Garrison Nursing Home & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements and kitchen sanitation.1. The facility failed to ensure the dietary manager effectively wore a hair net to cover all hair.2. The facility failed to ensure foods stored in the refrigerated were labeled and dated.3. The facility failed to ensure foods stored in the pantry were not out of date. These failures could place residents at risk of foodborne illness and food contamination. Findings Include:During an observation on 07/28/2025 at 8:40am, the dietary manager had hair from under her hair covering on the back of her head. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 5 residents (Resident #65) and 1 of 1 facility reviewed for accident hazards, in that: 1. The facility failed to ensure Resident #65 did not have a cigarette lighter and an alcoholic drink in her room on 7/28/25. 2. The facility failed to implement a policy and procedure to properly inspect the mechanical lift slings for signs of damage before each use and not removing damaged slings from service. These deficient practices could result in burn related injuries, medication interactions, and a loss of quality of life due to injuries if the damaged lift sling broke during transfer for residents that use a mechanical lift for transfers.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 3 of 10 residents (Resident's #4, #16, and #23) reviewed for MDS assessment accuracy. 1. The facility failed to ensure a quarterly MDS assessment dated [DATE] for Resident #4 captured a significant weight gain of 12.2% in 6 months. 2. The facility failed to ensure a quarterly MDS assessment dated [DATE] for Resident #16 captured a significant weight loss of 5.8% in 1 month. 3. The facility failed to ensure a quarterly MDS assessment dated [DATE] for Resident #23 captured a significant weight loss of 13% in 6 months. This failure could place residents at risk of not receiving adequate care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 residents (Resident #11, #12, and #43) reviewed for infection control. The facility failed to ensure CNA C sanitized or washed her hands between glove changes, CNA D changed gloves while providing incontinent care to Resident #11 and Resident #43 on 6/24/2024. The facility failed to ensure the COTA (certified occupational therapy assistant) followed enhanced barrier precautions when she provided care to Resident #12 on 6/24/2024. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #27) reviewed for quality of care. 1. The facility failed to ensure Resident #27's indwelling catheter (drains urine from your bladder into a bag outside your body) had a securement device to anchor catheter. This failure could place residents at risk for urinary tract infections and catheter related injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors with all required information for nurse staffing information for 5 of 5 days (6/21/24, 6/22/24, 6/23/24, 6/24/24 and 6/25/24). The facility failed to ensure the daily staffing information was accurate and posted daily for 6/21/24, 6/22/24, 6/23/24, 6/24/24 and 6/25/24. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and an environment free from hazards for 2 of 10 residents (Resident #1 and Resident #3) reviewed in that: 1. The facility failed to ensure Resident #1 did not sustain bruises due to her side rails. 2. The facility failed to ensure Resident #1 sustained bruises due to an improper transfer by an outside hospice aide. Resident #1 was a two person transfer and was transferred by one person. 3. The facility failed to ensure Resident #3 did not sustain at least two falls with side rails on his bed. 4. the facility failed to ensure Resident # 3 a resident did not suffer injuries from side rails. An IJ was identified on 2/8/24. The IJ began on 11/2/23and removed on 12/21/23. [...]

Inspectors wroteBased on interview and record review the facility failed to implement written policies that prohibit abuse for 1 of 4 residents reviewed ( Resident #2) in that: The facility failed to ensure CNA B reported, to the abuse coordinator, Resident #1's allegation of sexual assault after she was informed of it by Resident #1's roommate. An Immediate Jeopardy (J) situation was identified on 2/7/24 at 3:35 p.m. as PNC. The noncompliance began on 9/30/23 and ended on 10/12/23. The facility corrected the noncompliance before the survey began. This failure caused a delay in retrieving possible evidence and could have caused serious harm, if the abuse was allowed to continue.

Inspectors wroteBased on interview and record review, the facility failed to report an allegation of abuse 1 of 4 residents reviewed ( Resident #2) in that: CNA B did not report to the abuse coordinator Resident #1's allegation of sexual assault after she was informed of it by Resident #1's roommate. This failure caused a delay in retrieving possible evidence and could have caused serious harm, if the abuse was allowed to continue.

Inspectors wroteBased on interview and record review, the facility failed to ensure services furnished by an outside resource complied in writing that the facility assumed responsibility to meet professional standards while providing care to 1 of 1 resident reviewed ( Resident #2) in that: The facility failed to have a contract with the Outpatient Behavior Day clinic and did not have any method in place to track the residents' progress, decline, or wellbeing. This negative finding resulted in emotional, mental, and possible physical harm. Findings Included: Record review of resident #2 Face sheet dated 9/19/23 indicated she was a [AGE] year-old female, admitted to the facility on [DATE]. Some of her diagnoses were schizoaffective disorder, major depression, severe with psychotic symptoms, and dementia. Record review of Resident #2 care plan dated 4/10/23. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 2 of 4 halls (Hall 100 and Hall 200) and the dining area. The facility failed to ensure one hundred hall, two hundred hall, and the dining area were free from flies. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life. Findings Included: Record review of facility roster, Census Report, dated 05/08/2023 revealed: Resident #33 resided in room [ROOM NUMBER] in Hall 200. Resident #37 resided in room [ROOM NUMBER] in Hall 200 Resident #127 resided in room [ROOM NUMBER] in Hall 100. Resident #128 resided in room [ROOM NUMBER] in Hall 100. Review of the most recent pest control visit on 05/09/23 titled Service Report, revealed American roaches . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 18 residents (Resident # 7) reviewed for resident rights. The facility failed to ensure Resident # 7 was assisted with eating in a dignified manner. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility did not ensure the ice chest used for distributing ice were clean and sanitized before serving ice. This failure could place residents at risk for food borne illness.