Cycle 1
Health 2025-03-26 · Fire 2025-03-26
10 health deficiencies
Top issue: Pharmacy Service (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Amarillo, TX
Five Points Nursing and Rehabilitation
3-star overall rating with 3-star inspections with $12,740 in total fines with 10 recent health deficiencies
1625 Point West Parkway, Amarillo, TX
(817) 348-8969
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
1 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
88
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Creative Solutions In Healthcare
Operator or chain grouping
Approved since
2018-10-04
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
149 facilities
Chain averages 3 overall / 3 health / 2 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
0.38
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.18
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
1.88
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.44
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.56
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
2.98
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.24
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.40
CMS adjusted RN staffing hours
Adjusted total hours
3.61
CMS adjusted total nurse staffing hours
Case-mix index
1.30
Higher values indicate more complex resident acuity
RN turnover
62%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
56%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
10,094
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
21.46
Composite VBP score used to determine payment impact.
Payment multiplier
0.9826
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
1.06
Baseline 21.25% · Performance 20.94% · Measure score 1.06 · Achievement 1.06 · Improvement 0.24
Healthcare-associated infections
6.39
Baseline 5.97% · Performance 5.93% · Measure score 6.39 · Achievement 6.39 · Improvement 0
Total nurse turnover
0.55
Baseline 47.50% · Performance 61.43% · Measure score 0.55 · Achievement 0.55 · Improvement 0
Adjusted total nurse staffing
0.58
Baseline 2.71 hours · Performance 3.04 hours · Measure score 0.58 · Achievement 0 · Improvement 0.58
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.61% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 558 · Observed rate 9.5% · Lower 95% interval 8.31% |
| Discharge to community | 69.08% |
50.57%
18.5 pts better
|
Better than the National Rate · Eligible stays 518 · Observed rate 66.22% · Lower 95% interval 64.53% |
| Medicare spending per beneficiary | 0.79 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 75.75% |
95.27%
19.5 pts worse
|
Numerator 253 · Denominator 334 |
| Falls with major injury | 0.3% |
0.77%
0.5 pts better
|
Numerator 1 · Denominator 334 |
| Discharge self-care score | 64.15% |
53.69%
10.5 pts better
|
Numerator 170 · Denominator 265 |
| Discharge mobility score | 59.62% |
50.94%
8.7 pts better
|
Numerator 158 · Denominator 265 |
| Pressure ulcers or injuries, new or worsened | 3.59% |
2.29%
1.3 pts worse
|
Numerator 12 · Denominator 334 · Adjusted rate 4.13% |
| Healthcare-associated infections requiring hospitalization | 5.93% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 282 · Observed rate 4.26% · Lower 95% interval 3.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 124 |
| Staff flu vaccination coverage | 24.76% |
42%
17.2 pts worse
|
Numerator 51 · Denominator 206 |
| Discharge function score | 68.68% |
56.45%
12.2 pts better
|
Numerator 182 · Denominator 265 |
| Transfer of health information to provider | 96.39% |
95.95%
0.4 pts better
|
Numerator 80 · Denominator 83 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 222 · Denominator 222 |
| Resident COVID-19 vaccinations up to date | 6.36% |
25.2%
18.8 pts worse
|
Numerator 11 · Denominator 173 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.2 |
2.1
0.1 pts worse
|
1.9
0.3 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.2 · Observed 1.7 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
2.1
0.8 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · 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% · Q2 100.0% · Q3 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 | 4.4% |
3.3%
1.1 pts worse
|
3.3%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 3.6% · Q2 3.4% · Q3 3.6% · Q4 6.8% · 4Q avg 4.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.3% |
2.7%
0.6 pts worse
|
11.4%
8.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.0% · Q2 3.8% · Q3 3.8% · Q4 3.5% · 4Q avg 3.3% |
| Percentage of long-stay residents who lose too much weight | 0.5% |
3.3%
2.8 pts better
|
5.4%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.0% · 4Q avg 0.5% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 7.4% |
18.9%
11.5 pts better
|
19.6%
12.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 7.8% · Q3 12.0% · Q4 5.9% · 4Q avg 7.4% |
| Percentage of long-stay residents who received an antipsychotic medication | 1.1% |
10.8%
9.7 pts better
|
16.7%
15.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 4.3% · 4Q avg 1.1% · 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% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.9% |
