Georgia Manor Nursing Home

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 3 (Resident #1, Resident #37, and Resident #44) of 13 residents reviewed for resident rights. The facility failed to ensure Resident #1, Resident #37, and Resident #44 did not have hairy chins. This failure could put residents at risk of embarrassment, feelings of insecurity, and/or diminished self-esteem. Findings Included:1. Record review of Resident #1's admission record revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of muscle weakness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 out of 2 medication carts (Hall A and Hall B Medication Carts) reviewed for pharmacy services. The 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: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #37) of 13 residents reviewed for accommodation of needs. The facility failed to ensure Resident #37's call light was in reach on 06/03/26. This failure could place residents at risk of unmet needs, injury, and/or feelings of helplessness and frustration. [...]

Inspectors wroteBased on observations and interviews the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 out of 13 residents (Resident #55) reviewed for privacy/confidentiality of medical records. The facility failed to ensure the protected health information, personal identifiers, and clinical medical charts were adequately safeguarded against unauthorized viewing, public disclosure, on 06/4/2026 at 8:39 AM and 8:42 AM. This failure could result in a breach of personal privacy, lead to medical identity theft, or cause emotional distress and humiliation to the residents due to the unauthorized exposure of their private medical history and diagnoses. Findings Included: [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #7) of 13 residents reviewed for accuracy of assessment. The facility coded Resident #7 as having significant weight loss in the last month when, in fact, he had not had 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. [...]

Inspectors wroteBased on interview and record review the facility failed to perform a preadmission screening for individuals with a mental disorder and individuals with intellectual disability for 1 (Resident #53) of 13 residents reviewed for preadmission screening. The facility failed to perform an accurate preadmission 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Residents #8 and #53) of 13 Residents reviewed for comprehensive care plans. -The facility failed to address the diagnosis of PTSD in Resident # 8's care plan. -The facility failed to address the diagnosis of bipolar disorder in Resident # 53's care plan These failures could result in residents not being able to attain or maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 2 (Residents #8 and #44) of 13 residents reviewed for quality of care. The facility failed to ensure nursing staff were aware of residents who were diagnosed with PTSD and their triggersThe facility failed to develop and ensure staff were educated in PTSD triggers and interventions for Resident's #8 and #44. [...]

