Inspection visit
Inspection
3 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 3 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0641
Ensure each resident receives an accurate assessment.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure the assessment accurately reflected
the resident's status for 1 (Resident #19) of 17 residents reviewed for accuracy of assessments.
Residents Affected - Few
The facility failed to accurately assess Resident #19, in that her MDS coded her as having no delusions or
hallucinations despite physician's documentation to the contrary.
This failure could place residents at risk of not receiving necessary care and/or treatment.
Findings include:
Record review of Resident #19's admission record, dated 12/06/23, revealed a [AGE] year-old female
admitted to the facility on [DATE] with diagnoses that included, but were not limited to, muscular dystrophy
(a group of inherited conditions affecting the muscles, gradually leading to disability), type 2 diabetes
(insufficient production of insulin, causing high blood sugar), delusional disorders (a type of mental health
condition in which a person cannot distinguish between what is real and what is imagined, often resulting in
an unshakeable belief in something that is untrue), and schizoaffective disorder (a mental health disorder
that is marked by a combination of schizophrenia symptoms such as hallucinations or delusions, and mood
disorder symptoms, such as depression or mania).
Record review of Resident #19's Quarterly MDS with an ARD date of 11/06/23 revealed a BIMS of 15
which indicated intact cognition. Section E of the MDS was titled Behavior and question E0100 had
directions to check all that apply. The question had Hallucinations (perceptual experiences in the absence
of real external sensory stimuli) and Delusions (misconceptions or beliefs that are firmly held, contrary to
reality) as options to check. Both options were left unchecked and the option None of the above was
checked. Section I of the MDS listed psychotic disorder and schizophrenia among the active diagnoses for
Resident #19.
Record review of Resident #19's care plan with a completion date of 11/21/23 revealed, Resident #19 is At
risk for impaired cognitive function/dementia or impaired though processes r/t Difficulty making decisions
and dx of delusional disorders. The care plan also indicated Resident #19 has Potential for a behavior
problem r/t r/t DX of schizoaffective disorder and delusions disorders, Hx of yelling out and using profanity
type of language, aggravation, and hallucinations .
Record review of Resident #19's primary physician's progress note with 11/01/23 as the date of service
revealed Resident #19 is a poor historian due to cognitive/psychiatric impairment. The progress note further
revealed Resident #19 stated she won't drink protein drinks because it contains Chromium 22 that attracts
radiology and causes cancer. The progress note stated Resident #19 continues to
(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 9
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
12/06/2023
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)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
state she is pregnant. The progress note also stated Resident #19 was Insight Impaired and had Grandiose
delusions.
During an observation and interview on 12/04/23 at 08:56 AM Resident #19 was lying on her back in bed
with the head of the bed raised to a sitting position watching TV and eating breakfast off an over-the-bed
table. Resident #19 stated staff took good care of her and she had been impregnated by one of doctors
who worked in the facility. She stated that due to the European lineage on both of their parts the pregnancy
has been rather unusual, and the gestation period will be longer. Resident #19 stated they planned to move
to New Mexico due to New Mexico having a constitution that keeps blacks out.
During an observation on 12/04/23 at 09:04 AM the surveyor had just exited Resident #19's room leaving
Resident #19 alone in the room and overheard Resident #19 having a conversation with someone while
alone in her room. She was telling someone to shut up, leave her alone, stop hurting her stomach, and to
give her life back.
During an observation on 12/05/23 08:49 AM Resident #19 was in her bed with the head of the bed
elevated talking to someone who was not visible in the room. She stated she wanted that person to stop
hurting her and asked them to please shut up.
During an observation and interview on 12/05/23 at 09:04 AM Resident #19 was asked if she ever refused
to take any of her medications. She replied, Yeah, because I am a doctor, and I don't want to take any
opioids. She stated it was hard to move her legs because of the robots but she would not let staff work with
her because they are not professionals, and they are not really knowledgeable.
During an interview on 12/06/23 at 01:18 PM LVN E stated if she saw a behavior in a resident, she
documented it in the progress notes or on the MAR.
During an interview on 12/06/23 at 01:21 PM ADON stated Resident #19 would not have an area to
document behaviors on her MAR because she was not taking any psychotropic medications. He stated it
was a normal behavior for Resident #19 to talk to people who are not there and to yell out and to talk about
being pregnant by a doctor from the facility. ADON stated the facility had a psychiatrist visit Resident #19,
but she refused to speak to the psychiatrist. He stated they have had to remove Resident #19 from the
dining hall on occasion due to her behaviors and comments about people with different skin colors.
