Kirkland Court Rehab: Hand Saw Immediate Jeopardy - TX
He was making fun with everyone in the common area about it. Showing off, in a way, that he could saw through the metal. The nurse walked to his side and asked him to put it down. He put it on the ground.
That was September 10, 2025, at Kirkland Court Health and Rehabilitation Center in Amarillo. Federal inspectors arrived the next day and, by the afternoon of September 12, had declared an Immediate Jeopardy, the most serious level of citation the government issues, reserved for situations where inspectors determine that a facility's failures have placed residents in immediate risk of serious harm or death.
Nobody could fully explain how the man, identified in the inspection report as Resident 3, got the saw. The maintenance office, staff said, was supposed to be locked.
The maintenance staffer, identified in the report only as MS, told inspectors on September 11 that he had heard about the incident. He said he did not know how Resident 3 obtained the saw, because he always locked the maintenance office when he left. Then he paused on that.
"I always lock the door behind me when I'm going out," he told inspectors. "If it happens to be I made a mistake, I have so much going on and I am always in a hurry, it is a possibility. But there is no excuse for that, and it will not happen again."
When inspectors asked him what could have happened, what the possible negative outcome was of a resident having access to a hand saw, he did not hedge.
"Somebody gets chopped up," he said. "He could hurt someone else or hurt himself."
The nurse who was present when Resident 3 picked up the saw, identified as LVN G, described the lead-up to the moment in detail. Resident 3 had been agitated that day, telling her his doctor had increased his Parkinson's medication and that he needed more of it. She told him she could not increase his dosage without an order. He became more upset. She called his doctor's office. The office said the medication was not to be increased. He became even more upset.
At some point during this back-and-forth, LVN G left Resident 3 at the nurses' station in his motorized wheelchair and went to help another resident. When she returned, the saw was already in his hands and he was already cutting.
She told inspectors what she thought could have happened. "Someone could have been cut due to Resident 3 having access to the hand saw."
After Resident 3 put the saw down, LVN G called the doctor for a medication order to help calm him. He was given Vistaril. It seemed to help.
The following day, September 11, an inspector observed Resident 3 wheeling himself through the front door of the facility after smoking in the courtyard. That same day, a registered nurse identified as RN C told inspectors she had been told on September 12 to keep a closer eye on Resident 3. The instruction came after the hand saw incident, not before.
Inspectors notified the administrator and the assistant director of nursing at 1:00 PM on September 12 that an Immediate Jeopardy had been identified. They provided Immediate Jeopardy templates and requested a Plan of Removal, the formal document a facility must produce to demonstrate it has identified the problem, corrected it, and put safeguards in place to prevent recurrence. The facility submitted its plan that evening. Inspectors accepted it at 8:12 PM.
What the plan revealed was that the hand saw incident was not the only reason inspectors had escalated to Immediate Jeopardy. The facility's own written plan described "a break in the facility's risk management process regarding abuse, neglect, and elopement," and specifically called out the need to prevent future incidents of elopement, particularly when residents were showing signs of wanting to leave. The plan stated that all residents considered high risk for elopement were at risk from the deficiency identified.
Elopement, in nursing home terms, means a resident leaving the facility without staff awareness or authorization, often a resident with dementia or cognitive impairment who may not be able to find their way back or recognize danger. The inspection report does not describe a separate elopement incident in the narrative provided, but the facility's own corrective plan treated the two issues together, as connected failures in how the facility managed resident safety.
The corrective measures the facility described were extensive on paper. Staff education on dementia care, wandering, and elopement protocols had been provided on August 21, before the September inspection, with a completion date listed as that same day. Charge nurses received additional training. All new staff were to be educated before their first shift. An audit of elopement assessments was completed August 21. Going forward, charge nurses would complete elopement risk assessments quarterly, on admission, and whenever a resident showed exit-seeking behavior. Residents who scored at risk or high risk would have a shoe emblem placed above their nameplate, a visual cue for staff.
The administrator and director of nursing would be responsible for ensuring that residents requiring one-on-one supervision received it, and for monitoring that it was being followed.
None of that was in place on the afternoon of September 10, when a man in a motorized wheelchair, agitated about his medication and left briefly unattended at the nurses' station, came back into view with a hand saw and cut through a piece of equipment that another resident depended on to walk.
The walker belonged to a woman. The inspection report does not say whether she was present when the cutting happened, whether she saw it, or what she was told about it afterward. It does not say whether her walker was replaced, or whether she was left without it while the facility sorted out what had happened. It does not say whether Resident 3's family was notified, or what his care plan said about supervision during periods of agitation.
What it says is that a nurse asked him to put the saw down, and he did. That the maintenance worker said there was no excuse for the door being unlocked. That the facility produced a plan and inspectors accepted it. That by the following afternoon, the Immediate Jeopardy designation had been formally declared, and the clock had started on whether the facility could demonstrate it had fixed what broke.
The woman whose walker was cut through is not named in the report. There is no follow-up on her condition, no note about whether she fell, no record of what she did in the hours or days after the bar of her walker was sawed partway through by a man who was showing off in the common area. She is a detail in someone else's incident, a piece of equipment damaged, a potential victim mentioned once and not again.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Kirkland Court Health and Rehabilitation Center from 2025-09-13 including all violations, facility responses, and corrective action plans.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
Kirkland Court Health and Rehabilitation Center in Amarillo, TX was cited for immediate jeopardy violations during a health inspection on September 13, 2025.
He was making fun with everyone in the common area about it.
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.