The Mildred & Shirley L. Garrison Geriatric Educat

In the surveyor’s words

From the most serious findings on record at The Mildred & Shirley L. Garrison Geriatric Educat, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678Mar 1, 2026

  Based on observation, interview, and record review, the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 5 residents reviewed for full code status. The facility failed to ensure staff were able to perform CPR, according to standard protocol, when RN J and LVN S were unable to provide timely rescue breaths to Resident #1 during a code, due to the Ambu bag (a device used to provide manual ventilation) not being readily available on the crash cart. Resident #1 was pronounced deceased at the facility. An Immediate Jeopardy was identified on [DATE] at 5:05 PM. […]

• Immediate jeopardy, isolatedF684Mar 1, 2026

  Based on observation, interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 27 residents reviewed for quality of care. 1. The facility failed to ensure that the crash cart shared for Magnolia hall, housing Resident #1, and Sage Hall (which housed a total of twenty-seven residents who had elected Full Code status) was audited daily, sanitized, and had all resuscitative equipment readily available and easily located to deliver life-saving measures in the event of a medical emergency. 2. […]

• Immediate jeopardy, isolatedF580Aug 22, 2025

  Based on interviews and record review, the facility failed to notify the residents physician and representative regarding a change in the resident's condition, for 1 of 6 residents (Resident #1) reviewed for changes in condition - The facility failed to immediately consult with Resident #1's physician when Resident #1 sustained a fall with complaints of pain to the knee on the evening of 08/07/2025 until the next morning 08/08/2025, because CNA C failed to inform nursing staff. An Immediate Jeopardy (IJ) was identified on 08/21/25 at 2:23 PM. The IJ template was provided to the facility on [DATE] at 2:51 PM. […]

• Immediate jeopardy, isolatedF600Aug 22, 2025

  Based on interview and record review the facility failed to ensure residents were free from neglect for 1 of 6 residents (Resident #1) reviewed for neglect in that: 1. CNA C neglected to notify LVN A or any licensed nurse of Resident #1's incident on 8/7/2025, that resulted in a broken distal femur. 2. The facility neglected to ensure Resident #1's pain was adequately assessed and treated for approximately 12 hours on 8/7/2025-8/8/2025, after Resident #1 reported having pain to her right knee following an incident with CNA C. An Immediate Jeopardy (IJ) was identified on 08/21/25 at 2:23 PM. The IJ template was provided to the facility on [DATE] at 2:51 PM. […]

• Immediate jeopardy, isolatedF607Aug 22, 2025

  Based on interview and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 6 residents (Resident #1) reviewed for neglect.1. The facility failed to ensure staff followed the abuse policy by not preventing neglect for Resident #1 on 8/7/2025 when CNA C failed to notify a licensed nurse of an incident that resulted in a broken distal femur for Resident #1. 2. The facility failed to ensure staff followed the abuse policy by not preventing neglect for Resident #1 on 8/7/2025 when staff failed to adequately assess and treat Resident #1's report of pain, for approximately 12 hours, to her right knee following an incident with CNA C. […]