Health inspection·April 17, 2025

F 0641 listed Resident #2 as not having oxygen therapy while a resident. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's Treatment Administration Record (TAR) with treatment administered from 03/01/25 to 03/31/25 listed Resident #2 as having the following: Residents Affected - Some Continuous Oxygen via Nasal Canula @ 3 liters N/C @ HS with ear padding at bedtime -D/C Date03/28/2025. (Received daily 03/01/205 through 03/08/25 - the 7-day look back period for the 03/08/25 MDS assessment) Record review of Resident #2's care plan with admission date of 05/07/24 revealed the following care plan: -Focus: Resident has Congestive Heart Failure. -Intervention/Tasks: Oxygen therapy as ordered. During an observation and interview on 04/17/25 at 08:10 AM Resident #2 was observed in bed with the head of her bed elevated and she was eating her breakfast. Resident #2 appeared in good condition but was noted to be short of breath with effort such as conversation. Resident #2 verified that she does use oxygen but mostly at night. During an interview on 04/17/25 at 08:26 AM the MDS/RN verified that Resident #2 did not have oxygen marked on her 03/08/25 MDS and that her TAR had that Resident #2 had received oxygen during the 7-day look back period. The MDS/RN stated, I missed that one. The MDS/RN reported that the facility uses the RAI Manual to complete all MDS assessments. Resident #13 Record review of Resident #13's admission record dated 04/15/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included major depressive disorder recurrent (a mental disorder characterized by persistent low mood, low self-esteem, and loss of interest or pleasure in normally enjoyable activities). Record review of Resident #13's significant change MDS revealed a completion date of 03/26/25. Section C-Cognitive Pattern revealed a BIMS of 6 which indicated severely impaired cognition. Section I-Active Diagnoses revealed a diagnosis of depression. Section N-Medications revealed Resident #13 was not receiving antidepressant medication. Record review of Resident #13's care plan completed on 04/10/25 revealed a focus area of [Resident #13] requires antidepressant medication. This focus area was initiated on 12/20/22. One of the interventions which was also initiated on 12/20/22 was Give antidepressant medications ordered by physician. Record review of Resident #13's active orders dated 04/15/25 revealed an order for antidepressant medication with a start date of 04/19/22. The instructions for this order were: Give 1 capsule by mouth one time a day for depression related to MAJOR DEPRESSIVE DISORDER, RECURRENT, UNSPECIFIED. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 2 of 19 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 04/17/2025 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 0641 Resident #18 Level of Harm - Minimal harm or potential for actual harm Record review of Resident #18's face sheet printed 12-5-2024 revealed a [AGE] year-old male resident admitted to the facility on [DATE] with diagnoses to include chronic kidney disease (longstanding disease of the kidneys leading to kidney failure), intermittent explosive disorder (a behavioral disorder characterized by explosive outburst of anger and/or violence, often to the point of rage that are disproportionate to the situation at hand), malnutrition (lack of proper nutrition), cerebral infarction (occurs as a result of disrupted blood flow to the brain due to problems with the blood vessels that supply it) with hemiplegia (a condition characterized by sever or completed paralysis on once side of the body, typically resulting from brain damage), and contracture (a condition of shortening and hardening of muscles, tendons, or other tissue, often leading to deformity and rigidity of joints) to left hand. Residents Affected - Some Record review of Resident #18's MDS assessment dated [DATE] revealed he had a BIMS of 7 indicating he was severely cognitively impaired, he had a functionality of requiring partial/moderate assistance with most of his activities of daily living, and for Section K - Swallowing/Nutritional Status Resident #18 for question

K0300 Weight Loss-loss of 5% or more in the last month or loss of 10% or more in the last 6 months, Resident #18 was marked yes. Record review of Resident #18's care plan with admission date of 02/28/2024 revealed the following care plan: Focus: Resident is on a regular/thin diet. Date initiated 04/05/24. Goal: Resident will maintain ideal weight x 90 days. Target date 06/04/25. During an observation and interview on 04/15/25 at 09:23 AM Resident #18 was leaving his room in a specialized wheelchair to go for a smoke break. Resident #18 appeared in good condition and was wheeling himself independently. Resident #18 reported no concerns and that his care had been good. Record review of Resident #18's weight record revealed he had been weighed on 03/10/25 (the closest weight to the 03/22/25 MDS) at 200 lbs. and he was weighed on 02/07/25 at 201 lbs. for a weight loss of 0.05% in the last month and Resident #18's weight on 10/02/24 was 184.8 lbs. for a weight gain of 0.823% in the last 6 months. During an interview on 04/17/25 at 08:26 AM the MDS/RN reported that she started as the MDS coordinator for the facility approximately 1 month ago. The MDS/RN reviewed Resident #18's 03/22/25 quarterly MDS and verified that Resident #18 was marked with weight loss in section K. The MDS/RN reviewed Resident #18's weights and