Garrison Mem Hosp Nsg Fac

Inspectors wroteBased on record review, review of facility policy, and resident and staff interview, the facility failed to ensure residents remain free from abuse for 7 of 7 sampled residents (Resident #1, #2, #3, #4, #5, #6 and #7) who were subjected to physical/verbal abuse by other residents. Failure to prevent resident-to-resident physical abuse resulted in altercations involving hitting, slapping, and scratching and placed all residents at risk for serious injury, pain, mental anguish, and emotional distress. During the on-site facility reported incident investigation survey, the team consulted with the State Survey Agency (SSA) and determined an Immediate Jeopardy (IJ) situation existed beginning on 05/24/26 when documentation identified Resident #1 placed her hands around Resident #7's neck. *06/29/26 at 5:00 p.m. [...]

Inspectors wroteBased on observation, record review, review of facility policy, and staff interviews, the staff failed to provide appropriate supervision for 1 of 1 sampled resident (Resident #1) who wandered. Failure to provide adequate staff supervision resulted in Resident #1 accessing unsafe areas, hazardous items, and urinating/defecating in common areas and other residents' rooms and placed Resident #1 and all residents at risk of accidents, falls, and/or injuries. [...]

Inspectors wroteBased on observation, record review, review of facility policy, and resident and staff interviews, the facility failed to provide appropriate dementia care and services for 1 of 1 sampled resident (Resident #1) with a diagnosis of dementia. Failure to develop and implement interventions to address Resident #1's dementia care needs resulted in the resident's inability to achieve her highest level of functioning as well as other residents resident in the facility.

Inspectors wroteBased on staff interviews, the facility failed to have a designated staff member trained in the assessment of residents' psychosocial needs and in the provision of services to meet those needs and failed to have on-site quarterly consultation from a qualified social worker. Failure to have a designated staff member and failure to have on-site consultation from a qualified social worker has the potential for residents to experience unrecognized changes in their mental and psychosocial health.

Inspectors wroteBased on review of the current Facility Assessment and staff interview, the facility failed to review and update the facility assessment annually. Failure to review and update the assessment annually may result in the facility's inability to provide the resources necessary to care for the residents.

Inspectors wroteBased on record review, review of facility policy, resident representative interview, and staff interview, the facility failed to notify the resident's physician and/or resident representative for 6 of 6 sampled residents (Resident #1, #2, #3, #4, #5, and #6) involved in resident-to-resident altercations. Failure to notify the physician and/or the resident representative of the altercations does not allow the physician or the representative to make informed decisions regarding medical care.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to report incidents of potential abuse to officials including the State Survey Agency (SSA) for 4 of 4 sampled residents (Resident #1, #2, #6 and #7) reviewed for resident-to-resident altercations. Failure to report incidents of potential physical abuse to the State agency placed all residents at risk of abuse, mental and emotional distress, and/or physical injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to investigate incidents of alleged violations of potential abuse for 4 of 4 sampled residents (Resident #1, #2, #6 and #7) reviewed for resident-to-resident altercations. Failure to investigate resident to resident altercations for potential abuse placed all residents at risk of abuse, mental and emotional distress, and/or physical injury.

Inspectors wroteBased on record review, the facility failed to ensure a physician completed the initial comprehensive in-person visit within 30 days of the resident's admission and complete an in-person visit at least once every 60 days thereafter for 2 of 7 sampled residents (Resident #1 and #6). Failure to ensure residents receive the required physician visits may result in a delay of treatment and negative outcomes for the residents.

Inspectors wroteBased on observation and review of nurse staffing records, the facility failed to ensure staff posted accurate nurse staffing information on 47 of 47 days (May 23 - July 7, 2026) reviewed. Failure to ensure current facility census and nurse staffing information is updated daily and accurate at the beginning of each shift infringes on residents' and visitors' rights to access /review staffing patterns of the facility.

Inspectors wroteBased on record review and staff interview the facility failed to fully inform the resident or resident representative regarding treatment with psychotropic medications for 5 of 5 sampled residents (#2, #4, #5, #9, and #16) reviewed for unnecessary medications. Failure to fully inform the resident or the resident's representative of the risks, benefits, alternatives and obtain consent for psychotropic medications does not allow the right to choose treatment options.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to review and revise care plans to reflect the resident's current status for 6 of 12 sampled residents (Resident #2, #3, #4, #8, #16, and #21). Failure to update care plans limited staffs' ability to communicate needs and ensure continuity of care for each resident.

Inspectors wroteBased on observation, review of the dishwasher temperature and chemical concentration logs, review of the manufacturers' guidelines, and vendor and staff interview, the facility failed to ensure the low temperature dishwasher provided adequate heat and sanitization for dishes and utensils washed in 1 of 1 kitchen (main kitchen). Failure to ensure the appropriate wash temperature for the dishwash cycle may result in inadequate cleaning and sanitation of dishware.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to notify the resident's physician of a change in condition for 1 of 1 sampled resident (Resident #2) reviewed for a fall with injury. Failure to notify the physician of the fall, potential fracture, and pain prevented the physician from altering the treatment and care for the resident.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents remained free of chemical restraints for 1 of 5 residents (Resident #2) reviewed for unnecessary medications. Failure to document an assessment and appropriate diagnosis for the use of an antipsychotic medication does not allow the resident to attain and/or maintain his/her highest level of practicable well-being.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for 1 of 1 sampled resident (Resident #5) observed to self-administer medications (SAM). Failure to assist/observe residents who are not SAM take their medications may result in adverse health consequences.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure appropriate care and services for 1 of 1 sampled resident (Resident #8) with an indwelling urinary catheter. Failure to obtain a physician's order for an indwelling catheter and catheter cares may result in urinary tract infections (UTIs), discomfort, skin issues, and sepsis.

