Benedictine Living Community-Garrison

    609 4th Ave NE, Garrison, ND 58540
    • Independent Living
    • Assisted Living
    • Skilled Nursing

    Warm attentive family-oriented affordable care

    My mom lives here and I'm very pleased. The staff are attentive, empathetic and honest - they provide personalized care and excellent health/rehab support. Rooms are bright and clean (private and shared options), grounds tidy, and the salon is nice. The intimate dining area is welcoming and the food is acceptable; they offer activities like cards, bingo and a chapel. It feels family-oriented and is more affordable than other places we considered. Overall a warm, kind community with great staff.

    Loved one of resident
    Jul 2026

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    Amenities

    Healthcare services

    • Activities of daily living assistance
    • Assistance with bathing
    • Assistance with dressing
    • Assistance with transfers
    • Medication management
    • Mental wellness program

    Healthcare staffing

    • 12-16 hour nursing
    • 24-hour call system
    • 24-hour supervision

    Meals and dining

    • Diabetes diet
    • Meal preparation and service
    • Restaurant-style dining
    • Special dietary restrictions

    Room

    • Air-conditioning
    • Cable
    • Fully furnished
    • Housekeeping and linen services
    • Kitchenettes
    • Private bathrooms
    • Telephone
    • Wifi

    Transportation

    • Community operated transportation
    • Transportation arrangement
    • Transportation arrangement (non-medical)

    Common areas

    • Beauty salon
    • Computer center
    • Dining room
    • Fitness room
    • Gaming room
    • Garden
    • Outdoor space
    • Small library
    • Wellness center

    Community services

    • Concierge services
    • Fitness programs
    • Move-in coordination

    Activities

    • Community-sponsored activities
    • Planned day trips
    • Resident-run activities
    • Scheduled daily activities

    Reviews

    3.67·(12)

    Overall rating

    1. 5
    2. 4
    3. 3
    4. 2
    5. 1
    • Care

      2.7
    • Staff

      3.6
    • Meals

      3.5
    • Amenities

      4.0
    • Value

      4.0

    Pros

    • Clean, well‑maintained rooms and grounds
    • Friendly, welcoming and accommodating staff
    • Bright private and shared room options
    • Pleasant, intimate dining area
    • On‑site chapel
    • Regular recreational activities (cards, bingo)
    • Salon services available
    • Rehab and health‑care services on site
    • Lower cost relative to some alternatives
    • Personalized, family‑style care environment

    Cons

    • Inconsistent staffing coverage, including weekends
    • Slow response times to call‑button requests
    • Gaps in emergency‑response and escalation procedures
    • Inconsistent dementia‑specific nutritional support
    • Incontinence‑care delays
    • Limited amenity offerings compared with larger communities
    • Variable continuity of care across shifts

    Summary of reviews

    Benedictine Living Community–Garrison is described as a clean, bright facility with well‑kept grounds and an intimate interior. Reviewers frequently praise the physical environment: rooms are described as bright and the dining area as pleasant, and the campus includes an on‑site chapel and salon. The community offers basic social programming such as cards and bingo and provides on‑site rehabilitation and health services. Cost is cited as a relative advantage compared with some other local options, and several families characterized the atmosphere as family‑oriented and personalized.

    Staff descriptions are mixed. Many families and residents describe staff as kind, welcoming, upfront and accommodating; caregivers are credited with empathy and individualized attention in many accounts. However, other comments indicate variability in staffing reliability and responsiveness. Notable operational concerns center on staffing levels and response times — particularly slower call‑button responses and inconsistent coverage on weekends — which reviewers link to instances of unmet needs and frequent hospital transfers. Several reviewers flagged gaps in emergency escalation procedures and oxygen management protocols, and there are concerns following a resident's death that point to the need for clearer clinical escalation and oversight processes.