During an interview on 12/06/23 at 01:22 PM LVN C stated she had documented Resident #19's behaviors
in the progress notes of her EHR.
During an interview on 12/06/23 at 01:29 PM MDS LVN stated he was responsible for completing the MDS
assessments. He stated he filled out Section E of the MDS based on information gleaned from nursing
notes, and we talk as an IDT in the mornings and in our morning meeting. MDS LVN stated the IDT was
made up of DON, ADM-T, SW, BOM, ADON, and DOR. He stated the ARD date was the day he started an
assessment and the look back period was the seven days prior to that date. When asked why Resident #19
was coded in MDS Section E as having no delusions or hallucinations he stated he was not sure and would
have to look. MDS LVN stated a possible negative outcome of a MDS not reflecting behaviors on the part of
a resident was something might get missed and the resident might not get treated properly.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675282
If continuation sheet
Page 2 of 9
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
12/06/2023
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)
F 0641
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 12/06/23 at 01:33 PM ADM-T stated she could not speak to a possible negative
outcome of Resident #19 being coded for no delusions or hallucinations on her MDS as she [ADM-T] was
not real familiar with Resident #19.
During an interview on 12/06/23 at 01:35 PM DON stated some mornings in morning meetings Resident
#19's behaviors were not mentioned. She said of Resident #19, Some mornings she is very pleasant and
then some mornings I will walk in there and she is talking to the window. DON stated they had a psychiatrist
go and speak to Resident #19 but Resident #19 would not talk to him and said, Get that man outta here.
During an interview on 12/06/23 at 01:37 PM MDS LVN stated he did look at physician's notes when he
was completing Section E of the MDS. He stated he was not sure why he did not see the physician's note
regarding Resident #19 with a service date of 11/01/23.
During an interview on 12/06/23 at 02:08 PM MDS LVN stated the policy he followed for completing the
MDS assessment was the RAI.
Record review of the RAI, version 1.18.11 dated October 2023, revealed the following instructions for
completing Section E of the MDS:
. 1. Review the resident's medical record for the 7-day-look-back period.
2. Interview staff members and others who have had the opportunity to observe the resident in a variety of
situations during the 7-day-look-back period.
3. Observe resident during conversations and the structured interview in other assessment sections and
listen for statements indicating an experience of hallucinations, or the expression of false beliefs
(delusions).
Record review of an undated facility policy titled; Off-site Storage of Records revealed in part:
. The facility maintains clinical records for each resident that are complete, accurately documented, .
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675282
If continuation sheet
Page 3 of 9
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
12/06/2023
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)
F 0695
Provide safe and appropriate respiratory care for a resident when needed.
Level of Harm - Minimal harm
or potential for actual harm
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review the facility failed to ensure that a resident who needs respiratory
care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with
professional standards of practice, the comprehensive person-centered care plan, and the residents' goals
and preferences for 2 (Resident #5 and Resident #57) of 17 residents reviewed for respiratory care.
Residents Affected - Few
1. Resident #5 had a physician's order for continuous oxygen via nasal cannula at 2-4 lpm and was
receiving oxygen therapy at higher concentrations.
2. Resident #57 had no physician's orders for oxygen and was receiving oxygen via nasal cannula on a
continuous basis.
These failures could place residents who receive oxygen at an increased risk for receiving oxygen at the
wrong rate which could lead to hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen
toxicity (damage to lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood,
decreasing the oxygen supply to vital organs), and shortness of breath.
Findings Included:
1. Record review of Resident #5's admission Record dated 12/04/23 revealed an [AGE] year-old female
admitted to the facility on [DATE] with diagnoses that included, but were not limited to, diastolic heart failure
(a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of
breath and fatigue), fatty liver (fat build up in the liver resulting in damage and possible scarring to the liver),
and hypertension (high blood pressure).
Record review of Resident #5's Quarterly MDS with an ARD date of 11/17/23 revealed a BIMS of 14 which
indicated intact cognition. Section O of the MDS revealed Resident #5 received oxygen therapy while a
resident.
Record review of Resident #5 Care Plan dated 11/01/23 revealed Resident #5 had Oxygen Therapy r/t
Ineffective gas exchange.
Record review of Resident #5's active orders dated 12/04/23 revealed the following order with a start date
of 07/08/23:
O2 AT 2-4 L/MIN CONTINUOUS PER NC every shift.
Record review of Resident #5's oxygen saturation summary revealed 36 entries. 28 of the entries were from
July 2023 with two entries for August, September, October, and November 2023. Of the 36 entries 4 were
on Room Air and the remaining 32 were on Oxygen via Nasal Cannula. Resident #5's oxygen saturation
percentages ranged from 90-99% according to the summary.
