Below average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Garrison Mem Hosp Nsg Fac during CMS and state inspections, most recent first.
Failure to Prevent Resident-to-Resident Abuse: Surveyors found repeated resident-to-resident abuse involving hitting, slapping, scratching, and one report of a resident grabbing another resident by the neck. A resident with dementia and impaired decision-making was involved in multiple altercations with several other residents, while care plans did not address wandering, rummaging, or aggressive behaviors. Records also showed other residents with dementia, Alzheimer’s disease, PTSD, and other conditions were involved, and staff confirmed the incidents and the lack of individualized behavior interventions.
Failure to supervise a wandering resident led to repeated access to unsafe areas, hazardous items, and other residents’ rooms. The resident, who had vascular dementia and moderately impaired cognition, was documented entering storage and supply areas, attempting to elope, and urinating/defecating in common areas and other residents’ rooms. The care plan did not address the resident’s wandering, rummaging, or toileting behaviors, and an admin nurse agreed the behaviors posed a risk to all residents.
Failure to provide appropriate dementia care and services for a resident with vascular dementia. The resident had repeated wandering, exit-seeking, disrobing, incontinence, and aggressive behaviors, including entering other residents’ rooms, taking belongings and food, and hitting staff and residents. The care plan contained general dementia interventions and PRN psychotropics were used frequently, but the record lacked individualized behavior interventions, effective ongoing behavior management, and documented reassessment after medication changes. Other residents reported feeling unsafe and fearful because of the resident’s actions.
Lack of Social Work Designee and On-Site Social Worker Consultation: The facility did not have a designated staff member trained to assess residents' psychosocial needs or provide related services, and it did not have on-site quarterly consultation from a qualified social worker. An administrative nurse stated the facility had no social work designee and that a social worker in Nebraska was available by phone as needed; another administrative nurse confirmed the same.
Failure to annually review and update the Facility Assessment was identified. The current assessment showed a review date of 12/03/24, and an administrative staff member confirmed that staff had not reviewed or updated it since then.
Failure to notify providers and resident representatives after resident altercations: A resident with dementia and moderately impaired cognition was involved in multiple altercations with several other residents, including hitting, scratching, and slapping incidents, and the record lacked documentation that providers and/or representatives were notified for most of the events. Other involved residents had diagnoses including dementia, Alzheimer’s disease, multiple sclerosis, and an unspecified mental disorder, with cognition ranging from intact to severely impaired. Staff interviews confirmed at least one altercation was known but not reported to the resident’s provider, and an admin nurse stated staff were expected to notify providers and representatives of all altercations and changes in condition.
The facility failed to report multiple resident-to-resident abuse incidents to the SSA. A resident with vascular dementia and impaired cognition was documented in nursing notes as grabbing, hitting, and using profanity toward other residents, including residents with dementia and one resident with PTSD; staff interviews confirmed the altercations, and an administrative nurse confirmed the incidents were not reported as required.
Failure to Investigate Resident-to-Resident Altercations: The facility failed to report and investigate multiple resident-to-resident altercations involving a resident with vascular dementia and moderately impaired cognition. Documentation showed one resident reported being grabbed around the neck, another resident was hit in the head after grabbing the resident’s arm, and a third resident was struck on the wrist and told to leave. Staff confirmed the incidents, but the altercations were not reported to administration or investigated.
A facility failed to ensure a physician completed the initial comprehensive in-person visit within the required timeframe and continued in-person visits at least every 60 days for two residents. In both cases, an NP completed the initial visit and monthly visits were documented, but the first physician face-to-face visit occurred months after admission.
A facility failed to post accurate nurse staffing information for 47 of 47 days reviewed. On observation, staffing information on a clipboard across from the nurses’ station did not show the actual hours worked by direct care staff for all shifts, and the facility census was missing on 9 days.
Failure to fully inform residents and/or their representatives about psychotropic medication treatment was identified for 5 sampled residents. Record review showed orders for multiple psychotropics, including antianxiety, antidepressant, and antipsychotic medications, but the charts lacked documentation that risks, benefits, alternatives, or consent were discussed and obtained. An administrative staff member confirmed the missing documentation during interview.
Care plans were not kept current for several residents. A resident with opioid and antipsychotic meds, another with diuretics, PRN opioid, and anticoagulation therapy, and others with a catheter, diuretics, antipsychotics, or communication needs had care plans that did not address the resident’s current meds, problems, goals, or interventions. One resident was observed asleep at a dining room table and staff reported he preferred to stay there, but this was not reflected in the care plan.
