Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around January 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 Ware Memorial Care Center during CMS and state inspections, most recent first.
A resident with multiple cardiac and psychiatric diagnoses, dependent in most ADLs but cognitively intact, was given several high-risk oral medications by an LVN, who then left the medications in a cup on the dining table while standing several yards away at the med cart. The resident reported that staff routinely leave medications for self-administration, despite no care plan for self-administration and facility education materials stating that medications must not be left unattended and that nurses should observe ingestion. Other nursing staff, including an RN, another LVN, the ADON, and the DON, stated it was never acceptable to leave residents alone with medications, highlighting that the LVN’s practice conflicted with facility expectations and documented best practices.
A resident admitted without a pressure ulcer developed an unstageable ulcer on the coccyx within two weeks due to the facility's failure to notify the wound care nurse, perform weekly skin assessments, and document skin conditions accurately. The resident, with severely impaired cognition and dependent on staff for ADLs, was at risk for skin issues. The facility's lack of communication and documentation led to delayed care and worsening of the ulcer.
The facility failed to adhere to professional standards for food service safety, with deficiencies observed in 7 out of 8 resident snack refrigerators. Issues included improper storage, labeling, and dating of food items, as well as the presence of expired foods and staff items. Staff frequently used the refrigerators for personal food storage, and there was confusion about who was responsible for cleaning them. The lack of policies and cleaning schedules contributed to unsanitary conditions, posing a risk of foodborne illness.
The facility failed to inform residents about the removal of bedrails, affecting their mobility and comfort. Several residents, including those with conditions like epilepsy and Alzheimer's, reported their bedrails were removed without consent, despite requests for their return. The facility's plan to reassess bedrail needs was delayed, leading to resident complaints and a failure to uphold their rights to participate in care decisions.
The facility failed to provide necessary Medicare/Medicaid coverage notices to three residents, preventing them from being informed of their rights to appeal the termination of skilled services. The residents, with various medical conditions, were not given the required NOMNC and SNF ABN forms upon discharge from skilled services. Staff members were either unfamiliar with the process or deemed the notices unnecessary, leading to a deficiency in communication and documentation.
A resident with multiple health conditions was inaccurately assessed as having an indwelling catheter in her MDS assessment, despite no medical records or observations supporting this. The MDS Coordinator confirmed the error, highlighting potential financial and service impacts. The facility's policy mandates accurate assessments, and the error could affect reimbursement and billing.
The facility failed to change nebulizer tubing for two residents, one for four months and the other for six months, despite a policy requiring monthly changes. Observations showed cloudy tubing and particles in masks, indicating poor maintenance. Staff confirmed the oversight, acknowledging the risk of infection due to prolonged use of the same equipment.
A facility failed to provide adequate pharmaceutical services, leaving a resident unattended with medications and storing expired medications in two areas. The resident, with multiple medical conditions, was left with her morning pills by an LPN, contrary to the facility's expectations. Expired medications were found in the Rehabilitation and LTC medication room and the 1-North medication room, with staff acknowledging the potential negative impact on resident care. The facility lacked comprehensive policies for medication storage and self-administration.
A Schedule III narcotic was improperly stored in the Rehabilitation and LTC medication room, found on a refrigerator shelf instead of in a locked box. LVN C confirmed the issue, noting the lack of a log for tracking its use. The DON acknowledged the storage error, citing a missing key for the lock box. The facility also lacked a policy for medication storage, as confirmed by a review of the policy manual and unanswered requests for the policy.
The facility failed to maintain accurate fall risk evaluations for a resident with a history of falls, leading to discrepancies in medical records. The resident experienced multiple falls, including one resulting in a laceration and ER transfer, but the fall risk evaluations incorrectly stated no falls in the last three months. Interviews with the DON and LVNs confirmed the errors in documentation.
