Landmark Of Amarillo Rehabilitation And Nursing
Landmark of Amarillo Rehabilitation and Nursing in Amarillo, TX — inspection on March 26, 2026.
Found 9 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
his or her rights.
observation, interview, and record review, the facility failed to ensure all residents had a right to a
facility failed to: Ensure Resident #56 was treated with respect, dignity and consideration when she failed to receive her noon meal at the same time as her table mates.
This failure could place residents at risk of feeling neglected or ignored and could negatively impact residents' quality of life.
Findings included:Resident #56 was a 95-y o female admitted to the facility on [DATE] with diagnoses of dementia (a decline in mental ability), diabetes ( a condition causing high blood sugar due to insufficient insulin production), dysphagia- oropharyngeal type ( difficulty initiating a swallow, moving food from the mouth to the throat ), Vitamin B deficiency ( ( when the body lacks sufficient B vitamins needed for metabolism, red blood cell production and nerve function), Vitamin D vitamin deficiency causing weak or brittle bones, muscle weakness and chronic fatigue) and Vitamin D deficiency ( when the body lacks sufficient Vitamin D causing weak or brittle bones, muscle weakness and chronic fatigue). A Care Plan dated 1/1/26 documented resident was independent in most ADLs, wanders and is at risk for falls. A Quarterly MDS dated [DATE] documented a BIMS score of 5 out of 15 which indicates cognition is severely impaired.
The MDS documented Resident #56 usually understood what was said to her and was usually understood.
The MDS documented Resident # 56 was 57 inches tall and weighed 108 pounds. Resident #56 had not had any weight loss in the past 6 months. In an observation on 3/24/26 at 12:00 pm, Resident #56 did not receive her food at the same time as her tablemates.
Further observation revealed Resident #56 sat at the table at the same time the other 2 tablemates were seated.
The other 2 tablemates received their trays and began eating.
Resident # 56 was not served the lunch meal until after the 2 tablemates and 2 other tables of 4 residents each had gotten their food. In an interview on 3/25/26 at 2:50 pm Resident # 56 stated she was in the dining room and the residents at her table all had their food except her.
She stated she felt left out and had been wondering why she did not get her food.
She stated she thought she might not get to eat.In an interview on 3/26/26 at 10:15 am, the DM stated she had not been aware Resident #56 had not received her tray at the same time as the rest of the residents at her table.
The DM stated all residents at a table should be served at the same time.
She stated the consequences of not serving all residents at the table at the same time could be residents feeling left out of the group.
Record review of the facility's policy titled, ' Nursing Responsibilities at Meal Service ' dated 2012, documented: A tray sequence is used in dining rooms so all residents at a table are served at the same time.
Record review of the facility's policy titled, ' Resident Rights documented Residents have the right to be treated with dignity, courtesy, consideration and respect.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
455675 03/26/2026
Landmark of Amarillo Rehabilitation and Nursing Ce 5601 Plum Creek Dr Amarillo, TX 79124
existence.The facility must treat each resident with respect and dignity and care for each resident in
455675 03/26/2026
Landmark of Amarillo Rehabilitation and Nursing Ce 5601 Plum Creek Dr Amarillo, TX 79124
resident's status for 2 (Resident #18 and Resident #71) of 18 residents reviewed for accuracy of
not have a bipolar diagnosis.This failure could place residents at risk of receiving unnecessary care/medication or not receiving necessary care/medication.Findings Included:
Record review of Resident #18's admission record dated 03/25/26 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, Parkinson's disease (chronic and progressive movement disorder that initially causes tremors in one hand and stiffness or slowing of movement), dementia (a group of thinking and social symptoms that interferes with daily functioning), and anxiety disorder (a group of mental health conditions characterized by excessive and persistent worry, fear, and nervousness that can significantly interfere with daily life).
The admission record did not reveal a diagnosis of bipolar disorder.
Record review of Resident #18's significant change MDS assessment completed on 01/25/26 revealed a BIMS of 6 which indicated severely impaired cognition.
Section I Active Diagnoses in the Last 7 Days revealed he had a diagnosis of bipolar disorder.
Record review of Resident #18's care plan completed on 01/25/26 revealed no mention of bipolar disorder.
Record review of Resident #18's diagnosis report dated 03/25/26 revealed no mention of bipolar disorder.
During an interview on 03/26/26 at 08:58 AM RN D stated MDS RN was responsible for completing MDS assessments.
She stated an inaccurate MDS assessment could negatively affect a resident because a lot of times the doctors use it and nurses use it and it can give you an incorrect clinical depiction of your resident.
They might not be getting the care they need.
During an interview on 03/26/26 at 09:03 AM ADON stated MDS RN was responsible for completing MDS assessments.