reported that he lost less than 5% in the previous 30 days (1 month) and gained weight in the last 180 days (6 months). The MDS/RN reported that she marked him as Answer #2-yes for the weight loss questions because he was having weight fluctuations. The MDS/RN was asked to read the RAI manual instructions which she did and for section K Weight loss/gain she read that a resident was supposed to be marked Code #2-yes if the resident had a 5% weight loss in the last 30 days (1 month) or a 10% weight loss in the last 180 days (6months) and the resident was not on a physician prescribed weight loss program. The MDS/RN reported that she understood she was allowed to mark the resident as Code #0-no weight loss/gain or Code #2-yes if the resident was having weight fluctuations. The MDS/RN reported that the facility uses the RAI Manual to complete all MDS assessments. Resident #41 (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 3 of 19 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 04/17/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #41's admission record dated 04/15/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, urinary tract infection. Record review of Resident #41's quarterly MDS with ARD date of 03/16/25 revealed a completion date of 03/25/25. Section C-Cognitive Patterns revealed Resident #41 had a BIMS of 13 which indicated intact cognition. Section I-Active Diagnoses revealed the Resident #41 did not have a urinary tract infection. Section N-Medications revealed Resident #41 was taking antibiotic medication. The instructions for this section were Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Record review of Resident #41's care plan completed on 03/27/25 revealed no mention of antibiotic medication. Record review of Resident #41's active order summary dated 04/15/25 revealed no mention of antibiotic medication. Record review of Resident #41's discontinued orders revealed one order for an antibiotic medication with an order start date of 12/07/25 and an order end date of 12/14/25. Record review of facility matrix dated 04/15/25 revealed Resident #41 was marked for receiving antibiotic medication. Resident #43 Record review of Resident #43's admission record dated 04/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure (heart muscle fails to pump blood as it should), atherosclerotic heart disease (hardening of arteries due to plaque buildup), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Record review of Resident #43's quarterly MDS with ARD date of 02/18/25 revealed a completion date of 02/19/25. Section C-Cognitive Patterns revealed Resident #43 had a BIMS of 15 which indicated intact cognition. Section N-Medications revealed Resident #43 was taking anticoagulant medication. The instructions for this section were Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if less than 7 days. Section O-Special Treatments, Procedures, and Programs revealed the following instructions: Check all of the following treatments, procedures, and programs that were performed . b. While a Resident Performed while a resident of this facility and within the last 14 days. Resident #43 was not coded as receiving oxygen therapy while a resident. Record review of Resident #43's care plan completed on 03/27/25 revealed the following focus areas: The resident is on Anticoagulant therapy This focus area was initiated on 01/28/25. The resident has Congestive Heart Failure This focus area had Oxygen therapy as an intervention. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 4 of 19 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 04/17/2025 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 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some The resident has Emphysema/COPD This focus area had Give oxygen therapy as ordered by the physician as an intervention which was initiated on 01/28/25. The resident has Oxygen Therapy This focus area was initiated on 01/28/25. Record review of Resident #43's oxygen saturation report during the 14-day look-back period for her quarterly MDS 02/04/25 to 02/18/25 revealed 15 entries. Resident #43 was noted to be receiving Oxygen via Nasal Cannula for 13 of the 15 entries. Record review of Resident #43's active order summary dated 04/15/25 revealed no mention of anticoagulant medication. The order summary did reveal the following orders: Ear Padding for Continuous Oxygen via Nasal Cannula This order was dated 01/28/25. May use oxygen @ 4 l/m via nasal canula every shift This order had a start date of 01/28/25. Record review of Resident #43's discontinued orders revealed one order for an anticoagulant medication with a start date of 01/29/25 and an end date of 02/08/25. During an interview on 04/17/25 at 08:26 AM MDS RN stated she was responsible for completing MDS assessments. She stated she used the RAI manual as her policy. She stated she gathered information from the MAR and TAR as well as looking at nursing and CNA notes and orders within the last 7 days in order to complete the MDS assessments accurately. MDS RN stated she did not think an inaccurate MDS assessment would affect the care of the resident. She stated, It is more on the money side, because either you are going to code something, or you missed something that could add more money to that resident. But it doesn't necessarily affect the resident. MDS RN stated a lack of funding could absolutely affect resident care, Because you are not gonna be able to pay your staff. During an interview on 04/17/25 at 09:32 