Benedictine Living Center of Garrison

In the surveyor’s words

From the most serious findings on record at Benedictine Living Center of Garrison, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 18, 2025

  Based on review of the facility reported incident (FRI) investigation, record review, and review of facility policy, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 1 sampled resident (Resident #1) who fell from a mechanical lift. Failure to safely use the mechanical lift resulted in a fall with injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: The surveyor determined a deficient practice existed on 06/17/25. The facility immediately implemented corrective action, completed corrective action on 06/18/25, and continues with staff education and monitoring. […]

• Actual harm, isolatedF580Jan 13, 2021

  Based on record review, policy review, and staff interview, the facility failed to notify the physician of a deterioration in skin condition for 1 of 3 sampled residents (Resident #5) with a pressure ulcer. Failure to notify the physician of a deterioration in skin condition resulted in complications to the resident and prevented the physician from evaluating the effectiveness of the current treatment plan. Findings include: Review of the facility policy titled Prevention and treatment of [REDACTED]. This policy, dated September 2018, stated, . 10. Weekly the licensed nurse will . and examine the wound bed and surrounding skin. If wound bed has deteriorated; notify provider. 11. Notify the attending provider, . […]

• Actual harm, isolatedF686Jan 13, 2021

  Based on record review, review of facility policy, and staff interview, the facility failed to provide appropriate treatment and services to prevent the deterioration of pressure ulcer for 1 of 3 sampled residents (Resident #5) with pressure ulcers. Failure to implement interventions as ordered, and ensure adequate monitoring/assessment resulted in the delayed treatment/deterioration of Resident #5's pressure ulcer. Findings include: Review of the facility policy titled Prevention and treatment of [REDACTED]. This policy, dated September 2018, stated, . Those residents' who experience a break in skin integrity or wounds are provided care and service to heal the skin according to professional standards of care. 10. […]

• No harm, potential for more than minimal, patternF600Jul 24, 2024

  Based on record review, review of facility policy, and staff interviews the facility failed to ensure residents remained free from resident-to-resident abuse for 2 of 3 sampled residents (Residents #24 and #51) and 4 supplemental residents (Resident #3, #11, #31, and #36) who received or displayed physical and/or verbal abuse. Failure to identify physical altercations between residents as physical abuse placed residents at risk for possible emotional distress and/or physical injury. This citation is considered past non-compliance based on review of the corrective action the facility implemented following the incidents. Findings include: This surveyor determined a deficient practice existed on 06/08/24. The facility implemented corrective actions and staff education on 07/16/24. […]

• No harm, potential for more than minimal, patternF641Sep 7, 2023

  Based on record review, review of the Long-Term Care Facility Resident Assessment Instrument (RAI) 3.0 User's Manual (Version 1.17.1), and staff interview, the facility failed to ensure accurate coding of the Minimum Data Set (MDS) for 5 of 13 sampled residents (Resident #11, #14, #21, #26, and #27) and one supplemental resident (Resident #33). Failure to accurately complete the MDS does not allow each resident's assessment to reflect their current status/needs and may affect the accurate development of a comprehensive care plan and the care provided to the residents. Findings include: SECTION K: SWALLOWING/NUTRITIONAL STATUS The Long-Term Care Facility RAI User's Manual, revised October 2019, page K-3 through K-9, stated, . Coding Instructions . K0310: Weight Gain . […]