She stated if an MDS assessment was inaccurate some level of care (for the resident) might be missed.
During an interview on 03/26/26 at 09:05 AM DON stated MDS RN was responsible for completing MDS assessments.
She stated if an MDS assessment was inaccurate it would cause the care plan to be inaccurate and residents might not receive needed care.
During an interview on 03/26/26 at 09:09 AM ADM stated MDS RN was responsible for completing MDS assessments.
She stated if an MDS assessment was inaccurate residents might not receive care or services they needed.
During an interview on 03/26/26 at 9:10 AM CN stated MDS RN was responsible for completing MDS assessments.
She stated if an MDS assessment was inaccurate residents might not receive the care they needed.
During an interview on 03/26/26 at 09:17 AM MDS RN stated she was responsible for completing MDS assessments.
She stated she used the RAI manual as her policy for completing MDS assessments.
The MDS RN stated she was not sure why Resident #18 was coded as having bipolar disorder. MDS RN stated an inaccurate MDS assessment could affect facility funding.
She stated she did not believe an inaccurate MDS assessment would negatively affect resident care because the facility would treat the resident regardless of funding.
Record review of the facility provided policy titled, Documentation, revealed the following in part.
Goal:1.
The facility will maintain complete and accurate documentation for each resident on all appropriate clinical record sheets.
Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 dated October 2025 revealed the following: . SECTION I: ACTIVE DIAGNOSES Intent: The items in this section are intended to code diseases that have a direct relationship to the resident's current functional status, cognitive status, mood, or behavior status, medical treatments, nursing monitoring, or risk of death.
One of the important functions of the MDS assessment is to generate an updated, accurate picture of the resident's current health status.
Once a diagnosis is identified, it must be determined if the diagnosis is active.
Active diagnoses are diagnoses that have a direct relationship to the resident's current functional, cognitive, or mood or behavior status, medical treatments, nursing monitoring, or risk of death during the 7-day look-back period.
455675 03/26/2026
Landmark of Amarillo Rehabilitation and Nursing Ce 5601 Plum Creek Dr Amarillo, TX 79124
following a qualifying diagnosis could negatively impact resident care.
She stated, We could not
She stated she did not think a resident's care would be negatively impacted if they did not receive a
of whether or not they have the positive on the PASRR they still receive the services in the building.
MDS RN stated without a new PASRR screening the residents would not be offered the opportunity to get outside services.
During an interview on 03/26/26 at 09:41 AM PC stated residents might not get needed care if they do not receive a new PASRR screening following a qualifying diagnosis.
She stated the facility could enter a change of condition into the system rather than performing a new PASRR screening and that would alert her to call and find out what the change was and if it qualified the resident for services or not.
Record review of an undated facility policy titled Form 1012 Policy and Procedure with Instructions revealed the following: .
Form 1012 assists nursing facilities (NF) in determining whether a resident with a negative Preadmission Screening and Resident Review (PASRR) Level 1 (PL1) Screening form . needs further evaluation for Mental Illness (MI).
When to Prepare The NF completes Form 1012 following: . An individual's diagnosis is changed.
Depression, unless diagnosed as major depressive disorder in the medical record by the physician is not considered a mental illness.
Record review of facility policy titled, PASRR Level 1 Screen Policy and Procedure and dated 03/06/19 revealed no information on what to do if an individual receives a qualifying diagnosis after admission.
455675 03/26/2026
Landmark of Amarillo Rehabilitation and Nursing Ce 5601 Plum Creek Dr Amarillo, TX 79124
coded.
Record review of an undated facility policy titled Form 1012 Policy and Procedure with
titled, PASRR Level 1 Screen Policy and Procedure and dated 03/06/19 revealed the following: .
RE on day of admission or prior to admission. 3.
The Facility will review the PL1 Screening Form for completion and correctness prior to admission . review each item on the PL1 to ensure accuracy and prevent a regulatory problem. 7.
The facility will maintain PL1 Best Practices as follows: .
Review the PL1 form for completion and correctness before admission.
455675 03/26/2026
Landmark of Amarillo Rehabilitation and Nursing Ce 5601 Plum Creek Dr Amarillo, TX 79124
prescribed oxygen.
Record review of the facility provided policy titled, Documentation, not dated,
455675 03/26/2026
Landmark of Amarillo Rehabilitation and Nursing Ce 5601 Plum Creek Dr Amarillo, TX 79124
She stated foods should be pureed first with no added liquid and then small, measured amounts of
before bread or gravy was used to ensure flavors were as close as possible to the food cooked.
She
dissatisfaction.
She stated residents could also have poor meal experiences.
Record
Review of the facility recipe from Menu Manager titled Pureed [NAME] Beans documented:Measure number of servings.
