Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Georgia Manor Nursing Home during CMS and state inspections, most recent first.
Failure to Maintain Female Residents' Dignity With Unwanted Chin Hair: Three female residents were observed with visible chin hair after showers, despite needing staff assistance with bathing and grooming. Two residents had severe cognitive impairment and one had moderate cognitive impairment; one resident said the hair bothered her and another said she was waiting for the beauty shop to shave it off. Family members stated the residents would not choose to have beards and that the unwanted chin hair caused embarrassment and affected dignity.
Controlled substance records were not properly maintained for the Hall A and Hall B medication carts because shift-change narcotic count signatures were missing on multiple occasions. LVNs stated that two nurses were not verifying the count by signing the book, and the DON, ADM, and CCN confirmed that missing signatures meant there was no proof the count was completed and accurate. The facility policy required a physical inventory of controlled meds at each shift change by two licensed nurses or an allowed nurse and med aide.
A resident with severe cognitive impairment, wheelchair use, lower-extremity impairment, and dependence for most ADLs had her call light repeatedly observed on the floor out of reach while lying in bed. Her care plan directed staff to keep the call light within reach and encourage use of the bell for assistance, and multiple staff members stated call lights should always be within reach and that staff were responsible for placement. The resident's family member said she could use the call light, but survey observations showed it was not accessible during several checks.
An LVN left a medication cart computer monitor active and unsecured during med pass, visibly displaying a resident’s eMAR and private clinical details in a hallway near resident rooms. The screen was left open a second time while the LVN stepped away to retrieve keys, and the LVN later acknowledged the exposure was an unauthorized sharing of PHI and a HIPAA violation. The DON, ADM, and CCN stated that leaving the terminal open allowed others to view private resident information.
A resident’s quarterly MDS incorrectly coded significant weight loss even though his documented weights did not show 5% loss in 1 month or 10% loss in 6 months. The MDS RN said she based the coding on weight fluctuations and medication changes rather than actual loss during the look-back period, and the resident’s care plan continued to reflect significant unplanned weight loss, poor intake, and anxiety.
A resident admitted with bipolar disorder had an inaccurate PL 1 from the hospital that coded no mental illness, even though the admission MDS listed bipolar disorder as an active diagnosis and the resident had a BIMS of 14. The baseline and admission care plans did not mention the bipolar diagnosis except in the diagnosis list, and the DON, ADM, and MDS RN stated the PL 1 should have been reviewed for accuracy before admission.
Incomplete Care Plans for Mental Health Diagnoses: The facility failed to include PTSD in one resident’s care plan and bipolar disorder in another resident’s care plan. One resident’s record showed PTSD, severe cognitive impairment, and anxiety related to leaving the facility, but the care plan addressed only unrelated needs and did not include trauma-informed care, behavior monitoring, measurable objectives, or goals. Another resident’s baseline and updated care plans listed bipolar disorder only in the diagnosis list, without any specific care plan interventions or details.
Failure to Provide Trauma-Informed Care for Residents with PTSD: The facility did not ensure staff knew which residents had PTSD or what their triggers were, and it did not document resident-specific PTSD approaches, measurable goals, or behavior monitoring for two residents with significant mental health histories. One resident reported anxiety when leaving the facility and said staff had never discussed her PTSD, while another resident had a trauma history with current depressed and anxious symptoms, but the care plan and TAR lacked documented interventions and staff were unaware of her triggers.
Medication Storage and Labeling Deficiencies: The facility failed to keep meds and biologicals securely stored and properly labeled in 2 med carts and the medication storage room. Surveyors found loose pills in both the Hall A and Hall B med carts, including one Levothyroxine tablet and one unidentified tablet, and found incomplete med refrigerator temp logs with missing AM and PM entries. The DON, ADM, CCN, and LVNs stated that temp checks are required each shift and that loose pills must be discarded.
A resident experienced severe pain during a wound vac change due to inadequate pain management. The facility staff did not allow sufficient time for pain medication to take effect, leading to significant distress for the resident. Despite the resident's complaints, the staff proceeded with the procedure without consulting the physician for alternative pain management options.
A facility failed to report an abuse incident within the required timeframe. A male resident with mental health issues flipped off and hit a female resident with chronic health conditions. Although the incident was documented internally, it was reported to the state six days later, beyond the required two-hour window. This delay in reporting could place residents at risk of continued abuse.
A resident with chronic heart conditions missed a scheduled procedure due to the facility's failure to enter physician's orders into the EHR. The orders, which included medication adjustments and fasting instructions, were communicated by the cardiology office but were not processed due to miscommunication and lack of accountability among staff. This resulted in the resident missing the initial appointment, which was later rescheduled.
A resident with a history of leg amputation and polyneuropathy experienced severe pain during a wound care procedure. Although the charge nurse administered Tylenol #3 after obtaining an order from the PCP, the administration was not documented in the MAR. Interviews with staff confirmed the medication was given, but the lack of documentation could lead to incorrect dosages. The facility's policy requires accurate medical records, which was not followed in this case.
