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Complaint Investigation

The Mildred & Shirley L. Garrison Geriatric Educat

August 22, 2025 · Lubbock, TX · 3710 4th St
Citations 3
CMS Rating 2/5
Beds 120
Provider ID 675925
Healthcare Facility
The Mildred & Shirley L. Garrison Geriatric Educat
Lubbock, TX  ·  View full profile →
Inspection Summary

The Mildred & Shirley L. Garrison Geriatric Educat in Lubbock, TX — inspection on August 22, 2025.

Found 3 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF0580
Resident Rights Deficiencies
Immediate Jeopardy

jeopardy to resident health or safety

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/22/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Mildred & Shirley L.

Garrison Geriatric Educat

3710 4th St Lubbock, TX 79415

SUMMARY STATEMENT OF DEFICIENCIES

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.

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

08/22/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

The Mildred & Shirley L.

Garrison Geriatric Educat

3710 4th St Lubbock, TX 79415

SUMMARY STATEMENT OF DEFICIENCIES

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.

  • 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.

Facility ID:

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Lubbock, TX, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from The Mildred & Shirley L. Garrison Geriatric Educat or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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