Dishwasher Failed to Reach Required Wash Temperature: The main kitchen’s low-temp chemical sanitizing dishwasher was observed running at 99 degrees F, below the manufacturer’s required 120 degrees F. Staff said the unit did not always reach the proper temp because hot water was being used by other departments, and management and maintenance were already aware of the issue. Logs showed the dishwasher water failed to reach 120 degrees F over multiple days, even though sanitizer levels were recorded within the required ppm range.
A resident with a right femur fracture and fall risk was found on the floor with increased R leg pain after a fall. Staff contacted the ER for guidance, gave Tylenol and ice, and delayed notifying the provider on call about the fall, possible fracture, and pain until later, with x-rays and ER transfer occurring afterward.
A resident was given Risperidone, but the record did not include an assessment or appropriate diagnosis supporting the antipsychotic use. The resident had Alzheimer’s disease, dementia, and anxiety, and MDS assessments noted antipsychotic use, with later documentation of physical behaviors. An administrative nurse confirmed the order came after a psych consult but lacked a diagnosis or MD progress note.
A nurse failed to assist and observe a resident with medication administration while the resident consumed pills from a medication cup in the dining room. The resident’s record had no physician order for SAM, and the care plan stated the resident was unable to self-administer medications due to dementia and a CVA history.
Failure to provide appropriate catheter care occurred for a resident with an indwelling Foley catheter when the physician's orders did not include the catheter or how often it should be changed. Staff changed the catheter after the resident reported severe pain at the insertion site, with pus-like urine, blood in the tubing, a clot noted after irrigation, and minimal urine return before the old Foley was removed and a new one inserted.
Missing Oxygen Order for a Resident: A resident returned to the facility after an acute hospital stay for pneumonia and CHF exacerbation and was observed wearing oxygen via nasal cannula at 2 L/min. The physician's orders did not include an oxygen order, and an administrative staff member confirmed the resident had no order for oxygen.
Infection control standards were not followed during high-contact care for multiple residents. CNAs provided toileting, brief changes, hygiene, and transfer assistance without gowns for residents on EBP, and another CNA applied PPE without hand hygiene before emptying a urine drainage bag and did not disinfect the floor after a urine spill. An admin nurse confirmed the expected PPE, hand hygiene, and spill cleanup practices.
Several residents' care plans were not updated to reflect current physician and dietary orders, resulting in conflicting or missing instructions for weight monitoring, ambulation, and diet. These discrepancies limited staff communication and continuity of care, as confirmed by an administrative nurse.
The facility did not establish a separate QAPI process or QA committee for the nursing home and instead relied on hospital-side quality meetings, with audits that did not address previously cited deficiencies. This resulted in ongoing noncompliance with federal requirements.
Nursing staff failed to follow physician orders and facility policies for medication administration, including administering an extra dose of pain medication to a resident after the order was changed, documenting insulin administration before giving it, not properly priming insulin pens, and administering insulin without privacy in a communal area.
Two residents who required total assistance for wheelchair transfers were transported without wheelchair foot pedals, resulting in their feet dragging or being positioned unsafely under the wheelchair. CNAs involved were unaware of the location of the necessary equipment, and an administrative nurse confirmed that foot pedals should have been used for residents unable to lift their feet. The facility could not provide a policy on foot pedal use when asked.
Facility staff did not consistently obtain or monitor monthly weights for two residents with significant medical conditions, resulting in missed identification and assessment of substantial weight fluctuations. Required weight variance reports were not completed, and staff failed to follow established policies for monitoring nutritional status.
Three insulin pens were found in a medication cart without required labeling, including the resident's name and the date opened, contrary to facility policy. An administrative nurse confirmed that staff are expected to label insulin pens with identifying information and dosing details.