    Dining and clinical care show a similar pattern of strengths and gaps. The regular dining service is described as acceptable, and the intimate dining space is appreciated, but reviewers raised specific concerns about meeting the nutritional needs of residents with dementia. Rehabilitation and routine health care were praised by some as excellent, yet the overall pattern suggests variability in clinical follow‑through and continuity of care across shifts. Incontinence‑care delays and related sanitation concerns were mentioned and align with the broader staffing and responsiveness issues.

    Management and amenity expectations are areas for potential improvement. While some families described management as honest and upfront, the mixed experiences imply inconsistent operational execution — staffing, emergency procedures, and dementia‑specific care protocols in particular. Amenities are modest compared with larger communities, so prospective residents who prioritize an extensive activity or amenity roster should confirm availability. In summary, Benedictine Living Community–Garrison offers a clean, affordable, and personal environment with several staff members and services that families find caring; however, prospective residents should evaluate staffing patterns, emergency response procedures, and dementia‑care supports to ensure they meet the individual's needs.

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    Medicare Ratings

    3·/ 5
    • Overall

    • Health Inspection

    • Staffing

    • Quality Measures

    Ratings from the U.S. Centers for Medicare & Medicaid Services (Care Compare). View on Medicare.gov

    Location

    Map showing location of Benedictine Living Community-Garrison

    Benedictine Living Community-Garrison is located at 609 4th Ave NE, Garrison, ND, 58540.

    About Benedictine Living Community-Garrison

    Benedictine Living Community-Garrison sits in Garrison and gives older adults many ways to live, from independent senior living to assisted living, skilled nursing, rehabilitation, and memory care for dementia and Alzheimer's, so you can find lots of help in one place as needs change. The facility has 52 nursing beds and offers amenities made for comfort, like community rooms, dining choices for every meal, and spaces for activities and social events, plus the place is well kept and clean so residents can feel at home. There are care suites and special programs for veterans, with skilled nursing for qualified veterans through a VA contract, and the staff includes nurses, CNAs, dietary and therapy providers, social workers, and housekeeping teams who work together to make sure each resident has help that matches what they need, like diabetic care, incontinence help, or non-ambulatory care. They do offer spiritual care, with weekly Bible study led by the St. Paul Lutheran Church pastor, and the community focuses on choice, wellness, and independence, letting people join group activities, use puzzles, enjoy music, or watch TV with neighbors, plus there are transportation options and a gallery for events or virtual tours. They also provide adult day programs, home care, hospice, palliative care, respite care, therapy like physical or occupational, and sensory therapy, so people who want to stay active can join in what fits best. The facility stays connected to the larger Benedictine network, being a faith-based, not-for-profit group that values respect, stewardship, hospitality, and justice, with a mission carried through more than 30 communities. Memory care is specialized, with staff trained for cognitive impairments and routines that help those struggling with memory, and the bronze award from the American Health Care Association and the National Center for Assisted Living shows they've been recognized for their commitment to quality care. Living choices range from apartments with private kitchens and baths to care suites for higher needs, and folks here usually pick what works for them, whether living more independently with neighbors or needing daily help for health and daily chores. You'll find a safe, friendly environment where every resident's health, purpose, and ability to make choices is respected, and you can always see everything going on or learn more through their website at www.bhshealth.org.

    About Benedictine

    Benedictine Living Community-Garrison is managed by Benedictine.

    Benedictine, established in 1985 by the Benedictine Sisters of St. Scholastica Monastery in Duluth, Minnesota, has grown into one of the largest Catholic senior living organizations in the United States, operating over 35 communities across Minnesota, North Dakota, Wisconsin, Illinois, and Missouri. With annual revenues reaching billion, approximately 5,000 employees, and over million of senior living assets under management, this faith-based nonprofit organization has experienced significant expansion from a single skilled nursing facility to a multi-state healthcare network through strategic acquisitions, partnerships, sponsorship transitions, and joint ventures.

