Benedictine Living Center Of Garrison

F-F600 is considered past non-compliance. The facility implemented corrective actions.

* The IDT met after each incident to problem solve and implement changes

* Policies were reviewed to make sure they were followed

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 10 355064 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355064 B. Wing 07/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Benedictine Living Center of Garrison 609 4th Ave NE Garrison, ND 58540

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0600 * Providers and resident representatives were notified

Level of Harm - Minimal harm or * Group staff education was completed as well as 1 to 1 staff education specific to redirecting and interacting potential for actual harm with residents' with behaviors

Residents Affected - Some 46259

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 10 355064 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355064 B. Wing 07/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Benedictine Living Center of Garrison 609 4th Ave NE Garrison, ND 58540

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 46259

Residents Affected - Few Based on record review, review of facility policy, and staff interview the facility failed to report incidents of resident-to-resident abuse to the State Survey Agency (SSA) for 2 of 3 sampled residents (Resident #24 and #51) and 1 supplemental resident (Resident #31). Failure to report resident-to-resident abuse allegations and

the results of the facility's investigation to the SSA placed all residents at risk for possible abuse.

Findings include:

Review of the facility policy titled, Abuse Prevention Plan occurred on 07/24/24. This undated policy stated, . All events will be investigated whether they cause injury or harm or no injury or harm. Events may include, but are not limited to, . resident to resident altercations [a resident to resident altercation is an incident involving a resident who willfully inflicts injury upon another resident. 'Willful' means the individual must have acted deliberately, not that the individual must have intended to inflict injury or harm], . If the event that caused suspicion involves abuse or results in serious bodily injury, the individual is to report the suspicion to

the state immediately, but not later than 2 hours after forming the suspicion. If the event does not involve abuse and does not result in bodily injury, the individual is required to report to the state no later than 24 hours after forming the suspicion.

- Review of Resident #24's medical record occurred on all days of survey. Diagnoses included psychotic disorder, schizoaffective disorder, major depressive disorder, and Alzheimer's disease.

A progress note dated 06/13/24 at 10:16 a.m., stated, at 8pm last night, neighbor [Resident #24] was at [another resident] room, she started kicking him and punch him like 3-4 times while he was checking the O2 [oxygen] tubing that was tangled at [Resident #24's] wheelchair. [The other resident] then held her hand and told her to go, by the time CNA [certified nurse aide] seen her in his room and moved her back to her apartment. no injury noted, nor [sic] neighbor reported any pain, although she has known dementia [sic] and cannot recall what happened last night. neighbor to neighbor incident documentation done, POA [Power of Attorney] was notified.

-Review of Resident #31's medical record occurred on 07/23/24. Diagnoses included bipolar disorder, current episode manic severe with psychotic features, primary insomnia, and other drug induced secondary parkinsonism.

A progress note dated 06/08/24 at 3:02 p.m., stated, At 1:30pm, one neighbor reported to CNA that somebody slapped him, this morning the same CNA overheard a conversation of [Resident #31] that she slapped him telling at story to [another resident] about it. When [Resident #31] confronted about it, then she admitted that this [sic] happened this morning around 6-6:30 am. She verbalized that [Resident #51] was all over her face following her from nook to chapel and she was annoyed and suddenly slapped him, cannot remember if once or 2 times. She verbalized she just got up and didn't sleep well, then upon realizing what happened, she then started avoiding him.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 10 355064 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355064 B. Wing 07/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Benedictine Living Center of Garrison 609 4th Ave NE Garrison, ND 58540

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 - Review of Resident #51's medical record occurred on all days of survey. The MDS, dated [DATE REDACTED], showed Resident #51 unable to complete the BIMS interview. The care plan stated Problem. Behavior: I may show Level of Harm - Minimal harm or fluctuations in behavior r/t [related to] Korsakoff's syndrome [brain changes due to prolonged alcohol potential for actual harm consumption] .

Residents Affected - Few Resident #51's progress notes showed the following:

* 06/22/24 at 3:36 p.m. Neighbor was reported by the homemaker in Sunflower area that he hit [another resident], while the [Resident #51] is walking down the hallway at 2:25pm he hit him in [sic] the top of the head and cussed him.

* 07/15/24 at 8:00 p.m. [Recorded as Late Entry on 07/16/2024 12:34 AM] [Resident #51] had gotten upset about something said to him by a male neighbor. He was moved away from that neighbor. A female neighbor was mad and put her fists up towards [Resident #51's] face. This triggered [Resident #51] to slap her across

the left side of her face. Neighbors were again moved away from each other. CNA was able to redirect [Resident #51] to another area.

The facility lacked evidence the above incidents were reported to the administrator and the SSA.

During an interview on 07/23/24 at 11:45 a.m., an administrative staff member (#1) confirmed the resident-to- resident incidents had not been reported to the SSA.

