F 0607
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Level of Harm - Minimal harm
or potential for actual harm
Based 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:.
Residents Affected - Few
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.
In an interview on 9/5/23 at 2:53 PM with the ADM revealed that Human Resources position was filled by
ADM prior to hire of current employee. She indicated that she is aware these records were pulled after hire
due to previous Human Resources manager failing to complete items.
Record review of Abuse, Neglect, and Exploitation policy, revised 3/29/28, under heading Procedure, line
one states, The facility administrator will be responsible for ensuring compliance with the policy and Texas
Health and Safety Code, Chapter 250.
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 2
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
09/05/2023
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based 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.
Residents Affected - Few
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.
During an interview 9/5/23 at 3:15 PM, DM stated that all staff are to don hair nets, masks, and gloves while
in the kitchen. The DM stated it was part of the training on proper dress in the kitchen. The DM stated that a
negative outcome would be cross contamination with hair.
During an interview with on 9/5/23 at 3:18 PM , ADON, DON, ADM, and Comp. Nurse revealed that proper
attire for the kitchen would be a hair net, to be dressed appropriately, and non-slick shoes. The Comp.
Nurse advised that training is done in during on-boarding and in the employee handbook during orientation.
When revelation of staff entering the kitchen twice without donning a hair net, the Comp. Nurse stated that
the employee would immediately get an in service and a coaching. The Negative outcomes stated by
ADON, DON, ADM, and Comp. Nurse were contamination, hair in the food, and infection control.
Record review of CNA A's employee file revealed CNA A signed an acknowledgement and understanding
of employee handbook form on 2/15/23.
Record review of Employee Handbook, dated 2019, on page 31, line 2 reveals that all dietary staff must
wear hair nets while in the dietary department.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
675851
If continuation sheet
Page 2 of 2