Staff failed to disinfect mechanical stand lifts between uses after transferring multiple residents, instead moving unsanitized equipment between rooms and to storage. Although facility policy requires disinfection of multi-use devices after each use, staff either did not perform this task or believed it was housekeeping's responsibility, leading to lapses in infection control practices.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to ensure residents remained free from abuse when seven sampled residents were involved in repeated resident-to-resident physical and verbal altercations. Surveyors reviewed records, facility policy, and interviewed residents and staff, and found incidents involving hitting, slapping, scratching, and one report of hands being placed around a resident’s neck. The deficiency was cited under the facility’s abuse prevention requirements, and surveyors determined an Immediate Jeopardy situation existed beginning when documentation showed one resident placed her hands around another resident’s neck. Resident #1, who had vascular dementia and moderately impaired cognition, was involved in multiple incidents with other residents. Her care plan stated she had impaired decision-making related to dementia and was not able to make safe decisions, but it did not address wandering, rummaging, behaviors toward others, or individualized interventions for those behaviors. Nursing notes documented Resident #1 entering another resident’s room and making threatening statements, hitting a resident in the head after being grabbed by the arm, rummaging through a roommate’s belongings, being scratched after hitting the roommate, hitting a male resident on the arms, hitting another resident in the wrist and telling her to get out, and slapping another resident on the arm. Other residents involved had diagnoses including dementia, Alzheimer’s disease, PTSD, multiple sclerosis, generalized anxiety disorder, and an unspecified mental disorder, with several MDS assessments showing severely impaired cognition or intact cognition. Resident #2’s care plan addressed avoiding overstimulation, but the record documented an altercation in which Resident #1 hit him in the head. Resident #3 reported feeling unsafe around Resident #1 and said Resident #1 continued to enter her room and take her bible. Resident #5’s record documented that he struck Resident #1 back after she hit him, and his care plan did not address his physical behaviors toward other residents. Resident #6’s record lacked documentation of the altercation with Resident #1, and Resident #7 reported that Resident #1 came up behind him and grabbed him by the neck, which he feared could trigger his PTSD. An administrative nurse confirmed the resident-to-resident altercations and that the facility failed to update care plans and implement interventions to address Resident #1’s behaviors.
Failure to Supervise a Wandering Resident
Penalty
Summary
The facility failed to provide appropriate supervision for one resident who wandered throughout the building, entered unsafe areas, and repeatedly accessed hazardous items and other residents’ rooms. The resident had a diagnosis of vascular dementia and a quarterly MDS identified moderately impaired cognition. The care plan, last reviewed by facility staff on 04/09/26, addressed impaired decision-making, fall risk, increased staff supervision, toileting support, and one-on-one assistance as needed, but it did not address wandering, rummaging, urinating/defecating in inappropriate places, behaviors toward others, or individualized interventions for those behaviors. Nursing notes documented repeated unsafe behaviors over the course of the month, including exit-seeking, entering resident rooms and storage areas, attempting to elope through exits and elevators, and taking items from closets, supply areas, and other residents’ rooms. The resident was documented in common areas and other residents’ rooms urinating and defecating on floors, in trash cans, in bathrooms, and in the dining room, activity room, kitchenette, hallway, and nurses’ station area. Notes also described the resident handling feces, attempting to clean urine with her hands, and continuing to wander despite redirection. The record also showed access to hazardous items and unsafe situations, including a sit-to-stand lift placed under the resident’s feet, a broom removed from a storage closet, a glass vase, electric cords around the resident’s neck, a fluorescent light bulb, scissors taken from another resident’s room, and a butter knife used to cut off a wanderguard. During interview, an administrative nurse confirmed the expectation that doors with locks should be closed and locked, and agreed the resident’s behavior posed a risk to all residents. The nurse also agreed the care plan failed to identify the resident’s behaviors or individualized interventions to address them, and that the facility failed to implement interventions to address the behaviors and the safety risk posed to all residents.
Failure to Provide Appropriate Dementia Care and Services
Penalty
Summary
The facility failed to provide appropriate dementia care and services for a resident with vascular dementia whose behaviors escalated over time and were repeatedly documented in nursing notes. The resident was described as wandering into other residents’ rooms, entering staff-only and storage areas, attempting to exit the building, disrobing in common areas, urinating and defecating in hallways, dining areas, bathrooms, trash cans, and other residents’ rooms, and taking other residents’ belongings and food. The record also documented episodes of verbal and physical aggression toward staff and residents, including hitting, grabbing, threatening, and becoming combative when redirected. The resident’s care plan included general dementia-related interventions such as cues, reminders, structure, and one-on-one supervision as needed, but the record lacked individualized interventions that addressed the resident’s specific behaviors and safety issues. The facility policy required assessment, care planning, and timely updates, including related social service goals and approaches, and a separate 1:1 supervision policy described assessment and care planning for residents with severe behavioral symptoms or wandering/elopement risk. Despite these policies, the record showed repeated behaviors over many weeks without documentation of an effective behavior management program, consistent meaningful activities, or ongoing evaluation and modification of interventions based on patterns and triggers. The resident was treated with psychotropic medications, including quetiapine, Rexulti, and frequent PRN lorazepam, but the notes showed continued behaviors despite these medications. Provider notes documented increasing behaviors, frequent disrobing, eating and drinking from other residents’ plates, and digging through garbage, yet the record lacked documentation of a reassessment after a dose increase. During observation, the resident continued to attempt to enter other residents’ rooms, hit out at staff, and wander near unattended equipment. Other residents reported feeling unsafe, and one resident stated the resident came into his room and took his bible, while another stated the resident had grabbed him by the neck and that he feared his PTSD could be triggered.
