Cycle 1
Health 2025-01-09 · Fire 2025-01-09
3 health deficiencies
Top issue: Infection Control (1 deficiency)
2 fire-safety deficiencies
Top issue: Miscellaneous (1 deficiency)
Amarillo, TX
Amarillo Medical Lodge
5-star overall rating with 5-star inspections with 3 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
9 Medical Dr, Amarillo, TX
(806) 352-2731
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
102
Certified beds
Average residents
65
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
The Ensign Group
Operator or chain grouping
Approved since
1994-04-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
329 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.63
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.03
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.70
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.35
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.65
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.94
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.71
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.12
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.06
CMS adjusted total nurse staffing hours
Case-mix index
1.50
Higher values indicate more complex resident acuity
RN turnover
58%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
58%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
13,155
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
7.88
Composite VBP score used to determine payment impact.
Payment multiplier
0.9807
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 19.01% · Performance 21.40% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0
Baseline 6.26% · Performance 7.93% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
3.15
Baseline 71.15% · Performance 54.24% · Measure score 3.15 · Achievement 2.31 · Improvement 3.15
Adjusted total nurse staffing
0
Baseline 3.51 hours · Performance 3.14 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 12.02% |
10.72%
1.3 pts worse
|
No Different than the National Rate · Eligible stays 242 · Observed rate 13.64% · Lower 95% interval 8.9% |
| Discharge to community | 52.42% |
50.57%
1.9 pts better
|
No Different than the National Rate · Eligible stays 255 · Observed rate 46.67% · Lower 95% interval 46.54% |
| Medicare spending per beneficiary | 1.04 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 97.35% |
95.27%
2.1 pts better
|
Numerator 220 · Denominator 226 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 226 |
| Discharge self-care score | 49.69% |
53.69%
4 pts worse
|
Numerator 80 · Denominator 161 |
| Discharge mobility score | 37.27% |
50.94%
13.7 pts worse
|
Numerator 60 · Denominator 161 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 226 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.93% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 175 · Observed rate 8% · Lower 95% interval 5.18% |
| Staff COVID-19 vaccination coverage | 0.83% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 120 |
| Staff flu vaccination coverage | Not Available |
42%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge function score | 50.31% |
56.45%
6.1 pts worse
|
Numerator 81 · Denominator 161 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 132 · Denominator 132 |
| Transfer of health information to patient | 98.41% |
96.28%
2.1 pts better
|
Numerator 62 · Denominator 63 |
| Resident COVID-19 vaccinations up to date | 1.57% |
25.2%
23.6 pts worse
|
Numerator 2 · Denominator 127 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 2.3 · Expected 4.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.8 |
2.1
1.3 pts better
|
1.8
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.8 · Observed 1.4 · Expected 2.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
97.1%
2.9 pts better
|
93.4%
6.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
97.9%
2.1 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 0.0% |
3.3%
3.3 pts better
|
3.3%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 5.6% |
2.7%
2.9 pts worse
|
11.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q4 9.1% · 4Q avg 5.6% |
| Percentage of long-stay residents who lose too much weight | 1.2% |
3.3%
2.1 pts better
|
5.4%
4.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 4.2% · 4Q avg 1.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 5.7% |
18.9%
13.2 pts better
|
19.6%
13.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.4% · Q4 7.7% · 4Q avg 5.7% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.5% |
10.8%
9.3 pts better
|
16.7%
15.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 1.5% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 12.3% |
15.4%
3.1 pts better
|
16.3%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 12.3% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 8.5% |
16.1%
7.6 pts better
|
14.9%
6.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · 4Q avg 8.5% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.7% |
0.5%
0.2 pts worse
|
1.0%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
0.8%
0.8 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 17.9% |
15.0%
2.9 pts worse
|
19.8%
1.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.4% · Q4 7.7% · 4Q avg 17.9% |
| Percentage of long-stay residents with pressure ulcers | 6.5% |
4.2%
2.3 pts worse
|
5.1%
1.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 5.2% · Q4 0.0% · 4Q avg 6.5% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.0% |
89.7%
9.3 pts better
|
81.7%
17.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.7% · Q3 98.2% · Q4 98.5% · 4Q avg 99.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.1% |
12.0%
4.9 pts better
|
12.0%
4.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.1% · Observed 8.0% · Expected 12.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.0% |
1.5%
1.5 pts better
|
1.6%
1.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 98.6% |
88.0%
10.6 pts better
|
79.7%
18.9 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 98.6% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 19.6% |
25.9%
6.3 pts better
|
23.9%
4.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 19.6% · Observed 20.9% · Expected 25.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-06 · Fire 2023-12-06
4 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-02 · Fire 2022-11-02
3 health deficiencies
Top issue: Resident Assessment and Care Planning (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
D · Potential for more than minimal harm
2025-01-09
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-01-27
D · Potential for more than minimal harm
2025-01-09
K741 · Miscellaneous Deficiencies
Fire Safety
Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.
Corrected 2025-01-27
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-01-09
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-01-10
D · Potential for more than minimal harm
2025-01-09
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-01-10
D · Potential for more than minimal harm
2025-01-09
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-01-10
D · Potential for more than minimal harm
2024-05-07
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-05-08
D · Potential for more than minimal harm
2023-12-06
F641 · Resident Assessment and Care Planning Deficiencies
Health
Ensure each resident receives an accurate assessment.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-12-06
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-12-06
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-12-07
D · Potential for more than minimal harm
2023-08-03
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2023-08-18
D · Potential for more than minimal harm
2023-07-12
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2023-07-13
D · Potential for more than minimal harm
2022-11-02
F656 · Resident Assessment and Care Planning Deficiencies
Health
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected 2022-11-09
Penalties and ownership
What sits behind the stars
Ownership
Booker Hospital District
5% Or Greater Direct Ownership Interest · Organization
Burnam, Soon
Corporate Officer · Individual
Cantrell, Christopher
Operational/Managerial Control · Individual
Hoover, Shawn
Corporate Officer · Individual
Keetch, Chad
Corporate Officer · Individual
Rankin, Ron
Operational/Managerial Control · Individual
Rowlett Creek Healthcare LLC
Operational/Managerial Control · Organization
Nearby options
Other facilities in reach
#1
Windflower Health Center
Amarillo, TX
3-star overall rating with 3-star inspections with $4,922 in total fines with 9 recent health deficiencies
#2
Heritage Convalescent Center
Amarillo, TX
2-star overall rating with 3-star inspections with 11 recent health deficiencies
#3
Landmark Of Amarillo Rehabilitation And Nursing Ce
Amarillo, TX
4-star overall rating with 4-star inspections with $147,878 in total fines with 5 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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