13101

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 10 355064 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355064 B. Wing 07/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Benedictine Living Center of Garrison 609 4th Ave NE Garrison, ND 58540

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 Ensure services provided by the nursing facility meet professional standards of quality.

Level of Harm - Minimal harm or 40489 potential for actual harm Based on observation, record review, review of manufacturer's instructions for use, and staff interview the Residents Affected - Few facility failed to ensure staff followed standards of practice for 3 of 4 residents (Resident #6, #23, and #40) observed during administration of rapid acting insulin. Failure to administer rapid acting insulin within the time specified by the manufacturer may result in a hypoglycemic (low blood sugar) reaction.

Findings include:

Prescribing information for Humalog insulin (a raid acting insulin), found at https://www.humalog.com, occurred on 07/24/24 and stated, Administer HUMALOG . within 15 minutes before a meal or immediately

after a meal.

Important safety information for NovoLog (a rapid acting insulin), found at novolog.com, occurred on 07/24/24 and stated, Novolog starts acting fast. Eat a meal within 5 to 10 minutes after taking it.

- Review of Resident #6's medical record occurred on all days of survey. Current physician's order included, Novolog insulin; 20 units with meals three times a day.

Observations on 07/22/24 showed the following:

* 3:38 p.m., a nurse (#2) prepared and administered 20 units of Novolog insulin to Resident #6.

*4:50 p.m., Resident #6 received the evening meal. (One hour and 12 minutes after receiving a rapid acting insulin)

- Review of Resident #23's medical record occurred on all days of survey. Current physician's order included, Humalog insulin; give 8 units three times a day and sliding scale insulin based on the resident's blood glucose level.

Observations on 07/22/24 showed the following:

* 4:04 p.m., a nurse (#2) prepared and administered 20 units of Humalog insulin to Resident #23.

*4:33 p.m., Resident #23 received the evening meal. (29 minutes after receiving a rapid acting insulin)

- Review of Resident #40's medical record occurred on 07/24/24. Current physician's order included, Novolog insulin; 2 units and sliding scale insulin based on the resident's blood glucose level.

Observations on 07/23/24 showed the following:

* 8:43 a.m., a nurse (#3) prepared and administered 2 units of Novolog insulin to Resident #40.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 10 355064 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355064 B. Wing 07/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Benedictine Living Center of Garrison 609 4th Ave NE Garrison, ND 58540

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0658 * 9:11 a.m., Resident #40 received the morning meal. (28 minutes after receiving a rapid acting insulin)

Level of Harm - Minimal harm or The facility failed to follow prescribing instructions for fast-acting insulin related to timing and meals for potential for actual harm Resident #6, #23, and #40.

Residents Affected - Few During an interview on 07/24/24 at 10:40 a.m., an administrative nurse (#5) confirmed she expected staff to follow the manufacture's guidelines for administering rapid acting insulin

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 10 355064 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 355064 B. Wing 07/24/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Benedictine Living Center of Garrison 609 4th Ave NE Garrison, ND 58540

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or 40489 potential for actual harm Based on observation, review of professional reference, and staff interview, the facility failed to ensure a Residents Affected - Few medication error rate of less than five percent for 2 of 4 residents (Resident #20 and Resident #40) observed

during medication administration. Four medication errors occurred during staff administration of 32 medications, resulting in a 12.5 percent error rate. Failure to properly prepare medications may result in residents receiving an ineffective dose and experiencing adverse reactions.

Findings include:

Review of the prescribing information for NovoLog insulin, found at www.novo-pi.com/novolog.pdf, occurred

on 07/24/24, and stated, Instructions for use . C. Pull off the big outer needle cap . E. Turn the dose selector to select 2 units. F. Hold your NovoLog FlexPen with the needle pointing up. G. Keep the needle pointing upwards, press the push-button all the way in. The dose selector returns to zero.

- Observation of medication administration on 07/23/24 at 8:43 a.m. showed a nurse (#3) prepared a Lantus (long-acting) insulin pen and a Novolog (rapid-acting) insulin pen for Resident #40. The nurse attached a needle and with the cap on, dialed each pen to two units to prime the insulin pen. The nurse (#3) failed to remove the cap prior to priming the insulin pen.

- Observation of medication administration on 07/23/24 at 9:00 a.m. showed a nurse (#4) prepared a Lantus (long-acting) insulin pen and a Novolog (rapid-acting) insulin pen for Resident #20. The nurse attached a needle, removed the cap, dialed each pen to two units, and held each pen pointed down to prime the insulin pen. The nurse (#4) failed to prime the insulin pen with the needle pointing upward.

During an interview on 07/24/24 at 10:40 a.m., an administrative nurse (#5) stated she expects staff to prime

the insulin pens with the cap off and with the needle pointing upwards.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 10 355064