    Under the leadership of President and CEO Jerry Carley, who joined in 2018 bringing over 35 years of senior care experience, Benedictine has maintained its position as an industry leader while preserving its Catholic heritage and mission-driven focus. Carley's leadership has earned significant recognition, including being named to The Minnesota 500 as one of the state's most powerful executives (2018-2020) and designation as one of Minnesota's Most Influential Health Care Leaders by Minnesota Physician Magazine in 2020. His extensive background includes previous roles as president and CEO of CSJ Initiatives and service on LeadingAge Minnesota's board of directors, where he serves as Chair.

    Benedictine's innovative memory care program exemplifies their commitment to specialized care through two distinct neighborhoods: Tabitha, named after Sister Tabitha who was the first woman to head a hospital setting, which serves residents with mild to moderate memory loss, and Pauline, honoring Sister Pauline who devoted her life to dementia care, providing specialized support for those with moderate to advanced dementia. These research-based programs employ best practices in dementia care, offering engaging activities, personalized care plans, and family integration support. The organization's comprehensive service continuum extends to Adult Day Programs in Duluth and Winona, providing daytime respite care with trained memory care staff, while facilities like Benedictine Minneapolis specialize in complex medical care including tracheostomy and ventilator support.

    The organization's care philosophy centers on nurturing mind, body, and spirit, rooted in Benedictine values of Hospitality, Stewardship, Respect, and Justice. This holistic approach emphasizes listening with the "ear of the heart," creating welcoming environments where unique needs are respected and each person's spirituality is honored. Through comprehensive rehabilitation services, spiritual care programs led by Director of Spiritual Care Rev. J. Scott Cartwright, and purposeful recreation incorporating art, music therapy, and movement, Benedictine continues the healthcare ministry begun by the Benedictine Sisters over a century ago. Recent strategic decisions, including the 2024 transition of Benedictine Living Community-Wausau to The Ensign Group, demonstrate the organization's commitment to ensuring sustainable, high-quality care while adapting to evolving market dynamics and maintaining their mission of empowering older adults to live to their highest potential.

    People often ask...

    Benedictine Living Community-Garrison offers independent living, assisted living, and skilled nursing.

    There are 9 photos of Benedictine Living Community-Garrison on Mirador.

    The full address for this community is 609 4th Ave NE, Garrison, ND 58540.

    No, Benedictine Living Community-Garrison does not offer respite care. Respite care in assisted living communities provides temporary, short-term relief for primary caregivers by offering professional care for their loved ones. It allows individuals to stay in an assisted living community for a limited time, giving caregivers a break while ensuring residents receive necessary support and assistance with daily activities.

    Safety & Compliance

    In North Dakota, Health & Human Services' Health Facilities unit licenses care facilities and publishes the health and life-safety deficiencies found during inspections.

    License numberSNF-benedictine-living-center-of-garrison-garrison
    Facility typeSkilled Nursing Facility

