Inspection·January 7, 2025

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, the facility failed to ensure in accordance with accepted professional standards and practices, the facility maintained medical records on each resident that were complete, accurately documented, and readily accessible for 2 of 5 residents (Residents #1 and #2) reviewed for clinical records. The facility failed to ensure the altercation that occurred on 12/4/2024 between Resident #1 and Resident #2 was documented in their clinical records. This failure could place residents at risk for incorrect or omitted treatment, duplicated treatments, poor self-esteem and self-worth, and a failure to ensure continuity of care. Findings included: 1. Record review of Resident #1's face sheet, dated 01/07/2025, reflected a [AGE] year-old-female who was admitted to the facility on [DATE]. Resident #1's current diagnoses included but were not limited to cerebral infarction (stroke), vascular dementia (impaired blood flow to the brain/brain damage), major depressive disorder and generalized anxiety disorder . Record review of Resident #1's quarterly MDS Assessment, dated 11/07/2024, reflected Resident #1 had a BIMS score of 00 out of 15, which indicated her cognition was severely impaired. Record review of Resident #1's care plan, dated 11/11/2024, reflected Resident #1 had a behavior problem with interventions to intervene as necessary to protect the rights and safety to others, divert attention and remove from situation and take to alternate location as needed. No documentation of incident that occurred on 12/4/2024 was noted in care plan. Record review of Incident Report dated 12/4/2024 reflected Resident #1 was getting a cup of juice off the table in the dining room. Because the cup did not belong to Resident #1, Resident #2 attempted to get the cup back from the resident. The Incident Report reflected both residents were assessed, residents families were notified, and physician notified. The residents were separated. Record review of Resident #1's progress notes reflected no documentation of the incident that occurred on 12/4/2024 between Resident #1 and Resident #2. 2. Record review of Resident #2's face sheet, dated 01/07/2024, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #2's current diagnoses included but were not (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: 675336 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 675336 B. Wing A. Building (X3) DATE SURVEY COMPLETED 01/07/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Kirkland Court Health and Rehabilitation Center 1601 Kirkland 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)