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 July 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 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 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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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) |
|---|---|---|---|---|
| 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 | ★★★★★ | 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.