15.4%
0.5 pts better
|
16.3%
1.4 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 14.9% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.2% |
16.1%
4.9 pts better
|
14.9%
3.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.0% · Q2 14.3% · Q3 10.4% · Q4 12.0% · 4Q avg 11.2% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.5%
0.5 pts better
|
1.0%
1 pts better
|
Long 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 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% · Q2 0.0% · Q3 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 | 16.2% |
15.0%
1.2 pts worse
|
19.8%
3.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 14.8% · Q2 18.6% · Q3 20.2% · Q4 11.5% · 4Q avg 16.2% |
| Percentage of long-stay residents with pressure ulcers | 1.7% |
4.2%
2.5 pts better
|
5.1%
3.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.7% · Q2 2.9% · Q3 1.4% · Q4 0.0% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 99.8% |
89.7%
10.1 pts better
|
81.7%
18.1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.7% · Q3 99.7% · Q4 100.0% · 4Q avg 99.8% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 9.1% |
12.0%
2.9 pts better
|
12.0%
2.9 pts better
|
Short Stay · 20240701-20250630 · Adjusted 9.1% · Observed 8.5% · Expected 10.4% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.2% |
1.5%
1.3 pts better
|
1.6%
1.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.5% · Q3 0.5% · Q4 0.0% · 4Q avg 0.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 99.7% |
88.0%
11.7 pts better
|
79.7%
20 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 99.7% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.7% |
25.9%
0.2 pts better
|
23.9%
1.8 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.7% · Observed 23.8% · Expected 22.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-13 · Fire 2024-02-13
4 health deficiencies
Top issue: Freedom from Abuse and Neglect and Exploitation (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-12-13 · Fire 2022-12-13
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
J · Immediate jeopardy
2026-01-08
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Not marked corrected
D · Potential for more than minimal harm
2025-06-04
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 2025-06-17
E · Potential for more than minimal harm
2025-03-26
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2025-03-27
E · Potential for more than minimal harm
2025-03-26
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 2025-03-27
E · Potential for more than minimal harm
2025-03-26
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 2025-03-27
D · Potential for more than minimal harm
2025-03-26
F578 · Resident Rights Deficiencies
Health
Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-26
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-26
F655 · Resident Assessment and Care Planning Deficiencies
Health
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-26
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-03-26
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-27
D · Potential for more than minimal harm
2025-02-20
F600 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Corrected 2025-01-26
F · Potential for more than minimal harm
2024-02-13
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 2024-03-01
D · Potential for more than minimal harm
2024-02-13
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 2024-03-01
D · Potential for more than minimal harm
2024-02-13
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2024-03-01
F · Potential for more than minimal harm
2022-12-13
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 2023-01-04
D · Potential for more than minimal harm
2022-12-13
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2022-12-14
D · Potential for more than minimal harm
2022-12-13
F755 · Pharmacy Service Deficiencies
Health
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Corrected 2022-12-14
Penalties and ownership
What sits behind the stars
$12,740
2026-01-08
Fine
Fine · fine $12,740
Fine
Ownership
Liberty County Hospital District No. 1
5% Or Greater Direct Ownership Interest · Organization
Amarillo Vii Enterprises, LLC
Operational/Managerial Control · Organization
Blake, Gary
Operational/Managerial Control · Individual
Blake, Malisa
Operational/Managerial Control · Individual
Huggins, Linda
Corporate Director · Individual
Stratton, Charles
Corporate Officer · Individual
Willig, Zachary
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Kirkland Court Health and Rehabilitation Center
Amarillo, TX
1-star overall rating with 1-star inspections with abuse icon flag with $25,480 in total fines with 14 recent health deficiencies with 3 fire-safety deficiencies in the latest cycle
#2
Amarillo Center For Skilled Care
Amarillo, TX
4-star overall rating with 3-star inspections with $21,390 in total fines with 8 recent health deficiencies
#3
Heritage Convalescent Center
Amarillo, TX
2-star overall rating with 3-star inspections with 11 recent health deficiencies
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