A facility failed to report a staff-inflicted injury on a resident's right hand within the required 24-hour timeframe. The incident, observed by a CNA, involved clawing fingernails into the resident's skin. The Night Charge LVN was informed but did not report to the Administrator until eight days later. The resident had multiple diagnoses and severely impaired cognitive functioning.
The facility failed to ensure drugs and biologicals were stored in locked compartments and labeled correctly. Observations revealed loose medications in carts and insulin without open dates. Staff were unsure of proper procedures, and medication carts were left unattended and unlocked, posing risks to residents.
The facility failed to maintain an effective infection prevention and control program, with multiple instances of staff not performing proper hand hygiene and glove use during medication administration and incontinent care. These actions were confirmed through staff interviews and observations, highlighting significant gaps in infection control protocols.
The facility failed to ensure an accurate MDS assessment for a resident, whose assessment indicated adequate vision despite a physician's order for corrective lenses. Staff were unaware of the resident's need for glasses, and the resident's care plan did not address vision issues.
The facility failed to develop and implement a comprehensive care plan for a resident, neglecting to address the need for prescription glasses as ordered by the physician. This oversight was confirmed through record reviews and staff interviews, highlighting the potential negative outcomes such as increased risk of falls and inability to participate in activities.
A resident with multiple diagnoses did not receive prescribed corrective lenses for six months, despite repeated requests and staff awareness. The resident's care plan and MDS records did not reflect the need for glasses, leading to potential negative outcomes such as increased fall risk and decreased participation in activities.
The facility failed to maintain the required RN coverage for at least 8 consecutive hours a day, 7 days a week, as evidenced by the absence of an RN on two specific dates. The issue was confirmed through interviews and record reviews, with conflicting information and altered documents complicating the verification process.
A resident with type 2 diabetes mellitus was administered expired insulin on multiple occasions, despite facility policies requiring the disposal of expired medications. The error was identified during a medication administration observation, and staff acknowledged the potential risks of reduced medication effectiveness.
The facility failed to follow food safety and hand hygiene protocols. Cook A was observed preparing food without washing hands between tasks and touching various kitchen surfaces, leading to potential cross-contamination. The Dietary Manager confirmed the lapses in protocol.
A resident with multiple diagnoses, including COPD and Bipolar disorder, experienced distress due to a loud and confrontational roommate. The resident's care plan was not followed, and staff were unaware of her distress until informed by a surveyor. The resident was eventually moved to a different room, allowing her to sleep well.
The facility failed to provide adequate pharmaceutical services, resulting in the administration of expired insulin to three residents and incorrect medication documentation. Additionally, a resident received another resident's medication while on a weekend pass due to the lack of a proper procedure to ensure medication accuracy.
The facility failed to maintain accurate and organized records for a resident, with staff documenting medication administration under incorrect credentials. This led to confusion about who administered the medication and the use of expired insulin, potentially compromising the resident's care.
Failure to Maintain Female Residents' Dignity With Unwanted Chin Hair
Penalty
Summary
The facility failed to treat three residents with dignity and respect when each had visible chin hair that was not consistently removed after bathing. Resident #1, a female resident with moderately impaired cognition, was dependent on staff for toileting and required assistance with bathing. Her record showed she was showered on 06/02/26, but on 06/03/26 and again on 06/04/26 she was observed with several white, approximately one-inch-long hairs on her chin. During interview, she stated the hairs bothered her and said she was waiting for the beauty shop ladies to come because they usually shaved her chin hair off for her. She also stated CNAs never shaved her chin. Resident #37, a female resident with severely impaired cognition, was dependent or required partial/moderate assistance across all ADLs except eating and required one staff member to assist with bathing. Her record showed she received a shower on 06/02/26. On 06/03/26, she was observed multiple times lying in bed with several dark and light grey hairs sprinkled across her chin, approximately half an inch long. During interview, her family member stated she would not choose to have a beard and that when at home she used a trimmer to remove unwanted chin hair. The family member also stated CNAs shaved her chin when they showered her. Resident #44, a female resident with severely impaired cognition, Parkinson's disease, lack of coordination, and muscle weakness, was dependent across all ADLs except eating and required two staff members for bathing. Her record showed she was showered on 06/02/26. On 06/03/26 and again on 06/04/26, she was observed with long, white, curling hairs on both sides of her chin. During interview, she stated it bothered her to have chin hair and that she did not like it. She said she could shave her chin if she had a razor and stated CNAs had shaved her chin in the past, but she did not know why they had not done so lately. Her family member stated the chin hair bothered her, that he had never seen her with chin hair before she came to the facility, and that she would become emotional and embarrassed if it was mentioned.