Lack of Social Work Designee and On-Site Social Worker Consultation
Penalty
Summary
Provide medically-related social services to help each resident achieve the highest possible quality of life was not met because the facility did not have a designated staff member trained to assess residents' psychosocial needs and provide services to meet those needs, and it did not have on-site quarterly consultation from a qualified social worker. During an interview on the morning of 07/07/26, an administrative nurse stated the facility did not have a social work designee and that a social worker in Nebraska was assigned to the nursing home, but she was unaware whether a licensed social worker had visited the facility. A phone interview with another administrative nurse on 07/07/26 at 12:41 p.m. confirmed the facility did not currently have a social work designee and that the social worker in Nebraska was available by phone as needed.
Failure to Annually Review and Update Facility Assessment
Penalty
Summary
The facility failed to review and update its Facility Assessment annually. Review of the current Facility Assessment showed a review date of 12/03/24, and during an interview on 07/07/26 at 3:15 p.m., an administrative staff member confirmed that staff had not reviewed or updated the Facility Assessment since that date.
Failure to Notify Providers and Representatives After Resident Altercations
Penalty
Summary
The facility failed to notify residents’ physicians and/or resident representatives after multiple resident-to-resident altercations involving 6 sampled residents. The facility policy on Notification of Changes stated that the facility must inform the resident, consult with the resident’s physician, and/or notify the resident’s family member or legal representative when there is a change requiring such notification, including a change of room or roommate assignment. The facility’s policy on Mandatory Reporting of Abuse, Neglect, Exploitation, Mistreatment, Misappropriation Prevention or Acts of Violence also stated to notify the patient/resident provider and patient/resident representative. Resident #1 had diagnoses including vascular dementia and moderately impaired cognition. Nursing notes documented several altercations involving Resident #1 and other residents: grabbing and hitting Resident #2, being scratched by Resident #3 after rummaging through belongings, hitting Resident #5 on the arms, hitting Resident #6 on the wrist, and slapping Resident #4 on the arm. The record lacked documentation that Resident #1’s provider and/or representative were notified of the altercations with Residents #2, #3, #5, and #6. Resident #1’s representative stated the facility did not notify her of those altercations, and also stated that after the incident with Resident #3, the facility moved Resident #3 to a different room and gave Resident #1 a different roommate without notifying her of the room change. Resident #2 had dementia and severely impaired cognition, and the record documented that Resident #1 grabbed Resident #2 by the arm and Resident #2 hit Resident #1 in the head, but there was no documentation that Resident #2’s provider or representative was notified. Resident #3 had multiple sclerosis and generalized anxiety disorder with intact cognition, and the record documented that Resident #1 rummaged through Resident #3’s belongings and Resident #3 scratched Resident #1, but there was no documentation of provider notification. Resident #4 had Alzheimer’s disease and a court-appointed guardian, and the record documented that Resident #1 slapped Resident #4 on the arm, but there was no documentation that Resident #4’s provider and guardian were notified. Resident #5 had an unspecified mental disorder and intact cognition, and the record documented that Resident #1 hit Resident #5 on both upper arms and Resident #5 struck back, but there was no documentation that Resident #5’s provider and representative were notified. Resident #6 had dementia and severely impaired cognition, and the record lacked documentation of the altercation with Resident #1 and of notification to Resident #6’s provider and representative. A nurse confirmed the altercation involving Resident #6 and stated she did not notify the provider because there was no injury and was unsure whether the representative was notified; an administrative nurse stated staff were expected to notify resident providers and representatives of all altercations and changes in condition.
Failure to Report Resident-to-Resident Abuse Incidents
Penalty
Summary
The facility failed to report incidents of potential abuse to the State Survey Agency for 4 of 4 sampled residents involved in resident-to-resident altercations. The facility policy titled Mandatory Reporting of Abuse, Neglect, Exploitation, Mistreatment, Misappropriation Prevention or Acts of Violence stated that employees must report any reasonable suspicion of abuse or acts of violence in a timely manner and that alleged violations involving abuse or mistreatment must be reported immediately to the administrator and to other officials, including the State survey and certification agency. Resident #1 had a diagnosis of vascular dementia and a quarterly MDS showing moderately impaired cognition. Nursing notes documented that Resident #1 was involved in altercations with Resident #7, Resident #2, and Resident #6, including grabbing around the neck, hitting another resident in the head, and hitting a resident in the left wrist while using profanity. Resident #2 had dementia with severely impaired cognition, Resident #6 had dementia with severely impaired cognition, and Resident #7 had PTSD with intact cognition. Interviews with nursing staff confirmed the altercations, and an administrative nurse confirmed the facility did not report the incidents involving Resident #1 and Residents #2, #6, and #7 to the SSA.
