Inspection·July 12, 2023

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 out of 4 residents reviewed for clinical records (Resident #1). The facility failed to accurately document information for Resident #1 due to another Resident's name being present in care plan. This failure can place residents at risk of inaccurate needs or services based on comprehensive assessment. Findings included: Record review, dated July 12, 2023, of Resident #1's face sheet revealed a [AGE] year-old male admitted into the facility on [DATE]. Resident #1 diagnoses included but not limited to cerebral palsy (inability to control muscles), interstitial pulmonary (inflammation causing lungs to not get enough oxygen), Chronic Obstructive Pulmonary Disease,(COPD -Blockage of airway), Cystic Fibrosis (disorder that damagers lungs, digestive tract and other organs), Reduced mobility, unsteadiness of feet, cognitive communication deficit, dysphagia (difficulty swallowing), aphasia (loss of ability to understand speech), schizoaffective disorder; bipolar type, intellectual disabilities, muscle weakness, need for assistance with personal care. Record review of Resident #1's MDS assessment Section C-Cognitive Pattern, dated 7/10/23, revealed the resident was not assessed due to limited communication skills. Record review on 7/12/23 of Resident #1's care plan, dated 3/27/23, revealed a goal for PASARR indicating a positive screening. The information presented for the focus goal stated, I, [Resident] is receiving PASRR service through Texas Panhandle Services. [Wrong Resident] has a PASRR positive diagnosis Dx: IDD due to Cerebral Palsy. Case worker is [Employee] w/TPC. Incorrect name of resident identified in focus goal. Record review on 7/12/23 of Resident #1's care plan, dated 3/27/23 and revised on 6/7/23, revealed a goal for PASARR indicating a positive screening. The information presented for the focus goal stated, I, [Resident], is receiving PASRR service through Texas Panhandle Services. [Wrong Resident] has a PASRR positive diagnosis Dx: IDD due to Cerebral Palsy. Case worker is [Employee] w/TPC. Incorrect name of resident identified in focus goal. Interview on 7/12/23 at 3:01 PM, the MDS Coordinator confirmed that wrong resident name was care (continued on next page) 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 REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 675282 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675282 B. Wing A. Building (X3) DATE SURVEY COMPLETED 07/12/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Amarillo Medical Lodge 9 Medical Dr Amarillo, TX 79106 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)