Missing Controlled Substance Count Signatures on Medication Carts
Penalty
Summary
The facility failed to determine that controlled drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for the Hall A and Hall B medication carts. During record review, the narcotic books for both carts were found to have missing signatures documenting shift-to-shift controlled substance counts. On the Hall A medication cart, signatures were missing on 12/30/2025, 1/1/2026, 1/2/2026, 1/19/2026, 1/26/2026, 1/30/2026, 1/31/2026, 2/12/2026, 3/9/2026, 3/11/2026, 3/26/2026, and 4/2/2026. On the Hall B medication cart, signatures were missing on 5/3/2026 and 5/30/2026. During interviews, LVN G and LVN F stated that two nurses were not verifying the narcotic count by signing the book and that, if the count was off, there would be no way to know who to contact or verify that two nurses had counted the medications. The DON stated that when the narcotic book lacks signatures, the count could be incorrect and directly affect the medications the resident receives. The ADM stated missing shift-count signatures can result in an inaccurate count and lead to missing medication doses for residents. The CCN stated that without the narcotic sheet signatures, there is no physical proof that a medication count was completed and accurate. The facility policy required a physical inventory of controlled medications at each shift change by two licensed nurses or an allowed nurse and medication aide, documented on an audit record or accountability record.
Call Light Not Kept Within Reach
Penalty
Summary
The facility failed to ensure Resident #37 had her call light within reach. Resident #37 was a [AGE]-year-old female admitted most recently on [DATE] with diagnoses including vascular dementia with agitation, intermittent explosive disorder, muscle weakness, unsteadiness on feet, and cerebral infarction. Her quarterly MDS showed a BIMS score of 7, indicating severely impaired cognition, and she used a wheelchair with impairment to both lower extremities. She was dependent or needed partial/moderate assistance for all ADLs except eating, and she was always incontinent of bladder and bowel. Her care plan identified an ADL self-care deficit and included interventions to encourage her to use the bell to call for assistance and to be sure her call light was within reach. During observations on 06/03/26 at 09:01 AM, 11:11 AM, 12:19 PM, and 02:12 PM, Resident #37 was observed lying in bed and her call light was on the floor between her bed and the wall at the foot of her bed. During the 12:19 PM observation and attempted interview, she did not answer when asked if she had a call light or had ever used one. During interview, the resident's family member stated she was capable of using her call light and would sometimes push it just to mess with staff. Multiple staff members, including LVN, RN, CNA, DON, MDS RN, ADM, and HR, stated call lights should be in reach of residents and that staff were responsible for ensuring proper placement. HR stated she checked Resident #37's room twice a day and said the call light was in reach both times, which differed from the surveyor observations showing it on the floor.
Unsecured eMAR Screen Exposed Resident Information
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident’s personal and medical records for 1 of 13 residents reviewed. During an observation on 06/04/2026 at 8:39 AM during medication pass on Hall B, an LVN was observed walking away from the medication cart to administer medications while the cart’s computer monitor remained active and unsecured, visibly displaying the eMAR and private clinical details of a resident. The cart was positioned in the hallway near resident rooms, exposing the screen to residents passing through the corridor. During a second observation on 06/04/2026 at 8:42 AM, the same LVN again walked away from the Hall B medication cart to retrieve keys from another nurse, and the computer screen was again left fully open and active with residents’ private eMAR information displayed. In interviews later that morning, the LVN acknowledged that leaving a resident’s personal health information visible on an open monitor was an unauthorized sharing of patient information and a HIPAA violation. The DON, ADM, and CCN each stated that leaving a computer terminal open with resident information allows others to see private information that is not supposed to be shared, and that screen security is the responsibility of the nurse assigned to that cart and unit.
Inaccurate MDS Weight Loss Coding
Penalty
Summary
The facility failed to ensure Resident #7’s assessment accurately reflected his status when the quarterly MDS completed on 03/23/26 coded Section K0300 as significant weight loss in the last month or last 6 months. Resident #7 was a 63-year-old male admitted with diagnoses including unspecified protein-calorie malnutrition and dehydration, and his BIMS score was 9, indicating moderately impaired cognition. The MDS also supported a care plan focus area for significant unplanned/unexpected weight loss, poor food intake, and anxiety issues that had been initiated on 10/16/25. Record review of Resident #7’s weights showed no 5% weight loss in 1 month or 10% weight loss in 6 months relative to the ARD date of the quarterly MDS. His documented weights were 119 pounds on 03/22/26, 117.2 pounds on 02/20/26, and 120 pounds on 09/24/25. During interview, the MDS RN stated she coded significant weight loss because the resident’s weight had fluctuated and medication changes seemed to have affected his weight, rather than because of actual weight loss during the look-back period. The facility policy stated the purpose of the MDS is to ensure each resident receives an accurate assessment, and the RAI manual stated that only the two snapshot weights closest to 30 and 180 days are considered for K0300.