Inspectors wroteBased on observation, record review, professional reference review, and staff interview, the facility failed to obtain an order for oxygen for 1 of 1 sampled resident (Resident #12) observed with oxygen. Failure to obtain a physician's order for oxygen use may result in complications and compromise the residents' respiratory status.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 3 of 6 sampled residents (Resident #5, #6, and #8) observed during cares. Failure to practice infection control standards related to enhanced barrier precautions (EBP), personal protective equipment (PPE), hand hygiene, and surface disinfection has the potential to spread infection throughout the facility.

Inspectors wroteBased on record review, review of facility policies, and staff interview, the facility failed to review and revise care plans to reflect the residents' current status for 4 of 12 sampled residents (Residents #1, #4, #5, and #7). Failure to update care plans limited the staffs' ability to communicate needs and ensure continuity of care.

Inspectors wroteBased on review of the State Agency (SA) facility files, survey findings, and staff interview, the facility failed to develop a Quality Assurance and Performance Improvement (QAPI) process to evaluate and identify problems and opportunities to improve services/outcomes, decrease or prevent likelihood of problems or occurrence of adverse events, and ensure compliance with federal requirements.

Inspectors wroteBased on observation, policy review, and staff interview, the facility failed to follow professional standards of practice for medication administration for 2 of 13 sampled residents (Residents #1 and #15) and one supplemental resident (Resident #14). Failure to follow a physician's order, document medications after administration, properly prime insulin pens, and provide privacy during insulin administration, may impede the therapeutic effectiveness of the medications, cause adverse events such as medication errors and low blood sugar, and infringes upon the residents right to privacy.

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to provide assistive devices necessary to prevent accidents for 2 of 4 sampled residents (Residents #1 and #13) observed without wheelchair foot pedals. Failure to use wheelchair foot pedals while transporting residents, places all residents at risk for falls and/or injury.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to maintain acceptable parameters of nutritional status for 2 of 2 sampled residents (Residents #1 and #5) with documented weight variances. Failure to obtain weights and reassess weight variances may delay needed treatment for weight loss/gain and alter the resident's ability to maintain a sufficient health/nutritional status.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to ensure accurate labeling of 3 of 3 insulin pens observed during review of medication storage. Failure to obtain a label for an insulin pen and identify the resident's name and date opened may result in a resident receiving another resident's insulin or outdated insulin.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control and prevention for 2 of 8 sampled residents (Resident #5 and #13) and 1 supplemental resident (Resident #6) requiring stand lift transfers. Failure to practice infection control standards related to disinfection of equipment has the potential to spread infection throughout the facility.

Inspectors wroteBased on review of nurse staffing schedules, staff time sheets, and staff interview, the facility failed to provide the services of a registered nurse (RN) for eight consecutive hours a day, seven days a week, for 2 of 91 days reviewed (05/14/23 and 05/26/23). Failure to ensure sufficient, qualified nursing staff are available eight consecutive hours a day has the potential to affect the health and safety of all the residents residing in the facility.

Inspectors wroteBased on staff interview, the facility failed to ensure 1 of 1 dietary manager (#1) maintained the proper qualifications to serve as the director of food and nutrition services. Failure to ensure staff have the qualifications to carry out the functions of food and nutrition services has the potential to result in foodborne illness to residents, staff, and visitors.

Inspectors wroteBased on observation, record review, review of facility policy, resident interview, and staff interview, the facility failed to remove medication from the bed side for 1 of 1 sampled resident (Resident #6) assessed as not able to self-administer medications (SAM). Failure to remove medication from the resident's room for a resident assessed as not able to self-administer medications may result in medication errors and/or harm to the resident.

Inspectors wroteBased on observation, review of facility policy, and staff interview, the facility failed to promote privacy and confidentiality of the medication administration records for 1 of 3 days of survey. Failure to promote resident privacy may result in viewing of resident records by other residents, visitors, or unlicensed staff.

Inspectors wroteBased on record review, review of facility policy, and staff interview, the facility failed to provide the resident or resident's representative a written bed hold notice for 3 of 3 residents (Resident #3, #5, and #17) reviewed for hospital transfers. Failure to provide a written copy of the bed hold notice and include the reserve bed amount does not allow the resident and/or their representative to make an informed decision regarding their rights.

Inspectors wroteBased on observation, record review, policy review, and staff interview, the facility failed to follow professional standards of practice for medication administration for 1 of 2 sampled residents (Resident #17) who received insulin and 1 of 1 sampled resident (Resident #13) who received eye drops. Failure to document medication administrations after administration, prime insulin pens, and follow the physician's orders when administering medications may impede the therapeutic effectiveness of the medications, cause adverse events such as medication errors and low blood sugar.

Inspectors wroteBased on observation, record review, review of facility policy, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 6 residents (Resident #13 and #17) observed during medication pass. Three medication errors occurred during staff administration of 28 medications, resulting in a 10% error rate. Failure to administer medications correctly and per physician's orders may result in residents receiving an ineffective dose and experiencing adverse side effects such as low blood sugars.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure residents records contained the hospice election form for 1 of 2 residents (Resident #12) and the certification of a terminal illness for 2 of 2 residents (Resident #9 and #12) receiving hospice services. Failure to obtain these documents limits staff's ability to ensure coordination of care between the facility and the hospice.