Medications Left Unattended and Unobserved Administration by LVN
Penalty
Summary
The deficiency involves the facility’s failure to provide pharmaceutical services that ensure accurate dispensing and administration of medications by not remaining with a resident until medications were taken. An [AGE]-year-old male resident with persistent atrial fibrillation, depression, essential hypertension, heart failure, and edema was admitted with multiple high-risk medications ordered, including an antidepressant, anticoagulant, diuretics, an opioid, and an anticonvulsant. His MDS showed intact cognition (BIMS 15) and dependence in all ADLs except eating and oral hygiene, and his care plan did not identify him as self-administering medications. On the morning in question, record review of the MAR showed that an LVN administered several medications to this resident, including Lasix, a multivitamin, Senna-Plus, spironolactone, Zoloft, Eliquis, gabapentin, metoprolol tartrate, and hydrocodone-acetaminophen. During observation in the dining room, the resident was seen sitting at a table with another resident, with a small oval orange-pink pill on the table and a plastic medication cup containing approximately eight medications in front of him, along with a lidded cup of what appeared to be coffee. No staff were present at that time, and the resident stated that staff leave his medications with him for him to take on his own every day. A subsequent observation showed the resident still seated with the medications in front of him while the LVN stood 4–6 yards away at the medication cart looking at a computer screen. The LVN stated she leaves the medications with the resident because he takes one pill at a time and will not take them if she stands there, adding that she stays close where she can watch and acknowledging that not watching could result in him not taking the medicine or saving it. Other nursing staff, including an RN, another LVN, the ADON, and the DON, stated it was never acceptable to leave residents alone with medications, citing risks such as other residents taking the medications, hoarding, or missed treatment. Facility documents, including the admission packet and a POC Education-Medication Administration form signed by the LVN, specified that medications are not to be left unattended with residents and that best practice is to observe residents while they take medications, but the facility’s written drug administration and pharmacy services policies did not explicitly address remaining with residents until medications are taken.
Failure to Prevent and Treat Pressure Ulcer
Penalty
Summary
The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing for a resident who was admitted without a pressure ulcer. Within two weeks of admission, the resident developed an unstageable pressure ulcer with eschar on her coccyx. The facility did not notify the wound care nurse of the ulcer, nor did they accurately document the resident's skin conditions, which led to delayed care for the ulcer. The resident, who was admitted for rehabilitation services, had a severely impaired cognition and was dependent on staff for activities of daily living. Despite being at risk for skin issues, the facility did not perform weekly skin assessments or document any treatment for a coccyx pressure ulcer until after the resident was admitted to the hospital. The hospital records indicated that the pressure ulcer was present upon admission, and the resident's responsible party, who was a nurse, confirmed that the ulcer was unstageable with eschar and tunneling. Interviews with facility staff revealed a lack of communication and documentation regarding the resident's pressure ulcer. The Director of Nursing and other staff members admitted that weekly skin assessments were not conducted, and the wound care nurse was not informed of the ulcer. The facility's failure to follow its own policies on skin care and prevention contributed to the development and worsening of the resident's pressure ulcer.
Deficiencies in Food Storage and Safety Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, as observed in 7 out of 8 resident snack refrigerators located in the dining rooms. The deficiencies included improper storage, labeling, and dating of food items, as well as the presence of expired foods, non-food items, and staff items in the refrigerators. Additionally, the cleanliness of the refrigerators was not maintained, with food spills and crumbs observed in several units. During observations and interviews, it was noted that the refrigerators were intended for resident use, but staff frequently used them for personal food storage, contrary to facility policy. There was a lack of clarity among staff regarding who was responsible for maintaining and cleaning the refrigerators. Interviews with various staff members, including the Dietary Manager, Housekeeping Supervisor, and nursing staff, revealed confusion and a lack of policies or cleaning schedules for the resident refrigerators. The facility's policies on food storage and safety were not adequately implemented, as evidenced by the unlabeled, undated, and improperly stored food items. The absence of cleaning sheets and clear responsibility for refrigerator maintenance contributed to the unsanitary conditions. The report highlights the risk of foodborne illness due to these deficiencies, as acknowledged by several staff members during interviews.
