Health inspection·July 26, 2023

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some were placed in the medication carts by two night nurses - LVN A and LVN B which was what they were supposed to do. The Administrator stated both LVN A and LVN B came back to the facility to work the night shift the next day and all the Tizanidine blister packs for all four residents (Residents 1, 2, 3, 4) was missing from both medication carts. The Administrator stated both medication carts, the narcotics, the medication room and the emergency kit were searched for the blister packs and they were never found. The Administrator stated she interviewed both night nurses and both day shift staff, LVN C and MA D, and all denied taking any medications out of the medication carts. The Administrator stated Trazadone was delivered to the facility on the same day as the Tizanidine (7/5/23) but no one noticed the medication blister packs for two residents (Residents 5 and 6) were missing until 7/14/23 when one of the residents asked for a PRN dose of Trazadone. The Administrator stated LVN C and MA D were both drug tested and LVN C tested positive for opiates, which LVN C had a prescription for. The Administrator stated no other staff were drug tested due to the medications that were missing would not show up on a drug test. The Administrator stated LVN C was a new nurse to the facility and was named in both drug diversions and acted very suspicious when questioned but they could not prove that LVN C or anyone else took the medications. The Administrator stated the only blister packs that are counted at each shift change were the narcotic medications, not any other medication. During an interview on 7/25/23 at 11:40 a.m., the ADON E stated they know when the medications were delivered to the facility by looking at the pharmacy delivery sheet, dated 7/5/23, and MA D saw the Tizanidine in the cart that morning and then that evening, the medication was gone. During an interview on 7/25/23 at 11:50 a.m., the DON stated the two medications were delivered the same day (7/5/23) on the evening shift when two nurses placed the medications in the appropriate medication carts as was there protocol. The DON stated the narcotic blister packs were counted at every shift change but not the other medication blister packs. During a telephone interview on 7/25/23 at 1:45 p.m., LVN C stated she was not aware that any medications were missing. LVN C stated they do not count all the blister packs in the medication cart, just the narcotics. LVN C stated MA D was working with her and had keys to the medication carts. During a telephone interview on 7/25/23 at 2:00 p.m., MA D stated she never gave any medications out of the medication cart the day the medication was missing (7/14/23). MA D stated LVN C was supposed to give her the keys to Medication Cart B/C at 10:00 a.m. so the nurse could do charting, give insulin and any treatments that needed to be done. MA D stated LVN C was not done with her morning medication pass and she would hand over the cart later. MA D stated at 11:30 a.m., MA D asked LVN C to give her the keys and LVN C said she had started to give her 1:00 p.m. medication pass so she would just keep the cart. MA D stated around 2:00 p.m. or 3:00 p.m., LVN C gave her the keys to the medication cart so she could go to lunch but she never got into the medication cart while LVN C was gone. MA D stated she had a 4:00 p.m. medication to give a resident morphine (pain medication) so she got into the cart with LVN C by her side and LVN C got the morphine out of the cart for her. MA D stated she had the keys to both medication carts at shift change but never gave another medication after the morphine. MA D stated at shift change, that was when the Trazadone was missing During an interview on 7/25/23 at 2:20 p.m., LVN B stated she checked in the medications that were missing out of the medication carts on 7/5/23 on the evening shift. LVN B stated LVN A had put her medications in the top drawer because she was going to need them the next night so she put them in the current medication stock. LVN B stated they both worked the next night and the medications were not there. LVN B stated they checked both carts and all the Tizanidine that the residents were taking was gone. LVN B stated she called LVN C via snap chat and asked her about the missing medications (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 2 of 3 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 07/26/2023 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)

F 0761 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some and LVN C said she never touched those medications because she had to wear gloves because she was allergic to them but LVN C never wears gloves even when checking blood sugars. During an interview on 7/25/23 at 2:35 p.m., LVN F stated she worked the day shift when the Tizanidine was missing. LVN F stated Resident #1 asked for the Tizanidine and the medication was not in the cart so she ordered and the medication was delivered the next day. LVN F stated she did not take the medication and would never do that. During a follow-up interview on 7/25/23 at 3:30 p.m., MA D stated LVN C got into her medication cart on both occasions when the medications went missing. MA D stated she gave her keys to LVN C while she was at lunch. Record review on 7/25/23 at 4:05 p.m. of Resident # 1's clinical record documented Resident #1 was prescribed Tizanidine 4 mg tablet by mouth every eight hours as needed for pain. Record review on 7/25/233 at 4:10 p.m. of Resident # 3's clinical record documented Resident #3 was prescribed Tizanidine 4 mg capsule by mouth every eight hours as needed for muscle spasms. Record review on 7/25/23 at 4:15 p.m. of Resident # 2's clinical record documented Resident #2 was prescribed Tizanidine 2 mg tablet by mouth every six hours as needed for arthritis. Record review on 7/25/23 at 4:20 p.m. of Resident # 4's clinical record documented Resident #4 was prescribed Tizanidine 4 mg tablet by mouth every eight hours as needed for muscle spasms. Record review on 7/25/23 at 4:25 p.m. of Resident # 5's clinical record documented Resident #5 was prescribed Trazodone 50 mg tablet by mouth one time a day related to bipolar disorder. Record review on 7/25/23 at 4:30 p.m. of Resident # 6's clinical record documented Resident #6 was prescribed Trazodone 100 mg tablet by mouth at bedtime related to schizophrenia. Record review on 7/27/23 at 11:43 a.m. of a policy titled, Pharmacy Policy and Procedure Manual, revised 7/2012, documented a policy for the following areas: *Bedside Storage of Medications *Storage & Documentation of Controlled Medications, and *Recommended Medication Storage (when a medication has a limited shelf life. The policy did not document about ensuring the medication cart security and being able to account for all medications stored in the cart. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 3 of 3