The Mildred & Shirley L. Garrison Geriatric Educat

The facility failed to ensure Residents #9 and #35 who were listed as DNR (Do Not Resuscitate), had Do Not Resuscitate forms that did not have missed required information.

This failure could place residents at risk of not having their end-of-life wishes honored and incomplete records.

Findings include: Resident #9

Record review of Resident #9's, undated, face sheet revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #9 had diagnoses which included Chronic Respiratory Failure (lungs cannot get enough oxygen into the blood), Heart Failure (the heart does not pump blood as effectively as it should), and Type 2 Diabetes (high blood sugar).

The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate.

Record review of Resident #9's physician order summary, dated 06/04/26, reflected the following order: DNR-Do Not Resuscitate dated 04/20/2026.

Record review of Resident #9's care plan, dated 03/06/26, reflected a care plan for DNR.

Record review of Resident #9's DNR form dated 11/20/25 reflected the resident's signature was signed on the wrong signature line.

The resident's signature was signed on the signature line for a Guardian/Agent/Proxy/Relative Signature.

The signature line for Person's Signature was blank. In addition, the physician's signature was not dated. Resident #35 Record review of Resident #35's, undated, face sheet revealed a [AGE] year-old-male who was admitted to the facility on [DATE]. Resident #35 had diagnoses which included Renal Disease (damage to the kidneys that result in the inability to filter waste and excess fluid) and Type 2 Diabetes (high blood sugar).

The face sheet indicated under the advance directive section - DNR-Do Not Resuscitate.

Record review of Resident #35's physician order summary, dated 06/04/26, reflected the following order: DNR-Do Not Resuscitate dated 06/23/25.

Record review of Resident #35's care plan, dated 05/27/26, reflected a care plan for DNR.

Record review of Resident #35's DNR form dated 06/19/25 reflected the DNR reflected the resident's signature was signed on the wrong signature line.

The resident's signature was signed on the signature line for a Guardian/Agent/Proxy/Relative Signature.

The signature line for Person's Signature was blank.

During an interview on 06/04/26 at 2:45PM with the DON, he stated the DNR was not valid if not filled out correctly. He stated the SW was responsible for making sure the DNR was completed accurately.

He stated quarterly audits of DNRs are completed for accuracy. He verified the missing information on the DNR for Residents #9 and #35. He stated he did not know why the information was missing. He stated the potential negative outcome was the residents' end of life wishes may not be followed. He stated he was trained in how to complete DNRs and his expectations were for them to be filled out completely and be correct.

During an interview on 06/04/26 at 3:35pm with the SW, she stated the DNR was not valid if it's not filled out correctly.

She stated she and the resource nurses were responsible for ensuring DNRs were completed correctly.

She verified the missing information on DNR for Residents #9, and #35.

She stated she completed quarterly audits of DNRs for accuracy.

She stated the reason the DNR's were not complete was human error.

She stated she was trained on DNRs.

The SW stated the potential negative outcome for residents if a DNR was not completed correctly was the resident's end of life wishes may not be honored.

Record review of the Social Services Policies and Procedures Advanced Directives (Revised April 2025) reflected the following: Advance Directives will be recognized and respected.

The facility recognizes the resident's rights to choose their treatment and make decisions about care to be received at the end of their life. It is the policy of this facility to implement the residents' decisions and directives that are in compliant with state and federal law and the policies of this facility.

675925 06/04/2026

The Mildred & Shirley L.

Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415

The facility failed to ensure there was not two loose pills in the Sage medication cart.

These failures could place residents at risk for medication errors and adverse drug reactions.

The findings include: 1.

During an observation with LVN A on [DATE] at 8:59am of the Oak Medication Cart, one loose white pill, scored (a shallow groove or debossed line across the surface) with a number 3 and letter L was found in the second drawer unlabeled.

During an interview with LVN A he stated medication carts were checked upon arriving to shift. He stated they are trained monthly and yearly on checking medication carts. He stated the medication arts were checked for cleanliness, organization, loose pills and expired medication. He stated he had not seen that pill when he arrived on shift. He stated the potential negative outcome of a loose pill being in the medication cart could be medication error, or residents not getting their medication. He stated if a pill was dropped into the medication drawer, they were trained to identify the pill and discard it in the appropriate receptacle.

During an interview with the DON on [DATE] at 9:20am, the DON identified the white loose pill as Trazadone (a medication used for sleep insomnia, and in higher doses to treat major depressive disorders). 2.

During an observation and interview of the Sage Medication cart on [DATE] at 10:15am with CMA B, one white round pill with a number 113, and a tan pill with a number 34 on one side and an E on the other side, were found loose in the second drawer. CMA B stated medication carts are checked throughout the shift and if any loose pills are found, they are disposed of.