Failure to Investigate Resident-to-Resident Altercations
Penalty
Summary
The facility failed to investigate incidents of alleged abuse involving resident-to-resident altercations for 4 of 4 sampled residents. The facility policy titled Mandatory Reporting of Abuse, Neglect, Exploitation, Mistreatment, Misappropriation Prevention or Acts of Violence stated that all alleged violations involving abuse or mistreatment must be reported immediately to the administrator and other officials, thoroughly investigated, and reported in accordance with state law. However, the record showed that staff did not investigate or report the altercations involving Resident #1 with Residents #2, #6, and #7. Resident #1 had a diagnosis of vascular dementia and a quarterly MDS identified moderately impaired cognition. Documentation showed that on 05/24/26 Resident #7 complained that Resident #1 entered his room, told him he would not get dinner if certain things were not finished, and that Resident #1 had previously grabbed him around the neck. On 05/27/26 Resident #1 walked by Resident #2, Resident #2 grabbed Resident #1 by the arm, and Resident #1 hit Resident #2 in the head. On 06/12/26 Resident #1 walked up to Resident #6 in the dining room, hit her in the left wrist, and told her '[profanity] you get out.' Resident #2 had dementia and severely impaired cognition, Resident #6 had dementia and severely impaired cognition, and Resident #7 had PTSD with intact cognition. Staff interviews confirmed the altercations, and an administrative nurse confirmed staff failed to report the incidents to administration and the facility failed to investigate them.
Delayed Physician In-Person Visits
Penalty
Summary
The facility failed to ensure that a physician completed the initial comprehensive in-person visit within 30 days of admission and then completed in-person visits at least once every 60 days thereafter for 2 of 7 sampled residents. Resident #1 was admitted on 02/09/26, and the record showed a nurse practitioner completed the initial comprehensive in-person visit on 02/11/26 with monthly in-person visits through June 2026, but the first in-person physician visit did not occur until 07/01/26, almost five months after admission. Resident #6 was admitted on 01/22/26, and the record showed a nurse practitioner completed the initial comprehensive in-person visit on 01/28/26 with monthly in-person visits through March 2026, but the first in-person physician visit did not occur until 04/11/26, almost three months after admission.
Inaccurate Daily Nurse Staffing Postings
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted accurately every day for 47 of 47 days reviewed, from May 23 through July 7, 2026. On observation of the clipboard on the wall across from the nurses’ station on the afternoon of 07/07/26, nursing staff information for the review period was present, but the records did not identify the actual hours worked by direct care staff for all shifts on any of the 47 days and did not identify the facility census on 9 of the 47 days. The deficiency involved the facility’s posted staffing information and census documentation being incomplete and not updated accurately at the beginning of each shift.
Failure to Inform Residents and Representatives About Psychotropic Medications
Penalty
Summary
The facility failed to fully inform residents or their resident representatives about treatment with psychotropic medications for 5 of 5 sampled residents reviewed for unnecessary medications. Record review showed that Resident #2 had physician orders for Buspirone, Duloxetine, Lorazepam, Mirtazapine, and Risperidone; Resident #4 had orders for Citalopram and Quetiapine; Resident #5 had orders for Quetiapine and Lorazepam; Resident #9 had orders for Lorazepam and Bupropion; and Resident #16 had orders for Seroquel and Memantine. For each of these residents, the medical record lacked documentation that the facility informed the resident and/or their representative of the risks, benefits, and alternatives of the prescribed treatment or obtained consent. The deficiency was identified through record review on all days of survey and confirmed in an interview with an administrative staff member on 04/08/26 at 12:15 p.m. The staff member acknowledged that the facility failed to fully inform the resident and/or their representatives regarding psychotropic medication treatment for Residents #2, #4, #5, #9, and #16.
