Inspection·April 2, 2024

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 complete, accurate, readily accessible, and systemically organized records for 1 (Resident #1) of 8 residents reviewed for medical records. The facility failed to document the fall risk evaluation for Resident #1's history of falls within the last 90 days. This failure could place all residents at risk of not receiving appropriate care through inadequate documentation possibly resulting in deterioration in condition, exacerbation of disease process, and increased risk of harm or injury. Finding include: Record review of Resident #1's medical record revealed an [AGE] year-old-female admitted to the facility on [DATE]. Resident #1's current diagnoses include muscle weakness, history of falling, insomnia, unspecified dementia, unspecified severity, with other behavioral disturbance, hallucination, long term use of anticoagulants. Resident #1's last MDS, dated [DATE] was a quarterly with a BIMS of 13 indicating Resident #1 is cognitively intact. Resident #1 had a functionality of total dependency with mobility tasks while needing partial/moderate assistance with other self-care areas. Further record review of Resident #1's nurse's notes (NN) revealed that a fall risk evaluation dated 01/08/2024 stated the resident slid out of her raising lift recliner that resulted in a bruise to the left hip, no other injury noted. Fall Risk evaluation noted 1-2 falls in past 3 months. Record review of a NN note dated 02/16/2024 stated that Resident #1 was trying to toilet herself and slid from the bed, no injury s/t this fall, fall risk evaluation stated no Hx of falls in the last 3 months. Record review of a NN note dated 03/16/2024 stated that Resident #1 had a fall when she rolled out of her bed, resident hit her head on the floor, laceration to forehead and transfer to ER was performed. Fall risk evaluation stated no Hx of falls in the last 3 months. Record review of a NN note dated 03/17/2024 stated that Resident #1 received 3 stitches at local ER, no other injury noted. Record review of Resident 1's care plan reveals that resident is at risk for falls s/t to Resident 1's in ability to transfer alone. (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: 745022 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 745022 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/02/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Ware Memorial Care Center 1510 S Van Buren St. Amarillo, TX 79101 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)