Drain well to minimize the use of thickener to obtain appropriate consistency.
Puree.
Add liquid if needed.
Record
Review of the facility recipe from Menu Manager titled Pureed BBQ Chicken documented:Measure number of servings.
Drain well to minimize the use of thickener to obtain appropriate consistency.
Puree.
Add liquid if needed.
Record
Review of the facility recipe from Menu Manager titled Honey Kissed Rolls documented:Measure number of servings.
Drain well to minimize the use of thickener to obtain appropriate consistency.
Puree.
Add liquid if needed.
Record review of the facility's policy titled, ' Menus ' dated 2012, documented:Menus are planned to meet the Recommended Dietary Allowances of the Food and Nutrition al Board.
The menus will be prepared as written using standardized recipes.
Record review of the facility's policy titled, ' Resident Menus ' dated 2012, documented: The menus will be prepared as written using standardized recipes.
The DM and cook are trained and responsible for the preparation and service of therapeutic diets as prescribed.
455675 03/26/2026
Landmark of Amarillo Rehabilitation and Nursing Ce 5601 Plum Creek Dr Amarillo, TX 79124
Findings included: In an observation on 3/24/26 at 8:15 am, a sign posted on the main door of the kitchen stated, A hairnet must be worn at all times in the kitchen. Do not enter without putting on a hairnet. Do not cross the threshold without one. No Exceptions. In an observation and interview on 3/24/26 at 10:00 am, [NAME] A walked through the kitchen with his beard and sideburns sticking out of his beard cover.
The beard cover did not cover the mouth, sideburns or the upper part of his bushy beard. He stated as far as he knew he was supposed to have a beard cover and hair net on while in the kitchen.
When asked if the hairnet was supposed to cover all parts of the hair on his face he stated What am I supposed to do about that? In an observation and interview on 3/24/26 at 12:05 pm, [NAME] B walked into the kitchen from the front door and through the kitchen to the staff changing room with no hairnet or beard cover on.
When asked he stated I just walked through the kitchen. I am not sure I am supposed to put it on. In an interview on 3/25/26 at 10:25 am, the RD stated she expected all staff to wear hairnets, and beard covers at all times while in the kitchen.
She stated she expected hairnets, and beard covers to cover all hair.
She stated the consequences of all issues would be food borne illness. In an interview on 3/26/26 at 10:15 am, the DM stated she had trained the staff in their kitchen duties She stated she expected all staff to wear hairnets and beard covers.
She stated she was aware all staff had to keep hair, moustache and beards covered while in the kitchen.
She stated she had been aware the beard cover had not covered [NAME] B's beard and moustache very well.
She stated she had drilled it into everyone's heads not to come to the kitchen without a hairnet.
She stated that food borne illness could result from all these issues.
Record review of the facility policy titled ' Preventing Foodborne Illness- Employee Hygiene and Sanitary Practices' dated 2001 documented: Hairnets and beard restraints are worn when cooking, preparing or assembling food to keep hair from contacting exposed food, clean equipment, utensils and linens.
Record review of the facility's policy titled, ' Dietary Food Service Personnel Policy and Procedures ' dated 2012 documented:Hairnets or hats covering the hairline are worn at all times. [NAME] guards are required for facial hair.
Record review of the facility's policy titled, ' Infection Control ' dated 2012, documented:Clean hair is required. It is to be covered with an effective hair restraint.
Facial hair is to be closely trimmed and is to be covered with a hair restraint.
455675 03/26/2026
Landmark of Amarillo Rehabilitation and Nursing Ce 5601 Plum Creek Dr Amarillo, TX 79124
During an interview on 03/26/2026 at 9:12 AM CNA H (the CNA providing care for Resident #65 this shift) reported staff make rounds every 2 hours. CNA H reported if the room had oxygen, then the oxygen tubing and cannula need to be stored off the floor so the residents will not develop an illness.
During an interview on 03/26/2026 at 9:49 AM the DON reported staff, especially the CNA's, should make rounds every two hours and they should check the oxygen and make sure the nasal cannula and tubing are stored in a bag off the floor.
The DON reported if the nasal cannula and tubing were not stored correctly then it could be contaminated, damaged, or the resident could get caught up in it and trip resulting in a fall.
During an interview on 03/26/26 at 09:32 AM the CN stated the facility did not have a policy or procedure specific to nasal cannula storage.
The CN provided the Oxygen policy which had no information related to nasal cannula/O2 tubing storage.
Record review of the facility provided policy titled, Fundamentals of Infection Control Precautions undated, revealed the following:-A variety of infection control measures are used for decreasing the risk of transmission of microorganisms in the facility.6.
Resident care equipment and articles 3.
Non-invasive resident care equipment is cleaned daily or as need between use by nursing assistant.