Legacy Rehabilitation And Living
Legacy Rehabilitation and Living in Amarillo, TX — inspection on September 9, 2025.
Found 1 citation. 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
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She explained the delay from the time she found the medications had not been discontinued to the time she notified facility staff by saying she was behind in her charting and was playing catch up from her vacation. NP A stated she 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. NP A said, I dug and dug to try to find out why they (hospital) discontinued them (the four medications in question). NP A stated she could not find the reason the medications were discontinued.
During an interview on 09/09/25 at 03:30 PM LVN C stated a resident could be negatively impacted by taking medications that were supposed to be discontinued.
She stated, I mean surely a doctor said discontinue this for a reason.
During an interview on 09/09/25 at 03:46 PM Resident #1's family member stated when NP A called to speak to her about Resident #1's care she (NP A) mentioned four medications were not discontinued as they were supposed to have been.
She stated, It was a short conversation, she (NP A) didn't go into it. Resident #1's family member stated Resident #1 was taking mirtazapine and escitalopram prior to entering the hospital on [DATE].
During an interview on 09/09/25 at 04:08 PM DON stated a resident could be negatively impacted by receiving medications that were supposed to be discontinued.
She stated the negative impact would depend on the medication. DON stated she asked for a different NP than NP A due to concerns about NP A not getting her charting into the EHR timely.
When asked why she though ADON did not catch the fact the four medications were to be discontinued, she stated she demoted ADON to a floor nurse when it became evident she did not have the necessary skills to be an ADON. DON did not answer what a specific negative outcome could be for taking discontinued antidepressant and/or pain medications. DON was asked for an unnecessary medication policy during this interview.
During an interview on 09/09/25 at 04:16 PM RN D stated a resident could be negatively impacted if they received a medication that was supposed to be discontinued.
She stated, If they no longer need it and it was discontinued at the hospital it can put the patient at risk.
During an interview on 09/10/25 at 01:20 PM ADON stated she did not remember entering orders for Resident #1.
She stated she did not remember Resident #1. ADON stated 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.
She stated 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.
Record review of facility policy titled Care and Treatment Psychotropic Drug Use revealed the following: . 2. On admission, the admitting nurses will review the transfer orders for any psychotropic medications.
Any information obtained will be documented in the resident's clinical record.
Record review of facility policy titled Pharmacy Services Physician Orders revealed the following: . it is the policy of this facility that drugs shall be administered only upon the written order of a person duly licensed and authorized to prescribe such drugs.
Record review of the facility policy titled Continuum of Care Admission, General revealed no mention of transcribing orders from the hospital into the facilities EHR.An unnecessary medication policy was not provided.
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