Cycle 1
Health 2025-04-11 · Fire 2025-04-11
11 health deficiencies
Top issue: Pharmacy Service (4 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Amarillo, TX
Windflower Health Center
3-star overall rating with 3-star inspections with $4,922 in total fines with 9 recent health deficiencies
5500 Sw 9th Ave, Amarillo, TX
(806) 352-7244
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
72
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Lifespace Communities
Operator or chain grouping
Approved since
2002-02-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
16 facilities
Chain averages 4 overall / 3 health / 4 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
0.64
Registered nurse staffing · state 0.44 · national 0.68
LPN hours / resident day
1.12
Licensed practical nurse staffing · state 0.95 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.01 · national 2.35
Total nurse hours
3.80
All reported nurse hours · state 3.40 · national 3.89
Licensed hours
1.76
RN + LPN hours · state 1.38 · national 1.54
Weekend hours
3.22
Weekend nurse staffing · state 2.99 · national 3.43
Weekend RN hours
0.43
Weekend registered nurse coverage · state 0.34 · national 0.47
Physical therapist
0.06
Reported PT staffing · state 0.07 · national 0.07
Adjusted RN hours
0.71
CMS adjusted RN staffing hours
Adjusted total hours
4.18
CMS adjusted total nurse staffing hours
Case-mix index
1.24
Higher values indicate more complex resident acuity
RN turnover
77%
Annual RN turnover · state 52% · national 45%
Total nurse turnover
54%
Annual nurse turnover · state 52% · national 46%
SNF VBP
Value-based purchasing
Program rank
12,159
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
13.65
Composite VBP score used to determine payment impact.
Payment multiplier
0.9812
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0
Baseline 20.45% · Performance 23.51% · Measure score 0 · Achievement 0 · Improvement 0
Healthcare-associated infections
0.82
Baseline 5.42% · Performance 7.59% · Measure score 0.82 · Achievement 0.82 · Improvement 0
Total nurse turnover
0.79
Baseline 59.09% · Performance 60.44% · Measure score 0.79 · Achievement 0.79 · Improvement 0
Adjusted total nurse staffing
3.84
Baseline 4.41 hours · Performance 4.17 hours · Measure score 3.84 · Achievement 3.84 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.6% |
10.72%
0.1 pts better
|
No Different than the National Rate · Eligible stays 382 · Observed rate 9.42% · Lower 95% interval 8.12% |
| Discharge to community | 60.3% |
50.57%
9.7 pts better
|
Better than the National Rate · Eligible stays 374 · Observed rate 56.68% · Lower 95% interval 55.9% |
| Medicare spending per beneficiary | 0.83 |
1.02
0.2 pts better
|
|
| Drug regimen review with follow-up | 99.6% |
95.27%
4.3 pts better
|
Numerator 249 · Denominator 250 |
| Falls with major injury | 0.4% |
0.77%
0.4 pts better
|
Numerator 1 · Denominator 250 |
| Discharge self-care score | 64.05% |
53.69%
10.4 pts better
|
Numerator 98 · Denominator 153 |
| Discharge mobility score | 33.33% |
50.94%
17.6 pts worse
|
Numerator 51 · Denominator 153 |
| Pressure ulcers or injuries, new or worsened | 3.6% |
2.29%
1.3 pts worse
|
Numerator 9 · Denominator 250 · Adjusted rate 4.59% |
| Healthcare-associated infections requiring hospitalization | 7.59% |
7.12%
0.5 pts worse
|
No Different than the National Rate · Eligible stays 231 · Observed rate 6.93% · Lower 95% interval 4.59% |
| Staff COVID-19 vaccination coverage | 0% |
8.2%
8.2 pts worse
|
Numerator 0 · Denominator 118 |
| Staff flu vaccination coverage | 70.35% |
42%
28.3 pts better
|
Numerator 121 · Denominator 172 |
| Discharge function score | 49.67% |
56.45%
6.8 pts worse
|
Numerator 76 · Denominator 153 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 139 · Denominator 139 |
| Transfer of health information to patient | 98.61% |
96.28%
2.3 pts better
|
Numerator 71 · Denominator 72 |
| Resident COVID-19 vaccinations up to date | 5.38% |
25.2%
19.8 pts worse
|
Numerator 7 · Denominator 130 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 2.7 |
2.1
0.6 pts worse
|
1.9
0.8 pts worse
|
Long Stay · 20240701-20250630 · Adjusted 2.7 · Observed 2.8 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.9 |
2.1
1.2 pts better
|
1.8
0.9 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.8 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.5% |
97.1%
2.4 pts better
|
93.4%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 98.1% · Q3 100.0% · Q4 100.0% · 4Q avg 99.5% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.1% |
97.9%
0.2 pts better
|
95.5%
2.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 6.6% |
3.3%
3.3 pts worse
|
3.3%
3.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.2% · Q2 7.7% · Q3 6.4% · Q4 6.1% · 4Q avg 6.6% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 4.5% |
2.7%
1.8 pts worse
|
11.4%
6.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 4.4% · Q4 13.3% · 4Q avg 4.5% |
| Percentage of long-stay residents who lose too much weight | 5.0% |
3.3%
1.7 pts worse
|
5.4%
0.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 4.7% · Q3 9.5% · Q4 2.5% · 4Q avg 5.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 17.0% |
18.9%
1.9 pts better
|
19.6%
2.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 20.5% · Q2 16.3% · Q3 14.3% · Q4 17.1% · 4Q avg 17.0% |
| Percentage of long-stay residents who received an antipsychotic medication | 9.3% |
10.8%
1.5 pts better
|
16.7%
7.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 8.8% · Q2 13.2% · Q3 7.5% · Q4 7.7% · 4Q avg 9.3% · 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 | 11.0% |
15.4%
4.4 pts better
|
16.3%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q2 10.1% · Q3 7.8% · 4Q avg 11.0% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 21.8% |
16.1%
5.7 pts worse
|
14.9%
6.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 19.4% · Q2 26.8% · Q3 20.0% · Q4 20.5% · 4Q avg 21.8% · 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 | 1.0% |
0.8%
0.2 pts worse
|
1.7%
0.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.2% · Q2 0.0% · Q3 2.1% · Q4 0.0% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 25.4% |