    Inspection Reports

    44

    Reports

    7

    Type A Citations

    0

    Type B Citations

    0

    Complaints

    16

    Years

    29 Jul 2025Life Safety
    Found no deficiencies related to emergency preparedness.
    18 Jun 2025Inspection
    Investigated an incident involving a mechanical lift transfer where two-person assistance was not provided, resulting in a resident fall and injury.
    • §483.25(d)Free of Accident Hazards/Supervision/Devices
    05 Jun 2025Inspection
    Found that a resident's advance directive rights were not honored, leading to CPR despite a DNR order.
    • 42 CFR Part 489, Subpart I; 42 CFR 483.10(c)(6)(8)(g)(12)(i)-(v)Advance directives and treatment decisions
    05 Aug 2024Life Safety
    Found no deficiencies.
    24 Jul 2024Inspection
    Investigated abuse and medication procedures; found resident-to-resident abuse not consistently prevented or reported, and insulin-related medication practices not always aligned with manufacturer guidance.
    • CFR 483.12(a)(1)Freedom from Abuse, Neglect, and Exploitation
    • CFR 483.12(c)(1)Reporting of Alleged Violations
    • CFR 483.21(b)(3)(i)Comprehensive Care Plans
    • CFR 483.45(f)Medication Errors
    18 Sept 2023Life Safety
    Found deficiencies in the kitchen exhaust hood fire-extinguishing system maintenance and in monthly emergency generator testing.
    • NFPA 96; NFPA 101, 19.3.2.5.1-5; 9.2.3Cooking Facilities - Fire-extinguishing system testing/maintenance
    • NFPA 99; NFPA 110; NFPA 111Electrical Systems - Emergency generator testing/maintenance
    07 Sept 2023Inspection
    Found deficiencies in self-administered medications assessment, assessments/diagnoses coding, catheter care, transfers, physician oversight, and infection control practices.
    • 483.10(c)(7)Resident Self-Admin Meds-Clinically Approp
    • 483.20(g)Accuracy of Assessments
    • 483.21(b)(3)(i)Services Provided Meet Professional Standards
    • 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices
    • 483.30(a)(1)(2)Resident's Care Supervised by a Physician
    • 483.80(a)(1)(2)(4)(e)(f)Infection Prevention & Control
    03 Apr 2023Inspection
    Investigated a sexual assault allegation and found failures in reporting to authorities and in the investigation process. The deficiencies included not reporting within two hours, not reporting investigation results within five working days, and not conducting a thorough investigation.
    • CFRs: 483.12(b)(5)(i)(A)(B)(c)(1)(4) and 483.12(c)Reporting of Alleged Violations
    • CFRs: 483.12(c)(2)-(4)Investigate/Prevent/Correct Alleged Violation
    23 Aug 2022Life Safety
    Identified several fire and life-safety deficiencies, including occupancy separation, egress obstructions, hazardous area enclosure, smoke detection, corridor doors, and exposed wiring.
    • 19.1.3.4.1, 6.1.14.4.1, 8.3.3.1, NFPA 80Cross-corridor doors self-close/self-latch
    • 7.1.10.1, 7.3.2.2, NFPA 101Means of Egress - General
    • 19.3.2.1, 19.3.5.9Hazardous Areas - Enclosure
    • 19.3.4.5.2, 19.3.4.5.1, NFPA 72, 9.6.2.10.1Smoke Detection
    • 19.3.6.3, 19.3.6.3.5Corridor - Doors Latching
    • NFPA 70 314.28 3(c), 250.110Electrical Systems - Other
    27 Jul 2022Inspection
    Found multiple deficiencies across privacy of records, care planning, restorative nursing, falls management, wound care, psychotropic meds, infection control, and food safety.
    • CFR 483.10(h)(1)-(3)(i)(ii)Privacy and Confidentiality of Records
    • CFR 483.21(b)(1)Comprehensive Care Plans
    • CFR 483.21(b)(3)(i)Services Provided Meet Professional Standards
    • CFR 483.24(a)Activities of Daily Living (ADLs)/Maintenance of Abilities
    • CFR 483.25(b)(1)-(ii)Treatment/Services to Prevent/Heal Pressure Ulcers
    • CFR 483.45(c)(3)-(5)Free from Unnecessary Psychotropic Medications/PRN Use
