Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Medical Lodge during CMS and state inspections, most recent first.
A facility failed to include key therapies and devices in baseline care plans for four residents, including dialysis, central lines, a PICC line, and a life vest. The residents had significant medical needs such as ESRD on HD, osteomyelitis requiring IV ABT, and cardiac conditions requiring a life vest, yet their baseline care plans did not reflect these immediate care needs. Staff interviews confirmed these items should have been included in the baseline plans.
MDS assessments for two residents did not accurately reflect current tobacco use. One resident with COPD and shortness of breath was coded as not using tobacco even though his care plan, smoking evaluation, and activity assessment documented that he smoked and attended monitored smoke breaks. Another resident with impulsiveness, muscle weakness, and oxygen therapy was also coded as not using tobacco despite smoking evaluations, care plan entries, and direct observation showing staff assisting him with cigarettes and lighting them.
Missing Catheter Care in Care Plan: A resident with an indwelling catheter, bladder dysfunction, and BPH was found to have no catheter or catheter care included in the comprehensive care plan, even though the MDS identified the catheter and there was an active Foley change order. Staff interviews confirmed the omission, and the DON stated the facility relied on a baseline care plan policy rather than a specific comprehensive care plan policy.
A resident with COPD and other cardiopulmonary diagnoses was left alone during nebulizer treatments, with staff filling the mask and leaving the room while the resident self-administered the medication. Observations showed the resident in bed with the nebulizer in place and no nurse present, and interviews revealed inconsistent staff practice regarding monitoring, line-of-sight supervision, and vital signs before and after treatment. The DON, RN, and ADON described expectations for monitoring during respiratory treatments, but the resident reported staff were not present and vital signs were not taken after treatments.
The facility failed to store and distribute food according to professional standards, as observed during a kitchen inspection. Issues included improperly labeled and expired food items in the refrigerator, freezer, and dry pantry. An interview with the Dietary Manager confirmed the risk of food-borne illnesses from these practices. The facility's food storage policy lacked specific guidelines for expiration dates in the dry pantry.
A resident with chronic pulmonary disease and severe cognitive impairment was found to have their nasal cannula improperly stored on the floor behind their oxygen concentrator on multiple occasions. The facility lacked procedures for respiratory equipment care, and the DON confirmed the absence of policies on employee round responsibilities and respiratory tubing care, leading to the deficiency.
A facility failed to adhere to infection control protocols when a CNA did not wear a gown during wound care for a resident with a Stage 3 pressure ulcer, despite the requirement for Enhanced Barrier Precautions. The resident, with multiple health issues, required EBP due to the wound. Misunderstandings among staff regarding PPE requirements contributed to this deficiency.
A facility failed to ensure proper storage and labeling of medications for a resident, with multiple medications found unsecured on the bedside table and in the room. The resident's records lacked physician's orders for these medications, and the care plan did not address self-administration. Interviews revealed inconsistent practices and a lack of awareness regarding medication storage policies.
The facility failed to maintain a safe and sanitary environment, as a resident's used urinal was observed on his bedside table, touching a water cup. The DON provided in-service training to a CNA, stating that urinals should not be placed on bedside tables. The facility's policy aims to decrease infection risk and ensure compliance with regulations.
Baseline care plans omitted key treatment devices and therapies
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission that included instructions needed to provide effective and person-centered care for four residents. The deficiency involved Resident #40, Resident #76, Resident #86, and Resident #97, and the report states that these omissions could place newly admitted residents at risk of not receiving safe, effective, person-centered care. Resident #40 was admitted with diagnoses including end stage renal disease and dependence on renal dialysis. Her baseline care plan, initiated on 02/23/26, did not mention dialysis except in the diagnosis list at the bottom of the plan. Her orders included a liberalized renal diet, a dialysis communication form to be completed on dialysis days, the dialysis clinic contact information, and hemodialysis three times per week. Progress notes documented that she was taken to dialysis and that she stated she went three times a week. During observation, she had bruising on her left upper wrist and stated that was where she got dialysis. Resident #76 was admitted with chronic osteomyelitis with draining sinus of the right ankle and foot, type 2 diabetes mellitus with foot ulcer, and a non-pressure chronic ulcer of the right foot. His baseline care plan, initiated on 02/26/26, did not mention a central line or IV medication administration. His orders included central line dressing changes, central line care, central line flushing, IV tubing changes, enhanced barrier precautions for implanted IV access and wounds, and IV nafcillin every 4 hours. During observation, his right upper subclavian central line was seen on his chest with a dressing dated 03/10/26, and he stated staff changed the dressing every 3 days. Resident #86 was admitted with osteomyelitis, NSTEMI, acute on chronic systolic CHF, and presence of aortocoronary bypass graft. His baseline care plan, initiated on 02/03/26, did not mention a central line or a life vest. His MAR showed central line/midline flushing and IV cefazolin, and the order summary included an order for the resident to wear a life vest at all times except for showers. Resident #97 was admitted with COPD, heart failure, and cirrhosis of the liver. His baseline care plan did not mention a central line, although his orders included IV ceftriaxone and an order that a PICC may be inserted due to IV antibiotic therapy. During observation, staff stated he received IV antibiotics. Interviews with RN A, ADON B, and the DON confirmed that central lines, PICC lines, dialysis, and life vests should be included in baseline care plans, and the DON stated she did not know why they were omitted from the residents’ baseline care plans.