15.0%
10.4 pts worse
|
19.8%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 10.1% · Q2 33.1% · Q3 25.4% · Q4 31.4% · 4Q avg 25.4% |
| Percentage of long-stay residents with pressure ulcers | 6.2% |
4.2%
2 pts worse
|
5.1%
1.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 12.1% · Q2 4.5% · Q3 8.7% · Q4 0.0% · 4Q avg 6.2% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 92.3% |
89.7%
2.6 pts better
|
81.7%
10.6 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 90.6% · Q2 90.4% · Q3 91.3% · Q4 97.2% · 4Q avg 92.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 12.9% |
12.0%
0.9 pts worse
|
12.0%
0.9 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 12.9% · Observed 12.4% · Expected 10.7% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.7% · Q2 1.4% · Q3 1.4% · Q4 0.8% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 88.1% |
88.0%
0.1 pts better
|
79.7%
8.4 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 88.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 30.2% |
25.9%
4.3 pts worse
|
23.9%
6.3 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 30.2% · Observed 26.9% · Expected 21.2% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-02-29 · Fire 2024-02-29
8 health deficiencies
Top issue: Resident Assessment and Care Planning (3 deficiencies)
1 fire-safety deficiencies
Top issue: Gas and Vacuum and Electrical Systems (1 deficiency)
Cycle 3
Health 2022-12-07 · Fire 2022-12-07
9 health deficiencies
Top issue: Pharmacy Service (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Fire safety
Fire-safety citations
F · Potential for more than minimal harm
2024-02-29
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2024-03-21
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-04-11
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 2025-05-23
E · Potential for more than minimal harm
2025-04-11
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 2025-05-23
E · Potential for more than minimal harm
2025-04-11
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 2025-05-23
E · Potential for more than minimal harm
2025-04-11
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-11
F644 · Resident Assessment and Care Planning Deficiencies
Health
Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-11
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 2025-05-23
D · Potential for more than minimal harm
2025-04-11
F695 · Quality of Life and Care Deficiencies
Health
Provide safe and appropriate respiratory care for a resident when needed.
Corrected 2025-05-23
D · Potential for more than minimal harm
2025-04-11
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2025-05-23
E · Potential for more than minimal harm
2025-04-02
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 2025-04-08
E · Potential for more than minimal harm
2025-04-02
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 2025-04-08
D · Potential for more than minimal harm
2025-04-02
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2025-04-08
D · Potential for more than minimal harm
2024-07-16
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2024-08-15
D · Potential for more than minimal harm
2024-02-29
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2024-03-20
D · Potential for more than minimal harm
2024-02-29
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2024-03-21
D · Potential for more than minimal harm
2024-02-29
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 2024-03-20
D · Potential for more than minimal harm
2024-02-29
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 2024-03-20
D · Potential for more than minimal harm
2024-02-29
F700 · Quality of Life and Care Deficiencies
Health
Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.
Corrected 2024-03-29
D · Potential for more than minimal harm
2024-02-29
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 2024-03-01
D · Potential for more than minimal harm
2024-02-29
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 2024-03-01
D · Potential for more than minimal harm
2023-11-20
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2023-12-15
F · Potential for more than minimal harm
2023-08-21
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 2023-09-15
D · Potential for more than minimal harm
2023-04-08
F609 · Freedom from Abuse, Neglect, and Exploitation Deficiencies
Health
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected 2023-05-15
F · Potential for more than minimal harm
2022-12-07
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 2023-01-16
E · Potential for more than minimal harm
2022-12-07
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 2023-01-16
D · Potential for more than minimal harm
2022-12-07
F638 · Resident Assessment and Care Planning Deficiencies
Health
Assure that each resident’s assessment is updated at least once every 3 months.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-07
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-07
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2023-01-16
D · Potential for more than minimal harm
2022-12-07
F757 · Pharmacy Service Deficiencies
Health
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Corrected 2023-01-16
Penalties and ownership
What sits behind the stars
$1,748
2023-08-07
Fine
Fine · fine $1,748
Fine
$3,174
2023-07-17
Fine
Fine · fine $3,174
Fine
Ownership
Craig Amarillo LLC
Operational/Managerial Control · Organization
Gorman, Joseph
Operational/Managerial Control · Individual
Haley, Kelsey
Corporate Director · Individual
Haley, Kelsey
Corporate Officer · Individual
Harshfield, Nicholas
Corporate Officer · Individual
Hemphill County Hospital District
Operational/Managerial Control · Organization
Jantzen, Jesse
Corporate Officer · Individual
Lifespace Communities Inc
Operational/Managerial Control · Organization
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#3
Landmark Of Amarillo Rehabilitation And Nursing Ce
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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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