AM ADM stated an inaccurate MDS assessment could negatively affect a resident in that, It can lead to having an inaccurate care plan and an inaccurate care plan can lead to having inaccurate care given to our residents. Record review of the Long Term Care Facility Resident Assessment Instrument 3.0 User's Manual Version 1.18.11, dated October 2023 revealed the following: Section O - Special Treatments, Procedures, and Programs Respiratory Treatments: C1. Oxygen Therapy a. On Admission b. While a Resident (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 5 of 19 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 (X3) DATE SURVEY COMPLETED A. Building 04/17/2025 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 0641 c. Level of Harm - Minimal harm or potential for actual harm At Discharge Coding Instructions for Column b. While a Resident Residents Affected - Some Check all treatments, procedures, and programs that the resident received or performed after admission/entry or reentry to the facility and within the last 14 days. Section K - Swallowing/Nutritional Status

K0300. Weight Loss Loss of 5% or more in the last month or loss of 10% or more in last 6 months 0. No or unknown 1. Yes, on physician-prescribed weight-loss regimen 2. Yes, not on physician-prescribed weight-loss regimen Coding Instructions: o Code 2, yes, not on physician-prescribed weight-loss regimen: if the resident has experienced a weight loss of 5% or more in the past 30 days or 10% or more in the last 180 days, and the weight loss was not planned and prescribed by a physician. SECTION N: MEDICATIONS

N0415: High-Risk Drug Classes: Use and Indication C. Antidepressant 1. Is takin 2. Indications noted o N0415C1. Antidepressant: Check if an antidepressant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). o N0415C2. Antidepressant: Check if there is an indication noted for all antidepressant medications taken by the resident any time during the observation period. (or since admission/entry or reentry if less than 7 days).

N0415: High-Risk Drug Classes: Use and Indication (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 6 of 19 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 04/17/2025 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 0641 F. Antibiotics 1. Is taking 2. Indications noted. Level of Harm - Minimal harm or potential for actual harm Coding Instructions o N0415F1. Antibiotic: Check if an antibiotic medication was taken by the resident at Residents Affected - Some any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). o N0415F2. Antibiotic: Check if there is an indication noted for all antibiotic medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days).

N0415: High-Risk Drug Classes: Use and Indication E. Anticoagulant 1. Is taking 2. Indications noted. Coding Instructions o N0415E1. Anticoagulant (e.g., warfarin, heparin, or low-molecular weight heparin): Check if an anticoagulant medication was taken by the resident at any time during the 7-day look-back period (or since admission/entry or reentry if less than 7 days). o N0415E2. Anticoagulant: Check if there is an indication noted for all anticoagulant medications taken by the resident any time during the observation period (or since admission/entry or reentry if less than 7 days). FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 7 of 19 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 04/17/2025 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 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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: Record review of Resident #43's admission record dated 04/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of bipolar disorder current episode depressed moderate (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings) dated 02/28/25 and listed as her primary diagnosis. Record review of Resident #43's quarterly MDS completed on 02/19/25 revealed in Section C-Cognitive Patterns a BIMS of 15 which indicated intact cognition. Section D-Mood revealed Resident #43 felt down, depressed or hopeless and had little interest or pleasure in doing things 2-6 of the previous 14 days. Section I-Active Diagnoses revealed Resident #43 had a diagnosis for bipolar disorder. The instructions for this section were Active Diagnoses in the last 7 days-Check all that apply. Section N-Medications indicated Resident #43 was receiving antidepressant medication and anticonvulsant medication. Record review of Resident #43's care plan completed on 03/27/25 revealed Resident #43 was receiving antidepressant medication but made no mention of bipolar except in the list of diagnoses on the last page of the care plan. The care plan did not mention anticonvulsant medication. Record review of Resident #43's active order summary dated 04/15/25 revealed an order for an antidepressant medication with the following instructions, Give 1 capsule by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MODERATE. This order had a start date of 04/02/25. The active order summary revealed an order for an anticonvulsant medication with the following instructions Give 500 mg by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MODERATE. This order had a start date of 02/28/25. Record review of Resident #43's Miscellaneous tab in her EHR revealed one PASRR. Record review of Resident #43's PASRR revealed it was completed on 01/28/25. Question C0100 revealed the following: Is there evidence or an indicator this is an individual that has a