Care Plans Not Kept Current for Multiple Residents
Penalty
Summary
The facility failed to review and revise care plans to reflect the current status of 6 of 12 sampled residents. Review of the facility policy titled Care Conference and Resident Centered Care Plan stated that each resident must have a comprehensive resident-centered care plan that is reviewed at least quarterly, as requested, or as needed, and kept current. Record review showed that Resident #2 had physician orders for Oxycodone and Risperidone, but the care plan did not identify problems or interventions for opioid and antipsychotic medication use. Resident #3 had orders for Spironolactone, Furosemide, Tramadol as needed, and Xarelto, but the care plan did not address diuretic use, opioid pain medication, or anticoagulation therapy. Resident #4 had orders for Hydrochlorothiazide and Xarelto, but the care plan did not identify problems or interventions for diuretic and anticoagulant use or for translation devices needed for communication. Resident #8 had an indwelling urinary catheter, but the care plan did not identify related problems, goals, or interventions. Resident #16 had orders for Lasix and Tramadol, but the care plan did not address diuretic and opioid pain medication use. Resident #21 had orders for Lasix and Seroquel, and progress notes documented that the resident had fallen from his chair. On observation, the resident was asleep at a dining room table, and nursing staff stated he had been there since lunch, had a recliner in his room that he would not sit in, and had also refused a recliner placed near his table. His care plan did not identify problems or interventions for diuretic and antipsychotic medications or his preference for spending most of the day at the dining room table.
Dishwasher Failed to Reach Required Wash Temperature
Penalty
Summary
The facility failed to ensure the low-temperature dishwasher in the main kitchen provided adequate heat and sanitization for dishes and utensils. Manufacturer specifications for the Energy Series “Green” Machine American Dish Service identified a water temperature of 120 degrees Fahrenheit, and the Ultra San Liquid Sanitizer instructions stated that for sanitizing tableware in low-temperature warewashing machines, the final rinse water must be at 100 ppm available chlorine and not exceed 200 ppm. During observation in the main kitchen, a dietary aide checked the dishwasher wash cycle temperature and obtained 99 degrees Fahrenheit, stating it does not always reach 120 degrees until later in the morning because other departments are using hot water for baths and laundry. A dietary supervisor stated administration and maintenance were aware of the low temperature, but no one had looked at the dishwasher. Review of the dishwasher temperature and chlorine logs from March 20 through April 6, 2026 showed the dishwasher water failed to reach 120 degrees Fahrenheit on those days, although the chlorine log showed 100-200 ppm. An administrative staff member stated maintenance was aware of the dishwasher concerns, and a dishwasher service representative confirmed that the low-temperature sanitizer requires a minimum wash temperature of 120 degrees Fahrenheit. The facility failed to address and correct the inadequate dishwasher temperature for 18 days.
Failure to Notify Physician After Resident Fall With Injury
Penalty
Summary
The facility failed to notify the resident's physician of a change in condition for 1 of 1 sampled resident reviewed for a fall with injury. Resident #2 had diagnoses including a right femur fracture and was identified in the care plan as being at risk for falls due to cognitive loss. After the resident was found on the floor on her back at about 1:35 a.m., staff documented that she had no signs or symptoms of head injury but voiced increased pain in her right leg above the knee. She was lifted back to bed, her leg was immobilized with a rolled blanket, and the nurse contacted the emergency room for guidance rather than immediately notifying the provider on call. The record states the ER nurse advised giving Tylenol and ice and waiting until 8:00 a.m. to call the provider and obtain x-rays if the situation did not appear emergent. Tylenol was given around 2:00 a.m., ice was applied, and staff continued to monitor the resident's pain through the night. The progress note later documented that the provider on call and family were notified, x-rays were taken around 8:15 a.m., and the resident was transported to the ER at 9:00 a.m. A later note documented pain in the right leg, swelling, slight rotation, and a femur fracture report. An administrative nurse confirmed during interview that staff failed to notify the physician about the resident's potential fracture.
Unnecessary Antipsychotic Medication Use
Penalty
Summary
The facility failed to ensure that Resident #2 remained free of chemical restraints by not documenting an assessment and appropriate diagnosis for the use of Risperidone, an antipsychotic medication. Resident #2’s medical record showed diagnoses of Alzheimer’s disease, dementia, and anxiety, and the medication list included Risperidone. The resident’s admission MDS identified no behaviors and the use of an antipsychotic medication, while a quarterly MDS later identified physical behaviors and the use of an antipsychotic medication. During interview, an administrative nurse confirmed the facility received an order for the antipsychotic medication after a psychiatric consultation, but the order lacked a diagnosis or physician progress note.
Failure to Assist and Observe Medication Administration
Penalty
Summary
The facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for Resident #5 when the resident was observed self-administering medications without a physician order for self-administration. During observation, Resident #5 was seated in the dining room with a medication cup containing several pills on the meal tray and consumed the pills while the nurse administered medications to other residents. When asked whether Resident #5 was capable of self-administering medications, the nurse stated, "Yes, I believe so." However, the medical record lacked a physician order for self-administration of medication, and the care plan stated that the resident was unable to self-administer medications due to a dementia history and CVA. The nurse failed to assist and observe Resident #5 with the medications.