Inaccurate PASARR Screening for Resident with Bipolar Disorder
Penalty
Summary
PASARR screening for mental disorders or intellectual disabilities was not accurately completed for Resident #53 prior to admission. The resident was admitted with a diagnosis of bipolar disorder unspecified, and the admission MDS completed on 06/03/26 listed bipolar disorder in Section I Active Diagnoses with a BIMS score of 14, indicating intact cognition. However, the PL 1 completed at a local hospital identified the resident as having no mental illness, despite the active bipolar diagnosis in the record. The resident’s baseline care plan initiated on 05/27/26 and the care plan completed on 06/04/26 did not mention the bipolar diagnosis except in the diagnosis list on the last page. During interviews, the DON, ADM, and MDS RN stated the MDS RN was responsible for ensuring PL 1 forms were completed at or prior to admission and reviewed for accuracy against the resident’s diagnoses. The MDS RN stated she had recently taken time off and that was probably why she missed Resident #53’s inaccurate PL 1.
Incomplete Care Plans for Mental Health Diagnoses
Penalty
Summary
The facility failed to develop and implement comprehensive care plans that included measurable objectives and timeframes for two residents with mental health diagnoses. For Resident #8, the record showed diagnoses of major depressive disorder, schizophrenia, PTSD, and alcohol dependence. Her quarterly MDS documented a BIMS score of 6 out of 15, indicating severely impaired cognition, and identified PTSD as an active diagnosis. However, her care plan dated 3/11/26 addressed incontinence, fall risk, antidepressant use, and impaired visual function, but did not include PTSD, trauma-informed care, behavior monitoring approaches, measurable objectives, or the resident’s goals for care. Resident #8 stated during interview that her main PTSD trigger was leaving the facility and that she became anxious when she had to go out for doctor appointments. She stated no one in the facility had ever spoken with her about her PTSD or anxiety, and she did not think staff knew she did not like to leave the facility. She also stated the van driver had never said anything to her about being anxious when she rode to appointments. The record review and interview showed that the resident’s PTSD diagnosis and related triggers were not reflected in the care plan or in the documented care planning materials reviewed. For Resident #53, the admission record showed a diagnosis of bipolar disorder unspecified, and the admission MDS identified bipolar disorder as an active diagnosis with a BIMS score of 14, indicating intact cognition. Her baseline care plan and subsequent care plan both listed diagnoses on the last page, but did not mention bipolar disorder anywhere else in the plan. During interviews, multiple staff members stated that bipolar disorder and PTSD should be included in care plans so staff would know how to care for residents and recognize behaviors or triggers. The DON stated she did not know whether triggers were on each resident’s care plan but thought they should be, and the MDS RN stated she was responsible for completing care plans and that bipolar disorder and PTSD should be included.
Failure to Provide Trauma-Informed Care for Residents with PTSD
Penalty
Summary
The facility failed to ensure residents with PTSD received trauma-informed and culturally competent care in accordance with professional standards of practice, including accounting for residents’ experiences and preferences to eliminate or mitigate triggers that could cause re-traumatization. The deficiency involved 2 of 13 residents reviewed for quality of care, Residents #8 and #44. Survey findings showed the facility did not ensure nursing staff were aware of residents diagnosed with PTSD or their triggers, did not develop and ensure staff were educated in PTSD triggers and interventions for these residents, and did not monitor Resident #44 for signs and symptoms of anxiety, depression, and suicidal thoughts. Resident #8 was a female admitted with diagnoses including major depressive disorder, schizophrenia, PTSD, and alcohol dependence. Her quarterly MDS documented a BIMS score of 6 out of 15, indicating severely impaired cognition, and her active diagnoses included PTSD. Her care plan documented incontinence, fall risk, antidepressant use, and impaired visual function, but the Treatment Administration Record contained no documentation of behavior monitoring approaches, measurable objectives, or resident goals related to PTSD. During interview, Resident #8 stated her main trigger was leaving the facility, that she became anxious when she had to go out, and that staff had never spoken with her about her PTSD or anxiety. Resident #44 was a female admitted with diagnoses including diabetes, PTSD, chronic pain, generalized anxiety disorder, obesity, and major depressive disorder. Her MDS documented a BIMS score of 5 out of 15, indicating severely impaired cognition, and her active diagnoses included PTSD. Her care plan identified a history of trauma/PTSD related to past sexual and physical abuse from loved ones and included a goal for staff to assist in avoiding triggers, with interventions to arrange a licensed mental health provider, consult with family, and monitor for escalating anxiety, depression, or suicidal thought. However, the comprehensive care plan and Treatment Administration Record did not contain documentation of behavior monitoring specific approaches, measurable objectives, or resident goals related to PTSD. A psychological services note documented that the resident screened positive for trauma with current symptoms and was depressed, anxious, and felt worthless, but no interventions were listed. Staff interviews showed multiple staff members were unaware that Residents #8 and #44 had PTSD or what their triggers were, and one RN stated she had not been trained on trauma-informed care or PTSD. The DON stated staff were trained to pay attention to behaviors and that knowledge about trauma would come from the SW and care plan, but she was not aware of the residents’ trauma histories or triggers. The facility policy stated residents who are trauma survivors must receive culturally competent, trauma-informed care, triggers must be identified, and resident-specific approaches must be developed and included in the care plan.
