35 AM Resident #42 had a NC on and oxygen concentrator was delivering oxygen on 4.5L/min. to Resident #42. During an observation on 07/22/2025 at 01:15 PM revealed Resident #42's oxygen concentrator set at 4.5L/min and Resident #42 had NC on and receiving oxygen at time of observation. During an interview on 07/22/2025 at 02:45 PM MD stated that if a resident was having out of the ordinary issues such as pneumonia, there could be a change in treatment strategy. MD stated if the resident had advanced COPD the O2 could be at a 4.5L/min depending on residents current status. Otherwise, it would be titrated to manage a O2 saturation at 92% or greater. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 6 of 7 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 07/23/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 07/23/2025 at 08:57 AM Resident #42 had a NC on and oxygen concentrator was delivering oxygen on 4.5L/min. to Resident #42. During an interview on 07/23/2025 at 09:01 AM MDS nurse stated it was not common practice to have a resident on 4.5L/min of oxygen. MDS nurse stated the facility had a standing order for 2-3L/min to maintain an O2 saturation of 92% or greater. MDS nurse was asked If a resident has some type of respiratory distress caused by pneumonia, flu, or COVID would the oxygen be titrated to maintain the O2 saturation of 92% or greater, MDS stated No usually it is just medications that are changed. During an interview on 07/23/2025 at 09:24 AM Interview with DON stated that the negative outcome for having an oxygen concentrator set to high could lead to the resident becoming more dependent upon oxygen. During an interview on 07/23/2025 at 09:48 AM Interview with LVN stated that she checks Resident #42’s oxygen saturation levels all of the time. LVN was asked if she observed the concentrator to see what it is set to, LVN stated that she had not. LVN stated that a negative outcome for having oxygen to high could lead to overload for the resident. Interview on 07/23/2025 at 09:52 AM Interview with DON stated NP was made aware that Resident #42's oxygen level was increased by the day shift nurse (LVN C). NP let the DON know that she would like for the level to be returned to the 2L/min. No new orders were provided to DON during her phone call to NP. Record review of the facility provided policy titled, “Oxygen Administration”, revised October 2010, revealed the following: “Purpose The purpose of this procedure is to provide guidelines for safe oxygen administration. Preparation 1. Verify that there is a physician’s order for this procedure. Review the physician’s orders for facility protocol for oxygen administration. …” FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675327 If continuation sheet Page 7 of 7