Mental Illness? The answer to this question was No. During an interview on 04/16/25 at 10:12 AM MDS RN stated she was responsible for ensuring PASRRs are completed as required. MDS RN stated she began working for the facility in March of 2025 and if a new PASRR was performed on Resident #43 following her diagnosis of bipolar disorder she (MDS RN) did not know where it would be. She stated, I don't even know where to start looking for that, but I (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 8 of 19 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 04/17/2025 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 0644 can start asking around. Level of Harm - Minimal harm or potential for actual harm During an interview on 04/16/25 at 11:44 AM ADM and MDS RN stated the previous MDS coordinator did not catch Resident #43's new diagnosis of bipolar disorder and a new PASRR was not completed. Residents Affected - Few During an interview on 04/16/25 at 03:15 PM a PASRR policy was requested from ADM. During an interview on 04/17/25 at 08:26 AM MDS RN stated if a resident was admitted to the facility with a negative PASRR and after admission received a qualifying diagnosis the resident should have a new PASRR completed. She stated a resident could absolutely be negatively affected if a new PASRR was not completed. MDS RN stated, They could be getting a treatment they really didn't need. They could have just had a bad day. During an interview on 04/17/25 at 09:32 AM ADM stated, We need to initiate a PASRR II when a resident who was already admitted to the facility received a new qualifying diagnosis like bipolar disorder. She stated if a PASRR II was not initiated the resident would be at risk of not receiving services they require or are eligible for. During an interview on 04/17/25 at 10:28 AM ADM stated the facility did not have a PASRR policy. She stated PASRR was covered in their Comprehensive Care Planning policy. Record review of undated facility policy titled Comprehensive Care Planning did not address when to perform a PASRR. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 9 of 19 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 04/17/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. These failures could lead to residents not receiving needed care and/or consideration from staff as care is provided and/or receiving improper care/treatment. Findings Included: 1. Record review of Resident #13's admission record dated 04/15/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included post-traumatic stress disorder acute (mental health condition caused by a traumatic event that affects your ability to function normally). The PTSD diagnosis had an onset date of 03/20/20. Record review of Resident #13's significant change MDS revealed a completion date of 03/26/25. Section C-Cognitive Pattern revealed a BIMS of 6 which indicated severely impaired cognition. Section I-Active Diagnoses revealed a diagnosis of PTSD. Record review of Resident #13's care plan completed on 04/10/25 revealed no mention of PTSD except in the diagnoses list on the bottom of the last page of the care plan. Record review of Resident #13's active orders dated 04/15/25 revealed no mention of PTSD except in the list of diagnoses at the top of the first page of the report. 2. Record review of Resident #43's admission record dated 04/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure (heart muscle fails to pump blood as it should), atherosclerotic heart disease (hardening of arteries due to plaque buildup), chronic atrial fibrillation (an irregular, often rapid heart rate that commonly causes poor blood flow), and bipolar disorder (serious mental illness characterized by extreme mood swings such as extreme excitement or extreme depressive feelings). Record review of Resident #43's quarterly MDS with ARD date of 02/18/25 revealed a completion date of 02/19/25. Section C-Cognitive Patterns revealed Resident #43 had a BIMS of 15 which indicated intact cognition. Section I-Active Diagnoses revealed a diagnosis of bipolar disorder. Section N-Medications revealed Resident #43 was taking anticoagulant and anticonvulsant medication. The instructions for this section were Is taking Check if the resident is taking any medications by pharmacological classification, not how it is used, during the last 7 days or since admission/entry or reentry if (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 10 of 19 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 04/17/2025 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 0656 less than 7 days. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #43's care plan completed on 03/27/25 revealed no mention of bipolar disorder or anticonvulsant medication. The care plan did include the following focus area: Residents Affected - Few The resident is on Anticoagulant therapy This focus area was initiated on 01/28/25. Record review of Resident #43's active order summary dated 04/15/25 revealed no mention of anticoagulant medication. The order summary did reveal the following: An order with a start date of 04/02/25 for an antidepressant medication. The instructions for this order were, Give 1 capsule by mouth at bedtime related BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MODERATE. An order with a start date of 02/28/25 for an anticonvulsant medication. The instructions for this order were, Give 500 mg by mouth at bedtime related to BIPOLAR DISORDER, CURRENT EPISODE DEPRESSED, MODERATE. Record review