Benedictine Living Center Of Garrison

Based on observation, record review, review of the facility competency guide, review of professional reference, and staff interview, the facility failed to follow professional standards for 1 of 2 sampled residents (Resident #3) reviewed for blood sugars levels, and 1 of 1 supplemental resident (Resident #27) observed during administration of an oral inhaler. Failure to notify the provider of out-of-range blood sugars levels may lead to inaccurate insulin dose administration and/or adverse health conditions, and failure to prompt a resident to rinse his/her mouth with water after administration of an inhaler has the potential to cause side effects in the oral cavity related to the medication. Findings include: Kozier & Erb's Fundamentals of Nursing, Concepts, Process and Practice, 11th Edition eText, 2021, Pearson, Boston, Massachusetts, page 63, stated, Nurses are expected to analyze procedures . ordered by the physician or primary care provider. If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of the Annual Skills…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of the facility competency guide, and staff interview, the facility failed to follow standards of infection control and prevention for 1 of 2 sampled residents (Resident #7) observed during a dressing change. Failure to practice infection control standards related to dressing changes and hand hygiene has the potential to spread infection throughout the facility.Findings include: Review of the Annual Skills Competency Resource Guide occurred on 07/22/25. This undated guide stated, . DRESSINGS/WOUND CARE: 1. Bring 2 pairs of clean gloves - one for removing the soiled dressing and another for applying clean dressing. 5. Wash your hands and apply gloves. 6. remove the soiled dressing . 7. Observe the wound . 8. Gather soiled dressing in gloved left hand. Remove left hand glove . right glove . dispose of soiled materials . 9. Wash your hands and apply a clean pair of gloves. Observation on 07/21/25 at 11:28 a.m. showed a licensed nurse (#3) performed dressing changes on Resident #7's abdominal wounds. The nurse (#3) applied gloves, removed the soiled…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview, the facility failed to ensure the resident's right to request, refuse, and/or discontinue treatment for 1 of 1 closed record resident (Resident #4) reviewed for advanced directives. Failure to honor the resident/resident representative's wishes for code status resulted in unwanted treatment for Resident #4. This citation is considered past non-compliance based on review of the corrective action the facility implemented immediately following the incident. Findings include: This surveyor determined a deficient practice existed on [DATE]. The facility implemented corrective action and completed on [DATE]. Review of the facility policy titled Initiation of CPR/AED [cardiopulmonary resuscitation/automated external defibrillator] and BLS [basic life support] Associate Training Expectations occurred on [DATE]. This policy, dated 2018, stated, . CPR/AED will be initiated on a resident who is found unresponsive, except when: 1) a Provider medical…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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. Review of the facility policy titled Abuse Prevention Plan occurred on 07/24/24. This policy, dated 2017, stated, Prevention Plan: . Population of neighbors [residents] who reside in facility vary in their ability to ambulate. Neighbors…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of facility policy, and staff interview the facility failed to report incidents of resident-to-resident abuse to the State Survey Agency (SSA) for 2 of 3 sampled residents (Resident #24 and #51) and 1 supplemental resident (Resident #31). Failure to report resident-to-resident abuse allegations and the results of the facility's investigation to the SSA placed all residents at risk for possible abuse. Findings include: Review of the facility policy titled, Abuse Prevention Plan occurred on 07/24/24. This undated policy stated, . All events will be investigated whether they cause injury or harm or no injury or harm. Events may include, but are not limited to, . resident to resident altercations [a resident to resident altercation is an incident involving a resident who willfully inflicts injury upon another resident. 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm], . If the event that caused suspicion…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of manufacturer's instructions for use, and staff interview the facility failed to ensure staff followed standards of practice for 3 of 4 residents (Resident #6, #23, and #40) observed during administration of rapid acting insulin. Failure to administer rapid acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction. Findings include: Prescribing information for Humalog insulin (a raid acting insulin), found at https://www.humalog.com, occurred on 07/24/24 and stated, Administer HUMALOG . within 15 minutes before a meal or immediately after a meal. Important safety information for NovoLog (a rapid acting insulin), found at novolog.com, occurred on 07/24/24 and stated, Novolog starts acting fast. Eat a meal within 5 to 10 minutes after taking it. - Review of Resident #6's medical record occurred on all days of survey. Current physician's order included, Novolog insulin; 20 units with meals three times a day. Observations on 07/22/24 showed the following: * 3:38 p.m., a nurse (#2)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of professional reference, and staff interview, the facility failed to ensure a medication error rate of less than five percent for 2 of 4 residents (Resident #20 and Resident #40) observed during medication administration. Four medication errors occurred during staff administration of 32 medications, resulting in a 12.5 percent error rate. Failure to properly prepare medications may result in residents receiving an ineffective dose and experiencing adverse reactions. Findings include: Review of the prescribing information for NovoLog insulin, found at www.novo-pi.com/novolog.pdf, occurred on 07/24/24, and stated, Instructions for use . C. Pull off the big outer needle cap . E. Turn the dose selector to select 2 units. F. Hold your NovoLog FlexPen with the needle pointing up. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to zero. - Observation of medication administration on 07/23/24 at 8:43 a.m. showed a nurse (#3) prepared a Lantus (long-acting) insulin pen and a Novolog (rapid-acting) insulin pen…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY 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 . Code 0, no or unknown: if the resident has not experienced weight gain of 5% or more in the past 30 days or 10% or more in the last 180 days or if information about prior weight is not available. Code 2, yes, not on physician-prescribed weight-gain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, review of facility policy, and staff interview, the facility failed to follow standards of infection control for 2 of 7 sampled residents (Resident #14 and Resident #27) and 5 supplemental residents (#1, #12, #18, #39, and # 47) observed during personal cares or transfers. Failure to practice infection control standards related to hand hygiene and cleaning of mechanical lifts has the potential to spread infection throughout the facility. Findings include: HAND HYGIENE: Review of the facility policy titled Hand Hygiene occurred on 09/06/23. This policy, effective June 2017, stated, . all associates will be trained and competent in following proper hand hygiene practices. Times to Perform Hand Hygiene are, but not limited to .Before and after direct resident contact . Before and after assisting a resident with personal cares . Before and after assisting a resident with toileting . After contact with a resident's mucous membranes and body fluids or excretions . After removing gloves or aprons . - Observation on 09/05/23 at 3:53 p.m. showed two certified nurse…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, review of facility policy, staff and resident interview, the facility failed to ensure the interdisciplinary team assessed the appropriateness to self-administer medications (SAM) for 1 of 1 supplemental resident (Resident #2) with medications observed in the room. Failure to determine whether SAM is a safe practice has the potential to limit a resident's right to SAM or result in a medication error and/or harm to a resident. Findings include: Review of the facility policy titled Self-Administration of Medication occurred on 09/07/23. This policy, dated 2020, stated, . 1. The nursing associates will assess each resident's mental and physical abilities. Assessment is documented in the EHR [Electronic Health Record]. 3. If it is determined a resident cannot safely administer medications, the nursing associates will administer the medication. Observations during medication administration on 09/05/23 at 4:11 p.m., showed a bottle of Refresh Plus (Sterile eye drops) located in Resident #2's room. When asked, Resident #2 stated, I'm allowed to use them…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, review of professional reference, and staff interview, the facility failed to ensure staff followed standards of practice for 1 of 3 sampled residents (Resident #13) with an indwelling catheter. Failure to follow physician's orders for residents with indwelling catheters may result in delayed treatment, pain and/or worsening of resident's condition. Findings include: [NAME], [NAME], and Frandsen's Kozier & Erb's Fundamentals of Nursing: Concepts, Process, and Practice, 11th ed., Pearson Education, Inc., page 63, states, . Carrying Out a Physician's Orders . If the order is neither ambiguous nor apparently erroneous, the nurse is responsible for carrying it out. Review of Resident #13's medical record occurred on all days of survey. Diagnoses included neuromuscular dysfunction of bladder and urinary retention. A physician order signed on 02/23/22, stated, Next appointment 1 [one] year. The medical record lacked evidence of a follow up physician visit. During an interview on 09/07/23 at…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review, and staff interview, the facility failed to provide appropriate and sufficient supervision and/or assistive devices for 1 of 4 sampled residents (Resident #13) observed during a pivot transfer. Failure to provide adequate assistance and use the assistive devices properly during transfers placed the residents at risk for accidents, falls, or injuries. Findings include: The facility failed to provide a copy of their policy addressing transfers. Review of Resident #13's medical record occurred on all days of survey and included diagnoses of multiple sclerosis and incomplete paraplegia. The current care plan stated, . I do need assistance with mobility due to weakness, unsteadiness, and diagnosis of multiple sclerosis and paraplegia. A1 [assist of one] to stand pivot transfer with FWW [front wheeled walker] and gait belt . During an observation on 09/06/23 at 8:29 a.m., a certified nurse aide (CNA) (#5) stood at the end of Resident 13's bed while the resident slid himself to the edge of the bed, stood, swung his hips towards the wheelchair, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on facility policy, record review, and staff interview, the facility failed to ensure a physician's response to changes in resident's weight for 3 of 3 sampled residents (Resident #23, #44, and #45) with significant weight loss. Failure to ensure the physician responded in a timely manner may result in a delay of treatment and further weight loss for residents. Findings include: Review of the facility policy titled Weight Monitoring and Documentation occurred on 09/07/23. This policy, dated August 2019, stated, . 7. Resident's weights are tracked monthly through an established monitoring system to ensure that significant changes are identified and addressed . 10. The physician . will be notified on any significant weight change. - Review of Resident #23's medical record occurred on all days of survey. Diagnoses included diabetes mellitus, diverticulosis, Parkinson's, and dementia. The current care plan stated, . I'm at risk for weight changes/nutritional deficiency due to dx Dementia, Diabetes and Diverticulosis. Assist me with meals. Review of dietary progress notes…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.