Average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Amarillo Center For Skilled Care during CMS and state inspections, most recent first.
Resident Council minutes showed repeated concerns about Nutrition Services, including incorrect meal tickets and meals not matching orders, with no documentation of resolution. Residents reported ongoing problems and felt staff were not listening. The AD said she only documented the meetings and did not follow up, the SW said she never received the notes, and the ADM acknowledged responsibility for ensuring resident concerns were addressed.
The facility failed to ensure accurate pharmaceutical services by leaving multiple blanks on shift-to-shift narcotic count records across 6 medication carts, showing the controlled drug count was not completed at shift change. Staff stated both nurses were supposed to count and sign the narcotic sheet when changing shifts. The facility also failed to complete nightly glucometer QC testing, with logs showing inconsistent high/low control checks across multiple halls, despite policy requiring routine testing.
Kitchen food storage and hygiene deficiencies were observed when opened boxes of food were left unsecured and exposed to air, multiple pantry and spice items were found past their best-by dates or expired, and a staff member was seen in the kitchen without a hairnet. The DM stated all staff were expected to wear hairnets and that foods should be sealed and expired items discarded; facility policy also required hairnets at all times and opened food to be stored in closed, dated containers.
A resident with intact cognition and a fall risk care plan was repeatedly observed with large sharp scissors in her room, despite facility policy allowing only blunt edge scissors and prohibiting scissors or knives in resident rooms. The resident said staff knew about and allowed the scissors for opening packages, and CNA staff confirmed they were aware. Separately, the sharps compartment on the 200 Hall front med cart was found broken and unlocked with used sharps inside, and staff stated the lock was not functioning.
A resident with acute respiratory failure with hypoxia and COPD was left unsupervised when an RN started a nebulizer treatment and left the room, stating she usually does not stay because the treatment takes 10 to 15 minutes. The resident’s care plan and orders included aerosol/bronchodilator treatments and oxygen via nasal cannula, and the facility policy directed staff to work with the patient throughout the treatment until all medication has been nebulized.
A medication cart was found with loose, unidentified pills in a clear plastic cup on the cart. RN F said she did not know the medication was there, and the Corp RN identified the pills as docusate and stated some nurses pour pills into cups during med pass. The facility policy stated meds are administered when prepared and are not pre-poured.
A CNA failed to follow proper hand hygiene during incontinent care for a resident. The CNA cleaned the resident’s buttocks and rectal area, then proceeded to place a clean draw sheet and new brief without performing hand hygiene between the dirty and clean portions of care. In a later interview, the CNA admitted she should have washed her hands when moving from dirty to clean tasks and acknowledged possible cross-contamination. The Corp RN and DON stated their expectation that staff perform hand hygiene before starting care, when transitioning from dirty to clean care, and after completing care, consistent with facility training and perineal care policy requiring hand hygiene before and after glove use.
Four SNAs failed to perform proper hand hygiene and infection control practices during incontinent care for two residents, including not changing gloves or washing hands after contact with soiled materials and improper perineal care technique. Interviews revealed gaps in training and understanding of care procedures, and documentation of required training was missing for several staff members.
Staff failed to perform proper hand hygiene during incontinent care for multiple residents, including not washing hands before or after care, not changing gloves appropriately, and touching clean items after contact with soiled materials. Some staff demonstrated improper perineal care techniques and lacked understanding of infection control protocols, despite facility policies outlining correct procedures.
A resident was not provided privacy during incontinent care when staff failed to close the blinds and door, resulting in the resident being potentially exposed to people passing by the window. The resident, who was cognitively intact and dependent on staff for care, expressed discomfort and concern about being seen. Staff interviews revealed a lack of training and understanding regarding the importance of privacy, despite facility policies requiring it.
The facility failed to treat residents with dignity by serving a cognitively intact resident a meal on disposable dinnerware as a staff convenience, and by not ensuring privacy covers were used on catheter bags for two residents with significant medical needs, despite physician orders. Staff actions and lack of policy guidance contributed to these deficiencies in resident rights and privacy.