Medication Storage and Labeling Deficiencies
Penalty
Summary
The facility failed to safely store drugs and biologicals in locked areas at the correct temperatures and failed to ensure that medications were properly labeled with professional instructions, cautionary warnings, and valid expiration dates for 2 medication carts and the only medication storage room reviewed. During an observation and inspection of the Hall B medication cart, a loose, small, light-purple tablet was found inside the cart drawer and was identified by an LVN as Levothyroxine 75 mcg. During an observation and inspection of the Hall A medication cart, a loose, large, red, oval-shaped tablet was found inside the cart drawer, and the LVN was unable to identify it before it was disposed of. An inspection of the facility's single medication storage room showed that the medication refrigerator temperature logs were incomplete, with daily temperature recordings missing for the AM shift on June 1, 2026, and both the AM and PM shifts on June 3, 2026. During interviews, the LVN, DON, ADM, and CCN stated that refrigerator temperatures must be monitored each shift and that failing to do so can affect medication effectiveness. Facility policy stated that medications and biologicals are to be stored safely, securely, and properly following manufacturers' recommendations or those of the supplier.
Inadequate Pain Management During Wound Care Procedure
Penalty
Summary
The facility failed to provide adequate pain management for a resident during a wound vac change, which was not consistent with professional standards of practice and the resident's care plan. The resident, who had a history of an above-knee amputation and other medical conditions, experienced severe pain during the procedure. Despite the resident's complaints of pain, the staff did not allow sufficient time for the pain medication to take effect before proceeding with the wound care. On the day of the incident, the resident was given Tylenol with Codeine #3 from the emergency kit after it was discovered that her prescribed hydrocodone was not available. The staff waited only 15 minutes after administering the medication before starting the wound vac change, which was not enough time for the medication to take effect. The resident expressed significant pain and distress during the procedure, which was audible to staff members in nearby areas. Interviews with staff members revealed that there was a lack of communication and assessment regarding the resident's pain management needs. The ADON, who was responsible for the wound care, did not adequately assess the resident's pain or consult with the physician for alternative pain management options. The DON, who was present during the procedure, acknowledged that the pain management was insufficient and that the resident's pain was not properly addressed before continuing with the wound care.
Failure to Timely Report Resident Abuse Incident
Penalty
Summary
The facility failed to report an incident of abuse within the required timeframe, involving two residents. Resident #5, a male with a history of cerebral infarction, schizoaffective disorder, and other mental health issues, was involved in an altercation with Resident #2, a female with chronic obstructive pulmonary disease and major depressive disorder. On the day of the incident, Resident #5 flipped off Resident #2 and then swung and hit her arm. Although Resident #2 was not hurt and did not seem upset about the incident, it was reported to the Assistant Director of Nursing (ADON) and the Administrator. The facility's records show that the incident was documented as a behavior incident on the same day it occurred. However, the report to the Health and Human Services Commission (HHSC) was not made until six days later, which is beyond the required two-hour reporting window for incidents involving abuse or serious bodily injury. Interviews with staff, including the ADON and a social worker, confirmed that the incident was communicated internally but not reported to the state in a timely manner. The facility's policy on abuse and neglect, as well as an in-service training conducted by the previous Administrator, emphasized the importance of immediate reporting of such incidents. Despite these guidelines, the delay in reporting this incident could place residents at risk of continued abuse. The facility's failure to adhere to its own policies and state regulations regarding timely reporting of abuse incidents constitutes a deficiency in their operations.
Failure to Enter Physician's Orders Led to Missed Procedure
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. This deficiency was identified when a resident missed a scheduled appointment to have an Implantable Loop Recorder (ILR) placed due to the facility's failure to enter the physician's orders into the Electronic Health Record (EHR). The resident, a female with chronic congestive heart failure, acute respiratory failure with hypoxia, anemia, and unspecified atrial fibrillation, was admitted to the facility with specific medical needs that required careful management. The incident occurred when the cardiology office communicated pre-procedure orders, including holding specific medications and fasting instructions, to the facility. However, these orders were not entered into the EHR, leading to the resident missing the appointment. The orders were initially taken over the phone by an agency nurse and noted on a sticky note, which was then passed to another nurse. The responsibility for entering the orders into the EHR was not clearly assigned, resulting in a breakdown of communication and the orders not being processed. Interviews with staff revealed confusion and miscommunication regarding the responsibility for entering the orders into the EHR. The nurse who received the orders did not follow through with entering them, and subsequent staff were not adequately briefed or did not recall being informed about the orders. This lack of clarity and accountability led to the resident missing the initial procedure, which was later rescheduled. The facility's policy on handling verbal or telephone orders was not adhered to, contributing to the deficiency.
