Georgia Manor Nursing Home

impacted mentally and physically if their call light was out of reach due to not getting the assistance

for ensuring proper placement of call lights. DON stated if a call light was out of reach of a resident

06/05/26 at 09:39 AM ADM stated call lights should be in reach or residents at all times.

She stated all staff were responsible for ensuring call lights were in reach of residents. ADM stated a resident could be negatively impacted if their call light was out of reach and something happens and they can't pull (the) call bell.

She stated all department heads had several rooms assigned to them which they were responsible for checking twice during each shift and part of the checking included call light placement. ADM stated HR checked Resident #37's room twice a day.

During an interview on 06/05/26 at 09:48 AM MDS RN stated call lights should be in reach of residents because that is how they talk to us.

She stated all staff were responsible for ensuring call lights were in reach of residents. MDS RN stated a resident could be negatively impacted if their call light was out of reach due to not being able to get needed help.

During an interview on 06/05/26 at 09:49 AM HR stated she checked on Resident #37 two times between 08:00 AM and 05:00 PM on 06/03/26.

She stated Resident #37's call light was in reach both times.

Record review of pages 4-6 of the facility's admission packet dated 09/01/25 and titled, Resident's Rights revealed the following: .

You have the right to: Receive all care necessary to have the highest possible level of health.

Record review of an undated facility policy titled, Resident Rights revealed the following, . 3.

The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences.

675851 06/05/2026

Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

During an observation on 06/04/2026 at 8:42 AM, LVN F was observed walking away from the Hall B medication cart a second time to retrieve keys from another nurse.

The computer screen was again left fully open and active, publicly displaying residents' private eMAR information.

During an interview on 06/04/2026 at 8:50 AM, regarding the unsecured computer screen, LVN F acknowledged that leaving a resident's personal health information visible on an open monitor constitutes an unauthorized sharing of patient information and was a HIPAA violation.

During an interview on 06/04/2026 at 10:35 AM, the DON stated that the negative outcome of leaving an active computer screen open was that someone could walk by and see information that is supposed to be protected and private.

The DON confirmed that maintaining screen security is the sole responsibility of the nurse assigned to that specific cart and unit.

During an interview on 06/04/2026 at 10:37 AM, the ADM stated that leaving a computer active with resident information on display is a HIPAA violation that allows other residents and family members to see information that isn't supposed to be shared.

The Administrator stated electronic privacy is the responsibility of all staff, particularly the nurse working in that specific hallway.

During an interview on 06/04/2026 at 11:01 AM, the CCN stated leaving a computer terminal open with private records allows family members and other residents to access information that is private and not authorized for disclosure.

During a record review of the facility's undated policy titled Resident Rights revealed the following mandates under the section Privacy and Confidentiality: The resident has a right to personal privacy and confidentiality of his or her personal medical records.The facility must respect the resident's right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications.The resident has a right to secure and confidential personal and medical records.

During a record review of the facility's standard Resident admission Packet, revised on September 1, 2025, revealed that under the Privacy and Confidentiality section, residents are guaranteed the right to: Have facility information about you maintained as confidential.

675851 06/05/2026

Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

resident's status for 1 (Resident #7) of 13 residents reviewed for accuracy of assessment.The facility

significant weight loss.This failure could place residents at risk of receiving unnecessary care/medication/supplementation.Findings Included:

Record review of Resident #7's admission record dated 06/03/26 revealed a 63-yeaer-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, unspecified protein-calorie malnutrition and dehydration.Record review of Resident #7's quarterly MDS assessment completed on 03/23/26 revealed a BIMS score of 9 which indicated moderately impaired cognition.

Section K Swallowing/Nutritional Status question K0300 was answered with a 2 which indicated Resident #7 had lost 5% or more in the last month or 10% or more in the last 6 months not on physician-prescribed weight-loss regimen.

Record review of Resident #7's care plan completed on 03/25/26 revealed the following focus area: The resident has a significant unplanned/unexpected weight loss Poor food intake-also anxiety issues.

This focus area was initiated on 10/16/25.