Missing Foley Order and Catheter Care
Penalty
Summary
Failure to provide appropriate care for a resident with an indwelling urinary catheter occurred when the resident had a catheter in place since admission, but the physician's orders did not include an order for the indwelling catheter or instructions for how often it should be replaced. The record showed facility staff changed the catheter 15 weeks after admission. A progress note documented that the resident reported severe pain at the catheter insertion site, urine in the tubing appeared pus-like with some blood, and the catheter was irrigated with approximately 40 cc of normal saline. A small clot was noted in the tubing after irrigation, urine return was minimal, and the resident reported minimal relief. The old Foley catheter was then removed and a new 16 Fr Foley catheter was inserted, with approximately 30 mL of cloudy yellow urine returned and the resident reporting relief from pain. An administrative staff member later confirmed that the physician's orders failed to include an indwelling Foley catheter and how often to change it.
Missing Oxygen Order for Resident
Penalty
Summary
Failure to obtain a physician's order for oxygen was identified for Resident #12. Review of the medical record showed the resident returned to the facility on 04/06/26 after an acute hospital stay for pneumonia and an exacerbation of congestive heart failure. Observation on 04/07/26 and 04/08/26 showed the resident wearing oxygen via nasal cannula at 2 liters per minute, but the physician's orders did not include an oxygen order. During an interview on 04/08/26 at 4:40 p.m., an administrative staff member confirmed that Resident #12 did not have an order for oxygen.
Infection Control and PPE Use During Resident Care
Penalty
Summary
The facility failed to follow infection control and prevention standards for 3 of 6 sampled residents during observed care. Review of the facility’s Enhanced Barrier Precautions policy stated that gown and glove use is required during high-contact resident care activities such as dressing, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, and wound care for residents with MDRO infection or colonization. Resident #6 had a history of an MDRO, and during an observation a CNA wearing gloves assisted the resident with a brief change, adjusted the top sheet, and placed the overbed table next to the bed without applying a gown. Resident #5 had a non-pressure chronic ulcer of the left lower leg and had EBP signage and PPE on the door. During two separate observations, two CNAs entered the room with gloves and assisted the resident with toileting, brief changes, hygiene, and transfer back to the wheelchair, but did not apply gowns before the high-contact care. For Resident #8, a CNA applied PPE without performing hand hygiene before emptying the urine collection bag, and urine dripped onto a paper towel and soaked through to the floor; the CNA did not disinfect the floor after the spill. An administrative nurse confirmed she expected staff to wear the required PPE for high-contact care, perform hand hygiene before applying PPE, and disinfect the floor after a urine spill.
Failure to Update and Revise Care Plans to Reflect Current Physician Orders
Penalty
Summary
The facility failed to review and revise care plans to accurately reflect the current status and physician orders for four of twelve sampled residents. For one resident with kidney disease and neuropathy related to diabetes mellitus, the care plan contained conflicting instructions regarding the frequency of weight monitoring, with both monthly and weekly weights documented. Another resident's care plan included contradictory ambulation instructions, listing both a restorative nursing ambulation program with a platform walker and assistance of two, as well as ambulation with assistance of one and a front-wheeled walker. A third resident's care plan also had conflicting orders for weight monitoring, with both monthly and weekly weights present. For a fourth resident, the care plan failed to include current physician orders for monthly weights and a specific diet order for a diabetic/regular consistency, low potassium diet. These discrepancies were identified through record review, facility policy review, and staff interviews. The facility's policies required care plans to be developed, reviewed, and revised by an interdisciplinary team to reflect current physician and dietary orders, and to be updated as needed. However, the care plans for these residents were not updated to remove outdated or conflicting information, or to include new orders, limiting staff's ability to communicate resident needs and ensure continuity of care. An administrative nurse confirmed that staff failed to update the care plans accordingly.
Failure to Establish and Utilize Nursing Home-Specific QAPI Process
Penalty
Summary
The facility failed to develop and implement a Quality Assurance and Performance Improvement (QAPI) process specific to the nursing home, as required by federal regulations. Review of state agency files and staff interviews revealed that the facility did not have a separate nursing home Quality Assurance (QA) committee and was not effectively utilizing QA activities to evaluate and identify problems, improve services or outcomes, or ensure compliance. Instead, QA audits conducted for the nursing home were brought to hospital meetings, and the issues currently audited did not address any of the deficiencies cited during the last standard survey. This lack of a dedicated and effective QAPI process resulted in continued noncompliance with federal requirements.