Failure to Document Pain Medication Administration
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident, specifically regarding the administration of pain medication. On 05/30/24, a resident with a history of acquired absence of a leg above the knee, polyneuropathy, and atherosclerosis was not documented as having received pain medication during a wound care procedure. The resident, who had moderately impaired cognition and frequently experienced pain, was admitted with a surgical wound and was at risk for uncontrolled pain. During the wound care procedure, the resident expressed severe pain, prompting the ADON to request pain medication from the charge nurse. The charge nurse obtained an order for Tylenol #3 from the PCP and administered it to the resident. However, the administration of this medication was not recorded in the Medication Administration Record (MAR), leading to a discrepancy in the resident's medical records. Interviews with facility staff, including the LVN, RN, ADON, and previous DON, confirmed that the medication was administered but not documented. The failure to document the administration of pain medication could result in the resident receiving incorrect dosages, as the MAR did not reflect the medication given. The facility's policy emphasizes the importance of accurate medical records as a legal document and proof of care, which was not adhered to in this instance.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately, but not later than 24 hours. Specifically, the facility did not report an injury of staff-inflicted injury (fingernail wound marks) on a resident's right hand to the Administrator and the state within the required 24-hour timeframe. This incident occurred on 4/16/24 but was not reported until 4/24/24, eight days later. The resident involved was a [AGE] year-old female with multiple diagnoses, including Schizoaffective Disorder Bipolar Type, Metabolic Encephalopathy, Acute Kidney Failure, Essential Hypertension, Unspecified Dementia, Dyspnea, and Acute Respiratory Failure with Hypoxia. The resident had severely impaired cognitive functioning, was totally dependent for toileting, and was always incontinent of bowel and bladder. The incident was initially observed by CNA A, who reported seeing CNA B clawing her fingernails into the resident's skin, causing the resident to yell and threaten to report the CNA. CNA A reported the incident to the Night Charge LVN C, who failed to inform the Administrator until 4/26/24. Interviews with staff revealed that the facility had policies in place for reporting abuse and neglect, which required immediate reporting to the Charge Nurse and Administrator. However, these policies were not followed in this instance. The Administrator only became aware of the incident during a meeting with LVN C on 4/26/24, who admitted to forgetting to report the incident earlier. The facility conducted in-service training on reporting abuse and neglect following the incident, but the initial failure to report in a timely manner could have placed residents at risk of continued or unrecognized abuse or neglect.
Failure to Properly Store and Label Medications
Penalty
Summary
The facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles. During an observation, 70 medications were found loose in the B & C Hall medication cart, and 4 medications were found loose in the A Hall medication cart. Additionally, 2 insulin medications in the B & C Hall medication cart had no date indicating when they were opened. RN B was unable to identify the loose medications, which were subsequently placed in the drug disposal bottle for destruction. MA D was unsure of the proper procedure for handling loose medications and initially suggested throwing them in the trash. LVN F was observed leaving the medication cart unattended and unlocked on two occasions, with residents nearby, posing a risk for unauthorized access to medications. Interviews with staff revealed a lack of understanding of the negative outcomes associated with these practices, including the potential for residents to miss their medications or access them inappropriately. The facility's policies, dated 2003, require that each prescription medication label includes the expiration date and that medication carts are to be locked when not in use or under direct supervision. The failure to adhere to these policies was evident in the observations and interviews conducted. The staff's inability to properly manage and secure medications, as well as their lack of knowledge regarding the procedures for handling loose medications, contributed to the deficiency. This oversight could potentially place residents at risk for drug diversion, overdose, or accidental administration of incorrect medications.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of staff not performing proper hand hygiene (HH) and glove use. RN B was observed administering an inhalation medication and performing a blood glucose check without performing HH before donning gloves. Additionally, RN G administered an injectable medication without performing HH or donning gloves, and used an expired insulin pen. LVN F also failed to perform HH or don gloves before and after administering an injectable medication. These actions were confirmed through interviews with the staff involved, who acknowledged the potential for infection control issues due to their lapses in protocol. CNA C and CNA E were observed performing incontinent care on residents without adhering to proper HH and glove-changing procedures. CNA C did not perform HH or change gloves after handling a dirty brief and before continuing with peri-care. Similarly, CNA E did not perform HH or change gloves during and after removing a dirty brief and before handling clean items. Both CNAs acknowledged in interviews that their actions could lead to the spread of infection. Additionally, CNA E performed peri-care in a back-to-front motion, which is against the facility's policy and could lead to contamination. The facility's policies on subcutaneous injection administration, perineal care, and hand washing were reviewed and found to be outdated or lacking specific instructions on when to perform HH. The deficiencies observed have the potential to affect all residents in the facility by exposing them to care practices that could lead to the spread of infections and communicable diseases. Staff interviews confirmed a lack of adherence to established infection control protocols, highlighting significant gaps in the facility's infection prevention and control program.