Inspectors wroteBased on observations, interviews, and a review of facility records, the facility failed to safely store all drugs and biologicals in locked areas at the correct temperatures. Additionally, the facility failed to 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. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an assessment accurately reflected a resident's status for 5 (Resident #2, #13, #18, #41, and #43) of 12 residents reviewed for accuracy of MDS assessments. -The facility failed to accurately assess Resident #2 for oxygen therapy on her 03/08/25 MDS assessment. -The facility failed to accurately assess Resident #13 for antidepressant medication therapy on her 03/26/25 MDS assessment. -The facility failed to accurately assess Resident #18 for weight loss on his 03/22/25 MDS assessment. -The facility failed to accurately assess Resident #41 for antibiotic therapy on her 03/16/25 MDS assessment. -The facility failed to accurately assess Resident #43 for anticoagulant therapy and oxygen therapy on her 02/18/25 MDS assessment. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 4 (Resident #3, Resident #13, Resident #41, and Resident #43) of 12 residents reviewed for respiratory care. 1. The facility failed to ensure Resident #3 received O2 via NC at the rate of 2 l/m as ordered by her physician. 2. The facility failed to ensure Resident #13 received O2 via NC at the rate of 2 l/m as ordered by her physician. 3. The facility failed to ensure Resident #41 received O2 via NC at the rate of 5 l/m as ordered by his physician. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for food safety. The facility failed to ensure kitchen staff used proper hand washing and sanitation procedures when handling food. This failure could place residents at risk of food borne illnesses.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #43) of 12 residents reviewed for PASRR. The facility failed to refer Resident #43 for a level II PASRR upon receipt of a bipolar diagnosis. This failure could place residents at risk of not receiving necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. Findings Included: [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 2 (Resident #13 and Resident #43) of 12 residents reviewed for comprehensive care plans. 1. The facility failed to include Resident #13's diagnosis of PTSD in her care plan. 2. The facility failed to remove anticoagulant medication from Resident #43's care plan and to include in her care plan her bipolar disorder diagnosis and the fact that she was receiving anticonvulsant medication. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents environment remained as free from accident hazards as was possible; and that each resident received adequate supervision to prevent accident hazards for one of one oxygen tanks observed during the lunch meal. -an unsecured oxygen bottle was observed in the dining room during the lunch meal with 16 residents and 10 staff present. This failure could affect all the residents at the facility by placing them at risk for accidents that lead to injuries such as bruising, skin tears, fractures, and feeling of isolation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 (Resident #4) of 6 residents reviewed for pain management. The facility failed to allow sufficient time for pain medication to take effect prior to changing Resident #4's wound vac on 05/30/24. This failure could place residents at risk of pain and/or anxiety related to pain. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #2 and Resident #5) of 6 residents reviewed for reporting of abuse, neglect, exploitation or mistreatment. The facility failed to report to the state within 2 hours when Resident #5 hit Resident #2. This failure could place residents at risk of continued abuse. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to, based on the comprehensive assessment of a resident, ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident # 1) of 6 residents reviewed for quality of care. The facility failed to enter physician's orders in the EHR which resulted in Resident #1 missing an appointment on 05/21/24 to have an ILR placed. This failure could place residents at risk of not receiving necessary care and/or treatment. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for one (Resident #4) of 6 residents reviewed for accuracy of records. The facility failed to document the administration of pain medication on 05/30/24 to Resident #4. This failure could place residents at risk of receiving medications in doses other than those ordered. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source are reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to the residents to the Administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 5 residents reviewed for abuse/neglect. The facility failed to report an injury of staff inflicted injury (fingernail wound marks to Resident #1's right hand) on 4/16/24 to the Administrator and to the state within 24 hours. [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 2 medication carts reviewed for medication storage. -70 medications were found left loose in the B & C Hall medication cart and 4 medications were found left loose in the A Hall medication cart. -2 insulin medications were found in Hall B & C medication cart with no date of when they were opened. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. -RN B failed to perform hand hygiene (HH) before donning gloves to administer an inhalation medication. -RN B failed to perform HH and don gloves before performing a glucose check. -LVN F failed to perform HH before or after administering an injectable medication. -LVN F failed to don or doff gloves before or after administering an injectable medication. -CNA C failed to perform HH or glove change after performing incontinent care on a resident and starting with the clean aspect of incontinent care. -CNA E failed to perform HH or glove change during incontinent care of resident. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for one (Resident #8) of 12 residents reviewed for rights, in that: The facility failed to ensure Resident #8 felt safe within her room environment as well as her preference for TV volume were met. This failure could place the residents at risk for a diminished quality of life, well-being, and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure the MDS assessment accurately reflected the resident's status for 1 of 12 residents (Resident #32) whose MDS assessments were reviewed. Resident #32's MDS assessment indicated in Section B that his vision was adequate, and he did not have corrective lenses. This failure to ensure accurate assessments may place resident at risk for improper or inadequate care due to staff lack of knowledge about the resident's status, needs, strengths, and areas of decline.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights and that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 12 residents (Resident #32) reviewed for comprehensive care plans in that: Resident #32 had a physician's order for prescription glasses that was not addressed in his care plan. This failure could place residents at risk of receiving care that is not person-centered, substandard, unable to meet their needs, or inadequate to prevent complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that one (Resident #32) of 12 residents reviewed for vision services, received proper treatment and assistive devices to maintain vision abilities. The facility did not address Resident #32's need for prescription glasses following a physician's visit, for 6 months. This failure could affect residents by causing them to have decreased vision awareness when ambulating, difficulty seeing and participating in activities, and decreased self-esteem.

