Legacy Rehab: Resident Got Wrong Meds for 24 Days - TX
The medications included antidepressants mirtazapine and escitalopram that Resident #1 had been taking before entering the hospital. Federal inspectors found that Legacy Rehabilitation and Living staff failed to properly review and implement hospital discharge orders when the resident returned to the facility.
Nurse Practitioner A discovered the error but waited to notify facility staff. She explained the delay by saying she was "behind in her charting and was playing catch up from her vacation."
When pressed about the potential harm, NP A dismissed the significance. "I did not think Resident #1 would have been negatively impacted by taking the discontinued medications for 24 days because it was just a transcription error," she told inspectors.
She couldn't explain why the hospital discontinued the medications. "I dug and dug to try to find out why they discontinued them. I could not find the reason the medications were discontinued."
Other nursing staff disagreed with her assessment of the risks.
"A resident could be negatively impacted by taking medications that were supposed to be discontinued," said LVN C during interviews. "I mean surely a doctor said discontinue this for a reason."
The facility's Director of Nursing echoed those concerns. "A resident could be negatively impacted by receiving medications that were supposed to be discontinued. The negative impact would depend on the medication."
RN D was more direct about the dangers. "If they no longer need it and it was discontinued at the hospital it can put the patient at risk."
The DON revealed broader staffing problems that may have contributed to the medication error. She had specifically requested a different nurse practitioner than NP A "due to concerns about NP A not getting her charting into the EHR timely."
The oversight failures extended beyond the nurse practitioner. The Assistant Director of Nursing who entered the original admission orders had been demoted to floor nurse. The DON explained she "demoted ADON to a floor nurse when it became evident she did not have the necessary skills to be an ADON."
During interviews, the former ADON claimed she barely remembered working at the facility. "She only worked for the facility for a short time, and she entered admission orders for one, maybe two residents the whole time I was there," according to her statement to inspectors.
She described a system where multiple people were supposed to check her work. "She had an admission checklist and when she was finished the other ADON, DON, or MDS RN would look over her work and sign off on it to indicate it was correct."
That system apparently failed.
Resident #1's family member confirmed receiving a brief call from NP A about the medication error. "It was a short conversation, she didn't go into it," the family member told inspectors. The call mentioned that "four medications were not discontinued as they were supposed to have been."
Facility policies required nurses to review transfer orders for psychotropic medications on admission and document any information in the resident's clinical record. The policy stated that "drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs."
However, inspectors found no facility policy addressing how to transcribe orders from hospitals into the facility's electronic health record system.
When inspectors requested the facility's unnecessary medication policy, none was provided.
The case highlights the critical transition period when residents move between hospitals and nursing homes. Medication reconciliation errors during these transfers can expose vulnerable residents to continued treatment they no longer need or medications that could interact dangerously with new prescriptions.
For 24 days, Resident #1 continued taking medications that hospital physicians had determined should be stopped. The nurse practitioner's vacation schedule and charting backlog became more important than ensuring accurate medication orders.
The facility's response revealed a pattern of staffing instability and inadequate oversight that allowed the error to persist for nearly a month before anyone noticed the discrepancy between hospital discharge orders and ongoing treatment.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Legacy Rehabilitation and Living from 2025-09-09 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 19, 2026 · Our methodology
Legacy Rehabilitation and Living in Amarillo, TX was cited for violations during a health inspection on September 9, 2025.
The medications included antidepressants mirtazapine and escitalopram that Resident #1 had been taking before entering the hospital.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.