Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Palo Duro Nursing Home during CMS and state inspections, most recent first.
The facility did not ensure that two staff members, including a Marketing/Admissions Coordinator and a CNA, received mandatory training in areas such as abuse prevention, fall prevention, restraint reduction, bloodborne pathogens, emergency procedures, and dementia care before beginning work with residents. Record reviews and staff interviews confirmed that these trainings were not completed as required, and there was no policy in place to ensure compliance.
The facility failed to follow professional standards for food safety, as observed in the kitchen. The Dietary Manager (DM) did not perform appropriate hand hygiene while preparing pureed foods, leading to potential cross-contamination. The DM was seen handling food items without changing gloves or washing hands between tasks, despite acknowledging the risk of foodborne illness. The facility's policy requires hand washing and glove changes between tasks, which was not adhered to in this case.
The facility failed to complete quarterly MDS assessments for five residents within the required timeframe, affecting individuals with various medical conditions. The MDS LVN, a remote employee, did not complete the assessments timely, citing the need for accurate coding. The ADON, responsible for resident interviews, felt overwhelmed by her dual roles. Staff interviews revealed concerns about the impact on funding and resident care, as care plans are based on MDS information.
The facility failed to refer two residents for PASRR Level II reviews after new diagnoses of serious mental disorders. One resident was diagnosed with bipolar disorder shortly after admission, and another with a psychotic disorder years after admission. Despite these diagnoses, the facility did not conduct the necessary reviews, and staff interviews revealed confusion over responsibility for PASRR completion.
A facility failed to perform a PASRR for three residents, including one with major depressive disorder, until 27 days after admission. Miscommunication about responsibility for PASRR completion led to the delay, contrary to the facility's policy requiring immediate completion. Staff interviews highlighted concerns about potential inadequate care due to this oversight.
A facility failed to maintain accurate medical records for a resident with bipolar disorder and major depressive disorder, resulting in an incorrect PASRR Level 1 Screening that did not indicate mental illness. This oversight led to the resident not receiving a necessary PASRR Level II evaluation. Interviews revealed confusion over PASRR responsibilities, with the ADON unaware of the oversight. The facility's policy mandates mental disorder screening for new admissions, which was not followed in this case.
A facility failed to maintain an effective infection control program as staff did not use PPE gowns during wound and Foley catheter care for a resident with a pressure ulcer and Foley catheter. Observations showed PPE gowns were absent, and interviews revealed staff were unaware of Enhanced Barrier Precautions (EBP). The resident had multiple diagnoses, including a pressure ulcer, requiring daily care. The facility's Infection Preventionist and ADON admitted to not being informed about EBP, contributing to the deficiency.
Failure to Provide Required Staff Training Prior to Resident Contact
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all new and existing staff members, as evidenced by the lack of required training for two out of five employees reviewed. Specifically, the Marketing/Admissions Coordinator and a CNA did not receive training in Abuse, Neglect and Exploitation, Fall Prevention, Restraint Reduction, HIV and Bloodborne Pathogens, Emergency Procedures, and Dementia prior to or on their first day of employment. Record reviews confirmed that these trainings were not completed as required before the employees began working with residents. Interviews revealed that the BOM/HR was responsible for assigning trainings through a computer-based system but was not familiar with the content or timing of the trainings. The DON was unaware that the required trainings had not been provided before the employees started working with residents. The Administrator, new to the position, acknowledged the issue and indicated a lack of existing policy on required trainings at hire. No evidence was provided to show that a policy for required trainings at hire existed.
Failure in Food Safety Practices
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed in the kitchen during food preparation. The Dietary Manager (DM) was seen preparing pureed foods without performing appropriate hand hygiene. The DM changed gloves but then touched various kitchen surfaces, including the prep table and blender, without washing hands or changing gloves again. This was followed by handling food items directly with gloved hands, such as removing chicken from the bone and placing it into the blender, without changing gloves or washing hands. The DM acknowledged the oversight, admitting to not washing hands or changing gloves between tasks, which could lead to cross-contamination. Further observations revealed that the DM continued to handle food items, such as corn and bread, without changing gloves or washing hands between tasks. The DM admitted to touching the bread with contaminated hands and recognized the potential for cross-contamination. During an interview, the DM confirmed awareness of the failure to wash hands between tasks and acknowledged the risk of foodborne illness due to improper hand hygiene. The facility's policy on preventing foodborne illness requires employees to wash hands and change gloves between tasks to prevent cross-contamination, which was not followed in this instance.
Failure to Complete Timely MDS Assessments
Penalty
Summary
The facility failed to complete quarterly Minimum Data Set (MDS) assessments for five residents within the required timeframe of every three months, as specified by state regulations and approved by CMS. The residents affected included individuals with various medical conditions such as chronic obstructive pulmonary disease, Parkinson's disease, traumatic brain injury, myocardial infarction, congestive heart failure, and cerebral infarction. The MDS assessments were either incomplete or not conducted at all, with the Assessment Reference Dates (ARDs) for these residents ranging from early May to mid-June 2024. The MDS LVN, who was responsible for completing the MDS assessments, was a remote employee and did not visit the facility. She acknowledged that several MDS assessments were past the 14-day completion mark after the ARD, as she was gathering information to ensure accurate coding. The ADON, who conducted the resident interviews, felt overwhelmed by her dual responsibilities and indicated that the MDS LVN should use her assessments to complete the MDS. The failure to complete these assessments timely was recognized as potentially affecting the facility's funding and, consequently, the care provided to residents. Interviews with facility staff, including the ADM, ADON, and LVN A, highlighted concerns about the impact of delayed MDS completion on funding and resident care. The ADM emphasized that resident care plans, which are based on MDS information, could be compromised, affecting the quality of care provided. The Long-Term Care Facility Resident Assessment Instrument 3.0 User's Manual specifies that MDS completion must occur no later than 14 days after the ARD, a requirement that was not met in these cases.
