Average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garrison Nursing Home & Rehabilitation Center during CMS and state inspections, most recent first.
Kitchen Food Storage and Sanitation Failures: The dietary manager was observed with hair exposed from under her hair covering, and multiple food items in the refrigerator and pantry were found undated, unlabeled, or expired. A low-temp dishwasher test strip also read below the recommended chlorine range, and the test strips used were expired. Staff, including the DON, ADON, and Administrator, stated that hair should be fully covered and food should be dated, labeled, and checked for expiration.
A resident’s room contained a cigarette lighter and an alcoholic drink despite the facility being non-smoking and having no alcohol order for the resident. In addition, multiple mechanical lift slings in the laundry area had illegible care labels, and one had faded connection straps; staff said they were not aware these conditions required removal from service. The DON, ADON, and Administrator acknowledged the lighter, alcohol, and sling condition issues, and the Administrator stated the items could be a safety issue.
MDS assessments failed to accurately capture significant weight changes for three residents. One resident with Alzheimer’s disease had a 12.2% weight gain over 6 months, one resident with metabolic encephalopathy had a 5.8% weight loss in 1 month, and one resident with a stroke history had a 13% weight loss over 6 months, yet each quarterly MDS indicated no significant weight change. The MDS nurse said the weights were overlooked, and the DON stated the MDS nurse was responsible for assessment accuracy.
A long-term care facility failed to maintain an effective infection prevention and control program, as staff did not consistently follow hand hygiene protocols and enhanced barrier precautions. Two CNAs did not sanitize their hands between glove changes during incontinent care, and a COTA neglected to wear PPE while assisting a resident with a surgical wound. These lapses occurred despite the facility's established protocols and staff training, placing residents at risk for cross-contamination and infection.
A resident with an indwelling catheter was found without a securement device, leading to discomfort and potential risk of complications. Despite training, staff failed to adhere to the facility's policy requiring securement devices for catheters, as confirmed by interviews with a CNA, LVN, DON, and the Administrator.
The facility failed to post accurate and accessible nurse staffing information for five consecutive days. Observations revealed that the postings were outdated, incomplete, and not easily visible. Interviews indicated that the restorative aide was responsible for the postings, but there was no clear policy in place, leading to a lack of oversight and accountability.
Kitchen Food Storage, Labeling, Hair Coverage, and Dishwasher Sanitation Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen reviewed for food safety and sanitation. During observation, the dietary manager had hair coming out from under her hair covering on the back of her head. Staff interviews stated that hair should be covered at all times in the kitchen because uncovered hair could fall into food and cause cross contamination. During the kitchen observation, multiple food items were found in the refrigerator and pantry that were undated, unlabeled, or expired. In the refrigerator, there were 2-gallon bags of red onions with no date or label and 1 gallon of parmesan cheese that had expired on 06/06/2025. In the pantry, there was 1 gallon of vanilla flavor expired on 02/16/2023, 1 gallon of pancake/waffle syrup with no date, label, or expiration date, 1 gallon of Teriyaki Glaze expired on 08/27/2024, and 1 gallon of Clabber Girl Baking Powder expired on 06/13/2025. Interviews with dietary and administrative staff stated that food should be dated and labeled when received, opened, prepared, or stored as leftovers, and that expired foods should be checked daily. During testing of the low temperature dishwasher, the sanitation test strip tested below the recommended range at 25 parts per milliliter, while the recommended range was 50 to 100 parts per milliliter. The test strips used were expired in February 2025. Staff interviews stated that proper sanitation, dating, labeling, and checking for expired foods were necessary parts of kitchen safety, and the DON, ADON, Administrator, and dietary staff all acknowledged that food items should be labeled and dated and that hair should be fully covered in the kitchen.
Unsafe Items in Resident Room and Improper Mechanical Lift Sling Inspection
Penalty
Summary
The facility failed to ensure Resident #65’s room remained free of accident hazards when a cigarette lighter was observed on her overbed table and an alcoholic drink labeled Buzz Ball was observed in her personal refrigerator. Resident #65 was a [AGE]-year-old female admitted with COPD, and her quarterly MDS indicated a BIMS score of 13, showing she was cognitively intact and independent with most ADLs. When interviewed, she said the lighter was hers but could not explain why she had it, stated she did not smoke, and said she did not drink alcohol, identifying the drink as a chocolate drink. The Administrator stated the facility had no residents allowed to have cigarette lighters or alcohol and that the facility was non-smoking. She said Resident #65 often went out of the facility with family and probably brought the items back after a visit. The Administrator also stated Resident #65 had no order for alcohol consumption. During a joint interview, the DON and Administrator said the lighter and alcohol could be a safety issue and lead to falls, medication interactions, or injury. The facility also failed to properly inspect mechanical lift slings for signs of damage before each use and to remove damaged slings from service. On observation, four mechanical lift slings were hanging in the clean laundry area, and all four had illegible care labels; one sling also had fading of the blue, green, and purple connection straps. The Housekeeping Supervisor said she washed and dried the slings after resident use and would remove slings only if they were worn, frayed, or torn, and she was not aware that faded connection loops or illegible care labels required removal from service. The ADON and Administrator stated staff were responsible for ensuring slings were in good condition and safe for use, and the Administrator said slings should be replaced if worn or faded in color.