The facility's kitchen failed to meet food service safety standards, with numerous items in the dry pantry and cold storage not properly sealed, labeled, or dated. This included items like cream soup base, quick grits, and various cheeses, which were either past their best-by dates or open to air, posing potential health risks.
An unsecured oxygen bottle was found in a resident's room, who did not have orders for oxygen therapy, posing a potential accident hazard. Facility staff confirmed that oxygen bottles should be stored securely to prevent accidents, as per facility policy. The source of the unsecured bottle was undetermined, with speculation that it might have been placed by hospice staff or during admission.
A resident with chronic respiratory failure was observed receiving oxygen at 5L/min instead of the prescribed 3L/min, leading to a deficiency in respiratory care. The discrepancy was noted over two days until an LVN corrected the dose. The DON confirmed that not following the oxygen order is a medication error.
The facility failed to maintain an effective infection prevention and control program, as evidenced by a resident's nasal cannula being on the floor and another resident's catheter bag and tubing also on the floor. Staff interviews confirmed that these practices could lead to contamination and infection, highlighting deficiencies in the facility's infection control practices.
The facility failed to report a resident's fall resulting in a right hip fracture within the required timeframe. Despite the resident's severe cognitive impairment and poor short-term memory, the facility determined the fall was not an injury of unknown origin based on the resident's statement. This decision led to a delay in reporting the injury for 38 days, violating state regulations.
Resident Council Concerns About Meal Orders Were Not Addressed
Penalty
Summary
The facility failed to consider the views of the resident council and act promptly on grievances related to resident care and life in the facility. Record review of Resident Council minutes from 12/04/2025, 01/01/2026, and 02/06/2026 showed repeated concerns about Nutrition Services, specifically incorrect menu tickets and meals not matching what residents ordered, with no documentation showing that these concerns were resolved. The facility’s grievance policy stated that the resident has the right to organize and participate in resident groups and that the facility must consider the views of a resident or family group and act promptly upon grievances and recommendations. During an anonymous interview on 02/19/2026, 5 of 5 residents stated they had ongoing concerns about not receiving the correct meal according to their tickets and felt staff were not listening because nothing had been done. One resident reported that when she ordered an alternative meal, she sometimes did not receive it and instead received the original meal. The AD stated she took notes during meetings and gave them to the ADM or SW, but said she did not believe follow-up was her responsibility and did not know what actions were taken after the meetings. The SW stated she had not received the meeting notes, and the ADM stated it was the ADM’s responsibility to ensure residents’ concerns were addressed and followed through to resolution. The DM stated she was not aware of the dietary concerns and acknowledged residents should receive the meal they ordered and that meal tickets should be accurate.
Incomplete narcotic counts and missed glucometer QC testing
Penalty
Summary
The facility failed to provide pharmaceutical services to meet the needs of each resident by not ensuring accurate acquiring, receiving, dispensing, and administering of drugs and biologicals on 6 of 6 medication carts reviewed. During observation of the shift-to-shift narcotic count books, the Controlled Drugs-Count Record for February 2026 showed multiple blank signature lines on every cart reviewed, including Hall 100, Hall 200 front and back, Hall 300 front and back, and Hall 400, indicating the narcotic count was not completed at shift change. The observed narcotic count records showed 5 blanks on the Hall 100 sheet, 6 blanks on the Hall 200 back sheet, 2 blanks on the Hall 200 front sheet, 25 blanks on the Hall 300 front sheet, 12 blanks on the Hall 400 sheet, and 25 blanks on the Hall 300 back sheet. Staff interviews reflected that nurses were expected to count narcotics together at shift change and both sign the sheet, with one nurse stating the count must be correct before taking over the medication cart. The facility also failed to complete glucometer quality control testing every night. Review of the Glucometer Quality Control Log High/Low Controls for February 1st through 19th showed inconsistent testing across the halls, including Hall 100 checked 3 of 19 days, Hall 300 back 10 of 19 days, Hall 300 front 0 of 19 days, Hall 200 back 10 of 19 days, Hall 200 front 10 of 19 days, and Hall 400 1 of 19 days. Staff interviews confirmed that night shift was responsible for checking the glucometers, and the facility policy required routine quality control testing using high and low control solutions.