Failure to Inform Residents and Return Bedrails
Penalty
Summary
The facility failed to ensure that residents were informed in advance about the risks and benefits of proposed care, treatment alternatives, and options, as well as their right to choose their preferred alternatives. This deficiency affected five specific residents and five additional residents interviewed anonymously. The issue primarily revolved around the removal of bedrails, which residents had requested to be returned for their mobility, positioning, and comfort. Despite these requests, the facility did not return the bedrails for ten days or more, leading to feelings of discomfort and disrespect among the residents. Resident #13, a cognitively intact male with multiple diagnoses including epilepsy and Alzheimer's, expressed his frustration over the removal of his bedrails, which he used for safety and mobility. Similarly, Resident #15, a cognitively intact female with conditions such as CHF and epilepsy, reported her bedrails were removed without her consent, despite having a physician's order for their use. Resident #47, who had been using bedrails for years, found them locked and inaccessible, and was told by staff that state regulations prohibited their use. Resident #70, who was severely cognitively impaired, also had his bedrails removed, affecting his ability to reposition himself. Resident #75, who used bedrails for stability during transfers, reported the removal of her bedrails and her desire to have them returned. The facility's Director of Nursing (DON) and Administrator acknowledged the removal of bedrails, citing a previous survey deficiency and a decision to reassess the need for bedrails facility-wide. They planned to replace bedrails with U-Bars unless ordered by physical therapy. However, the reassessment process was delayed, and the facility had not completed evaluations for all residents who requested the return of their bedrails. The facility's actions led to multiple resident complaints and a failure to uphold residents' rights to participate in their care and make decisions about their treatment.
Failure to Provide Medicare/Medicaid Coverage Notices
Penalty
Summary
The facility failed to inform residents of their rights regarding Medicare/Medicaid coverage and potential liabilities for services not covered. Specifically, the facility did not provide the required Notice of Medicare Non-Coverage (NOMNC) and Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) to three residents when their skilled services were terminated before the exhaustion of covered days. This oversight could prevent residents from being aware of their right to appeal the decision to end Medicare coverage for skilled services. Resident #31, a female with a history of cerebrovascular disease, COPD, heart failure, and dysphagia, was admitted to the facility from an acute care hospital. Her Medicare Part A coverage began on 10/15/24, and she was discharged to an assisted living facility on 11/20/24. Despite her transition, there was no documentation indicating that she received the necessary NOMNC or SNF ABN forms, which would have informed her of her rights to appeal the termination of skilled services. Similarly, Resident #82, a male with musculoskeletal issues, atrial fibrillation, and muscle weakness, and Resident #240, a female with a fracture, osteoarthritis, and heart failure, were also not provided with the required notices. Both residents were admitted from acute care hospitals and had Medicare Part A coverage. The facility's staff, including the IP and DON, were either unfamiliar with the process or believed the notices were unnecessary due to the residents' transitions to lower levels of care. This lack of communication and documentation highlights a significant deficiency in the facility's handling of Medicare/Medicaid coverage notifications.
Inaccurate MDS Assessment for Urinary Catheter
Penalty
Summary
The facility failed to ensure an accurate assessment of a resident's status, specifically regarding the presence of a urinary catheter. The resident, a female with multiple diagnoses including cerebrovascular disease, epilepsy, lupus, diabetes, and dementia, was marked as having an indwelling catheter in her quarterly MDS assessment. However, a review of her medical records, including her order summary report and care plan, revealed no orders or care plans for an indwelling catheter. An observation confirmed that the resident did not have an indwelling catheter, and interviews with the MDS Coordinator and the Director of Nursing (DON) verified that the MDS was marked incorrectly. The MDS Coordinator acknowledged the error, stating it might have been marked by accident, and emphasized the potential financial and service-related impacts of such inaccuracies. The facility's policy requires that assessments accurately reflect the resident's current status, and the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual provides specific steps for assessing the presence of urinary or bowel appliances. The incorrect marking of the MDS could affect reimbursement and billing, and if done intentionally, could be considered fraud.
Failure to Change Nebulizer Tubing in a Timely Manner
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents, as evidenced by the lack of timely changes to nebulizer tubing. Resident #6, a cognitively intact female with chronic obstructive pulmonary disease (COPD) and other health issues, had her nebulizer tubing unchanged for four months. Observations revealed that the tubing appeared cloudy, and the mask had small particles inside, indicating a lack of maintenance. Despite the resident's report that staff provided all necessary respiratory care, the facility did not have specific orders or procedures for changing respiratory equipment. Similarly, Resident #79, a moderately cognitively impaired male with obstructive sleep apnea and other conditions, had his nebulizer tubing unchanged for six months. Observations showed the tubing was cloudy and discolored, with particles on the mask's inner surface. The facility's policy required monthly changes and nightly assessments of respiratory equipment, but this was not adhered to, as confirmed by staff interviews. The Licensed Vocational Nurse (LVN) and Director of Nursing (DON) acknowledged the oversight and the potential risk of infection due to the prolonged use of the same equipment. The facility's administrator admitted that there was no specific policy detailing the frequency of respiratory equipment care, only that it should be provided. The facility's existing policy on respiratory equipment maintenance, dated 2016, emphasized standardized and consistent equipment changes to ensure cleanliness and proper maintenance. However, the lack of adherence to this policy resulted in the deficiency, placing residents at risk for respiratory infections and other complications.