2. Record review of Resident #57's admission Record dated 12/05/23 revealed a [AGE] year-old female
admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute respiratory
failure with hypoxia (a condition resulting from not enough oxygen in the tissues of the body), diastolic heart
failure (a condition resulting from not enough oxygen in the tissues of the body), hypertension (high blood
pressure), and pneumonia (lung infection characterized by cough with
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675282
If continuation sheet
Page 4 of 9
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
12/06/2023
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)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
phlegm, fever, chills, and difficulty breathing). The admission Record featured a picture of Resident #57
wearing oxygen tubing with nasal cannula.
Record review of Resident #57's admission MDS with an ARD date of 11/03/23 revealed a BIMS of 13
which indicated intact cognition. Section I of the MDS indicated Debility, Cardiorespiratory Conditions as
Resident #57's primary medical condition category and Respiratory Failure was checked under the section
titled, Pulmonary. Section J of the MDS indicated Resident #57 had shortness of breath or trouble breathing
with exertion and when lying flat. Section O of the MDS revealed Resident #57 received oxygen therapy On
Admission and While a Resident. Under the On Admission section Continuous was checked.
Record review of Resident #57's care plan dated 11/10/23 revealed no mention of oxygen therapy. An
update to Resident #57's care plan dated 12/04/23 revealed a new focus area of [Resident #57] has altered
respiratory status related to diagnosis of pneumonia . One of the interventions for this focus area was,
Provide oxygen as ordered.
Record review of Resident #57's active orders dated 12/05/23 revealed no order for oxygen therapy.
Record review of Resident #57's November 2023 MAR revealed her oxygen saturation percentages for the
month of November ranged from 92-97%.
Record review of Resident #57's oxygen saturation summary revealed 54 entries. 9 of the entries were on
Room Air and the remaining entries were on Oxygen via Nasal Cannula. The summary revealed Resident
#57 received O2 via nasal cannula for 30 of the 37 days she had been in the facility. Of the 36 days
represented by the summary Resident #57 was on room air and receiving oxygen on 3 of the days and on
room air only for 6 of the days. Over the course of the 36 days represented by the summary Resident #57's
oxygen saturation percentages ranged from 90-99%. Her oxygen saturation percentage was 90% two times
in 36 days and both times she was receiving oxygen via nasal cannula.
During an observation and on 12/04/23 at 08:53 AM Resident #5 was seated in her recliner in her room
watching TV and receiving O2 via nasal cannula at 5 lpm.
During an observation and interview on 12/04/23 at 09:45 AM Resident #57 was receiving O2 via nasal
cannula while on her back in bed. She stated she was on 1 liter of O2. An observation of her O2
concentrator revealed it to be set on 3 lpm.
During an observation on 12/04/23 at 02:06 PM Resident #57 was in her bed receiving O2 via nasal
cannula.
During an observation on 12/05/23 at 09:00 AM Resident #57 was asleep in her bed receiving O2 via nasal
cannula at 3 lpm.
During an observation and interview on 12/05/23 at 09:23 AM Resident #5 was seated in her recliner
watching TV and receiving O2 at 5 lpm. She stated she had been receiving O2 continuously via nasal
cannula since last year when she had COVID pneumonia. She said her O2 concentrator at home was set to
3 lpm. Resident #5 stated she thought her O2 concentrator in the facility was set to 3 lpm.
During an observation on 12/05/23 at 11:25 AM Resident #57 was seated in her w/c in the dining room
playing dominoes and receiving O2 via nasal cannula from the O2 tank attached to her w/c.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675282
If continuation sheet
Page 5 of 9
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
12/06/2023
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)
F 0695
Level of Harm - Minimal harm
or potential for actual harm
During an observation on 12/05/23 at 02:11 PM Resident #57 was asleep on her bed receiving O2 at 2 lpm
via nasal cannula.
During an observation on 12/05/23 at 03:12 PM Resident #57 was asleep on her back in her bed receiving
O2 via nasal cannula at 2 lpm.
Residents Affected - Few
During an observation on 12/06/23 at 08:14 AM Resident #5 was seated in her recliner receiving O2 at 5
lpm.
During an interview on 12/06/23 at 8:37 AM LVN A, who was working in Resident #57's hall for the day,
stated nurses were responsible to set the lpm on O2 concentrators for residents receiving O2. She stated
nurses knew what lpm to set the concentrator to by looking at the doctor's orders. When asked if there was
a possible negative outcome of a resident receiving O2 without orders or O2 at higher lpm than ordered,
LVN A stated, Oh yes, especially if they have COPD. If you crank it [O2] up it can lower their O2 sats
[saturation percentages].