    • CFR 483.60(i)(1)-(2)Food Procurement, Store/Prepare/Serve-Sanitary
    • CFR 483.80(a)-(f)Infection Prevention & Control
    26 Oct 2021Inspection
    Found no deficiencies related to COVID-19 infection control. Compliance with CMS/CDC infection control practices was confirmed.
    15 Apr 2021Inspection
    Investigated multiple deficiencies across resident care, safety, and treatment, including wandering-alarm management, timely physician communication, environment hazards, care planning, and wound/diabetes management.
    • 483.10(e)(3)Reasonable Accommodations Needs/Preferences
    • 483.10(g)(14)-(15)Notify of Changes (Injury/Decline/Room, etc.)
    • 483.10(i)Safe Environment
    • 483.21(b)(3)(i)Services Provided Meet Professional Standards
    • 483.25Quality of Care
    • 483.25(b)(1)(i)-(ii)Treatment/Svcs to Prevent/Heal Pressure Ulcer
    17 Feb 2021Life Safety
    Identified several life-safety deficiencies, including inadequate emergency lighting testing, improper kitchen fire protection, high mounting of a manual fire-extinguishing device, missing emergency call simulations in drills, and lack of GFCI protection near sinks.
    • NFPA 101 Emergency Lighting; 7.9.3.1.1Emergency Lighting
    • NFPA 96; NFPA 9.2.3; 18.3.2.5.1-5; 19.3.2.5.1; 10.5.1Cooking Facilities
    • NFPA 10; NFPA 70 6.1.3Portable Fire Extinguishers
    • NFPA 101 Fire Drills; 19.7.1.4-19.7.1.7Fire Drills
    • NFPA 70; NFPA 210.8Electrical Receptacles - GFCI
    13 Jan 2021Inspection
    Investigated a complaint; found failures in notifying a physician about a deteriorating pressure ulcer, using an improper Foley catheter size, and inadequate treatment and monitoring of a pressure ulcer.
    • CFR 483.10(g)(14)Notification of Changes
    • CFR 483.21(b)(3)(i)Comprehensive Care Plans
    • CFR 483.25(b)(1)(i)-(ii)Skin Integrity; Pressure Ulcers
    22 Dec 2020Inspection
    Investigated COVID-19 infection control and emergency preparedness and found no deficiencies.
    02 Dec 2020Inspection
    Found no deficiencies related to infection control or emergency preparedness.
    19 Aug 2020Inspection
    Verified compliance with COVID-19 infection control requirements and noted one positive resident.
    16 Mar 2020Inspection
    Found substantial compliance with infection control requirements after a focused survey conducted on 2020-03-16.
    02 Jul 2019Inspection
    Found multiple deficiencies related to medication/storage practices, resident transfer safety, chemical storage, staffing adequacy, and food storage sanitation.
    • CFR 483.21(b)(3)Comprehensive Care Plans
    • CFR 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices - Gait Belts
    • CFR 483.25(d)(1)(2)Free of Accident Hazards/Supervision/Devices - Chemical Storage
    • CFR 483.35(a)(1)(2)Sufficient Nursing Staff
    • CFR 483.60(i)Food Safety/Storage - Sanitary
    19 Jun 2019Life Safety
    Identified multiple life-safety and electrical deficiencies, including doors not self-closing on an occupancy separation wall, exit doors obscured by a mural, hazardous-area doors missing closers, non-GFCI outlets, and incomplete fire drills.
    • NFPA 101 18.1.3.4.1; 19.1.3.4.1; NFPA 80 6.1.4.3.1Occupancy separation walls; fire doors must latch
    • NFPA 101 18.2.1; 19.2.1; 7.1.10.1; 7.5.2.2Means of egress; exits not clearly recognizable/visible
    • NFPA 101 19.3.2.1Hazardous Areas - Enclosure
    • NFPA 70; 210.8; 210.8(B)(1); 210.8(B)(2); 210.8(B)(5)Utilities - Gas and Electric; GFCI protection
    • NFPA 101 19.7.1.4; 19.7.1.7Fire Drills
    19 Jul 2018Inspection
    Investigated identified multiple deficiencies across OBRA death tracking, care planning, enteral feeding safety, dialysis monitoring, controlled substances handling, medication storage, and emergency suction equipment.
    • 42 CFR §483.20(f)Encoding/Transmitting Resident Assessments