MDS assessments failed to reflect current tobacco use
Penalty
Summary
The facility failed to ensure the assessment accurately reflected resident status for two residents by coding them as not using tobacco when the record and observations showed they were current smokers. Resident #42 was admitted with diagnoses including COPD, muscle weakness, and shortness of breath. His admission MDS, completed 12/27/25, coded him as not using tobacco, even though his care plan identified a smoking-related injury risk, his Smoking Evaluation dated 12/23/25 documented that he smoked 6 times a day, and his Activity admission Evaluation dated 12/26/25 listed him as a current smoker who attended monitored smoke breaks. Resident #73 was admitted with diagnoses including impulsiveness, need for assistance with personal care, lack of coordination, and muscle weakness. His admission MDS completed 08/12/25 also coded him as not using tobacco. However, his care plan identified smoking-related injury risk and oxygen therapy, and Smoking Evaluations dated 05/21/25 and 08/14/25 documented that he smoked 6 times a day and then 5 times a day. During observation on 03/10/26, staff handed him a new cigarette and lit it for him after he placed a finished cigarette into a lidded ashcan. During interviews, RN A, ADON B, and the DON stated tobacco use should be included in comprehensive MDS assessments. The MDS LVN stated he was responsible for completing MDS assessments and acknowledged that Resident #42 should have been marked as using tobacco, saying he had missed it. He also stated he was not sure why Resident #73 was not coded as using tobacco and that he had a new partner working with him at the time of that assessment. The RAI Manual section on current tobacco use states to code yes if the resident or any other source indicates tobacco use during the look-back period.
Missing Catheter Care in Comprehensive Care Plan
Penalty
Summary
Failure to implement a comprehensive care plan for Resident #42 was identified when the facility did not include the resident’s indwelling catheter and catheter care needs in the care plan. Resident #42 was a [AGE]-year-old male with diagnoses including neuromuscular dysfunction of the bladder and benign prostatic hyperplasia. His admission MDS completed 12/27/25 indicated a BIMS score of 12, supervision/touch assistance with toileting hygiene, and that he had an indwelling catheter. The care plan created on 12/23/25 included urinary retention, but there was no care plan addressing the catheter or catheter care, despite an active order for monthly Foley catheter changes and reinsertion as needed for accidental removal, dislodgement, or obstruction of urine flow. During observation on 03/10/26, Resident #42 was seen in bed preparing to transfer to his wheelchair with a catheter bag on his bed containing dark urine. He stated he was having trouble with bleeding from his bladder and that the facility was keeping an eye on it, and he reported the facility did a good job taking care of his catheter needs. During interviews, the DON confirmed the resident had a catheter and that the care plan did not address it, the MDS LVN verified the resident was marked as having a catheter on the admission MDS and stated it should have been included in the care plan, and the nurse on duty stated catheter care should be covered in the care plan. The DON also stated the facility did not have a policy specific to comprehensive care plans and relied on the baseline care plan policy.
Inadequate Monitoring During Nebulizer Treatment
Penalty
Summary
The facility failed to ensure safe and appropriate respiratory care for a resident who required nebulizer treatment for COPD and related cardiopulmonary conditions. Resident #46 was a 67-year-old female with diagnoses including COPD, pleural effusion, pulmonary hypertension, NSTEMI, and heart failure. Her care plan directed staff to give aerosol or bronchodilator treatments as ordered and to monitor for difficulty breathing, acute respiratory insufficiency, and side effects or effectiveness of treatment. Her active orders included monitoring for shortness of breath when lying flat and albuterol nebulizer treatments every 6 hours as needed for shortness of breath. During interview and observation, the resident stated she often administered her own nebulizer treatments because staff were not present, and that staff would fill the nebulizer mask and leave the room. On 03/10/26, the resident was observed alone in her room with a nebulizer mask in place and medication visible in the mask while the medication cart remained outside the room and no nurse was present in the area. This condition continued across multiple observations over several minutes until LVN E and ADON C entered the room and asked whether the treatment was completed. LVN E stated she stood outside the door and monitored the resident during treatment, and ADON C stated staff were expected to remain outside the door and monitor the resident during the entire treatment. Further interviews showed inconsistent practice and lack of monitoring during treatments. The resident stated on another observation that she completed a breathing treatment on her own after the night-shift nurse left the medication in the mask, and she reported that nurses had never taken her vital signs after breathing treatments. RN A stated the facility policy was to remain within line of sight during breathing treatments and to take vital signs before and after treatment. The DON stated staff were expected to ensure treatments were administered correctly, check on residents before, during, and after treatment, and take vital signs before and after treatment. The facility policy also stated nursing staff would frequently monitor the resident based on clinical stability and document assessments, resident response, and equipment function.
