Health inspection·February 28, 2023

F 0636 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for one resident (Resident #91) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #91 was completed within 14 days after admission. This failure could place residents at risk for improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being. Findings include: Record review of Resident #91's admission Records revealed a [AGE] year-old female who was admitted to the facility on [DATE]. She had diagnoses which included: Other specified anxiety disorder, essential (primary) hypertension, chronic obstructive pulmonary disease, other chronic pain, reduced mobility, primary insomnia, polyneuropathy, poly osteoarthritis and mild cognitive impairment of uncertain or unknown etiology. Record review of Resident #91's medical record revealed no MDS had been completed. Record review of Resident #91's Baseline Care Plan, dated 2/3/23, revealed that only the Baseline Care Plan had been completed at admission; no further care planning had been completed for Resident #91. Interview with the MDS Coordinator on 2/28/23 at 1:13 PM revealed the time frame for an initial MDS to be completed was 14 days from admission and the Comprehensive Assessment within 21 days of admission. She stated she had been on Personal Time Off (PTO) and had not realized the assessments had not been done. She stated that she thought that assessments would be handled by the DON in her absence, but that the DON had been out on medical leave. Interview with the Business Office Manager revealed the resident was admitted to the facility on [DATE]. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 7 Event ID: 675851 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675851 B. Wing A. Building (X3) DATE SURVEY COMPLETED 02/28/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Georgia Manor Nursing Home 2611 W 46th Ave Amarillo, TX 79110 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)