Benedictine Living Center of Garrison
609 4th Ave NE, Garrison, ND 58540 · Mclean County · 52 certified beds · avg 49 residents/day · certified since Jul 1, 1978
Part of chain: BENEDICTINE HEALTH SYSTEM (23 facilities, chain avg rating 2.8★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★☆☆3/5 · CMS overall rating: 3/5
The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.
Most serious findings (actual harm or immediate jeopardy)
▲ Actual harm, one-off · Jun 18, 2025 · F-0689 · triggered by a complaint
The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.
Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.
Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.
Corrected: Jun 17, 2025 (Past Non-Compliance)
All citations in the current public record (14)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Jul 22, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jul 22, 2025 | D · Potential for harm, one-off | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. |
| Jun 18, 2025 | ▲ G · Actual harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Jun 5, 2025 | D · Potential for harm, one-off | The facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care. · from a complaint |
| Jul 24, 2024 | E · Potential for harm, repeated | The facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jul 24, 2024 | D · Potential for harm, one-off | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Sep 7, 2023 | E · Potential for harm, repeated | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint |
| Sep 7, 2023 | E · Potential for harm, repeated | The facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint |
| Sep 7, 2023 | D · Potential for harm, one-off | The facility did not allow residents to take their own medications when a clinical review showed they could do so safely. Residents have this right if their care team determines it's appropriate. · from a complaint |
| Sep 7, 2023 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint |
| Sep 7, 2023 | D · Potential for harm, one-off | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Sep 7, 2023 | D · Potential for harm, one-off | The facility admitted a resident without a doctor's order, or did not make sure each resident stayed under a doctor's ongoing care. · from a complaint |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (4 → 2).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2023 | 6 | 0 | E |
| 2024 | 4 | 0 | E |
| 2025 | 4 | 1 | G ▲ |
Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.
Fines and enforcement (last 3 years)
1 fine totaling $8,278.
| Date | Type | Amount / length |
|---|---|---|
| Jun 18, 2025 | Fine | $8,278 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | North Dakota avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.34 | 5.15 | 3.95 | bottom 1% in North Dakota; bottom 28% in the U.S. |
| Registered Nurse hours | 0.62 | 1.09 | 0.69 | bottom 3% in North Dakota; top 45% in the U.S. |
| Weekend total nurse staffing | 3.11 | 4.43 | 3.50 | bottom 1% in North Dakota; bottom 37% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.37 | 0.59 | 0.48 | bottom 11% in North Dakota; bottom 46% in the U.S. |
| Total nursing staff turnover (%) | 36.4 | 48.8 | 45.8 | top 23% in North Dakota; top 27% in the U.S. |
| RN turnover (%) | 55.6 | 40.3 | 42.9 | bottom 22% in North Dakota; bottom 28% in the U.S. |
Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.18, RN 0.59, weekend 2.96. Staffing rating: 3/5.
Self-reported quality measures
Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.
Quality measures rating: 3/5 · long-stay residents: 3/5 · short-stay residents: —/5
Who owns this facility
Non profit - Church related
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Benedictine Health System | Organization | 5% or Greater Indirect Ownership Interest | 100% | 06/01/1989 |
| Benedictine Living Communities INC | Organization | 5% or Greater Direct Ownership Interest | 100% | 06/01/1989 |
| Benedictine Health System | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/1989 |
| Benedictine Health System | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/1989 |
| Benedictine Living Communities INC | Organization | Operational/Managerial Control | NOT APPLICABLE | 06/01/1989 |
| Benedictine Living Communities INC | Organization | ADP of the SNF | NOT APPLICABLE | 06/01/1989 |
| Bergien, Tricia | Individual | Corporate Officer | NOT APPLICABLE | 11/17/2016 |
| Carley, Gerald | Individual | Corporate Director | NOT APPLICABLE | 01/01/2018 |
| Carley, Gerald | Individual | Individual Is an Owner, Partner or Trustee of Any ADP of the SNF | NOT APPLICABLE | 02/05/2026 |
| Dornacker, Jon | Individual | Operational/Managerial Control | NOT APPLICABLE | 09/01/2006 |
| Dornacker, Jon | Individual | ADP of the SNF | NOT APPLICABLE | 09/01/2006 |
| Foss, Scott | Individual | Operational/Managerial Control | NOT APPLICABLE | 10/01/2001 |
| Foss, Scott | Individual | ADP of the SNF | NOT APPLICABLE | 12/02/2025 |
| Glynn, Jeffrey | Individual | Corporate Director | NOT APPLICABLE | 09/01/2024 |
| Graeber, Luanna | Individual | Corporate Director | NOT APPLICABLE | 05/18/2023 |
| Greff, Kevin | Individual | Corporate Director | NOT APPLICABLE | 09/01/2018 |
| Hack, Taylar | Individual | Corporate Director | NOT APPLICABLE | 07/01/2022 |
| Kadrmas, Beverly | Individual | Corporate Director | NOT APPLICABLE | 09/01/2020 |
| Lindemann, Gene | Individual | Corporate Director | NOT APPLICABLE | 04/02/2024 |
| Rymanowski, Kevin | Individual | Corporate Officer | NOT APPLICABLE | 07/17/2000 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How do you record and honor each resident's treatment wishes and advance directives, and how do staff know about them?"
- "Tell me about this abuse or neglect citation — what happened, and what specific changes did you make afterward?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What is your current medication error rate, and what have you changed to bring errors down?"
- "Who completes resident assessments here, and how do you check them for accuracy?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Garrison Mem Hosp Nsg Fac | 0.5 mi | Garrison, ND | ★★☆☆☆ | 2/5 |
Compare this facility with the 1 closest →
Facility data as of CMS processing date 2026-08-01. CCN 355064.