Improper Food Storage Practices in Facility Kitchen
Penalty
Summary
The facility failed to adhere to professional standards for food service safety, as observed during a kitchen inspection. The inspection revealed multiple instances of improperly stored food items in the facility's refrigerator, freezer, and dry pantry. Specifically, the refrigerator contained a 2-quart bag of strawberries with an expired date, 15 sausage patties without a date opened and exposed to air, and cartons of chocolate and white milk without a date received. In the freezer, there were several items, including a 5-pound bag of frozen strawberries, a 2-pound bag of frozen green beans, and 80 count frozen hamburger patties, all without a date received and open to air. Additionally, the dry pantry contained a 1.57-pound bag of cream soup base with an expired date. An interview with the Dietary Manager confirmed the potential negative outcomes of serving improperly dated or expired foods, which could lead to food-borne illnesses among residents. The facility's policy for food storage was reviewed and found to lack specific guidelines for expiration dates or discard by dates for dry pantry items. The FDA Food Code was also referenced, highlighting the requirement for proper labeling of food items. These deficiencies in food storage practices could place residents at risk for food-borne illnesses and a diminished quality of life.
Improper Storage of Nasal Cannula for Resident on Oxygen Therapy
Penalty
Summary
The facility failed to provide proper respiratory care for a resident, identified as Resident #14, who required oxygen therapy due to chronic pulmonary disease. The resident's nasal cannula was repeatedly observed improperly stored on the floor behind the oxygen concentrator, with the nasal prongs facing upward. This improper storage was noted during multiple observations over several days, indicating a lack of adherence to professional standards of practice for respiratory care. Resident #14, a severely cognitively impaired male, required substantial assistance with activities of daily living and had an order for oxygen therapy as needed for shortness of breath. Despite this, the facility did not have procedures in place for the care of respiratory equipment, including the nasal cannula or tubing. The Director of Nursing (DON) confirmed that staff were expected to check on residents' equipment during rounds, but there was no policy on employee round responsibilities or respiratory tubing care, contributing to the deficiency.
Inadequate PPE Use During Wound Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of CNA A during wound care for a resident with a Stage 3 pressure ulcer. CNA A did not wear the appropriate personal protective equipment (PPE) as required by Enhanced Barrier Precautions (EBP), specifically failing to don a gown while assisting with the procedure. This oversight occurred despite the resident's care plan indicating the need for EBP due to the presence of a wound. The resident involved was an elderly female with multiple health issues, including metabolic encephalopathy, obesity, chronic kidney disease, and muscle weakness. Her clinical record indicated a moderately impaired cognitive function and a need for supervision or assistance with daily activities. The resident had a Stage 3 pressure ulcer on her right buttocks, which required wound care and the implementation of EBP to prevent infection and cross-contamination. Interviews with staff revealed a misunderstanding of the EBP requirements. CNA A believed that a gown was unnecessary since he did not directly touch the wound, while the Director of Nursing (DON) suggested that discretion could be used if there was no direct contact with the wound or catheter. However, the facility's policy clearly stated that gowns and gloves should be worn during high-contact activities, such as providing hygiene and changing briefs, regardless of MDRO colonization. This misinterpretation of the policy contributed to the deficiency in infection control practices.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for one resident. During an observation, three medications (Fluticasone nasal spray, Therea Tears eye drops, and Alaway eye drops) were found on the bedside table of a resident. The resident stated that she could administer the medications herself but had not used them that morning. A review of the resident's records revealed no physician's orders for these medications, and the resident's care plan did not include information about self-administration of medications. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) indicated a lack of awareness and inconsistent practices regarding the storage and administration of medications at the bedside. Further investigation revealed that the resident had additional medications in her room, including a stool softener, Biofreeze, Biotin, and Melatonin, which were not stored properly. The facility's policy on medication storage requires that medications for residents who do not self-administer be stored in a locked cabinet, accessible only to authorized personnel. The failure to adhere to this policy was evident, as medications were found unsecured in the resident's room. This deficiency could potentially place all residents at risk for adverse reactions due to improper medication storage and administration practices.
Infection Control Deficiency
Penalty
Summary
The facility failed to maintain a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for one resident. During initial rounds, a resident's used urinal was observed on his bedside table, touching a water cup that the resident was using. The resident confirmed that he had just used the urinal. The Director of Nursing (DON) was interviewed and observed giving an in-service training to a CNA, stating that urinals should not be placed on bedside tables. Later, the resident's empty, clean urinal was observed on the repositioning bar of his bed. The facility's Infection Prevention and Control program policy aims to decrease the risk of infection, identify and correct problems, ensure compliance with regulations, and promote resident rights and well-being while preventing the spread of infection.
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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 Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Windflower Health Center | 0.1 mi | ★★★★★ | 1 | 0 |
| Heritage Convalescent Center | 0.2 mi | ★★★★★ | 9 | 0 |
| Landmark Of Amarillo Rehabilitation And Nursing | 0.6 mi | ★★★★★ | 16 | 1 |
| Amarillo Center For Skilled Care | 0.8 mi | ★★★★★ | 8 | 0 |
| Ussery Roan Texas State Veterans Home | 1 mi | ★★★★★ | 0 | 0 |
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