MDS Assessments Did Not Reflect Significant Weight Changes
Penalty
Summary
The facility failed to ensure quarterly MDS assessments accurately reflected resident status for three residents by not capturing significant weight changes. For Resident #4, a quarterly MDS dated [DATE] indicated no weight gain of 10% or more in 6 months, even though monthly weights showed an increase from 193.2 lbs on 02/06/2025 to 216.8 lbs on 07/02/2025, a 12.2% gain. Resident #4 was a [AGE]-year-old female admitted with Alzheimer’s disease, and her care plan updated on 7/23/25 identified an alteration in nutrition related to significant weight loss. For Resident #16, a quarterly MDS dated [DATE] indicated no weight loss of 5% or more in one month or 10% or more in six months, despite weights showing a decrease from 107.4 lbs on 6/9/25 to 101.2 lbs on 7/2/25, a 5.8% loss in one month. Resident #16 was a [AGE]-year-old female admitted with metabolic encephalopathy, had a BIMS score of 14, and required set up or clean up assistance with eating. For Resident #23, a quarterly MDS dated [DATE] also indicated no significant weight loss, although weights showed a decrease from 158 lbs on 12/16/24 to 137 lbs on 6/3/25, a 13% loss in 6 months. Resident #23 was a [AGE]-year-old female admitted with cerebral infarction, had a BIMS score of 6, was independent with eating, and her care plan updated on 6/26/25 identified an alteration in nutrition related to significant weight loss.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple instances of improper hand hygiene and failure to follow enhanced barrier precautions. Specifically, two CNAs did not sanitize or wash their hands between glove changes while providing incontinent care to residents. This lapse in protocol was observed during care provided to a resident with cognitive and physical impairments, who required extensive assistance with activities of daily living. The CNAs acknowledged their failure to adhere to hand hygiene practices, despite having received training on infection control. Additionally, a COTA did not follow enhanced barrier precautions while providing care to another resident with a surgical wound. The COTA failed to don the required personal protective equipment, such as a gown and gloves, before assisting the resident. This oversight occurred despite the presence of signage and PPE outside the resident's room, indicating the need for enhanced precautions. The COTA admitted to forgetting the protocol due to nervousness, even though she had been trained on the facility's procedures. Interviews with facility staff, including the ADON, IP nurse, and DON, confirmed that the facility had established protocols for infection control and enhanced barrier precautions. However, the staff's failure to consistently implement these protocols during care placed residents at risk for cross-contamination and infection. The facility's policies required hand hygiene before and after glove changes and the use of PPE for residents with specific conditions, such as chronic wounds or MDROs, but these were not consistently followed during the observed incidents.
Failure to Secure Indwelling Catheter
Penalty
Summary
The facility failed to provide appropriate treatment and services to prevent urinary tract infections for a resident who was incontinent of bladder and had an indwelling catheter. The resident, a female with a history of heart disease and urinary retention, was observed without a securement device for her catheter, which is necessary to prevent discomfort and potential dislodgment. The resident reported experiencing a pulling sensation in her private area, indicating discomfort due to the unsecured catheter. Interviews with facility staff, including a CNA, LVN, DON, and the Administrator, revealed that there was a lack of adherence to the facility's policy requiring securement devices for catheters. The CNA did not check for securement devices, assuming it was the nurses' responsibility, while the LVN and DON acknowledged the importance of securement devices and confirmed that training had been provided. Despite this, the resident's catheter was not secured, which could lead to complications such as pain, infections, and skin issues.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing data was posted and readily accessible to residents and visitors with all required information for five consecutive days. During an observation, it was noted that the daily staffing posting was not in a central location and was dated several days prior, with the form being blank for reporting the daily census. The form was also not easily legible due to misprinting. Interviews with the Assistant Regional Nurse, the Director of Nursing (DON), and the Administrator revealed that the responsibility for posting the staffing information was assigned to the restorative aide, but the postings were not being maintained as required. The lack of a clear policy for nurse staffing information contributed to the deficiency, as the facility did not have a structured approach to ensure compliance with the regulation. The DON acknowledged the absence of a policy and the need to store the information for 18 months as per the regulation. The Administrator was unaware of when the last posting occurred, indicating a lack of oversight and accountability in maintaining the required staffing information postings.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Garrison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Stallings Court Nursing And Rehabilitation | 15 mi | ★★★★★ | 4 | 0 |
| Willowbrook Nursing Center | 15.1 mi | ★★★★★ | 0 | 0 |
| Westward Trails Nursing And Rehabilitation | 16.5 mi | ★★★★★ | 1 | 0 |
| Focused Care Of Center | 18.5 mi | ★★★★★ | 3 | 0 |
| Avir At Center | 20.1 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.