Record review of Resident #7's weights for the last 6 months revealed no weight loss of 5% in one month or 10% in 6 months relative to the ARD date (03/22/26) of his quarterly MDS assessment completed on 03/23/26. On 03/22/26 he weighed 119 pounds, on 02/20/26 he weighed 117.2 pounds, and on 09/24/25 he weighed 120 pounds.

During an interview on 06/05/26 at 08:58 AM LVN E stated MDS RN was responsible for completing MDS Assessments.

She stated an inaccurate MDS assessment could cause delays in getting proper care and could cause the care plan to be inaccurate.

During an interview on 06/05/26 at 09:05 AM RN D stated MDS RN was responsible for completing MDS Assessments.

She stated an inaccurate MDS assessment could negatively impact resident care and the care plan.

During an interview on 06/05/26 at 09:18 AM CNA B stated MDS RN was responsible for completing MDS Assessments.

She stated an inaccurate MDS assessment could cause residents to not receive needed assistance with ADLs.

During an interview on 06/05/26 at 09:30 AM DON stated MDS RN was responsible for completing MDS Assessments.

She stated an inaccurate MDS assessment would not affect resident care. DON stated, It (MDS assessment) doesn't change how we provide care.

Regardless of what MDS (assessment) says, we do what we need to do.

During an interview on 06/05/26 at 09:39 AM ADM stated MDS RN was responsible for completing MDS Assessments.

She stated an inaccurate MDS assessment could cause a resident not to get the care they need.

During an interview on 06/05/26 at 09:48 AM MDS RN stated she was responsible for completing MDS assessments.

She stated Resident #7's weight had fluctuated and changes in his medications seemed to have affected his weight.

She stated that was her reason for coding him for significant weight loss, not any real weight loss during the look back period.

She stated she used the RAI as her policy when completing MDS assessments.

Record review of facility policy titled, Minimum Data Set (MDS) Policy for MDS assessment Data Accuracy and dated 08/2025 revealed the following, .

The purpose of the MDS policy is to ensure each resident receives an accurate assessment by qualified staff to address the needs of the resident who are familiar with his/her physical, mental, and psychosocial well-being.

Record review of the Long-Term Care Facility RAI 3.0 User's Manual Version 1.20.1 dated October 2025 revealed the following: . K0300: Weight Loss Steps for Assessment This item compares the resident's weight in the current observation period with their weight at two snapshots in time: At a point closest to 30 days preceding the current weight. At a point closest to 180 days preceding the current weight.

The resident's weight captured closest to these two time points are the only two weights considered for this item, .

Coding instructions .

Code 0, no or unknown if the resident has not experience weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days .

Coding Tips A resident may experience weight variances in between the snapshot time periods.

Although these require follow up at the time, they are not captured on the MDS.

675851 06/05/2026

Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

with a mental disorder and individuals with intellectual disability for 1 (Resident #53) of 13 residents

screening for Resident #53 prior to admission on [DATE].This failure could place residents at risk of not receiving needed services.

Findings Included:

Record review of Resident #53's admission record dated 06/03/26 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of bipolar disorder unspecified with a diagnosis date of 05/27/26.

Record review of Resident #53's baseline care plan initiated on 05/27/26 revealed no mention of her bipolar diagnosis except in the list of her diagnoses on the last page of the care plan.

Record review of Resident #53's care plan completed on 06/04/26 revealed no mention of her bipolar diagnosis except in the list of her diagnoses on the last page of the care plan.

Record review of Resident #53's admission MDS assessment completed 06/03/26 revealed a BIMS of 14 which indicated intact cognition.

Section I Active Diagnoses revealed a diagnosis of bipolar disorder.

Record review of Resident #53's PL 1 revealed it was completed at a local hospital on [DATE]. Resident #53 was coded as having no mental illness.

During an interview on 06/05/26 at 09:30 AM DON stated MDS RN was responsible for completing PL 1's at or prior to admission.

She stated if a resident was coded by the hospital as having no mental illness but had an active diagnosis of mental illness the facility would correct the PL 1.

