Cycle 1
Health 2026-01-28 · Fire 2026-01-28
7 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (2 deficiencies)
6 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Pampa, TX
Avir at Pampa
5-star overall rating with 4-star inspections with 7 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
1504 W Kentucky Ave, Pampa, TX
(806) 665-5746
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
37
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Avir Health Group
Operator or chain grouping
Approved since
1992-06-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
90 facilities
Chain averages 2 overall / 2 health / 2 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.36
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.59
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.13
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.54
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.86
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.25
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
3.81
CMS adjusted total nurse staffing hours
Case-mix index
1.12
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
26%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
4,720
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
38.86
Composite VBP score used to determine payment impact.
Payment multiplier
0.9919
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Total nurse turnover
6.89
Baseline 100.00% · Performance 44.44% · Measure score 6.89 · Achievement 4.71 · Improvement 6.89
Adjusted total nurse staffing
0.88
Baseline 3.37 hours · Performance 3.33 hours · Measure score 0.88 · Achievement 0.88 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.63% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 51 · Observed rate 11.76% · Lower 95% interval 7.17% |
| Discharge to community | 48.65% |
50.57%
1.9 pts worse
|
No Different than the National Rate · Eligible stays 38 · Observed rate 42.11% · Lower 95% interval 33.66% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 22 · Denominator 22 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 22 |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 22 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays 24 · Observed rate Not Available · Lower 95% interval Not Available · Too few residents or stays to report publicly. |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 41 |
| Staff flu vaccination coverage | 62.22% |
42%
20.2 pts better
|
Numerator 28 · Denominator 45 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator 16 · Too few residents or stays to report publicly. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 2 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 9 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 14 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.7% |
3.3%
1.6 pts better
|
3.3%
1.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 3.7% · Q3 0.0% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
2.7%
1.8 pts worse
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 6.5% · Q2 0.0% · Q3 4.0% · Q4 6.7% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 0.9% |
3.3%
2.4 pts better
|
5.4%
4.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.0% · Q4 0.0% · 4Q avg 0.9% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 27.0% |
18.9%
8.1 pts worse
|
19.6%
7.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 25.8% · Q2 23.1% · Q3 28.0% · Q4 31.0% · 4Q avg 27.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 0.0% |
10.8%
10.8 pts better
|
16.7%
16.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 20.9% |
15.4%
5.5 pts worse
|
16.3%
4.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 20.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.0% |
16.1%
5.1 pts better
|
14.9%
3.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.2% · Q2 3.8% · Q3 8.0% · Q4 13.8% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.0% |
0.5%
0.5 pts worse
|
1.0%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 3.8% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 21.0% |
15.0%
6 pts worse
|
19.8%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 30.5% · Q2 10.7% · Q3 17.1% · Q4 24.7% · 4Q avg 21.0% |
| Percentage of long-stay residents with pressure ulcers | 3.4% |
4.2%
0.8 pts better
|
5.1%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.7% · Q2 0.0% · Q3 4.4% · Q4 0.0% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
89.7%
10.3 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
88.0%
12 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-10-30 · Fire 2024-10-30
6 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-09-13 · Fire 2023-09-13
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2026-01-28
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Not marked corrected
E · Potential for more than minimal harm
2026-01-28
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Not marked corrected
E · Potential for more than minimal harm
2026-01-28
K345 · Smoke Deficiencies
Fire Safety
Have approved installation, maintenance and testing program for fire alarm systems.
Not marked corrected
E · Potential for more than minimal harm
2026-01-28
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Not marked corrected
E · Potential for more than minimal harm
2026-01-28
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Not marked corrected
E · Potential for more than minimal harm
2026-01-28
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Not marked corrected
E · Potential for more than minimal harm
2023-09-13
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2023-09-14
D · Potential for more than minimal harm
2023-09-13
K511 · Services Deficiencies
Fire Safety
Have properly installed electrical wiring and gas equipment.
Corrected 2023-10-20
Inspection history
Recent health citations
E · Potential for more than minimal harm
2026-01-28
F761 · Pharmacy Service Deficiencies
Health
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.
Corrected 2026-02-13
E · Potential for more than minimal harm
2026-01-28
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2026-02-13
E · Potential for more than minimal harm
2026-01-28
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-28
F605 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-28
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2026-02-13
D · Potential for more than minimal harm
2026-01-28
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2026-02-13
D · Potential for more than minimal harm
2025-06-03
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2025-06-30
E · Potential for more than minimal harm
2025-02-05
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-04
E · Potential for more than minimal harm
2024-10-30
F565 · Resident Rights Deficiencies
Health
Honor the resident's right to organize and participate in resident/family groups in the facility.
Corrected 2024-12-15
E · Potential for more than minimal harm
2024-10-30
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-12-14
E · Potential for more than minimal harm
2024-10-30
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-14
D · Potential for more than minimal harm
2024-10-30
F558 · Resident Rights Deficiencies
Health
Reasonably accommodate the needs and preferences of each resident.
Corrected 2024-11-30
D · Potential for more than minimal harm
2024-10-30
F607 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Corrected 2024-12-14
E · Potential for more than minimal harm
2023-09-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2023-10-20
E · Potential for more than minimal harm
2023-09-13
F943 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.
Corrected 2023-10-20
D · Potential for more than minimal harm
2023-09-13
F660 · Resident Assessment and Care Planning Deficiencies
Health
Plan the resident's discharge to meet the resident's goals and needs.
Corrected 2023-10-20
F · Potential for more than minimal harm
2023-04-04
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2023-05-19
Penalties and ownership
What sits behind the stars
Ownership
Stratford Hospital District
5% Or Greater Direct Ownership Interest · Organization
Carlisle Taylor Whitworth 2020 Irrevocable Trust
5% Or Greater Mortgage Interest · Organization
Chumley, Richard
Corporate Director · Individual
Gary Scott Whitworth 2019 Irrevocable Trust
5% Or Greater Mortgage Interest · Organization
Leonard, Joshua
Operational/Managerial Control · Individual
Lqcp Management, LLC
5% Or Greater Mortgage Interest · Organization
Slp Coronado, LLC
Operational/Managerial Control · Organization
Wm 41 Pampa Re, LLC
5% Or Greater Mortgage Interest · Organization
Wm-Lqc Mm, LLC
5% Or Greater Mortgage Interest · Organization
Wt Holdings, LP
5% Or Greater Mortgage Interest · Organization
Nearby options
Other facilities in reach
#1
Pampa Nursing Center
Pampa, TX
4-star overall rating with 4-star inspections with $4,085 in total fines with 3 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Avir at Borger
Borger, TX
3-star overall rating with 2-star inspections with $54,797 in total fines with 12 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Caprock Nursing & Rehabilitation
Borger, TX
3-star overall rating with 2-star inspections with abuse icon flag with $10,145 in total fines with 9 recent health deficiencies
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