Kitchen Food Storage and Hygiene Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food under sanitary conditions in the kitchen. During observation of the walk-in freezer, opened boxes of peanut butter cookie dough, corn, and frozen biscuits were found open to air and unsecured. In the pantry, dented cans of [NAME] Chacherie creole seasoning were observed with a best if used by date of 10/2024, along with Smucker's plate syrup dated 9/30/25 and horseradish dated 7/20/25. On the kitchen shelving holding spices, sesame seeds were dated June 2025, cloves were dated September 2025, celery seeds were expired in January 2025, and thyme had a best by date listed as [DATE]. The same conditions remained present on a later observation with no corrections noted. The facility also failed to ensure hairnets were worn by all staff in the kitchen. During an observation and interview, [NAME] A was seen in the kitchen without a hair net covering his hair, and he stated he should have had a hairnet on while in the kitchen. The DM stated that all employees were expected to wear hairnets in the kitchen, that foods should be closed to air and securely sealed, and that expired foods should have been thrown out and not used. The DM also stated the dietician had trained her in the kitchen and she had trained the staff. Facility policy titled Dietary Food Services Personnel Policy and Procedures stated hairnets are worn at all times, and the Dry Storage and Supplies policy stated opened packages of food are stored in closed containers with tight covers and dated as to when opened.
Unsafe Sharp Objects and Broken Sharps Storage
Penalty
Summary
The facility failed to ensure the resident environment remained free of accident hazards and that residents received adequate supervision to prevent accidents for Resident #60. Resident #60 was an [AGE]-year-old female admitted with diagnoses including depression, anxiety disorder, weakness, and a personal history of thyroid cancer. Her admission MDS showed a BIMS of 14 out of 15, indicating intact cognition, and her care plan identified her as a fall risk with interventions for a safe environment. The facility admission packet stated that scissors or knives were not allowed in resident rooms and that only blunt edge scissors were permitted. Despite this, Resident #60 was observed multiple times with a pair of large cutting scissors with sharp edges in her room and on her bed or lap. She stated the scissors belonged to her and that she used them to open packages because she could no longer tear items open, and she stated staff were aware and had allowed her to keep them. CNA staff confirmed they knew she had the scissors and acknowledged that sharp scissors were against facility policy and could result in injury. In addition, the sharps storage compartment on the 200 Hall Front Medication Cart was observed unlocked and broken, with used sharps inside; staff stated the lock was not functioning and that the condition could cause needlestick injury. The DON and ADM confirmed staff were expected to follow facility policy regarding prohibited items and safety hazards.
Resident Left Unsupervised During Nebulizer Treatment
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for Resident #85 when RN J initiated a breathing treatment and then left the resident’s room, leaving the resident unsupervised during the treatment. Resident #85 was admitted with diagnoses including acute respiratory failure with hypoxia and COPD, and his MDS assessment documented shortness of breath or trouble breathing with exertion, at rest, and when lying flat. His care plan directed staff to give aerosol or bronchodilator treatments as ordered and to monitor and document side effects and effectiveness, and his order summary included oxygen via nasal cannula every shift and budesonide inhalation suspension every 6 hours. During observation, RN J provided new tubing and a mask, started the breathing treatment, and told the resident she would return in 10 to 15 minutes to check on him. In interview, RN J stated she usually did not stay in the room because the treatment takes 10 to 15 minutes to complete. The Administrator stated he was aware nurses needed to stay with residents when they are receiving breathing treatments, and the Corp RN stated she had spoken with the nurse and would start an in-service about the need for nurses to stay with residents during breathing treatments. The facility policy for aerosolized hand-held nebulizer treatments stated to encourage and work with the patient throughout the treatment and to continue treatment until all medication has been nebulized.