During an interview on [DATE] at 10:25am with the DON, he stated medication carts should be checked at the start of each shift. He stated the last time the medication carts had been checked were that morning.

The DON identified the white pill as Losartan (medication used to treat high blood pressure) and the tan pill as Clopidogrel (medication use to prevent blood clots). He stated the facility policy was to keep the medication carts clean and free of clutter.

During an interview on [DATE] at 1:54pm with the ADM, he stated medication cart checks should be done at the beginning of every shift. He stated medication carts were checked for cleanliness, expired medication, loose pills and medication stock. He stated a potential negative outcome of loose pills in the medication cart could be medication error or missing medication. He stated training was conducted annually and as needed for medication cart checks. He stated if there were loose pills identified in any cart, they should be brought to the DON for identification and disposal.

Record review of undated facility policy titled Medication Access and Storage revealed: Procedure: 1.

The provider pharmacy dispenses medication in containers that meet legal requirements, including requirements of good manufacturing practices where applicable.

Medication are kept and stored in these containers.

served at proper temperatures: Hot foods: hot and freshCold foods: appropriately chilled.

675925 06/04/2026

The Mildred & Shirley L.

Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415

why the food items were not labelled/dated, expired food items not discarded and all kitchen staff

review of the facility's policy and procedure titled, Food Storage, undated, reflected the following:

Food will be stored in an area that is clean, dry and free from contaminants.

Food will be stored, at appropriate temperatures and by methods designed to prevent contamination or cross contamination.

Procedure: 12.

Refrigerated food storage:All foods should be covered, labeled and dated.

All foods will be checked to assure that foods (including leftovers) will be consumed by their safe use by dates, or frozen (where applicable), or discarded.13.

Frozen Foods:All foods should be covered, labeled and dated.

All foods will be checked to assure that foods will be consumed by their safe use by dates or discarded.

Record review of the facility policy and procedure titled, Cleaning and Sanitation of Dining and Food Service Areas, undated, reflected the following: Policy: The food and nutrition services staff will maintain the cleanliness and sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule.

Procedure: The director of food and nutrition services will determine all cleaning and sanitation tasks.

Staff will be trained on the frequency of cleaning as necessary.The methods and guidelines to be used and agents used for cleaning shall be developed for each task or piece of equipment to be cleaned. (See sample forms on the following pages.)A cleaning schedule will be posted for all cleaning tasks, and staff will initial the tasks as completed. (See Sample Cleaning Schedule on the following pages.)Staff will be held accountable for cleaning assignments.

675925 06/04/2026

The Mildred & Shirley L.

Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415

During an interview on 06/04/2026 at 2:22 p.m., the HKS stated that MM was responsible for keeping the dumpster area clean and closing the door and she helped sometimes. HKS further added that the MM was responsible for monitoring such tasks.

She further stated, he forgot to close the doors and maybe the dumpsters were full, that was why the recliner was left out.

She stated, no I have not had any training on such task but could do one and have not come across waste disposal policy.

Such failure would make the area look bad and could cause falls for anyone including the residents assessing the place, equally led to bad smell due to those open doors.

During an interview on 06/04/2026 at 2:35 p.m., the MM stated, I am responsible for trashing the recliner chair properly and closing the doors of both dumpsters, equally responsible for monitoring of such task.

Because I am the only MM right now and there is a lot of work for me.He further stated, yes, I have been trained and have come across the waste disposal policy. He stated, it could be bad for the residents such as trash getting out of the dumpsters which could lead to environmental pollution.

During an interview on 06/04/2026 at 2:47 p.m., the ADM stated, anyone who throws away trash is responsible for keeping the dumpster area clean and closing the door, while the MM will be monitoring that task. He stated that he was not sure why the recliner on the ground was not properly trashed and equally why the dumpster doors were kept open.

The ADM added that all the staff have been trained on such task and had come across the waste disposal policy. He further stated, trash could spill out causing environmental pollution.

Record review of the facility policy and procedure titled, Waste Management, undated, reflected the following: Policy: External Dumpster Use and Door Control.

Procedures: 2.

Dumpster Use The dumpster shall only be opened for the time necessary to deposit waste.

Waste must be placed fully inside the dumpster; no bags or debris may be left outside.3.

Door/Lid Requirements Dumpster doors/lids must remain closed at all times when not in active use.

After each use, staff must verify:o Lids are fully shuto Side doors (if applicable) are secured Failure to close doors is considered a safety and infection control risk.6.

Maintenance & Monitoring The Maintenance or Environmental Services Department will:o Inspect dumpster areas routinely for cleanliness and complianceo Ensure dumpster doors/lids function properlyo Coordinate vendor pickups to prevent overflow.

675925 06/04/2026

The Mildred & Shirley L.

Garrison Geriatric Educat 3710 4th St Lubbock, TX 79415