Cycle 1
Health 2025-02-27 · Fire 2025-02-27
7 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Garrison, ND
Garrison Mem Hosp Nsg Fac
2-star overall rating with 2-star inspections with 7 recent health deficiencies
407 3rd Ave Se, Garrison, ND
(701) 463-2275
Overall
2 / 5
CMS overall stars
Health inspections
2 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
3 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
26
Certified beds
Average residents
17
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Commonspirit Health
Operator or chain grouping
Approved since
1992-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
19 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Hospital-based
Yes
CMS reports the provider resides in a hospital
Staffing
Hours and turnover
RN hours / resident day
2.24
Registered nurse staffing · state 0.93 · national 0.68
LPN hours / resident day
0.25
Licensed practical nurse staffing · state 0.50 · national 0.87
Aide hours / resident day
3.29
Nurse aide staffing · state 2.99 · national 2.35
Total nurse hours
5.79
All reported nurse hours · state 4.41 · national 3.89
Licensed hours
2.50
RN + LPN hours · state 1.42 · national 1.54
Weekend hours
4.86
Weekend nurse staffing · state 3.75 · national 3.43
Weekend RN hours
1.67
Weekend registered nurse coverage · state 0.59 · national 0.47
Physical therapist
0.02
Reported PT staffing · state 0.04 · national 0.07
Adjusted RN hours
2.40
CMS adjusted RN staffing hours
Adjusted total hours
6.20
CMS adjusted total nurse staffing hours
Case-mix index
1.28
Higher values indicate more complex resident acuity
RN turnover
0%
Annual RN turnover
Total nurse turnover
0%
Annual nurse turnover
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | Not Available |
10.72%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Discharge to community | Not Available |
50.57%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Medicare spending per beneficiary | Not Available |
1.02
|
No data were submitted for this measure. |
| Drug regimen review with follow-up | Not Available |
95.27%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Falls with major injury | Not Available |
0.77%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge self-care score | Not Available |
53.69%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Discharge mobility score | Not Available |
50.94%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Pressure ulcers or injuries, new or worsened | Not Available |
2.29%
|
Numerator Not Available · Denominator Not Available · Adjusted rate Not Available · No data were submitted for this measure. |
| Healthcare-associated infections requiring hospitalization | Not Available |
7.12%
|
Not Available · Eligible stays Not Available · Observed rate Not Available · Lower 95% interval Not Available · No data were submitted for this measure. |
| Staff COVID-19 vaccination coverage | 1.1% |
8.2%
7.1 pts worse
|
Numerator 1 · Denominator 91 |
| Staff flu vaccination coverage | 93.27% |
42%
51.3 pts better
|
Numerator 97 · Denominator 104 |
| Discharge function score | Not Available |
56.45%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator Not Available · No data were submitted for this measure. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 88.4% |
98.3%
9.9 pts worse
|
93.4%
5 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 88.4% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 4.3% |
5.1%
0.8 pts better
|
3.3%
1 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 4.3% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 3.2% |
4.4%
1.2 pts better
|
11.4%
8.2 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 3.2% |
| Percentage of long-stay residents who lose too much weight | 6.2% |
5.5%
0.7 pts worse
|
5.4%
0.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 6.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.9% |
17.4%
0.5 pts better
|
19.6%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 16.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 11.8% |
23.4%
11.6 pts better
|
16.7%
4.9 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 11.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 24.5% |
19.0%
5.5 pts worse
|
16.3%
8.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 24.5% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 18.3% |
20.1%
1.8 pts better
|
14.9%
3.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 18.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
1.8%
1.8 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.0% |
3.1%
3.1 pts better
|
1.7%
1.7 pts better
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 29.8% |
25.2%
4.6 pts worse
|
19.8%
10 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.8% |
| Percentage of long-stay residents with pressure ulcers | 5.3% |
5.3%
About the same
|
5.1%
0.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 5.3% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2023-12-20 · Fire 2023-12-20
8 health deficiencies
Top issue: Resident Rights (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2022-11-30 · Fire 2022-11-30
8 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2025-02-27
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2025-03-28
E · Potential for more than minimal harm
2025-02-27
F865 · Administration Deficiencies
Health
Have a plan that describes the process for conducting QAPI and QAA activities.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-27
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-27
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-27
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-27
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2025-03-28
D · Potential for more than minimal harm
2025-02-27
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2025-03-28
F · Potential for more than minimal harm
2023-12-20
F727 · Nursing and Physician Services Deficiencies
Health
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Corrected 2024-01-29
F · Potential for more than minimal harm
2023-12-20
F801 · Nutrition and Dietary Deficiencies
Health
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-12-20
F554 · Resident Rights Deficiencies
Health
Allow residents to self-administer drugs if determined clinically appropriate.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-12-20
F583 · Resident Rights Deficiencies
Health
Keep residents' personal and medical records private and confidential.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-12-20
F625 · Resident Rights Deficiencies
Health
Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-12-20
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-12-20
F759 · Pharmacy Service Deficiencies
Health
Ensure medication error rates are not 5 percent or greater.
Corrected 2024-01-29
D · Potential for more than minimal harm
2023-12-20
F849 · Administration Deficiencies
Health
Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.
Corrected 2024-01-29
D · Potential for more than minimal harm
2022-11-30
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-11-30
F658 · Resident Assessment and Care Planning Deficiencies
Health
Ensure services provided by the nursing facility meet professional standards of quality.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-11-30
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-11-30
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-11-30
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-11-30
F726 · Nursing and Physician Services Deficiencies
Health
Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-11-30
F732 · Nursing and Physician Services Deficiencies
Health
Post nurse staffing information every day.
Corrected 2023-01-04
D · Potential for more than minimal harm
2022-11-30
F758 · Pharmacy Service Deficiencies
Health
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Corrected 2023-01-04
Penalties and ownership
What sits behind the stars
Ownership
Commonspirit Health
5% Or Greater Direct Ownership Interest · Organization
Bopp, Timothy
Corporate Director · Individual
Dahmen, Kevin
Corporate Director · Individual
Garrison Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Giese, John
Corporate Director · Individual
Hyder, Syed Shiraz
Corporate Director · Individual
Kuiper, Evert
Corporate Director · Individual
Kunze, Nicole
Corporate Director · Individual
Lefor, Michael
Corporate Officer · Individual
Miller, Nancy
Corporate Director · Individual
Mongeon, John
Corporate Director · Individual
Preszler, Todd
Corporate Director · Individual
Reyman, Reed
Operational/Managerial Control · Individual
Reyman, Reed
Corporate Officer · Individual
St Alexius Medical Center
5% Or Greater Direct Ownership Interest · Organization
Weisbeck, Mike
Corporate Director · Individual
Nearby options
Other facilities in reach
#1
Benedictine Living Center Of Garrison
Garrison, ND
2-star overall rating with 3-star inspections with $8,278 in total fines with 4 recent health deficiencies
#2
Knife River Care Center
Beulah, ND
3-star overall rating with 2-star inspections with $35,890 in total fines with 3 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Souris Valley Care Center
Velva, ND
1-star overall rating with 1-star inspections with Special Focus status with $175,053 in total fines with 9 recent health deficiencies
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