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 Benedictine Living Center Of Garrison during CMS and state inspections, most recent first.
A resident was injured after being transferred with a mechanical lift by only one CNA, contrary to facility policy and the care plan requiring two staff. The resident fell from the sling, resulting in a head injury, after the CNA attempted the transfer alone and the resident slid out of the sling.
A nurse performed CPR on a resident with a documented DNR order, contrary to facility policy and the resident's advance directive. The resident was found unresponsive, CPR was initiated, and the resident was transferred to the hospital before returning to the facility. An administrative staff member confirmed that the nurse did not follow the resident's code status.
The facility failed to prevent resident-to-resident abuse, involving multiple incidents of physical and verbal aggression among residents with cognitive impairments. A resident with a history of aggression kicked and punched another, while another resident slapped a peer during a manic episode. The facility did not classify these as abuse, focusing instead on monitoring and redirection.
The facility failed to report incidents of resident-to-resident abuse to the SSA, involving three residents with various psychiatric and neurological conditions. Despite documentation of altercations, including physical aggression, there was no evidence of reporting to the SSA as required by the facility's policy. An administrative staff member confirmed the lack of reporting, highlighting a deficiency in compliance with abuse prevention protocols.
The facility failed to adhere to professional standards for administering rapid-acting insulin to three residents. Insulin was administered significantly earlier than the prescribed time relative to meal service, risking hypoglycemic reactions. An administrative nurse confirmed the expectation to follow manufacturer's guidelines.
The facility exceeded the acceptable medication error rate during administration for two residents, resulting in a 12.5% error rate. Errors included failing to remove the cap before priming insulin pens and not priming with the needle pointing upwards. An administrative nurse confirmed the correct procedure expectations.
Failure to Provide Required Supervision During Mechanical Lift Transfer
Penalty
Summary
A deficiency occurred when a resident was transferred using a mechanical lift by only one certified nurse aide (CNA), despite facility policy and the resident's care plan both requiring the assistance of two trained staff for such transfers. The CNA placed the resident in the lift sling, raised the lift, and began to move the resident into position to transfer her to a chair. During this process, the resident slid out of the sling head first and fell to the floor, sustaining a scalp abrasion and acute headache, as documented by a physician's progress note. Eyewitness accounts from the resident's roommate confirmed that only the CNA and the resident were present in the room at the time of the incident. The roommate observed the sling swinging before the resident suddenly fell to the ground and began screaming. The CNA admitted to dropping the resident from the sling and acknowledged not having a second staff member present, as required. The incident resulted in visible injury and distress to the resident.
Failure to Honor Resident DNR Order Resulting in Unwanted CPR
Penalty
Summary
A deficiency occurred when staff failed to honor a resident's advance directive regarding code status. Specifically, a nurse performed CPR on a resident who had a documented Do Not Resuscitate (DNR) order, as indicated by a Physician Order for Life Sustaining Treatment form. The facility's policy stated that CPR should not be initiated if a provider's medical order indicates DNR status, yet this was not followed in the case of this resident. The incident was documented in the resident's nursing notes, which described the resident being found unresponsive and CPR being performed despite the DNR order. The resident was subsequently sent to the hospital for further evaluation and later returned to the facility. An administrative staff member confirmed during an interview that the nurse performed CPR against the resident's code status and acknowledged that staff are expected to follow such orders.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect residents from resident-to-resident abuse, as evidenced by multiple incidents involving physical and verbal aggression among residents. Resident #24, who has a history of verbal and physical aggression due to cognitive impairments, was involved in an altercation where they kicked and punched another resident. This incident was not initially identified as abuse, and the facility's response was limited to moving Resident #24 back to their room without further intervention. Another incident involved Resident #31, who, during a manic episode, slapped Resident #51 after becoming irritated by their behavior. Resident #31 admitted to the act, which was overheard by a CNA. Despite Resident #31's admission and the acknowledgment of their manic state, the facility did not classify this as abuse, and the response was limited to monitoring and medication adjustments. Resident #51 was involved in multiple incidents, including hitting another resident and slapping a female resident after a verbal altercation. These incidents were not witnessed, and the facility's response focused on redirecting Resident #51 and conducting 15-minute checks. The facility failed to recognize these actions as abuse, and the interventions were primarily reactive rather than preventive.
Failure to Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report incidents of resident-to-resident abuse to the State Survey Agency (SSA) for three residents, placing all residents at risk for possible abuse. The facility's policy requires that all events, including resident-to-resident altercations, be investigated and reported to the state within specific timeframes depending on the severity of the incident. However, the facility did not adhere to this policy. For instance, Resident #24, diagnosed with psychotic disorder, schizoaffective disorder, major depressive disorder, and Alzheimer's disease, was involved in an altercation where she kicked and punched another resident. Despite the incident being documented and the Power of Attorney being notified, there was no evidence that it was reported to the SSA. Similarly, Resident #31, with diagnoses including bipolar disorder and other drug-induced secondary parkinsonism, admitted to slapping another resident, Resident #51, who has Korsakoff's syndrome. Additionally, Resident #51 was involved in two separate incidents where he hit another resident and slapped a female neighbor. These incidents were documented in progress notes, but there was no evidence that they were reported to the SSA. An administrative staff member confirmed that these incidents had not been reported, indicating a failure to comply with the facility's abuse prevention policy.
Failure to Follow Insulin Administration Guidelines
Penalty
Summary
The facility failed to ensure that staff followed professional standards of practice for administering rapid-acting insulin to three residents. The prescribing information for Humalog and NovoLog insulin specifies that these medications should be administered within a specific time frame relative to meals to prevent hypoglycemic reactions. However, observations during the survey revealed that the timing of insulin administration did not align with these guidelines for three residents. Resident #6 received 20 units of NovoLog insulin at 3:38 p.m., but did not receive their evening meal until 4:50 p.m., which is one hour and 12 minutes later. Resident #23 was administered 20 units of Humalog insulin at 4:04 p.m., but their meal was served at 4:33 p.m., 29 minutes after the insulin was given. Similarly, Resident #40 was given 2 units of NovoLog insulin at 8:43 a.m., with their meal following at 9:11 a.m., 28 minutes later. These discrepancies in timing indicate a failure to adhere to the manufacturer's instructions for rapid-acting insulin administration, as confirmed by an administrative nurse during an interview.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to maintain a medication error rate of less than five percent during medication administration for two residents. Specifically, four medication errors occurred out of 32 medications administered, resulting in a 12.5 percent error rate. During an observation, a nurse prepared insulin pens for a resident but failed to remove the cap before priming the pen. In another instance, a different nurse prepared insulin pens for another resident but did not prime the pen with the needle pointing upwards as required. An administrative nurse confirmed that the expectation is to prime insulin pens with the cap off and the needle pointing upwards.
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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) |
|---|---|---|---|---|
| Garrison Mem Hosp Nsg Fac | 0.5 mi | ★★★★★ | 9 | 0 |
| Knife River Care Center | 30.9 mi | ★★★★★ | 1 | 0 |
| Souris Valley Care Center | 35.4 mi | ★★★★★ | 6 | 1 |
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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.