Amarillo Center for Skilled Care

Inspectors wroteBased on interviews and record reviews the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there is a significant change in the resident's physical status and/or a need to alter treatment significantly for 1 (Resident #1) of 8 residents reviewed for notification. The facility failed to inform Resident #1's physician and family member immediately when a stage 3 pressure ulcer was noted on his tailbone the evening of 07/19/26. This failure could place residents at risk of not receiving timely, appropriate care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #1) of 8 residents reviewed for pressure ulcers. The facility failed to install an air mattress ordered as an option for Resident #1 on 06/26/26 until 07/20/26 when he was found to have a stage 3 pressure ulcer. This failure could place residents at risk of developing pressure ulcers and of not receiving accurate/necessary care/treatment. [...]

Inspectors wroteBased on interview and record review, the facility failed to consider the views of a resident group and act promptly upon the grievances of such groups concerning issues of resident care and life in the facility and demonstrate their response and rationale for such response for 3 of 4 months of Resident Council meetings reviewed in that: Feedback and follow-up to concerns expressed during Resident Council Meetings was not provided for December 2025, January 2026, and February 2026. This deficient practice had the potential to affect residents participating in Resident Council meetings and placed them at risk for decreased quality of life and unresolved grievances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 6 of 6 medication carts reviewed to meet the needs of each resident. The Controlled Drugs Count Record on 6 medication carts for shift-to-shift narcotic counts had multiple blanks which indicated that the narcotic count was not completed at shift change. The Glucometer Quality Control Log High/Low Controls were not tested every night. This failure could result in narcotics being misappropriated from the facility which could result in ineffective treatment resulting in exacerbation of residents' disease processed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen when they failed to: A. Ensure stored food was secured, dated and used or discarded before the expiration date. B. Ensure hairnets were worn by all staff while in the kitchen. These failures could place all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision to prevent accidents for 1 of 16 residents (Resident #60) reviewed for accidents and hazards. The facility allowed Resident #60 to possess large sharp scissors in her room despite facility policy prohibiting sharp objects in resident's rooms. The facility failed to ensure the sharps storage compartment on the 200 Hall Front Medication cart was secured. The lock was broken and the compartment contained used sharps. This failure could affect the residents at the facility by placing them at risk of injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided with such care consistent with professional standards of practice for 1 (Resident #85) of 22 residents reviewed for respiratory care. RN J started breathing treatment on Resident #85 and left the resident's room, so the resident was unsupervised. This failure could affect residents by placing them at risk for respiratory compromise by not receiving their full breathing treatment, and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure medication was labeled and stored in accordance with currently accepted professional principles for 1 of 6 medication carts reviewed for medication storage. The Hall 200 front medication cart had loose medication in a clear plastic drinking cup 3/4 full of unidentified medication. This failure could result in ineffective treatment resulting in exacerbation of residents' disease processes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (CNA A) of 4 staff observed for infection control. -CNA A did not perform hand hygiene properly while performing incontinent care. This deficient practice has the potential to place residents at risk for infections, tissue breakdown, and feelings of isolation related to poor hygiene.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical well-being for 4 of 6 staff (SNA A, SNA B, SNA C, SNA D) reviewed for nursing services. The facility failed to ensure the following: -SNA A failed to perform hand hygiene before, during, or after incontinent care for Resident #1. -SNA B failed to perform hand hygiene before assisting with incontinent care for Resident #1. -SNA C failed to perform hand hygiene before or after assisting with incontinent care for Resident #2. -SNA D failed to perform hand hygiene before, during, or after incontinent care for Resident #2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3 resident care areas (Resident #1, #2 and Resident #3) and 5 of 6 facility staff (SNA A, SNA B, SNA C, SNA D, and SNA F) reviewed for infection control. The facility failed to ensure that facility staff performed hand hygiene appropriately during incontinent care. This failure could place the residents at an increased risk for potentially exposing them to viral infections, secondary infections, tissue breakdown, communicable diseases and feelings of isolation related to poor hygiene.

Inspectors wroteBased on observation, interview, and record review; it was determined the facility failed to ensure each resident was provided privacy during personal care, for 1 of 3 residents reviewed for Resident rights (Resident #2). Facility failed to provide dignity and respect for Resident #2 by providing privacy during incontinent care. The facility's failure could place residents at risk of not being treated with respect, dignity, and care in a manner that protects and promotes the rights of the residents.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to treat each resident with respect, dignity, and care for each resident, in a manner and environment that promotes the maintenance or enhancement of his or her quality of life, while respecting each resident's individuality. The facility failed to protect and promote the rights of 3 of 8 residents (Residents #1, #2, and #3) reviewed for resident rights. The facility failed to ensure Resident #1 was served a meal with napkins, dinnerware and cutlery which were non-disposable. Resident #1 was served a meal with a Styrofoam plate and cup and plastic cutlery as a form a convenience for facility staff. The facility failed to ensure the full visual privacy of catheter bag contents for two residents (Residents #2 and #3) by using privacy covers. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure all food in the dry pantry and cold storage areas were properly sealed, labeled and dated. These failures could place residents at risk of residents at risk of food-borne illness and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one resident (Resident #171) of 18 residents observed for accident hazards. -Resident #171 had an oxygen bottle/cylinder left unsecured in her room. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, and feeling of isolation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 (Resident #4) of 4 residents reviewed for respiratory care. The facility failed to administer oxygen at the correct dose for Resident #4. This failure could affect all resident on oxygen therapy by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, and exacerbation of their condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #45 and Resident #221) of 18 residents reviewed for infection prevention and control. 1. The facility failed to keep Resident #45's nasal cannula off the floor. 2. The facility failed to keep Resident #221's catheter bag off the floor. These failures could place residents at risk of infections, secondary infections, tissue breakdown, and communicable diseases. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an alleged violation of injury of unknow origin immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation resulted in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for one (Resident #1) of 8 residents reviewed for injury of unknow origin. The facility failed to report that resident #1 had a fall on 2-27-2024 resulting in a right intertrochanteric fracture (right hip fracture) for 38 days after the fracture occurred. This failure could affect residents by resulting in a delay of identification of injuries and lack of timely follow-up on recommended interventions to prevent serious bodily harm, or lasting physical impairment.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that residents received treatment and care in accordance with the professional standards of practice and comprehensive person-centered care plan for 1 of 7 residents (Resident #1) reviewed for care provided. The facility failed to ensure Resident #1's surgical incision on his ankle was properly assessed and received physician ordered daily dressing changes. The facility failed to ensure a physician ordered wound vac, gently pulls fluid from a wound over time, was placed on Resident #1's surgical incision to help with healing. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/19/23 at 2:24 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 (Resident #20) of 17 residents. -Over flow medication cart left unlocked and unattended on Hall 300 -Medication discovered on bedside table for Resident #20 These failures could place all residents at risk for obtaining medications that could cause adverse reactions that could lead to death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communication diseases and infections for 1 (Resident #7) of 17 Residents in that: 1. LVN A did not perform hand hygiene during medication pass. 2. Observation during incontinent care for Resident #7 hand hygiene was not performed by NA B. These failures had the potential to affect all residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to bacterial or viral infections that could lead to the spread of communicable diseases.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of 3 (Resident #1, #2, and #3) of 7 residents reviewed for call lights. The facility failed to ensure call light system was within reach and able to use if desired for Resident #1, #2, and #3. This failure could place the residents at risk of not maintaining or decreasing the resident's independence and provide necessary assistance if needed.