During an observation on 12/06/23 at 08:40 AM Resident #57 was observed in her bed receiving O2 via
nasal cannula at 1.5 lpm.
During an interview on 12/06/23 at 08:47 AM ADON, who was working on Resident #5's hallway for the
day, stated nurses were responsible for setting lpm levels on O2 concentrators. He stated CNAs could set
the levels if a nurse directed them to do so. When asked how nurses knew what lpm to set the concentrator
to, ADON stated, Orders tell them. He said a possible negative outcome of a resident receiving O2 at a
higher lpm than ordered or without any orders was, We don't know their history.
During an interview on 12/06/23 at 08:50 AM LVN B stated CNAs or nurses were responsible for setting O2
levels on O2 concentrators. She said they knew what lpm to set the concentrators to by looking in the
resident's care plan or orders. When asked if there was a possible negative outcome of receiving O2 at
higher rates than ordered she stated, There can be, sometimes, it depends on their [the resident's]
diagnosis. When asked if there was a possible negative outcome of receiving O2 without orders, she
replied, Only if you don't know the correct level. We do have standing orders [from MD] that if O2 is below a
certain level you have the option to get 1 to 3 liters.
During an interview on 12/06/23 at 08:57 AM DON stated nurses were responsible for setting O2 levels on
the concentrators, but CNAs could do it if directed to do so by a nurse. She said nurses knew what level to
set the concentrators to whatever the physician starts it at. She stated MD had standing orders for the
facility to use O2 at 1-5 lpm to keep O2 saturation percentages greater than 90%. When asked for a
possible negative outcome of a resident receiving O2 at higher lpm than ordered she replied, It depends on
what their O2 saturation is. She stated she could not think of a possible negative outcome of a resident
receiving O2 continuously without physician's orders. When asked if it was normal for a resident to receive
O2 continuously without physician's orders DON stated, No, we would have put the orders in. DON
attempted to find physician's orders for O2 for Resident #57 in the EHR but could not find them.
During an interview on 12/06/23 at 09:25 AM MD stated he had facility-wide standing orders for O2 from
1-3 lpm to be used to maintain O2 saturation percentages above 90%. He stated he believed he changed
the standing order to O2 from 1-5 lpm at the beginning of 2023 but was not sure of the date. When asked if
there was a possible negative outcome for a resident to receive O2 at a higher level than ordered or without
orders he stated, Folks with COPD, we have to watch for CO2 retention.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675282
If continuation sheet
Page 6 of 9
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
12/06/2023
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)
F 0695
Record review of facility document titled [Title of medical practice of MD] Long-Term Care Standing Orders
[Name of Facility] and dated 03/01/23 revealed in part:
Level of Harm - Minimal harm
or potential for actual harm
. Respiratory
Residents Affected - Few
If Spo2 <90% Apply NC at 2-3 L to maintain >90% .
Record review of an undated facility policy titled Policy / Procedure - Nursing Clinical with the subject of
Oxygen Administration (Mask, Cannula, Catheter) revealed in part:
It is the policy of the facility that oxygen is administered, as ordered by the physician or as an emergency
measure until the order can be obtained. May use standing orders for oxygen for residents without orders in
PCC.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675282
If continuation sheet
Page 7 of 9
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
12/06/2023
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)
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
observation, interview, and record review, in accordance with accepted professional standards and
practices, the facility failed to maintain medical records on each resident that were complete, accurately
documented for 1 of 17 residents (Resident #57) reviewed for accurate medical records.
The facility failed to ensure Resident #57's physician's order for oxygen was documented in the resident's
clinical record.
This failure could place residents at risk of not receiving needed care or treatments or duplication of care or
treatment by misleading care providers regarding what care or treatments residents have or have not
received.
Findings included:
Record Review of Resident #57's face sheet dated 12/04/2023 revealed a [AGE] year-old female admitted
to the facility on [DATE] with diagnoses included, but were not limited to, Acute Respiratory Failure with
Hypoxia(life threatening condition where the lungs cannot provide enough oxygen to the blood and organs),
Unspecified congestive heart failure, pneumonia (infection in lungs)-unspecified, klebsiella
pneumoniae(causes bacterial pneumonia or infection in lungs).
Record Review of Resident #57's admission MDS dated [DATE], revealed a BIMS score of 13 of 15 which
indicated her cognition was intact. In the MDS assessment section J1100 indicated that the resident has
shortness of breath with exertion and when lying flat. In the MDS assessment section O0110 indicated that
Resident #57 was receiving continuous Oxygen therapy on Admission. The MDS assessment also
indicated that Resident #57 was receiving Oxygen therapy while a resident in the facility.