Unlabeled Medication Found in Medication Cart
Penalty
Summary
The facility failed to ensure medication was labeled and stored in accordance with currently accepted professional principles for 1 of 6 medication carts reviewed. During observation of the Hall 200 front medication cart with RN F present, a clear plastic drinking cup was found on the cart containing loose medication, about 3/4 full of unidentified pills. RN F stated the medication in the cup was Colace and said she did not know it was in her medication cart. During interview, the Corp RN identified the pills as docusate and stated there was a large bottle in the bottom drawer of the medication cart. The Corp RN also stated she had found that some nurses pour pills into cups to use during medication pass and then throw the pills out when finished. RN F later stated the medication in the plastic drinking cup was not given by her and that she disposed of it. The facility policy stated medications are administered at the time they are prepared and are not pre-poured.
Improper Hand Hygiene During Incontinent Care
Penalty
Summary
A deficiency occurred when CNA A failed to follow proper hand hygiene practices during incontinent care for a resident. During an observation, CNA A performed hand hygiene and then assisted the resident to roll onto her side. While wearing gloves, CNA A used wipes to clean the resident’s left buttocks, right buttocks, and rectal area. Without performing hand hygiene between dirty and clean tasks, CNA A then placed a clean draw sheet and a new brief under the resident. After this, CNA A removed her gloves, washed her hands, donned new gloves, rolled the resident onto her back, and secured the new brief. In a subsequent interview, CNA A acknowledged that when moving from the dirty portion of care to the clean portion, she should have washed her hands and that she was “dirty” after wiping the resident, stating she probably cross-contaminated. CNA A reported she had been trained in hand hygiene by the former DON. In a group interview, the Corp RN stated she expected staff to perform hand hygiene before beginning incontinent care, when moving from any dirty to clean portion of care, and upon completion of care, to prevent cross contamination. The DON agreed and added that he expected staff to use ABHR before entering a resident’s room. Training records showed CNA A had received hand hygiene education, and facility policy on perineal care required hand hygiene before and after glove use.
Failure to Ensure Nursing Staff Competency in Infection Control During Incontinent Care
Penalty
Summary
The facility failed to ensure that nursing staff, specifically student nurse aides (SNAs), possessed the appropriate competencies and skill sets to provide safe and effective care for residents. Observations revealed that four SNAs did not perform proper hand hygiene before, during, or after providing incontinent care to two residents. Additionally, one SNA wiped back to front during perineal care, and clean briefs were handled without changing gloves or performing hand hygiene after contact with soiled materials. These actions were directly observed during care activities, and staff were seen touching residents' clothing, bedding, and personal items without appropriate infection control measures. Interviews with the involved SNAs indicated a lack of understanding regarding the negative outcomes of improper hand hygiene, and one SNA reported not having been taught how to perform perineal care. Documentation of training for three SNAs could not be located, and the DON confirmed that orientation and clinical training were required but could not provide evidence for all staff. Facility policy required that SNAs only perform care for which they had received training, but this was not consistently followed or documented.
Failure to Perform Hand Hygiene During Incontinent Care
Penalty
Summary
Facility staff failed to adhere to established infection prevention and control protocols during incontinent care for three residents. Observations revealed that staff did not perform hand hygiene before starting care, after cleaning soiled areas, or after removing gloves. Staff were also seen touching clean briefs, residents' clothing, bedding, and personal items without changing gloves or performing hand hygiene. In one instance, a staff member used a single wipe multiple times and wiped from back to front, contrary to policy. Additionally, a clean brief was placed on a resident while the dirty brief was still in place, resulting in contact between the clean and soiled briefs. Interviews with staff indicated a lack of understanding regarding the negative outcomes of not performing hand hygiene, with some staff unable to articulate the risks or proper procedures. Record review confirmed that facility policies require hand hygiene before and after resident care, after glove removal, and specify correct perineal care techniques. Despite these policies, staff actions did not align with the documented procedures, leading to the identified deficiency.