Failure to Ensure Accurate MDS Assessment for Resident
Penalty
Summary
The facility failed to ensure the MDS assessment accurately reflected the resident's status for one resident. Resident #32's MDS assessment indicated that his vision was adequate and that he did not have corrective lenses, despite having a physician's order for corrective lenses dated several months prior. The resident confirmed during an interview that he had not received his glasses, and multiple staff members, including the social worker and MDS LVN, were unaware of the resident's need for glasses. The MDS LVN stated that it was not her job to follow up on physician's visits or appointments, and she did not know the resident needed glasses. The resident's care plan also did not mention any vision issues or the need for corrective lenses. During observations and interviews, it was noted that the resident was not wearing glasses and expressed difficulty in reading, which he enjoyed. Staff members acknowledged that not having prescription glasses could lead to negative outcomes such as increased falls and inability to participate in activities. The facility's policy on MDS assessment data accuracy requires that each resident receives an accurate assessment by qualified staff familiar with the resident's well-being. However, the MDS LVN maintained that the MDS was not coded incorrectly because the resident did not have glasses during the 7-day look-back period, despite the physician's order for corrective lenses.
Failure to Implement Comprehensive Care Plan for Resident
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs. Specifically, the care plan for a resident with multiple diagnoses, including pulmonary hypertension, major depressive disorder, generalized anxiety disorder, type 2 diabetes, hyperlipidemia, hypertension, and heart failure, did not address the resident's need for prescription glasses as ordered by the physician. The resident's care plan and MDS assessments did not reflect the need for corrective lenses, despite a physician's order dated 10/11/23 for such glasses. This oversight was confirmed through record reviews and interviews with staff members, who acknowledged the potential negative outcomes of not having the prescribed glasses, such as increased risk of falls and inability to participate in activities. During an observation and interview, the resident was seen ambulating without glasses and expressed frustration about not being able to read, despite having discussed the need for glasses with the social worker. Staff members, including the MDS LVN, CN, and ADON, admitted that the care plan did not accurately reflect the resident's needs and that it was not their responsibility to follow up on physician visits or appointments. The facility's policy on comprehensive care planning, which mandates the development and implementation of a person-centered care plan to meet the resident's needs, was not adhered to in this case.
Failure to Provide Prescribed Corrective Lenses
Penalty
Summary
The facility failed to ensure that a resident received proper treatment and assistive devices to maintain vision abilities. Specifically, the facility did not address the resident's need for prescription glasses following a physician's visit for six months. The resident, a male with multiple diagnoses including pulmonary hypertension, major depressive disorder, generalized anxiety disorder, type 2 diabetes, hyperlipidemia, hypertension, and heart failure, had a prescription order for corrective lenses dated 10/11/23. However, the resident's care plan and MDS records did not reflect this need, and the resident did not receive the prescribed glasses. Interviews with the resident and staff revealed that the resident had communicated his need for glasses, but no action was taken. The social worker, MDS LVN, CN, and ADON all acknowledged the potential negative outcomes of not having the prescribed glasses, such as increased risk of falls and decreased participation in activities. Despite the resident's repeated requests and the staff's awareness of the issue, the resident did not receive the necessary corrective lenses until an appointment was finally scheduled on 04/16/24 to pick out prescription glasses.
Failure to Maintain Required RN Coverage
Penalty
Summary
The facility failed to use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for the period reviewed from November 1, 2023, to April 13, 2024. Specifically, the facility did not have an RN on duty on November 18, 2023, and November 19, 2023. This deficiency was identified through interviews and record reviews. The Human Resources Coordinator (HRC) confirmed the absence of RN coverage on these dates after reviewing timecard information. The Chief Registered Nurse (CRN) acknowledged the oversight and highlighted the importance of having an RN as a resource for staff, especially for coordinating emergency care. The Administrator (ADM) initially presented time clock adjustment sheets indicating that RN H had worked on the specified dates, but RN H later confirmed that she did not work on those days and did not fill out any time clock adjustment sheets for those dates. The time clock adjustment sheets provided by the ADM appeared to have been altered, as they were warm from the copier and had white-out tape over certain entries. A policy for RN coverage was requested on April 15, 2024, but was never received. The absence of an RN on the specified dates left the facility without supervisory coverage, which could have impacted the coordination of events such as emergency care. The conflicting information and altered documents further complicated the verification of RN coverage, indicating a lapse in the facility's adherence to regulatory requirements for RN staffing.
Expired Insulin Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically involving the administration of expired insulin to a resident. The resident, a [AGE] year-old female with a diagnosis of type 2 diabetes mellitus, was administered expired insulin on multiple occasions. The insulin, which should have been discarded after 30 days, was used past its expiration date. This was observed during a medication administration where the RN was about to administer the expired insulin before being stopped by the investigator. The RN acknowledged the error and the potential negative outcomes of administering expired medication, such as reduced effectiveness. The resident's medical records indicated that she had received expired insulin on several dates, and her blood glucose levels were recorded as slightly elevated. The facility's policies on medication administration and labeling were reviewed, revealing that medication errors should be immediately reported and that prescription medication labels must include expiration dates. Despite these policies, the expired insulin was not discarded, leading to the administration error. Interviews with staff confirmed the potential risks of administering expired medication, including loss of effectiveness.