    • 42 CFR §483.21(b)(2)Care Plan Timing and Revision
    • 42 CFR §483.25(g)(4)-(5)Tube Feeding Mgmt/Restore Eating Skills
    • 42 CFR §483.25(l)Dialysis
    • 42 CFR §483.45(g)-(h)Label/Store Drugs and Biologicals
    • 42 CFR §483.90(d)(2)Essential Equipment, Safe Operating Condition
    11 Apr 2018Life Safety
    Found multiple life-safety deficiencies, including obstructed means of egress, inadequate emergency lighting, an unsecured fire alarm power source, unperformed fire alarm testing, and sprinkler system installation and maintenance gaps.
    • NFPA 101 7.2.1.4.3.1Means of Egress - General
    • NFPA 101 7.9.3.1.1Emergency Lighting
    • NFPA 70 760.41(B)Fire Alarm System - Installation
    • NFPA 72 14.4.2.2Fire Alarm System - Testing and Maintenance
    • NFPA 13 4.1, 8.15.1.2.18.1Sprinkler System - Installation
    • NFPA 25 5.3.2.1Sprinkler System - Maintenance and Testing
    03 Oct 2017Inspection
    Investigated a complaint and found failures to notify family of changes, incomplete investigations of resident-to-resident incidents, and incomplete/unclear medical records for several residents.
    • 483.10(g)(14)NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)
    • 483.12(b)DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES
    • 483.70(i)(1)(5)RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE
    25 May 2017Inspection
    Identified multiple deficiencies across resident rights notices, transfer/bed-hold procedures, abuse reporting, fall assessments, nutrition/hydration, and kitchen sanitation.
    • 42 CFR 483.10(g)(4)NOTICE OF RIGHTS, RULES, SERVICES, CHARGES
    • 42 CFR 483.10(g)(16)-(18)NOTICE OF BED-HOLD POLICY BEFORE/UPON TRANSFER
    • 42 CFR 483.12(a)(1)-(4)INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS
    • 42 CFR 483.10(e)REASONABLE ACCOMMODATION OF NEEDS/PREFERENCES
    • 42 CFR 483.21(b)(3)(i)SERVICES PROVIDED MEET PROFESSIONAL STANDARDS
    • 42 CFR 483.24; 42 CFR 483.25(k)(l)QUALITY OF LIFE; DIETARY/CONSTIPATION MANAGEMENT
    • 42 CFR 483.25(d)(1)-(3)ACCIDENT HAZARDS/SUPERVISION/DEVICES; BED RAILS
    • 42 CFR 483.25(g)(1)-(3)MAINTAIN NUTRITION STATUS
    • 42 CFR 483.25(g)(2)SUFFICIENT FLUID TO MAINTAIN HYDRATION
    • 42 CFR 483.60(i)(1)-(3)FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY
    13 Mar 2017Life Safety
    Identified that a risk assessment of building systems was not conducted or documented, creating potential fire hazards throughout the building.
    • NFPA 99, 4.1-4.2; NFPA 101, Chapter 19Building system risk assessment not conducted/documented
    31 Jan 2017Life Safety
    Inspections identified multiple fire and life safety deficiencies, including failed fire alarm and smoke detection testing, improper sprinkler head protection, damaged smoke barriers, and lack of a documented building risk assessment.
    • NFPA 72 (2010), Chapter 14 - Inspection, Testing and MaintenanceFire Alarm System - Testing and Maintenance
    • NFPA 72 (2010), Chapter 14 - Inspection, Testing and MaintenanceSmoke Detection
    • NFPA 13 (Standard for the Installation of Sprinkler Systems), 8.3.2, 8.3.2.5(1), Table 8.3.2.5(a)(2)Sprinkler System - Installation
    • NFPA 101, 19.3.7.3, 8.6.7.1(1)Subdivision of Building Spaces - Smoke Barrier Construction
    • NFPA 101, 19.3.7.6, 19.3.7.8, 19.3.7.9Subdivision of Building Spaces - Smoke Barrier Doors
    • NFPA 99, 4.1, 4.2Fundamentals - Building System Categories
    28 Dec 2016Inspection
    Investigated a complaint about changes in resident condition and medication safety; found multiple deficiencies in notifying physicians/families, fentanyl patch management, care for deteriorating residents, and timely treatment of UTIs.
    • 483.10(g)(14)Notify of Changes (Injury/Decline/Room, Etc)
    • 483.21(b)(3)(i)Services Provided Meet Professional Standards