Failure to Provide Privacy During Incontinent Care
Penalty
Summary
Staff failed to provide privacy for a female resident during incontinent care, as observed when two staff members did not close the blinds or the door to the resident's room. During this time, an unidentified person walked by the resident's bedroom window twice, potentially exposing the resident. The resident, who was cognitively intact and required significant assistance with most activities of daily living, expressed that she expected staff to close the blinds and door during care and did not want to be seen naked by people passing by, especially men who frequently took out trash and laundry near her window. Interviews with the staff involved revealed that one staff member was trained to leave the blinds open during the day, even during personal care, and could not identify any negative outcomes from not providing privacy. Another staff member stated she had not been trained on how to perform incontinent care and also could not identify negative outcomes. The facility's policies on resident rights and perineal care both require providing privacy and modesty by closing doors and/or curtains during care. The Director of Nursing acknowledged that not providing privacy could lead to embarrassment and a lack of dignity for the resident.
Failure to Honor Resident Rights and Dignity
Penalty
Summary
The facility failed to treat residents with respect and dignity, resulting in multiple deficiencies related to resident rights. One cognitively intact female resident with mild cognitive impairment and major depressive disorder was served a meal on a Styrofoam plate with plastic utensils, rather than regular dinnerware, after a CNA unilaterally decided to request disposable items for her. This decision was made after the resident, unable to reach her call light due to hip pain, used her knife to tap on her plate to summon assistance. The CNA, without consulting the charge nurse, documented the request for disposable dinnerware on the resident's dining slip, which led to the resident feeling embarrassed when served her next meal in this manner. Additionally, the facility failed to ensure the visual privacy of catheter bag contents for two female residents with significant medical conditions, including severe cognitive impairment and end-of-life care. Both residents had physician orders requiring the use of privacy covers on their catheter bags while in bed or in a wheelchair. Observations revealed that neither resident had privacy covers in place, making the contents of their catheter bags visible to others. In one case, the catheter bag was visible from the hallway when the resident's door was open, and in the other, the bag was exposed while the resident was at the nurse's charting station. Interviews with staff indicated a lack of awareness and follow-through regarding the use of privacy covers, with one CNA stating he was unsure if the resident minded the lack of a cover and another resident's representative reporting unsuccessful attempts to obtain a privacy cover from staff. The facility's policy on resident rights did not include specific guidance on the use of regular dinnerware or privacy covers for catheter bags.
Food Storage and Labeling Deficiencies in Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety in their kitchen, as observed during a survey. Specifically, the facility did not ensure that all food items in the dry pantry and cold storage areas were properly sealed, labeled, and dated. This included various food items such as cream soup base, quick grits, elbow macaroni, pepper gravy mix, creamy wheat cereal, English cucumbers, hot dogs, lime juice, sausage links, Queso Cotija cheese, feta cheese, and scrambled eggs. Many of these items were either past their best-by dates, had no dates, or were open to air, which could potentially compromise their safety and quality. During an interview, the Dietary Manager acknowledged the risks associated with consuming unlabeled and undated foods, including the possibility of residents becoming ill from expired foods and the deterioration of food quality. The manager confirmed that the kitchen staff had not been following proper food storage protocols, which require resealing, labeling, and dating all products, using items within their use-by dates, and ensuring airtight storage. The lack of adherence to these protocols was evident in the findings from the kitchen inspection.
Unsecured Oxygen Bottle Poses Accident Hazard
Penalty
Summary
The facility failed to ensure that the environment was free from accident hazards and that residents received adequate supervision to prevent accidents. Specifically, an unsecured oxygen bottle was found in the room of a resident who did not have orders for oxygen therapy. The resident, who had been admitted to the facility six days prior, was unaware of the oxygen bottle's presence and did not know who placed it there. The unsecured oxygen bottle was observed lying at the foot of an unoccupied bed in the resident's room, posing a potential risk for accidents. Interviews with facility staff, including a CNA, an LVN, and the DON, confirmed that oxygen bottles should be stored securely to prevent accidents. The staff members acknowledged that an unsecured oxygen bottle could fall and potentially cause injury. The facility's policy on the safe handling of compressed gas requires that all tanks and cylinders be stored in a secure manner, either in a cylinder cart or chained in a secure storage area. Despite this policy, the source of the unsecured oxygen bottle in the resident's room could not be determined, with the DON speculating that it might have been placed there by hospice staff or during the resident's admission.