During an interview on 06/05/26 at 09:39 AM ADM stated MDS RN made sure the facility had a PL 1 prior to a resident being admitted .

She stated if a resident was coded on the PL 1 as having no mental illness but had a diagnosis of mental illness they might not receive PASARR services timely.

During an interview on 06/05/26 at 09:48 AM MDS RN stated she was responsible for ensuring residents had correctly coded PL 1's at or prior to admission. MDS RN stated when she received a PL 1 from a hospital she checked it for accuracy against the resident's diagnoses.

She stated she had recently taken time off and that was probably why she missed Resident #53's inaccurate PL 1.

She stated if a resident was coded as having no mental illness but had a diagnosis of mental illness, They don't get the treatment they need.

Record review of facility policy titled, PASRR Level 1 Policy and Procedure and dated 03/06/19 revealed the following: . It is the policy of [name of corporate] facilities to obtain a PL 1 screening form from the RE prior to admission to the NF. 3.

The facility will review the PL 1 screening for completion and correctness prior to admission.

The facility will maintain PL 1 Best Practices as followed: .

Review the PL 1 Form for completion and correctness before admission.

675851 06/05/2026

Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

review of the facility policy dated 10/2022, titled Trauma Informed Care Policy revealed: Purpose: The

preferences to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Care

family members, friends and any other health care professionals to develop and implement individualized interventions.

Facilities are responsible to try to identify triggers that may retraumatize the resident and develop care plan interventions that minimize or eliminate the effect of the trigger on the resident.

Trigger specific interventions should identify ways to decrease the resident's exposure to triggers that retraumatize resident as well as identify ways to mitigate or decrease the effect of the trigger on the resident.

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Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

interventions must be provided consistently, and supervising staff should monitor the delivery of care

members, friends and any other health care professionals to develop and implement individualized

and develop care plan interventions that minimize or eliminate the effect of the trigger on the resident.

675851 06/05/2026

Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

services of a licensed pharmacist.

are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2

facility failed to ensure that drug records for controlled substances were accurately maintained, verified, and periodically reconciled by licensed nursing staff during shift exchanges.

This failure could place all residents receiving controlled medications at risk for medication errors, drug diversion, and a lack of therapeutic continuity due to unverified narcotics inventories across 100% of the facility's medication carts (2 out of 2) over a six-month period.Findings Included: During a record review on 06/04/2026 at 9:26 AM, it was noted that narcotic books were not filled out completely with signatures for both morning and night shifts on the Hall A medication cart. It was noted that signatures were missing on 12/30/2025, 1/1/2026, 1/2/2026, 1/19/2026, 1/26/26, 1/30/26, 1/31/2026, 2/12/2026, 3/9/2026, 3/11/2026, 3/26/2026, and 4/2/2026.

During an interview on 06/04/2026 at 9:26 AM, LVN G stated that two nurses were not verifying the narcotic count by signing the book, and if the count was off, no one would know who to contact to see why it was off and what happened. LVN G confirmed that accountability rests with both the nurse taking over the cart and the nurse leaving.During an observation on 06/04/2026 at 9:35 AM, the narcotic book for Hall B medication cart were missing signatures on 5/3/2026 and 5/30/2026.

During an interview on 06/04/2026 at 9:53AM, LVN F stated that two nurses are not verifying the narcotic count by signing the book, and if the count was off, there is no actual proof to verify two nurses counted, and there was no transfer of responsibility.

The LVN confirmed that accountability rests with both the nurse taking over the cart and the nurse leaving.

During an interview on 06/04/2026 at 10:35 AM, the DON revealed when the narcotic book lacks signatures, the count could be incorrect, directly affecting the medications the resident receives.

During an interview on 06/04/2026 10:37 AM, the ADM revealed missing shift-count signatures can result in an inaccurate count and lead to missing medication doses for the residents.

During an interview on 06/04/2026 at 11:01 AM, the CCN stated without the narcotic sheet signatures, there is no physical proof that a medication count was completed and accurate.

