Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Landmark Of Amarillo Rehabilitation And Nursing Ce during CMS and state inspections, most recent first.
A facility failed to maintain an accurate system for recording and reconciling the receipt and distribution of a controlled substance, OxyContin ER 10mg, for a resident with chronic pain. Although the medication was signed for by an LVN and the pharmacy driver, staff could not confirm whether the medication was actually received or properly distributed, and there was no documentation from the nurse responsible for the resident's unit. Administrative staff and the pharmacy driver acknowledged gaps in the process, and the required accountability record was not completed.
A resident with a seizure disorder received an incorrect dosage of Lamotrigine due to an error in entering physician orders. The ADON failed to update the dosage correctly in the MAR, resulting in the resident receiving 500 mg instead of the prescribed 250 mg. The error was discovered when the resident was sent to the hospital, and the facility's process for entering medication orders was not followed correctly.
The facility's kitchen failed to maintain sanitary conditions, with issues such as improper labeling and dating of food, staff not wearing hairnets, and improper storage of frozen foods. Observations revealed opened and improperly stored food items, and a cooler not maintaining the correct temperature. The dietary manager acknowledged these issues, which were against the facility's policies.
The facility failed to properly store and label medications, with instances of unattended medications, expired drugs, and missing open dates on inhalers. Staff interviews highlighted awareness of potential negative outcomes, such as drug diversion and ineffective treatment. The facility's policies were not adequately followed, posing risks to residents.
A resident with severe cognitive impairment and PTSD did not receive trauma-informed care due to the absence of a documented trauma assessment in his clinical file. Interviews with facility staff revealed that trauma assessments were expected upon admission, but the Social Worker was unsure if it had been completed due to a change in facility ownership. The facility's policy emphasized individualized care plans for trauma survivors, which was not implemented for this resident.
The facility failed to maintain effective infection control practices, as observed in the care of two residents. A resident's catheter bag and tubing were not kept off the floor and below waist level, contrary to the care plan, and the resident reported not receiving proper education on catheter care. Additionally, staff failed to perform hand hygiene and glove changes during incontinent and catheter care, leading to potential cross-contamination. These actions were inconsistent with the facility's infection control policies.
Failure to Accurately Account for Receipt and Disposition of Controlled Drugs
Penalty
Summary
The facility failed to establish and maintain an adequate system for recording the receipt and disposition of controlled drugs, specifically OxyContin ER 10mg, for one resident. The medication was documented as received from the pharmacy, with signatures from both the LVN and the pharmacy driver, but there was no accurate reconciliation or detailed record to confirm the medication was actually received and properly distributed. The process for checking in and distributing controlled substances was inconsistent, with staff unable to verify whether the medication was present or delivered to the correct unit. The resident involved was an adult male with a history of cauda equina syndrome, chronic pain syndrome, a displaced fracture, and benign prostatic hyperplasia. His care plan included scheduled opioid pain medication, and his medication administration record indicated he received pain medication daily. However, interviews with staff revealed uncertainty about the actual receipt and distribution of the OxyContin, with the responsible LVN unable to confirm if the medication was included in the delivery or handed off to the nurse responsible for the resident's unit. There was no documentation or signature from the second LVN to confirm receipt of the medication. Administrative staff, including the ADM and ADON, acknowledged the lack of an accurate process for receiving and reconciling controlled medications. The pharmacy driver also confirmed that, prior to the incident, he did not observe the nurse count in the medications upon delivery. The facility's policy required a controlled medication accountability record to be prepared upon receipt, but this procedure was not followed, resulting in an inability to account for the controlled substance in question.
Medication Administration Error Due to Incorrect Order Entry
Penalty
Summary
The facility failed to provide accurate pharmaceutical services for a resident, leading to incorrect medication administration. The resident, who had a history of seizures and was admitted to the facility from the hospital, was prescribed Lamotrigine to manage her condition. However, due to an error in entering the physician's orders, the resident received an incorrect dosage of the medication. Specifically, the resident was given 500 mg of Lamotrigine in the morning instead of the prescribed 250 mg, as the order was mistakenly entered as 200 mg tablets instead of 100 mg tablets. The error occurred because the Assistant Director of Nursing (ADON) did not update the dosage correctly in the Medication Administration Record (MAR) after being advised by the pharmacy to adjust the order to match the available tablet sizes. As a result, the resident received an excessive dose of Lamotrigine for several days, which was discovered when the resident was sent back to the hospital due to a bleeding head wound. Although the pharmacist indicated that the excess dosage would not cause hospitalization, it was noted that the resident's Lamotrigine blood level was slightly above the normal range. Interviews with the ADON and the Director of Nursing (DON) revealed that the facility's process for entering medication orders at admission was not followed correctly, leading to the medication error. The facility's policy requires that new medication orders be accurately transcribed to the MAR, but this was not done in this case. The DON acknowledged that incorrect medication entry could result in medication errors, potentially affecting the effectiveness of the treatment provided to residents.