Failure to Administer Correct Oxygen Dose
Penalty
Summary
The facility failed to administer oxygen at the correct dose for a resident, leading to a deficiency in providing safe and appropriate respiratory care. The resident, a female with chronic respiratory failure and hypoxia, was observed receiving oxygen at 5L/min via nasal cannula, despite the physician's order specifying 3L/min. This discrepancy was noted during multiple observations over two days, where the resident was consistently receiving a higher oxygen dose than prescribed. The issue was identified when an LVN checked the resident's oxygen level and realized it was set too high. The LVN confirmed the correct order from the resident's chart and adjusted the oxygen level accordingly. The Director of Nursing (DON) emphasized the importance of following physician orders and acknowledged that not adhering to the prescribed oxygen dose constitutes a medication error. The facility's policy on oxygen administration aims to ensure safe and effective delivery of prescribed oxygen, which was not adhered to in this instance.
Infection Control Deficiencies in Oxygen and Catheter Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by two specific incidents involving residents. Resident #45, a female with Alzheimer's, heart failure, and major depressive disorder, was observed with her nasal cannula on the floor, which was discolored and in direct contact with the floor. Despite having orders for oxygen therapy, her care plan did not mention oxygen use, and she stated she did not need or wear oxygen. Interviews with staff, including an LVN and the DON, confirmed that nasal cannulas should be stored in a plastic bag off the floor to prevent contamination and infection. In another incident, Resident #221, a male with a history of surgical aftercare and multiple cancers, was observed with his catheter bag and tubing on the floor. He reported not being informed that this was inappropriate. The facility's policy on catheter care explicitly states that tubing and drainage bags should be kept off the floor. Interviews with CNAs and the DON highlighted the risk of infection and other negative outcomes from catheter bags being on the floor. However, the ADON incorrectly stated that there was no negative outcome from a catheter bag on the floor, contradicting other staff members. The facility's infection control plan and policies on catheter care and oxygen administration were reviewed, revealing that the oxygen administration policy did not address tubing storage or infection control. These deficiencies in infection prevention and control practices could place residents at risk of infections and other complications, as noted by the surveyors.
Failure to Report Injury of Unknown Origin
Penalty
Summary
The facility failed to report an alleged violation of injury of unknown origin within the required timeframe for a resident who experienced a fall resulting in a right intertrochanteric fracture. The incident occurred on 2-27-2024, but the facility did not report the injury until 38 days later. The resident, who was severely cognitively impaired with a BIMS score of 4, was found on the floor by a CNA and assessed by an LVN. Despite the resident's poor short-term memory and inability to recall events, the facility determined that the fall was not an injury of unknown origin based on the resident's statement about not wearing socks and falling while returning from the bathroom. Interviews with staff and family members revealed that the resident had a history of poor short-term memory and often became confused. The MDS Coordinator and Social Worker both confirmed that the resident's cognitive impairment would likely prevent her from accurately recalling the events leading to her fall. Despite this, the facility's Administrator reported that the incident was not considered an injury of unknown origin and therefore was not reported as required by state law. The facility's policy on abuse and neglect requires that all allegations of abuse, neglect, exploitation, mistreatment, misappropriation of resident property, and injury of unknown origin be reported to the facility administrator, who must then report to the state agency within 2 hours if the allegations involve abuse or result in serious bodily harm. The failure to report the resident's fall and subsequent fracture in a timely manner was a clear violation of this policy and state regulations.
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Illustrative
What surveyors actually found near you
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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.
Illustrative
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Illustrative
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Nursing homes near Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Kirkland Court Health And Rehabilitation Center | 0.3 mi | ★★★★★ | 8 | 3 |
| Heritage Convalescent Center | 0.7 mi | ★★★★★ | 9 | 0 |
| Windflower Health Center | 0.8 mi | ★★★★★ | 1 | 0 |
| Amarillo Medical Lodge | 0.8 mi | ★★★★★ | 4 | 0 |
| Five Points Nursing And Rehabilitation | 1.2 mi | ★★★★★ | 7 | 1 |
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