    • 483.24, 483.25(k)(l)Provide Care/Services for Highest Well Being
    • 483.25(e)(1)-(3)No Catheter, Prevent UTI, Restore Bladder
    02 Jun 2016Inspection
    Identified multiple deficiencies in assessment accuracy, medication management, infection control, chemical storage, and nurse aide training.
    • 483.20(g)-(j)Assessment accuracy/coordination/certified
    • 483.20(k)(3)(i)Services provided meet professional standards
    • 483.25(h)Free of accident hazards/supervision/devices
    • 483.60(a),(b)Pharmaceutical services
    • 483.65Infection control
    • 483.75(e)(4)Nurse aide work < 4 months - training/competency
    09 Mar 2016Life Safety
    Identified two fire-safety deficiencies related to hazardous-area doors and exit access.
    • 19.3.2.1Hazardous areas require 1-hour fire barrier or automatic extinguishing system; doors self-closing
    • 19.2.1; 7.2.1.4.4; 7.2.1.5.1; 19.2.2.2.4; 7.2.1.6.2Exit access not readily accessible; doors with access-controlled locks lacking delayed egress
    03 Jun 2015Inspection
    Investigation found deficiencies related to resident rights and care planning, including inaccessible survey results and incomplete care planning details. Several findings showed gaps in documenting and implementing required resident care and related processes.
    • RIGHT TO SURVEY RESULTS - READILY ACCESSIBLE
    • Continued From page 2 – REASONABLE ACCOMMODATION/NEEDS/PREFERENCES
    • Continued From page 4 – RIGHT TO PARTICIPATE/CARE-REVISE PLAN
    24 Feb 2015Life Safety
    Identified multiple life-safety deficiencies involving corridor doors, wall openings, smoke detectors, ceiling tiles, and generator systems.
    • NFPA 101 LIFE SAFETY CODE STANDARDCorridor doors self-closing/automatic latching hardware
    • NFPA 101 LIFE SAFETY CODE STANDARDEast wall opening (AHU #2 room) and required patching
    • NFPA 101 LIFE SAFETY CODE STANDARDSmoke detectors
    • NFPA 101 LIFE SAFETY CODE STANDARDSmoke Detectors
    • NFPA 101 LIFE SAFETY CODE STANDARDCeiling Tiles in Dining Room
    • NFPA 101 LIFE SAFETY CODE STANDARDGenerators
    24 Feb 2015Inspection
    Investigated the complaint; found medication administration problems involving fentanyl patches, resulting in resident injuries and unsafe practices, with staffing and supervision issues identified.
    • Medications/Professional Standards
    • Resident safety and supervision
    • Staffing and medication administration practices
    28 Jul 2014Inspection
    Found deficiencies related to resident safety and nutrition assessment, plus infection control and security of stored items, with identified higher-risk residents and observed practice gaps.
    • Type AContinued From page 2
    • Type AContinued From page 4
    • Type AInfection Control: Hand Hygiene
    29 May 2014Inspection
    Identified multiple deficiencies concerning resident care and safety, including issues with medication management, hydration, sanitation, and meal-related processes.
    • Continued From page 2 – Insulin administration
    23 Apr 2014Life Safety
    Identified multiple life-safety deficiencies, including inadequate means-of-egress lighting, improperly placed smoke detectors, and missing/testing gaps for sprinkler, dampers, and emergency lighting systems.
    • NFPA 101 Life Safety Code; NFPA 13Illumination of means of egress
    • NFPA 101 Life Safety CodeIllumination of means of egress (exterior lighting) at exits
    • NFPA 101 Life Safety Code; NFPA 72Smoke detector placement and installation
    • NFPA 101 Life Safety Code; NFPA 25Maintenance of automatic sprinkler system
    • NFPA 101 Life Safety Code; NFPA 70; NFPA 72Fire dampers testing and records
    • NFPA 101 Life Safety CodeEmergency lighting and related testing
    10 Jul 2013Inspection