of Resident #43's discontinued orders revealed one order for an anticoagulant medication with a start date of 01/29/25 and an end date of 02/08/25. During an interview on 04/17/25 at 08:26 AM MDS RN stated she just recently discovered she was fully responsible for care plans. She stated she let administration and nursing know she would need nursing to assist by letting her know when a medication was discontinued, or a new one was started. She stated all the care areas identified in the MDS needed to be included in the care plan. MDS RN stated, pain, nutrition, potential for ulcers, or if they have a wound, diet, all meds should be included in a resident's care plan. She stated if a care plan was not complete and person-centered it could negatively affect the resident, because if you are looking for something and it is not in the care plan then how are you to know that they are to receive that care? MDS RN stated mental health diagnoses should absolutely be addressed in the care plan. She stated if mental health diagnoses are not addressed in the care plan, They [residents] don't get the care they need. MDS RN did not think there would be a negative outcome to a resident if a discontinued medication was still in the care plan. She stated, In my opinion I don't think so because it [the medication] might just be held for surgery or dental stuff. During an interview on 04/17/25 at 09:32 AM ADM stated the interdisciplinary team was responsible for care plans. She stated mental health diagnoses like PTSD should be addressed in the care plan. She stated if they were not addressed, It could trigger the resident's PTSD and go unaddressed and be exacerbation of the PTSD. ADM stated, an inaccurate care plan can lead to having inaccurate care given to our residents. Record review of undated policy titled Comprehensive Care Planning revealed the following: The facility will develop and implement a comprehensive person-centered care plan for each resident .to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Each resident will have a person-centered comprehensive care plan developed and implemented to meet his other preferences and goals and address the resident's medical, physical, mental and psychosocial needs. The facility will establish, document and implement the care and services to be provided to each resident to assist in attaining or maintaining his or her highest practicable quality of life. Care planning drives the type of care and services that a resident receives. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 11 of 19 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 04/17/2025 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 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Person-centered care includes making an effort to understand what each resident is communicating . identifying what is important to each resident . and having an understanding of the resident's life before coming to reside in the nursing home. When developing the comprehensive care plan, facility staff will, at a minimum, use the Minimum Data Set . The resident's care plan will be reviewed after each Admission, Quarterly, Annual and/or Significant Change MDS assessment, and revised based on changing goals, preferences and needs of the resident and in response to current interventions. The services provided or arranged by the facility, as outlined by the comprehensive care plan, will meet professional standards of quality. 'Professional standards of quality' means care and services are provided according to accepted standards of clinical practice. Event ID: Facility ID: 675851 If continuation sheet Page 12 of 19 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 04/17/2025 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 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based 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. Findings include: During an observation on 04/15/25 at 12:08 PM 16 resident and 10 staff were present in the dining room. Noted in the dining room by the exit door to the patio was a freestanding oxygen bottle that was unsecured. During an observation on 04/15/25 at 12:14 PM the HRD moved the unsecured oxygen tank to the back of the closest resident's chair and placed the oxygen tank in an oxygen tank holder. During an interview on 04/16/25 at 01:03 PM the HRD who reported she is a CNA reported that she removed the unsecured oxygen canister from the dining room on 04/15/25, that an oxygen tank should not be left on the floor unsecured. The HRD reported that if an oxygen tank was left unsecured it can fall and explode or it can fall and land on someone's toe, basically it could hurt a resident. The HRD reported that they have been trained on the proper storage of an oxygen tanks and that they discussed this incident in report this AM and plan on doing another training ASAP. The HRD could not remember when the last training on oxygen safety was completed and who presented the training. During an interview on 04/17/25 09:08 AM the ADM reported that the facility did not have a policy for oxygen tank storage/safety. During an interview on 04/17/25 at 09:26 AM the DON reported that oxygen tanks should be stored in the oxygen storage room in a rack for safety because they can fall and turn into a torpedo. The DON reported that if an oxygen tank was to fall then it would be possible for anyone to get hurt. During an interview on 04/17/25 at 09:49 AM the ADM presented an Inservice Training Report started 04/16/25 and currently signed by 28 staff members that had the following information: When taking off someone oxygen bottle to take them out to smoke make sure you are not leaving them on the ground unsecure. This could cause it to fall over and hurt a resident or staff member . The ADM reported that the facility had no previous trainings on Oxygen Bottle Safety that she could find. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 13 of 19 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 04/17/2025 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 0695 Provide safe and appropriate respiratory care for a resident when needed. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Residents Affected - Some 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. The facility failed to ensure Resident #43 received O2 via NC at the rate of 4 l/m as ordered by hi physician. These failures could place residents who receive oxygen at an increased risk of hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings Included: 1. Record review of Resident #3's admission record dated 04/15/2025 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included chronic obstructive pulmonary disease (a group of lung diseases that block airflow and make it difficult to breath) and chronic respiratory failure (a long-term condition that occurs when the body's respiratory system can't exchange oxygen and carbon dioxide properly). Record review of Resident #3's annual MDS assessment completed 03/22/2025 revealed a BIMS of 15 which indicated intact cognition. Section O-Special Treatments, Procedures, and Programs indicated she was receiving oxygen therapy while a resident. Record review of Resident #3's care plan completed 03/37/25 revealed a focus area of The resident has oxygen therapy as needed r/t COPD. This focus area was revised on 01/18/24 and included the following intervention Oxygen per physician orders. This intervention was revised on 02/13/25. Record review of Resident #3's active orders dated 04/16/2025 revealed the following order: Order start date 02/11/25 May use oxygen @ 2 l/m via nasal canula every shift related to CHRONIC OBSTRUCTIVE PULMONARY DISEASE, UNSPECIFIED. During an observation and interview on 04/16/25 at 07:56 AM Resident #3 was in bed receiving oxygen via NC at between 3.0 and 3.5 lpm. Resident #3 opened her eyes and stated. Everything is fine. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 14 of 19 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 04/17/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some During an observation on 04/16/25 at 10:55 AM Resident #3 was lying in bed with her eyes closed receiving oxygen via NC at between 3 and 3.5 lpm. 2. Record review of Resident #13's admission record dated 04/15/25 revealed an [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, emphysema, chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue), chronic respiratory failure with hypoxia (failure of lungs to provide oxygen), dependence on supplemental oxygen, and pleural effusion (abnormal build-up of fluid in space around lungs, causes pressure on lungs resulting in shortness of breath, coughing, and chest pain). Record review of Resident #13's significant change MDS revealed a BIMS of 6 which indicated severely impaired cognition. Section O-Special Treatments, Procedures, and Programs revealed she was receiving oxygen therapy while a resident. Record review of Resident #13's care plan completed on 04/10/25 revealed the following focus areas and corresponding interventions: [Resident #13] has Emphysema/COPD. This focus area was revised on 03/28/23 and included the intervention Give oxygen therapy as ordered by the physician. This intervention was initiated on 10/31/18. [Resident #13] has Oxygen Therapy. This focus area was revised on 03/28/23. Record review of Resident #13's active orders dated 04/15/25 revealed the following orders: Order start date 11/20/22 Change humidifier water. one time a day every Sun for O2 therapy. Order start date 11/18/22 change O2 cannula/tubing prn if damaged or visibly soiled as needed for O2 therapy. Order start date 10/16/22 Change oxygen tubing, nasal cannula or mask PRN or when visibly soiled every night shift every Sun or Oxygen therapy. Order start date 11/23/24 Check O2 sat Q shift every shift. Order start date 11/23/24 may use oxygen @ 2 l/m via nasal canula every shift related to CHRONIC RESPIRATORY FAILURE WITH HYPOXIA During an observation on 04/15/25 at 09:50 AM Resident #13 was in her bed receiving O2 via NC at 3 lpm. During an observation on 04/15/25 at 12:20 PM Resident #13 was in her bed receiving O2 via NC at 3 lpm. During an observation on 04/16/25 at 08:27 AM Resident #13 was in her bed receiving O2 via NC at 2.5 lpm. During an observation on 04/16/25 at 02:48 PM Resident #13 was in her bed receiving O2 via NC at 2.5 lpm. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 15 of 19 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 04/17/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 3. Record review of Resident #41's admission record dated 04/15/25 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses that included, but were not limited to, acute respiratory failure with hypoxia (failure of lungs to provide oxygen) and congestive heart failure (a progressive heart disease that affects the pumping action of the heart muscles resulting in shortness of breath and fatigue). Record review of Resident #41's quarterly MDS completed on 03/25/25 revealed a BIMS of 13 which indicated intact cognition. Section O-Special Treatments, Procedures, and Programs revealed he was receiving oxygen therapy while a resident. Record review of Resident #41's care plan completed on 03/27/25 revealed the following focus areas and corresponding interventions: The resident has Congestive Heart Failure. This focus area was initiated on 12/07/24 and included the intervention Oxygen therapy as ordered. This intervention was revised on 04/02/25. The resident has Oxygen Therapy. This focus area was initiated on 12/07/24 and included the intervention Oxygen therapy as ordered. This intervention was revised on 04/02/25. Record review of Resident #41's active order summary dated 04/15/25 revealed the following orders: Order start date 03/16/25 May use humidified Oxygen for resident comfort-change o2 bottle and tubing weekly at bedtime every Sun for comfort. Order start date 12/07/24 May use oxygen at 5 L via nasal canula continuously. every shift. During an observation on 04/15/25 at 09:02 AM Resident #41 was seated on the edge of his bed. His NC was next to him on the bed. His O2 concentrator was running and set to 2 lpm. He stated he was on continuous oxygen but was not wearing his NC at the moment due to just transferring to the bed from the wheelchair. Resident #41 stated he had been receiving oxygen for the last few months. During an observation on 04/16/25 at 10:21 AM Resident #41 was seated at a table in the dining room receiving O2 via NC from the tank hanging on the back of his wheelchair at 2 lpm. During an observation on 04/16/25 at 02:52 PM Resident #41 was seated on the edge of his bed. He was not receiving O2. He stated, I don't use it (O2) 24 hours a day, only when I feel anxious. 4. Record review of Resident #43's admission record dated 04/15/25 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included, but were not limited to, heart failure (heart muscle fails to pump blood as it should), chronic cough, and chronic obstructive pulmonary disease (inflammation of lung tissue due to non-infectious causes, which results in cough without mucus or phlegm, shortness of breath, and fatigue). Record review of Resident #43's quarterly MDS completed on 02/19/25 revealed a BIMS of 15 which indicated intact cognition. Resident #43 was not coded as receiving oxygen therapy while a resident. Record review of Resident #43's care plan completed on 03/27/25 revealed the following focus areas and corresponding interventions: (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 16 of 19 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 (X3) DATE SURVEY COMPLETED A. Building 04/17/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm The resident has Congestive Heart Failure. This focus area was initiated on 01/28/25 and had Oxygen therapy as an intervention. This intervention was revised on 04/02/25. The resident has Emphysema/COPD. This focus area was revised on 02/14/25 and had Give oxygen therapy as ordered by the physician as an intervention. This intervention was initiated on 01/28/25. Residents Affected - Some The resident has Oxygen Therapy. This focus area was initiated on 01/28/25 and had Oxygen therapy as ordered as an intervention. This intervention was initiated on 04/02/25. Record review of Resident #43's active order summary dated 04/15/25 revealed the following orders: Order start date 01/28/25 Change nasal canula every 12 hours as needed. Order start date 01/28/25 Check O2 sat Q shift and PRN as needed. Order start date 01/28/25 Check O2 sat Q shift and PRN every shift. Order date 01/28/25 Ear Padding for Continuous Oxygen via Nasal Cannula. Order start date 01/28/25 May use oxygen @ 4 l/m via nasal canula every shift. During an observation on 04/15/25 at 09:50 AM Resident #43 was lying in bed with her eyes closed receiving O2 via NC at 5 lpm. During an observation on 04/15/25 at 12:20 PM Resident #43 was lying in bed with her eyes closed receiving O2 via NC at 5 lpm. During an observation and interview on 04/16/25 at 08:23 AM Resident #43 was lying in bed receiving O2 via NC at 5 lpm. She stated she had been on O2 for a couple of years for congestive heart failure and COPD. During an interview on 04/17/25 at 09:22 AM RN A stated nurses were responsible for setting flow rates on oxygen concentrators and oxygen tanks. She stated they knew what rate to set the oxygen to by looking the physician's order. RN A stated a resident could be negatively affected by receiving oxygen at lower rates than it was ordered. She stated, They are not receiving enough oxygen for body so not oxygenating whole entire system appropriately. She stated receiving oxygen at higher rates than ordered could negatively impact the resident. RN A stated, I don't know exactly, but I know too much oxygen also be bad. RN A stated she did not know why Resident #41 and Resident #13 were receiving incorrect levels of oxygen. She stated regarding Resident #43's oxygen, On her, I know that sometimes she cranks it (oxygen flow rate) up and we (facility staff) try to adjust it. During an interview on 04/17/25 at 09:22 AM the DON reported that she was aware that Resident #3 was getting her oxygen at a dose that was higher that Resident #3's current orders, that she (the DON) had contacted the nurse practitioner to discuss the issue and had received new orders for Resident #3's oxygen to be administered at 2-4L/min from now on. The DON reported that she was having an issue with the night shift changing oxygen administration