Inspectors wroteBased on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a weekfor the period reviewed from 11/1/23 to 4/13/24. The facility did not have an RN in the facility on 11/18/23 and 11/19/23, accounting for 2 days in the past months for the peroiod reviewed from 11/1/23 to 4/13/24. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as emergency care.

Inspectors wroteBased on observation and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, administering, and documentation of all drugs and biologicals) to meet the needs of each resident for 4 out of 16 residents (Residents #2, #5, #32, #38,) whose medical records were reviewed for medication administration. -The facility administered insulin to Resident #5, Resident #32, and Resident #38 after it was expired. -RN B documented administration of an injectable medication under MA D's computer access, even though MA D did not give the medication. -RN G administered an injectable medication, and RN I documented medication administration under RN I's credentials. [...]

Inspectors wroteBased on observation, the interview and record review, the facility failed to ensure residents were free of any significant medication errors for one of 1 (Resident #5) residents reviewed for medication administration. -RN was attempting to administer Resident #5's expired insulin. This failure could place residents who receive insulin medications at an increased risk for complications such as increased blood glucose levels, change in cognition, and an exacerbation of symptoms and disease process.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen observed for food storage, preparation, and distribution. A. CK A did not perform hand hygiene appropriately when preparing pureed foods. This failure could place residents who ate food served by the kitchen at risk of food-borne illness from cross-contamination.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete, accurate, readily accessible, and systemically organized records for 1 (Resident #5) of 16 residents reviewed for medical records. -RN B documented administration of injectable medication under MA D's computer access. -RN G administered injectable medication, RN I documented medication administration under RN I's credentials. This failure could place residents at risk of not receiving appropriate care through inaccurate documentation which can be misleading to care providers regarding what care, medications, and treatments residents have or have not received.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 5 residents reviewed for care in that: Resident #1 was left exposed in his room in an undignified manner. This failure could cause residents to feel uncomfortable and disrespected leading to feeling of isolation and deterioration in general health conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. DC A failed to wear a proper hair restraints while in the kitchen. This failure could place residents at risk of food contamination.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 7 (Resident #3) residents reviewed for medication administration. Resident #3 did not receive a Fentanyl transdermal (pain medicine delivered through the skin) patch every three days as ordered by her physician. The failure was identified as past non-compliance as the facility had instituted adequate corrective measures to prevent reoccurrence of the non-compliance. The facility's failure to administer medications correctly could affect all residents resulting in exacerbation of their condition resulting in complications from deterioration in health, extended recoveries, hospitalizations, and death.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure compliance with Texas Health and Safety Code, Chapter 250 related to criminal history for potential employees for 2 of 5 employee records reviewed for criminal history, in that:. HK1 and HK2 were not cleared of criminal history prior to start date. This failure has the potential to affect residents in the facility by placing them at risk of abuse, neglect, physical harm, mental harm, injury, and hospitalization. Findings Included: Record review of HK1 employee file revealed a hire date of 7/31/23. Review revealed that criminal history was not obtained until after hire of HK1 on 8/1/23. Record review of HK2 HK1 employee file revealed a hire date of 7/31/23. Review revealed that criminal history was not obtained until after hire of HK2 on 8/2/23. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1of 1 kitchen reviewed for kitchen sanitation. CNA A failed to restrain hair when entering the kitchen. These failures placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness. Findings Included: During an observation on 9/5/23 at 9:40 AM, CNA A was observed walking into the kitchen from the dining area two times without donning a hair net. During an Interview on 9/5/23 at 2:42 PM, CNA A stated that policy states a hair net is to be worn in the kitchen. CNA A agreed that she entered the kitchen without donning a hair net. CNA A confirmed she does get the handbook where the policy is stated and indicated a negative outcome could be hair in the food. [...]