Failure to Follow Professional Standards for Medication Administration
Penalty
Summary
The facility failed to adhere to professional standards of practice for medication administration for multiple residents. For one resident with polyneuropathy, a physician's order for hydrocodone was changed from four times daily to twice daily, but the resident received a third dose after the order was changed. This was confirmed by review of the medication administration record and staff interview. Additionally, observations revealed that a nurse documented blood sugar and insulin administration on the medication administration record prior to actually administering the medications for two residents. The nurse also failed to prime insulin pens in accordance with facility policy, which requires the pen to be held pointing upward, instead priming them while pointing downward. Furthermore, insulin was administered to one resident in the dining room without privacy, in the presence of other residents, contrary to facility policy. An administrative nurse confirmed that these actions did not meet facility expectations or policy requirements.
Failure to Provide Wheelchair Foot Pedals During Resident Transport
Penalty
Summary
The facility failed to provide necessary assistive devices, specifically wheelchair foot pedals, for two residents who were dependent on staff for wheelchair transfers and had documented lower extremity impairments. In one instance, a certified nurse aide (CNA) was observed transporting a resident whose left foot dragged on the floor and became twisted under the wheelchair due to the absence of a foot pedal. The CNA acknowledged that the left foot pedal was missing and was unaware of its location. The resident's medical record indicated functional limitations in range of motion and a care plan requiring total assistance for locomotion once in the wheelchair. In another case, two CNAs transferred a resident from a recliner to a different wheelchair that lacked foot pedals and proceeded to push the resident down the hallway. The resident's legs were observed to be positioned under the wheelchair, and the CNA admitted not knowing the location of the resident's assigned wheelchair. Both residents' care plans required total assistance once in the wheelchair, and an administrative nurse confirmed that staff were expected to apply foot pedals for residents unable to lift their feet. The facility was unable to provide a policy regarding foot pedal use when requested.
Failure to Monitor and Address Significant Weight Variances
Penalty
Summary
Facility staff failed to maintain acceptable parameters of nutritional status for two residents with documented weight variances. For one resident with chronic kidney disease and congestive heart failure, staff did not obtain monthly weights for three consecutive months and did not identify or assess significant weight fluctuations, including a 17-pound loss in one month and an 18.4-pound loss in less than a week. The resident was prescribed Furosemide and had physician orders and care plans specifying monthly weights, but these were not followed. Another resident, diagnosed with hypertension and also prescribed Furosemide, was not weighed as ordered in two separate months. The facility's policy required monthly weights, consistent weighing methods, and completion of weight variance reports, but these procedures were not followed. An administrative nurse confirmed that charge nurses were expected to monitor weights and acknowledged that monthly weight variance reports were not completed as required by policy.
Insulin Pens Not Properly Labeled in Medication Storage
Penalty
Summary
Surveyors observed that three insulin pens stored in a medication cart were not labeled with the resident's name or the date the pen was opened, as required by facility policy. The facility's policies on insulin pen use and storage specify that all insulin pens must have patient identification and the date opened clearly marked. During the observation, an administrative nurse retrieved the insulin pens and confirmed that they lacked the necessary labeling. The nurse also acknowledged that staff are expected to follow the policy and ensure insulin pens are properly labeled with identifying information and dosing details.
Failure to Disinfect Stand Lifts Between Resident Uses
Penalty
Summary
Facility staff failed to follow established infection prevention and control protocols regarding the disinfection of mechanical stand lifts used for resident transfers. Observations revealed that after transferring residents from the toilet to a wheelchair using stand lifts, staff members, including certified nurse aides and a nurse, did not sanitize the lift equipment between uses. In one instance, a CNA stated that housekeeping was responsible for cleaning the lifts, while administrative staff clarified that housekeeping only cleans the lifts twice a month and that staff are expected to clean them after each use. The facility's policy requires all multi-use medical devices, including mechanical lifts, to be disinfected between resident uses as part of the infection control program. Despite this, staff were observed moving unsanitized lifts between resident rooms and to storage areas after use. Interviews with administrative staff confirmed the expectation that staff should sanitize the lifts after each use, but this was not consistently practiced, as evidenced by the observations involving three different residents requiring stand lift transfers.
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What surveyors actually found near you
We read the citations issued around you in the last 12 months — including the immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Garrison
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benedictine Living Center Of Garrison | 0.5 mi | ★★★★★ | 0 | 0 |
| Knife River Care Center | 30.5 mi | ★★★★★ | 1 | 0 |
| Souris Valley Care Center | 35.7 mi | ★★★★★ | 12 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 October 2026) and official state health department websites.