Sanitation and Food Storage Deficiencies in Kitchen
Penalty
Summary
The facility failed to maintain sanitary conditions in its kitchen, as observed during a survey. The deficiencies included improper labeling and dating of stored food, failure to wear hairnets by kitchen staff, and improper storage of frozen foods. Specifically, a dietary aide was seen washing dishes without a hairnet, citing an inability to find one, despite being trained to always wear one to prevent cross-contamination. Additionally, the cooler in the kitchen preparation area contained opened and improperly stored food items, such as crinkle cut fries and corndogs, which were not kept frozen as required by their labels. Further observations revealed that the walk-in freezer contained several items that were either unlabeled, undated, or uncovered, including cherry pie bites, bags of biscuits, and a cooked pumpkin pie. The dietary manager acknowledged these issues, stating that the food should have been labeled, dated, and covered, and that the cooler, which was supposed to function as a freezer, was not maintaining the correct temperature. The facility's policies from 2012 outlined the requirements for food storage and sanitation, including the use of hairnets and proper labeling and dating of food items, which were not adhered to in this instance.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in locked compartments and labeled according to professional principles. Medications were left unattended on top of a medication cart by an LVN, posing a risk of access by other residents. Additionally, expired medications were found on the 2C South medication cart and in the medication room refrigerator, including insulins and acetaminophen suppositories. Loose pills were also discovered on medication carts, and several inhalers lacked open dates, which are necessary to determine their expiration. Interviews with staff revealed awareness of the potential negative outcomes of these deficiencies, such as drug diversion, lack of drug efficacy, and adverse reactions. The staff acknowledged that leaving medications unattended could result in unauthorized access by residents, and administering expired medications could lead to ineffective treatment. The absence of open dates on medications could result in their use beyond the manufacturer's recommended period, compromising their effectiveness. The facility's policies on medication storage and discontinuation were reviewed, revealing a lack of adherence to procedures for dating medications upon opening and removing discontinued medications from storage. The facility did not provide a specific policy for medication cart or medication room storage, indicating a gap in their procedural framework. These deficiencies collectively placed residents at risk for medication errors and adverse health outcomes.
Failure to Provide Trauma-Informed Care for Resident with PTSD
Penalty
Summary
The facility failed to provide trauma-informed and culturally competent care for a resident with a history of trauma, specifically post-traumatic stress disorder (PTSD). The resident, a male with severe cognitive impairment and PTSD, did not have a trauma screening or assessment documented in his clinical file. This lack of documentation meant that the resident's care plan did not include any interventions to address his PTSD, which could potentially lead to re-traumatization. Interviews with facility staff, including a Licensed Vocational Nurse (LVN), Social Worker (SW), Director of Nursing (DON), Clinical Resource Nurse (CRN), and Assistant Director of Nursing (ADON), revealed that trauma assessments were expected to be completed upon admission. However, the SW was unsure if the assessment had been completed due to a change in facility ownership. The facility's policy on trauma-informed care emphasized the importance of collaborating with trauma survivors to develop individualized care plans, but this was not implemented for the resident in question.
Infection Control Deficiencies in Catheter and Incontinent Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue involved Resident #27, whose catheter bag and tubing were not consistently kept off the floor and below waist level, contrary to the care plan and facility policy. Observations revealed that the catheter bag was placed on the floor and above waist level, which could lead to potential infections. Despite the care plan indicating that staff should educate the resident on proper catheter care, Resident #27 reported not receiving such education, and staff interviews suggested challenges in redirecting the resident's behavior. Another deficiency was noted in the care provided to Resident #11, where CNA G failed to perform hand hygiene and change gloves between cleaning the resident's soiled buttocks and placing a clean brief. This lapse in infection control practices was acknowledged by CNA G, who admitted that such actions could lead to infections. The facility's infection control plan requires staff to wash their hands after each direct resident contact, but this was not adhered to during the observed care. Additionally, CNA C was observed not performing hand hygiene after removing gloves and before putting on new ones while providing catheter care to Resident #27. CNA C also placed a brief that had been on the floor onto a bedside table for later use, which could lead to cross-contamination. Interviews with facility staff, including the DON and ADON, confirmed that these actions could result in a lack of infection control. The facility's policies on catheter care and infection control were not followed, contributing to the deficiencies observed.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 45 citations issued within 25 miles in the last 12 months — including the 4 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ussery Roan Texas State Veterans Home | 0.6 mi | — | 0 | 0 |
| Amarillo Medical Lodge | 0.6 mi | — | 4 | 0 |
| Windflower Health Center | 0.7 mi | — | 0 | 0 |
| Heritage Convalescent Center | 0.8 mi | — | 9 | 0 |
| Amarillo Center For Skilled Care | 1.4 mi | — | 8 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Landmark Of Amarillo Rehabilitation And Nursing Ce.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.