Record review of the facility's policy and procedures titled Controlled Medications - Administration (dated 4/6/26) revealed the following directives: Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal, and record keeping in the facility, in accordance with federal and state laws and regulations.

Procedure: At each shift change, a physical inventory of all controlled medications is conducted by two licensed nurses and/or one nurse and a CMA, QMAP, Med Tech or equivalent as allowed by your State regulatory agency and is documented on an audit record.

Alternatively, the shift change audit may be recorded on the accountability record if there is a designated column for the audit.

675851 06/05/2026

Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110

Based on observations, interviews, and a review of facility records, the facility failed to safely store

ensure that all medications were properly labeled with professional instructions, cautionary warnings, and valid expiration dates for 2 out of 2 medication carts and the only medication storage room reviewed for pharmacy services.

The facility failed to ensure that medication carts were kept free of loose, unidentified pills.

The failed to maintain a consistent tracking system for medication refrigerator temperatures to protect the stability and therapeutic potency of stored pharmaceuticals.

These failures could result in residents receiving degraded or ineffective medications from unmonitored temperature variations, or lead to medication errors and accidental ingestion from loose, unaccounted-for pills left inside medication carts.Findings Included: An observation and inspection of the Hall B medication cart on 06/04/2026 at 8:46 AM, in the presence of LVN F, revealed one loose, small, light-purple tablet inside the cart drawer. At the surveyor's request, LVN F removed and identified the medication as Levothyroxine 75 mcg.

During an interview on 06/04/2026 at 8:49 AM, regarding the loose medication, LVN F stated the negative outcome of having unsecured pills in the cart was that it could be given to a resident who it doesn't belong to. LVN F also stated that it could throw off medication counts and impact residents by preventing them from receiving all the medications they paid for. An observation and inspection of the Hall A medication cart was conducted on 06/04/2026 at 9:26 AM in the presence of LVN G.

The inspection revealed one loose, large, red, oval-shaped tablet inside the cart drawer.

When asked to remove and identify the tablet, LVN G was unable to identify the medication.

The unknown tablet was subsequently disposed of by LVN G. An inspection of the facility's single medication storage room on 06/04/2026 at 9:46 AM revealed that the medication refrigerator temperature logs were incomplete.

Daily temperature recordings were omitted for the AM shift on June 1, 2026, as well as both the AM and PM shifts on June 3, 2026.

During an interview on 06/04/2026 at 9:46 AM, about the missing temperature records, LVN G stated that failing to monitor refrigerator temperatures could affect the medications and their effectiveness, and it was the responsibility of both the day and night shift floor nurses.

During an interview on 06/04/2026 at 10:35 AM, the DON stated the negative outcomes of failing to monitor refrigerator temperatures include medications becoming too hot or frozen, which renders them not as effective to residents.

The DON confirmed that floor nurses are responsible for completing these temperature checks every shift.

Regarding loose pills, the DON stated they must be discarded due to contamination, and not knowing who it belongs to could cause residents to miss a dosage or incur financial costs for replacement pills.

During an interview on 06/04/2026, the ADM stated that failing to check temperatures directly threatens the effectiveness of the medications.

Regarding loose pills, the Administrator stated that medications are wasted, residents can miss critical doses, and it negatively affects pharmacy reordering schedules.

During an interview on 06/04/2026 at 11:01 AM, the CCN stated that unmonitored storage temperatures negatively impact the effectiveness of meds and them not working as well for the residents.

For loose pills, she noted the facility is forced to reorder medications prematurely, which causes financial costs to the facility and increases the risk of residents missing a dose. A record review of the facility policy and procedures titled Storage of Medication (dated 3/3/2002) revealed the following procedure mandate: The provider pharmacy dispenses medications in containers that meet legal requirements, including requirements of good manufacturing practices where applicable.

Medications are kept and stored in these containers. A record review of the facility policy titled Medication Storage (dated 3/3/2002) revealed the following requirement: Medications and biologicals are stored safely, securely, and properly following manufacturers' recommendations or those of the supplier.