The Mildred & Shirley L. Garrison Geriatric Educat

F 0580 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

depending on the situation. 7. Record review of facility document titled QAPI Year 8 sign in sheet dated 8/21/2025, revealed signatures by MD, DON, SWK, Admissions, Marketing, DOR, MDS A, MDS B, HR, DM, HSK, CR and RN U. Document revealed Problem Areas: Abuse and Neglect, Failure to follow Abuse Policy, Failure to notify were reviewed during this QAPI. 8. Record review of Untitled Document, undated, revealed Competencies will be completed via written quiz with all nursing staff once a week times 4 weeks.

Trainings will be available on Tuesdays and Thursdays Signed by the DON.9. Record review of Untitled Document, undated, revealed Following completion of safe survey on all resident on 8/21/2025, no new complaints [of] pain or injury were discovered signed by the DON. 10. Record review of Untitled Document, undated, revealed scheduled QAPI meetings for 9/10/2025, 10/8/2025, 11/12/2025 and 12/10/2025. On 8/22/2025 at 2:51pm the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Mildred & Shirley L. Garrison Geriatric Educat

3710 4th St Lubbock, TX 79415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

coordinator. All suspicions and allegations of abuse or neglect must be reported directly to the abuse coordinator immediately. If anyone reports suspicious or witness abuse of any kind, it must be reported directly [ADM] per our policy.We must do everything we can to protect our residents. All allegations will be investigated per facility and state policy. 6. Record review of facility quiz titled Assessing and Reporting pain dated 8/21/-8/22 revealed 71 staff members had completed the quiz. The quiz revealed the following questions were asked to staff Give me an example of when you would assess for and report pain? Who would you report pain to? What are the non-verbal signs of pain? How would you communicate pain to the nurse?. Further review of the documents revealed staff stated they would assess for pain if a resident expressed pain at any time, or if they had facial or physical signs of pain. The staff stated they would report pain to the charge nurse and provider. The staff stated non verbal signs of pain would be frequent moaning, facial expressions, and elevated vital signs. The staff stated they would communicate the residents pain verbally to the nurse or provider and detail where the pain was expressed to be. 7. During interview on 8/22/2025 between 9:30AM-11:26 AM with CNA D, K, L, M, N, P, Q, R, S, T, GVN F, CMA G, LVN E, I, J, O, and RN H revealed all staff members had been trained on reporting abuse and neglect. All staff members stated they would report abuse and neglect to their ADM immediately. All staff members stated they would report any falls, injuries or incidents to the charge nurse, physician, and DON. They all stated they had been in-serviced prior to their shift on 8/22/2025. All staff members stated the potential negative outcome of not reporting abuse or neglect could be decrease in quality of life for the residents, decrease in care, and emotional anguish. 8. Record review of facility document titled QAPI Year 8 sign in sheet dated 8/21/2025, revealed signatures by MD, DON, SWK, Admissions, Marketing, DOR, MDS A, MDS B, HR, DM, HSK, CR and RN U. Document revealed Problem Areas: Abuse and Neglect, Failure to follow Abuse Policy, Failure to notify were reviewed during this QAPI. 9. Record review of Untitled Document, undated, revealed Competencies will be completed via written quiz with all nursing staff once a week times 4 weeks. Trainings will be available on Tuesdays and Thursdays Signed by the DON.10. Record review of Untitled Document, undated, revealed Following completion of safe survey on all resident on 8/21/2025, no new complaints [of] pain or injury were discovered signed by the DON. 11. Record review of Untitled Document, undated, revealed scheduled QAPI meetings for 9/10/2025, 10/8/2025, 11/12/2025 and 12/10/2025.On 8/22/2025 at 2:51pm the Administrator was notified the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/22/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

The Mildred & Shirley L. Garrison Geriatric Educat

3710 4th St Lubbock, TX 79415

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0607 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

change of condition dated 8/20/2025-8/21/2025 revealed 119 staff signatures out of 169. The in-service document revealed [ADM] is the facilities abuse and neglect coordinator. All suspicions and allegations of abuse or neglect must be reported directly to the abuse coordinator immediately. If anyone reports suspicious or witness abuse of any kind, it must be reported directly [ADM] per our policy.We must do everything we can to protect our residents. All allegations will be investigated per facility and state policy. 6.

Record review of facility quiz titled Assessing and Reporting pain dated 8/21/-8/22 revealed 71 staff members had completed the quiz. The quiz revealed the following questions were asked to staff Give me an example of when you would assess for and report pain? Who would you report pain to? What are the non-verbal signs of pain? How would you communicate pain to the nurse?. Further review of the documents revealed staff stated they would assess for pain if a resident expressed pain at any time, or if they had facial or physical signs of pain. The staff stated they would report pain to the charge nurse and provider. The staff stated non verbal signs of pain would be frequent moaning, facial expressions, and elevated vital signs. The staff stated they would communicate the residents pain verbally to the nurse or provider and detail where

the pain was expressed to be. 7. During interview on 8/22/2025 between 9:30AM-11:26 AM with CNA D, K, L ,M ,N ,P, Q, R, S ,T, GVN F, CMA G, LVN E, I,J, O, and RN H revealed all staff members had been trained

on reporting abuse and neglect. All staff members stated they would report abuse and neglect to their ADM immediately. All staff members stated they would report any falls, injuries or incidents to the charge nurse, physician, and DON. They all stated they had been in-serviced prior to their shift on 8/22/2025. All staff members stated the potential negative outcome of not reporting abuse or neglect could be decrease in quality of life for the residents, decrease in care, and emotional anguish. 8. Record Review of facility document titled QAPI Year 8 sign in sheet dated 8/21/2025, revealed signatures by MD, DON, SWK, Admissions, Marketing, DOR, MDS A, MDS B, HR, DM, HSK, CR and RN U. Document revealed Problem Areas: Abuse and Neglect, Failure to follow Abuse Policy, Failure to notify were reviewed during this QAPI.

1. 9. Record Review of Untitled Document, undated, revealed Competencies will be completed via written quiz

with all nursing staff once a week times 4 weeks. Trainings will be available on Tuesdays and Thursdays Signed by the DON.10. Record Review of Untitled Document, undated, revealed Following completion of safe survey on all resident on 8/21/2025, no new complaints [of] pain or injury were discovered signed by

the DON. 11. Record Review of Untitled Document, undated, revealed scheduled QAPI meetings for 9/10/2025, 10/8/2025, 11/12/2025 and 12/10/2025.On 8/22/2025 at 2:51pm the Administrator was notified

the IJ was removed. However, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems.

Event ID:

Facility ID:

If continuation sheet