Record Review of Resident #57's care plan dated 11/10/2023 revealed there was no documentation
focusing on oxygen therapy and no goal or interventions documented relating to oxygen therapy. The care
plan was updated on 12/4/2023 that indicated that Resident #57 had an altered respiratory status related to
diagnosis of pneumonia, klebsiella pneumonia with an intervention to provide oxygen as ordered.
Record Review of Resident #57's clinical record revealed no active orders for oxygen.
Record Review of Resident #57's progress note dated 12/3/2023 indicated the resident received
continuous oxygen.
Record Review of Resident #57's Medication Administration Record for November 2023 indicated that
Resident #57's oxygen saturation for the month of November ranged from 92-97%.
During an observation/interview on 12/04/2023 at 9:35 AM, revealed Resident #57's was sitting up in her
bed. The resident was receiving oxygen via nasal cannula at 3 liters per minute. The resident stated she
was supposed to be receiving oxygen daily via nasal cannula at 1 liter per minute.
During an observation on 12/5/2023 at 9:00 AM revealed Resident #57 sleeping in her bed, she was
receiving oxygen via nasal cannula at 3 liters per minute.
(continued on next page)
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675282
If continuation sheet
Page 8 of 9
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
12/06/2023
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)
F 0842
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
During an interview on 12/6/2023 at 8:37 AM, LVN A stated she knew what level to set the O2 on the
concentrators by looking at the physician's orders. LVN A stated the possible negative outcome for setting a
higher LPM than ordered would be that if the resident had COPD, it could cause their O2 saturations to be
lower.
During an observation on 12/6/2023 at 8:40 AM revealed Resident #57 sleeping in her bed. She was
receiving oxygen via nasal cannula at 1.5 liters per minute.
During an interview on 12/6/2023 at 8:45AM, the ADON stated that she, the DON or admission Nurse were
responsible for putting physician's orders in the EHR system. The ADON stated that the facility meets each
morning and that any missed orders would be addressed at the meeting, and it would be caught before
anything happened. ADON stated that a possible negative outcome for missed orders would be that a
resident would not get their medication.
During an interview on 12/6/2023 at 8:47AM, the ADON stated that the physician orders indicate what LPM
on the O2 concentrator are set at. ADON stated the possible negative outcome for receiving O2 at a higher
LPM than ordered or receiving O2 without orders would be that they wouldn't know the resident's history.
During observation/interview on 12/06/2023 at 8:50 AM, the admission Nurse stated she was responsible
for putting physician's orders in the system on weekdays and the charge nurse on the weekends.
Observation of admission Nurse looking up Resident #57's physician's orders via the EHR system revealed
admission Nurse stated that she could not find any orders for oxygen for Resident #57. admission Nurse
stated that a possible negative outcome for missed orders would that the staff would not know what the
saturation of oxygen should be at for the resident.
During an interview on 12/6/2023 at 8:57 AM, the DON stated that it is not normal for the resident to
receive O2 continuously without physician's orders.
During an observation/interview on 12/06/2023 at 9:00 AM, the DON stated that she and the admission
Nurse were responsible for putting physician's orders in the resident's chart. DON stated that they have a
lot of checks and balances and wouldn't miss orders. DON was observed looking at Resident #57's
admission record and physician's orders and stated that the resident was on oxygen at the hospital. DON
could not think of a negative outcome for a resident receiving oxygen without physician orders.
During an interview on on 12/6/2023 at 9:50AM, the DON stated she would get the policy regarding
medical records.
Record Review of Off-site Storage of Records (no date on the policy) revealed that the facility maintain
clinical records for each resident that are complete, accurately documented and readily accessible and
systematically organized.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675282
If continuation sheet
Page 9 of 9
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Back to topCitations
3 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
F695 - Respiratory care, including tracheostomy care and tracheal suctioning
Provide safe and appropriate respiratory care for a resident when needed.
F842 - Resident-identifiable information
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
FAQ · About this visit
Common questions about this visit
What happened during the December 6, 2023 survey of AMARILLO MEDICAL LODGE?
This was a inspection survey of AMARILLO MEDICAL LODGE on December 6, 2023. The surveyor cited 3 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at AMARILLO MEDICAL LODGE on December 6, 2023?
Yes, 3 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Ensure each resident receives an accurate assessment."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.
Researching this visit professionally?Book a 15-minute calland we will walk through what we have on file.
Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.