Palo Duro Nursing Home

Inspection findings

1. Aug 20, 2025 Health · 8 findings
   • Not serious Scope/severity D

     F0550 Resident Rights Deficiencies

     Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

     Corrected Sep 19, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Sep 19, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0679 Quality of Life and Care Deficiencies

     Provide activities to meet all resident's needs.

     Corrected Sep 19, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0699 Quality of Life and Care Deficiencies

     Provide care or services that was trauma informed and/or culturally competent.

     Corrected Sep 19, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0727 Nursing and Physician Services Deficiencies

     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 Sep 19, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0839 Administration Deficiencies

     Employ staff that are licensed, certified, or registered in accordance with state laws.

     Corrected Sep 19, 2025 · CMS health inspection

   • Not serious Scope/severity D

     K0353 Smoke Deficiencies

     Inspect, test, and maintain automatic sprinkler systems.

     Corrected Sep 19, 2025 · CMS fire safety

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     CMS fire safety

2. Jul 15, 2025 Health · 1 finding
   • Not serious Scope/severity E Complaint

     F0940 Administration Deficiencies

     Develop, implement, and/or maintain an effective training program for all new and existing staff members.

     Corrected Aug 8, 2025 · CMS health inspection

3. Jul 30, 2024 Health · 7 findings
   • Not serious Scope/severity E

     F0638 Resident Assessment and Care Planning Deficiencies

     Assure that each resident’s assessment is updated at least once every 3 months.

     Corrected Aug 30, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0644 Resident Assessment and Care Planning Deficiencies

     Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

     Corrected Aug 30, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Aug 30, 2024 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Aug 30, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0842 Resident Assessment and Care Planning Deficiencies

     Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

     Corrected Aug 30, 2024 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Aug 30, 2024 · CMS health inspection

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Aug 30, 2024 · CMS fire safety

4. Nov 20, 2023 Health · 1 finding
   • Not serious Scope/severity D Complaint

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Dec 20, 2023 · CMS health inspection

5. Jun 1, 2023 Health · 8 findings
   • Not serious Scope/severity E

     F0578 Resident Rights Deficiencies

     Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

     Corrected Jul 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Jul 1, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Jul 1, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Jul 1, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Jul 1, 2023 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Jul 1, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Jul 1, 2023 · CMS health inspection

   • Not serious Scope/severity C

     K0521 Services Deficiencies

     Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

     Corrected Jul 31, 2023 · CMS fire safety

Owners and managers (as published by CMS)

• GLEISNER, STONEY — adp of the snf, NOT APPLICABLE, since 10/01/2025
• GLEISNER, STONEY — operational/managerial control, NOT APPLICABLE, since 10/01/2025
• HOLCOMB, HOLLY — corporate officer, NOT APPLICABLE, since 05/29/2021
• MISTRETTA, CASSANDRA — operational/managerial control, NOT APPLICABLE, since 04/01/2025
• PFEIFER, MARY — operational/managerial control, NOT APPLICABLE, since 04/01/2025
• STEWART, RANDY — operational/managerial control, NOT APPLICABLE, since 10/01/2010
• STEWART, RANDY — adp of the snf, NOT APPLICABLE, since 10/01/2010
• STRATTON, EMILEE — corporate officer, NOT APPLICABLE, since 03/18/2018
• CLAUDETX LLC — adp of the snf, NOT APPLICABLE, since 10/21/2025
• CLAUDETX LLC — operational/managerial control, NOT APPLICABLE, since 04/01/2025