Failure to Conduct PASRR Level II Reviews for Residents with New Mental Health Diagnoses
Penalty
Summary
The facility failed to refer two residents for a PASRR Level II review following new diagnoses of serious mental disorders. Resident #5 was diagnosed with bipolar disorder one day after admission, but the facility did not initiate a PASRR Level II review. The resident's records indicated a history of bipolar disorder and major depressive disorder, with medications prescribed for these conditions. Despite these indicators, the initial PASRR Level 1 Screening noted no evidence of mental illness. Resident #11, who had been admitted to the facility several years prior, was diagnosed with a psychotic disorder with hallucinations. This diagnosis was made almost six years after admission, yet the facility did not conduct a PASRR Level II review. The resident's records showed a history of traumatic brain injury, anxiety, depression, and psychotic disorder, with various medications prescribed for these conditions. The initial PASRR Level 1 Screening also failed to identify any mental illness. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of PASRRs. The ADON believed the MDS LVN was responsible for PASRRs, but later took over the responsibility upon realizing they were not being completed. The ADON admitted to not being aware of Resident #5's mental illness and did not recognize the potential negative outcomes of not referring residents for a PASRR Level II review. The facility's policy stated that all new admissions should be screened for mental disorders, but this was not adhered to in these cases.
Failure to Complete PASRR Prior to Admission
Penalty
Summary
The facility failed to perform a Pre-Admission Screening and Resident Review (PASRR) for individuals with mental disorders or intellectual disabilities prior to admission for three residents, including Resident #31. Resident #31 was admitted to the facility with diagnoses including cerebral infarction, major depressive disorder, and hemiplegia. Despite these conditions, the PASRR Level 1 Screening for Resident #31 was not completed until 27 days after admission, which is contrary to the facility's policy that requires PASRRs to be completed immediately. Interviews with facility staff revealed a misunderstanding regarding the responsibility for completing PASRRs. The Assistant Director of Nursing (ADON) initially believed that the MDS Licensed Vocational Nurse (LVN), who was a remote employee, was responsible for completing the PASRRs. Upon discovering that the MDS LVN was not completing them, the ADON resumed responsibility for the task. The ADON acknowledged that PASRRs should be completed immediately but did not recognize any potential negative outcomes from the delay in completing Resident #31's PASRR. The facility's policy, dated 2019, states that all new admissions and readmissions must be screened for mental disorders, intellectual disabilities, or related disorders as part of the PASRR process. The failure to adhere to this policy could place residents at risk of receiving inadequate care, as noted by other staff members who expressed concerns about the potential harm to residents if PASRRs are not completed prior to or at the time of admission.
Failure to Maintain Accurate Medical Records and PASRR Compliance
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, identified as Resident #5, who was admitted with a diagnosis of bipolar disorder and major depressive disorder. Despite these diagnoses, the Pre-Admission Screening and Resident Review (PASRR) Level 1 Screening completed by an acute care facility employee indicated no evidence of mental illness. This oversight resulted in the resident not receiving a PASRR Level II evaluation, which is necessary for residents with mental health conditions to ensure their needs are adequately met. Interviews with facility staff revealed a lack of clarity and responsibility regarding the completion of PASRRs. The Assistant Director of Nursing (ADON) admitted to being responsible for PASRRs but was unaware of the oversight concerning Resident #5's mental illness at the time of admission. The facility's policy requires that all new admissions be screened for mental disorders, but this was not adhered to in this case. The failure to recognize and document the resident's mental illness could potentially place residents at risk of harm and not having their mental health needs met.
Inadequate Infection Control Practices Due to Lack of PPE Use
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of four staff members, including an LVN and three CNAs, who did not don PPE gowns during wound care and Foley catheter care for a resident with an unstageable pressure ulcer and a Foley catheter. Observations revealed that PPE gowns were not present in the resident's room or in the hallway, indicating a lack of adherence to infection control protocols. The resident involved was a male with multiple diagnoses, including hypertension, diabetes, and a pressure ulcer in the sacral region. The resident required daily wound care and Foley catheter care, as outlined in his care plan and active order summary. Despite these requirements, staff members failed to use appropriate PPE, which is crucial for preventing the spread of infections, especially in residents with chronic wounds or indwelling medical devices. Interviews with the staff, including the facility's Infection Preventionist and ADON, revealed a lack of awareness and training regarding Enhanced Barrier Precautions (EBP). Staff members admitted to not being informed about the necessity of wearing gowns during certain care activities, and the Infection Preventionist acknowledged not having taught the staff about EBP. This lack of knowledge and training contributed to the deficiency in infection control practices, as highlighted by the CMS guidelines and the facility's own policies.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Claude
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ware Memorial Care Center | 27.9 mi | — | 9 | 0 |
| Georgia Manor Nursing Home | 28.5 mi | — | 0 | 0 |
| Clarendon Nursing Home | 29.1 mi | — | 5 | 0 |
| Legacy Rehabilitation And Living | 29.6 mi | — | 2 | 0 |
| Heritage Convalescent Center | 31.3 mi | — | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.