Failure to Follow Food Safety and Hand Hygiene Protocols
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. During an observation, Cook A was seen preparing mechanical soft and pureed foods without performing appropriate hand hygiene. Cook A changed her gloves but did not wash her hands, then touched various kitchen surfaces, including the prep table and the puree machine. She handled food directly with her gloved hands without changing gloves or washing her hands between tasks. Cook A admitted that she was not supposed to touch the food with her hands and should change gloves between tasks to prevent cross-contamination. In another observation, Cook A was seen preparing pureed foods and again failed to wash her hands after changing gloves. She touched various kitchen surfaces and the fryer basket, then returned to handling the pureed chicken. Cook A even licked a small amount of pureed chicken off her ungloved hand and only rinsed her hand with water before continuing food preparation. The Dietary Manager (DM) confirmed that Cook A did not follow proper handwashing and glove-changing protocols, which could lead to food-borne illness. The facility's policies on food safety and infection control were reviewed and indicated that gloves must be worn for food preparation and service, and careful handwashing should be done between handling different types of food and equipment.
Failure to Ensure Resident Safety and Respect Preferences
Penalty
Summary
The facility failed to ensure that a resident felt safe within her room environment and that her preference for TV volume was met. The resident, who had diagnoses including COPD, Bipolar disorder, Anxiety disorder, and Polyneuropathy, was observed to be in distress due to her roommate's loud TV and confrontational behavior. The resident expressed that she had not slept well and felt afraid, but did not know who to talk to about the situation. The social worker was unaware of the resident's distress until informed by the surveyor. The resident's care plan indicated that staff should encourage her to discuss any concerns and respect her right to view the nursing facility as her home. However, the resident's progress notes did not reflect any follow-up on her anxiety and crying episodes. The social worker and other staff members acknowledged that the situation could lead to negative outcomes such as depression, anxiety, and emotional distress. Despite reports from other residents about the loud and confrontational behavior, the issue was not addressed promptly. The resident was eventually moved to a different room, which allowed her to sleep well. Observations confirmed that the resident no longer had a roommate and was able to rest peacefully. The facility's policy on resident rights emphasized the importance of respect, dignity, and a safe environment, but these were not upheld in this case, leading to a diminished quality of life for the resident.
Pharmaceutical Services Deficiency
Penalty
Summary
The facility failed to provide adequate pharmaceutical services to meet the needs of four residents, resulting in the administration of expired insulin and inaccurate medication documentation. Specifically, insulin was administered to three residents after it had expired, and there were instances of incorrect documentation of medication administration under the wrong staff credentials. These actions led to potential risks for the residents, including the possibility of receiving ineffective medication and misleading care providers about the treatments administered. Resident #2 was given another resident's medication, Depakote, while on a weekend pass, despite not having a prescription for it. This error occurred because the facility did not have a procedure to ensure that the resident's medications were correctly identified before leaving the facility. The resident experienced increased sleepiness as a result of this medication error. Additionally, the facility's staff failed to adhere to proper documentation procedures. RN B documented the administration of an injectable medication under MA D's credentials, even though MA D did not administer the medication. Similarly, RN G administered an injectable medication, but RN I documented the administration under their credentials. These documentation errors were not corrected promptly, leading to false records of medication administration.
Inaccurate Documentation of Medication Administration
Penalty
Summary
The facility failed to maintain complete, accurate, readily accessible, and systemically organized records for one resident. Specifically, RN B documented the administration of injectable medication under MA D's computer access, and RN G administered injectable medication while RN I documented the medication administration under RN I's credentials. This discrepancy in documentation was identified during a record review and interviews with the involved staff. The medication administration record (MAR) for Resident #5 indicated that MA D gave the insulin injection, which was later confirmed to be incorrect as MA D does not administer injections. RN B admitted to documenting under MA D's credentials by mistake, and the error was not corrected promptly. Additionally, RN G and RN I admitted to improper documentation practices, with RN I documenting the administration of insulin that was actually given by RN G. This practice was confirmed through interviews and further record reviews, revealing that the documentation errors had not been corrected even after being identified. Resident #5, a [AGE] year-old female with multiple diagnoses including unspecified dementia, type 2 diabetes mellitus, and bipolar disorder, was directly affected by these documentation errors. The resident's care plan required the administration of insulin as ordered by the doctor, and the MAR indicated that the insulin was administered on specific dates. However, the insulin used had expired, and the documentation errors created confusion about who administered the medication. Interviews with the resident and staff confirmed that the medication administration was not performed by the individuals documented in the MAR, leading to false documentation and potential risks to the resident's care and treatment.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 77 citations issued within 25 miles in the last 12 months — including the 6 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Amarillo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Legacy Rehabilitation And Living | 1.2 mi | ★★★★★ | 5 | 1 |
| Ware Memorial Care Center | 2.8 mi | ★★★★★ | 9 | 0 |
| Kirkland Court Health And Rehabilitation Center | 3.6 mi | ★★★★★ | 8 | 3 |
| Heritage Convalescent Center | 3.8 mi | ★★★★★ | 9 | 0 |
| Windflower Health Center | 3.8 mi | ★★★★★ | 1 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.