Not rated by CMS — ratings are suppressed for new or low-volume facilities.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 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.
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.
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.
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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.
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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 | — | 2 | 0 |
| 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 | — | 0 | 0 |
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