Garrison Nursing Home & Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Garrison Nursing Home & Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 8, 2024

  Based 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. […]

• Immediate jeopardy, isolatedF607Feb 8, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF812Jul 30, 2025

  Based 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 The facility failed to ensure foods stored in the pantry were not out of date.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. […]

• No harm, potential for more than minimal, patternF689Jul 30, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF880Jun 26, 2024

  49017 Based 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. […]