levels based on the residents needs and not contacting the physician. The night shift was not reporting the issue and getting an order. The DON stated that her expectation was for staff to get an order for any medication change prior to changing a medication and that included oxygen. The DON reported that if a staff member did not administer a (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 17 of 19 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 04/17/2025 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 0695 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some resident medication as it was ordered such as with the oxygen then that resident could become more dependent, it could make their COPD worse, and it could affect their overall health. During an interview on 04/17/25 at 09:28 AM ADON stated nurses were responsible for setting oxygen flow rates. She stated they know what rate to set the oxygen to by referring to the orders. ADON stated residents receiving oxygen at lower rates than ordered can hallucinate from low oxygen. She stated residents receiving oxygen at higher rates than ordered can have too much CO2. During an interview on 04/17/25 at 09:37 AM DON stated nurses were responsible for setting oxygen flow rates. She stated the correct flow rate is in the orders. She stated the oxygenation of residents receiving oxygen at lower rates than ordered by the physician won't be where it should be. DON stated residents receiving oxygen at higher rates than ordered might change their need levels prematurely. She stated she did know why Resident #13 was receiving oxygen at higher rates than ordered. She stated Resident #41 was with it enough to adjust his own O2 rates as he feels better. DON stated Resident #43 probably changes her oxygen flow rate as well. Record review of facility policy titled Oxygen Administration and dated 02/13/07 revealed the following: Oxygen therapy includes the administration of oxygen (O2) in liters/minute (l/min) . to treat hypoxemic conditions caused by pulmonary or cardiac diseases. O2 therapy is also prescribed to ensure oxygenation of all body organs and systems. The amount of oxygen . and the method of administration, is ordered by the physician. The administration, monitoring of responses, and safety precautions associated with it are performed by the nurse. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 18 of 19 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 04/17/2025 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 1 of 1 kitchen reviewed for food safety. Residents Affected - Some 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. Findings include: Observation of the kitchen food prep activities on 4/15/25 from 11:15 a.m. to 12:15 p.m. revealed the following: At 12:00 p.m., [NAME] B was observed in the kitchen serving the noon meal. [NAME] B changed her gloves, picked up plates and set them on the serving line, took lids off food, touched the plates, picked up a knife and laid the knife on the serving line. [NAME] B picked up a plate and plated one piece of chicken. [NAME] B put the plate down and picked up the knife with her gloved hands. [NAME] B then placed her right hand over the chicken piece and began slicing the chicken into strips on the plate. [NAME] B then rearranged the chicken on the plate with her gloved hands. [NAME] B put the knife down and picked up the plate of chicken. [NAME] B plated the rest of the meal, using her gloved hands to touch the serving utensils and the plates. [NAME] B placed the plate on the serving cart. [NAME] B picked up another plate and serving utensils and plated another piece of chicken. [NAME] B picked up the knife and began cutting the chicken into strips. [NAME] B put her right hand on the chicken to hold it in place while she cut the chicken. [NAME] B then put the knife down and rearranged the chicken on the plate. [NAME] B picked up the plate and serving utensils and plated the rest of the meal. [NAME] B did not make any attempts to change her gloves or wash her hands. In an interview on 4/15/25 at 12:10 p.m., [NAME] B was asked if she realized she touched the chicken while cutting the food after touching numerous surfaces in the kitchen. [NAME] B did not speak English. The DM was also present and observed [NAME] B touching the food after touching multiple surfaces. The DM stated [NAME] B was not supposed to touch the food and should have used utensils and should have washed hands and changed gloves between tasks. The DM stated the consequences of not washing hands and changing gloves would be risk of food borne illness. The DM stated she trained the staff in hand washing and glove use and expected all staff to wash hands and change gloves between tasks. Record review of the undated facility policy titled Dietary Department Glove Standard Protocol documented: Per the Texas Food Establishment Rules, there will be no bare hand to food contact in the kitchen. Use tongs, spoons, deli tissue paper .If a glove must be used, such as for sandwich assembly, hands will be washed prior to putting on a glove and immediately after removing it. Gloved hands are considered a food contact surface that can get contaminated or soiled. Failure to change gloves between tasks can lead to cross contamination. Gloves will not be worn on the tray line. Instead pre -assembly and /or prep work will be done prior to tray line service . FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675851 If continuation sheet Page 19 of 19