Deficiencies in Medication Management and Storage
Penalty
Summary
The facility failed to provide adequate pharmaceutical services, as evidenced by the improper handling and administration of medications for Resident #75 and the presence of expired medications in two medication storage areas. Resident #75, a cognitively intact female with multiple medical conditions including rheumatoid arthritis and osteoporosis, was left unattended with her morning medications by LVN B. The resident reported difficulty swallowing pills and often took them slowly, yet LVN B felt comfortable leaving the medications with her, assuming she could take them independently. This practice was contrary to the facility's expectations, as stated by the DON, who emphasized that nurses should ensure residents take their medications and document the administration. Additionally, the facility's medication storage practices were found to be deficient. During observations, expired over-the-counter medications were discovered in both the Rehabilitation and Long-Term Care medication room and the 1-North medication room. LVN C and LVN D acknowledged the issue, noting that expired medications could be ineffective and negatively impact resident care. The DON confirmed that it was the responsibility of floor nurses to check for expired medications and dispose of them properly, highlighting a lapse in adherence to this protocol. The facility's policies were also found lacking, as there was no policy available for medication storage despite multiple requests. The Drug Administration Policy did not cover self-administration, and there was no documentation of a care plan for Resident #75's self-administration of medications. This lack of comprehensive policies and oversight contributed to the deficiencies observed in medication management and storage within the facility.
Improper Storage of Controlled Drug in Medication Room
Penalty
Summary
The facility failed to properly store a controlled drug, specifically a Schedule III narcotic, in the Rehabilitation and Long-Term Care medication room. During an observation, it was found that Buprenorphine tablets were placed on a refrigerator shelf instead of being secured in the locked box provided on the refrigerator door. This improper storage was confirmed by LVN C, who acknowledged that the narcotic was accessible to any nurse without a log to track its use, potentially affecting resident care by making the medication unavailable for treatment. The Director of Nursing (DON) confirmed that the narcotic should have been stored in a locked box to comply with the double lock system. The DON mentioned an issue with not having a key to the lock box, which led to the narcotic being improperly stored. Despite attempts to address the issue with maintenance, the problem persisted. Additionally, the facility lacked a policy for medication storage, as confirmed by a review of the facility's policy manual and multiple requests for the policy from the Administrator and DON, which went unanswered.
Inaccurate Fall Risk Documentation
Penalty
Summary
The facility failed to maintain complete, accurate, and systemically organized medical records for a resident, leading to inadequate documentation of fall risk evaluations. Specifically, the medical records for a resident with a history of falls did not accurately reflect the resident's fall incidents within the last 90 days. The resident, who had multiple falls resulting in injuries, had fall risk evaluations that incorrectly stated no history of falls in the last three months. This discrepancy was noted in the nurse's notes and fall risk evaluations dated January, February, and March, despite the resident experiencing falls during this period, including one that resulted in a laceration and transfer to the ER. Interviews with the Director of Nursing (DON) and Licensed Vocational Nurses (LVNs) revealed that the assessments were made in error, and the incorrect documentation could lead to inadequate care planning and risk management for the resident. The resident involved was an elderly female with diagnoses including muscle weakness, history of falling, insomnia, unspecified dementia with behavioral disturbances, hallucinations, and long-term use of anticoagulants. The resident was cognitively intact with a BIMS score of 13 and required total dependency for mobility tasks. Observations revealed the resident had bruising and a healing laceration on her forehead from a recent fall. The facility's policy on Electronic Health Records emphasized the importance of accurate and complete documentation, which was not adhered to in this case, leading to potential risks for the resident's safety and care quality.
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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.
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Nursing homes near Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Georgia Manor Nursing Home | 2.8 mi | — | 0 | 0 |
| Heritage Convalescent Center | 3.4 mi | — | 9 | 0 |
| Windflower Health Center | 3.4 mi | — | 0 | 0 |
| Amarillo Medical Lodge | 3.4 mi | — | 4 | 0 |
| Landmark Of Amarillo Rehabilitation And Nursing Ce | 3.6 mi | — | 14 | 0 |
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