Garrison Mem Hosp NSG Fac

In the surveyor’s words

From the most serious findings on record at Garrison Mem Hosp NSG Fac, in the surveyor’s own words.

• Immediate jeopardy, patternF600Jul 7, 2026

  Based 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. […]

• Immediate jeopardy, patternF689Jul 7, 2026

  Based 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. 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 05/02/26 when documentation showed the facility failed to provide adequate supervision for Resident #1 which resulted in access to unsafe areas… […]

• Actual harm, isolatedF744Jul 7, 2026

  Based 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. Findings include:Review of the facility policy titled Assessment and Plan of Care occurred on 07/01/26. This policy, dated September 2022, stated, . The comprehensive resident assessment . and plan of care will be developed to maintain or improve each resident's mental, psychosocial and physical well-being. […]

• No harm, potential for more than minimal, widespreadF745Jul 7, 2026

  Based 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.Findings include: During an interview the morning of 07/07/26, an administrative nurse (#1) stated the facility does not have a social work designee, but they have a social worker in Nebraska who is assigned to the nursing home. […]

• No harm, potential for more than minimal, widespreadF838Jul 7, 2026

  Based 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. Findings include: Review of the current Facility Assessment showed a review date of 12/03/24. During an interview on 07/07/26 at 3:15 p.m., an administrative staff member (#8) confirmed staff failed to review or update the Facility Assessment since 12/03/24.