    Investigated a complaint about transfer/discharge notice requirements and the accuracy of resident assessments, and found multiple deficiencies.
    • Notice Requirements Before Transfer/Discharge
    • Assessment/Minimum Data Set (MDS) - Accuracy and Procedures
    • MDS Coordinator Training/In-Service
    20 Mar 2013Life Safety
    Identified multiple life-safety deficiencies during a licensing review, including construction type, corridor and exit issues, fire protection systems, and emergency power and lighting conditions.
    • Continued From page 1 construction type for a one-story health care occupancy
    • Continued From page 2 – corridor and life safety elements
    • Continued From page 3 – fire suppression systems
    • Continued From page 4 – exit and egress
    • Continued From page 5 – emergency and life safety lighting
    • Continued From page 5 – fire drills and emergency procedures
    • Continued From page 7 – egress and obstruction control
    • Continued From page 8 – generator room and electrical equipment
    • Continued From page 9 – generator and electrical safety improvements
    31 May 2012Inspection
    Found deficiencies related to assessment accuracy, care plans, MDS data, and unsafe staff practices during transfers. Several issues involved failure to maintain current care plans and accurate documentation of residents' needs.
    • Assessment accuracy/Coordination/Certified
    • Care Plans - Comprehensive
    • MDS data accuracy
    • Staff supervision/assistance during transfers
    03 Apr 2012Life Safety
    Identified life-safety deficiencies involving the building construction type, lack of an automatic sprinkler system, and inadequate corridor fire separation.
    • NFPA 101 Life Safety Code StandardLife Safety Code standard for automatic sprinkler protection
    • NFPA 101 Life Safety Code StandardCorridor wall construction and fire-resistance
    24 Aug 2011Inspection
    Found deficiencies in food service sanitation practices during a Medicare/Medicaid recertification survey, including improper glove use and dishwashing procedures.
    • FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY
    13 Jul 2011Inspection
    Investigated weight loss documentation and care planning deficiencies; weight loss was not accurately reflected in the MDS and care plans were not adequately updated.
    • Type A483.20(g)-(j)Develop Comprehensive Care Plans
    • Type A483.20(k)Develop Comprehensive Care Plans
    01 Mar 2011Life Safety
    Identified multiple life-safety and fire-protection deficiencies in a long-term care building, including inadequate fire barriers, deficient means of egress, and maintenance gaps in fire-safety systems.
    • NFPA 101 Life Safety Code; NFPA 13Life Safety Code compliance – building separation and sprinkler system
    • NFPA 101 Life Safety CodeCorridor separation by fire-resistive walls
    • NFPA 101 Life Safety CodeMeans of egress – door operation/clearances
    • NFPA 101 Life Safety CodeExit access and door hardware – egress
    • NFPA 101 Life Safety CodeMeans of egress illumination
    • NFPA 96; NFPA 101 Life Safety CodeFire suppression – cooking areas and hood inspections
    03 Jun 2010Inspection
    Investigated, found deficiencies in dementia-related resident care planning and in providing medically-related social services to address residents’ behavioral issues and potential self-harm.
    • Type AContinued From page 2: Dementia with behavioral disturbances and care planning
    • Type AContinued From page 4: Medically-related social services
    27 Jan 2010Life Safety
    Identified life-safety code deficiencies: corridors were not adequately fire‑resistant and the current construction relied on an alternative safety method.
    • NFPA 101 Life Safety Code 19.3.6.1; 19.3.6.2.1; 19.3.6.5Corridor walls fire-resistance requirements

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