Inspection·December 17, 2025

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete which would be against the resident's expressed wishes.During an interview and observation on 12/17/2025 at 9:00 AM, Resident #1 was observed sitting in bed eating breakfast. The resident stated she was on hospice services and that her wish was to be a DNR.During an interview and observation on 12/17/2025 at 9:50AM, the SW and ADM presented a second DNR obtained from the hospice agency. Review of this document revealed it was signed and dated by Resident #1, and two witnesses on 07/15/2025, with RN and LVN written after the witness signatures and signed and dated by the physician on 07/16/2025. During the discussion the ADM stated that both witnesses were employed by the facility at the time the DNR was signed. After reviewing the DNR instructions, the ADM acknowledged the DNR was not valid because both witnesses were direct care staff at the time of execution. The ADM who was aware the SW was responsible for the DNRs stated she would get with SW and conduct an audit of all DNR documents.Record review of the facility provided policy titled Advanced Directives updated December 2016, revealed the following: Policy Statement: Advanced Directives will be respected in accordance with state law and facility policy.Record review of the OUT-OF-HOSPITAL DO-NOT-RESUSCITATE (OOH-DNR) ORDER-TEXAS DEPARTMENT OF STATE HEALTH SERVICES, revealed the following:-The original or a copy of a fully and properly completed OOH-DNR Order or the presence of an OOH-DNR device on a person is sufficient evidence of the existence of the original OOH-DNR Order and either one shall be honored by responding health care professionals. Event ID: Facility ID: 675336 If continuation sheet Page 2 of 4 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 12/17/2025 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review the facility failed to review the risks and benefits of bed rails with 1 of 5 (Resident #1) residents or their resident representatives and obtain informed consent prior to installation of bed rails, in that:Resident #1 had (1) one-half length bed rail installed on the right side of her bed without a physician order, without documented informed consent from the resident or resident representative and without inclusion of bed rail use in the resident's comprehensive care plan. This failure placed the residents at risk for injury, including entrapment of bedrails, hindered the resident's' ability to independently exit the bed and could negatively impact the resident's' ability to engage in activities of daily living.Findings included:Record review of Resident #1's face sheet printed 12/17/2025 revealed she was a [AGE] year-old female resident admitted to the facility on [DATE] with diagnoses to include chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath), atherosclerotic heart disease of native coronary artery with unstable angina pectoris (narrowing and hardening of the arteries due to buildup of plaque) and an aneurysm of the ascending aorta, without rupture (weak spot on aorta). Unspecified fracture of sacrum, subsequent encounter for fracture with routine healingRecord review of Resident #1's Quarterly MDS Assessment completed 10/29/2025 indicated a Brief Interview of Mental status (BIMS) score of 12, reflecting moderately impaired cognition, and documented that the resident required supervision or touching assistance with activities of daily living. Record review of Resident #1's care plan, most recently revised on 10/29/2025, did not have any documentation relating to bed rail use. Care plan also indicated resident was a high risk for falls, with a history of falls prior to admission.Record review of Resident #1's active physician orders on 12/17/2025 did not include a physician order authorizing bed rail use.Record review of Resident #1's electronic medical record under consents on 12/17/2025 did not include documented informed consent for bed rail use. Record review of Resident #1's Bed Rail Safety Review dated 12/10/2025 reflected the bed rails will promote mobility.During an interview and observation on 12/17/2025 at 7:45 AM, LVN A (the nurse responsible for Resident #1 this shift) was observed reviewing Resident #1's orders and did not find an order for bed rails and stated she was new and unsure if orders were required for bed rails.During an interview and observation on 12/17/2025 at 8:25 AM, the ADON reviewed Resident #1's electronic medical record and could not find an order or consent in the record and stated she would look through her paper files to see if it did not get put in the system. The ADON said a possible negative outcome for having bed rails without orders or consent could cause harm.During an interview on 12/17/2025 at 8:45 AM, the DON stated she was responsible for documenting the use of bedrails in the care plan but stated since there was no physician order for the bed rail it did not alert her to add it to the care plan. The DON stated a possible negative outcome for bed rail use without an order, informed consent, and care plan intervention could result in harm.During an interview and observation on 12/17/2025 at 9:00 AM, Resident #1 was observed sitting in bed watching tv, head of bed raised, she was eating breakfast. The Resident stated she liked the bed rail on her bed because it made her feel safe and helped with her mobility. During an interview on 12/17/2025 at 9:50AM, the ADON stated she could not find the consent and reported contacting the resident's representative to obtain consent. Record review of the facility's policy Proper Use of Side Rails dated December 2016 reflected the following: The purposes of these guidelines are to ensure the safe use of side rails as resident mobility aids and to prohibit the use (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675336 If continuation sheet Page 3 of 4 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 12/17/2025 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)

F 0700 Level of Harm - Minimal harm or potential for actual harm of side rails as restraints unless necessary to treat a resident's medical symptoms. The use of side rails as an assistive device will be addressed in the resident care plan Consent for the side rail use will be obtained from the resident or legal representative Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675336 If continuation sheet Page 4 of 4