Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
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 Benefis Senior Services - Grandview during CMS and state inspections, most recent first.
A staff member did not perform hand hygiene before donning gloves and failed to disinfect a handheld glucometer between uses while conducting blood glucose monitoring for two residents. The device was placed on various surfaces and returned to storage without cleaning, contrary to facility policy and staff knowledge.
Three residents were admitted and began receiving care, including oxygen therapy and, in one case, urinary catheter care and extensive ADL assistance, but their baseline care plans did not include necessary problems, goals, or interventions for these needs. Staff interviews confirmed that baseline care plans were not always comprehensive, omitting key information required for effective and person-centered care.
Surveyors found that several residents received oxygen therapy without provider orders specifying the delivery rate, and there was no consistent documentation or labeling of when oxygen tubing was last changed. Additionally, a nebulizer machine and mouthpiece were observed on the floor next to a trash can, with the mouthpiece touching the floor and covered with used tissues, indicating a lapse in infection control practices.
A resident who received Medicare Part A skilled services was not given the required SNF Beneficiary Notification (CMS-10055) upon discharge from skilled care. Staff confirmed the form was not completed and could not provide a reason for the omission, and facility records did not show evidence that the notification was provided.
The facility did not ensure that PRN psychotropic medication orders were limited to 14 days or had documented rationale for extended use. Two residents had PRN orders for alprazolam and lorazepam that lacked appropriate stop dates or exceeded the 14-day limit, with staff acknowledging the oversight and expressing uncertainty regarding hospice care exceptions.
A resident and their representative were not given written notification of the facility's bed hold policy when the resident was transferred to the hospital, as confirmed by staff and a review of facility policy.
Two residents receiving oxygen therapy did not have this intervention addressed in their care plans, and one resident with a recent aspiration event and documented swallowing difficulties lacked care plan interventions for aspiration risk. Staff confirmed these omissions, despite the needs being identified in MDS assessments.
Two residents experienced multiple falls, but their care plans were not updated to reflect the incidents or to include new interventions based on root cause analysis. Despite established processes for event reporting and fall committee review, care plans remained unchanged after each fall, leaving interventions outdated.
A staff member was observed preparing multiple residents' breakfast trays in the kitchen while wearing a hairnet but not a beard net, despite having facial hair that required coverage according to facility policy. The staff member and other employees confirmed that a beard net should have been worn during food preparation.
The facility failed to respond to call lights in a timely manner for three residents, with documented wait times significantly exceeding the expected seven to nine minutes. One resident reported waiting up to 20 minutes, while another experienced a two-hour delay. A third resident, after waiting over 45 minutes, attempted to move without assistance, resulting in a fall. These delays indicate a failure in the facility's response system.
A resident was discharged from an LTC facility without meeting rehabilitation goals and without necessary home health services in place. The resident, who had a wound/fistula and required multiple medications, was sent home alone, leading to safety concerns and potential medication errors. The facility failed to ensure that physical therapy, occupational therapy, and skilled nursing services were arranged prior to discharge, resulting in a deficiency in the discharge process.
Failure to Follow Infection Control Protocols During Blood Glucose Monitoring
Penalty
Summary
Staff member C failed to follow proper infection control practices during blood glucose monitoring for two residents. Specifically, staff member C did not perform hand hygiene before donning gloves prior to testing a resident's blood glucose. After completing the blood glucose monitoring, staff member C placed the handheld glucometer on various surfaces, including a supply cart and the medication cart, without cleaning or sanitizing the device between uses or after use. The glucometer was then returned to the locked supply room and placed on the charger without being disinfected. Interviews with staff members confirmed that the facility's policy requires the glucometer to be disinfected with appropriate wipes between each resident use and after the last use before returning it to the charger. Staff also acknowledged that hand hygiene should be performed before donning gloves and after glove removal. Despite this, staff member C did not adhere to these protocols, as observed and confirmed during interviews. The facility's policy, last revised in February 2024, clearly outlines these infection prevention requirements.
Failure to Include Essential Needs in Baseline Care Plans
Penalty
Summary
The facility failed to develop and implement baseline care plans that included the minimum necessary instructions to provide effective and person-centered care for three of seventeen sampled residents. Specifically, observations revealed that multiple residents were receiving oxygen therapy, but their baseline care plans did not address problems, goals, or interventions related to oxygen use. One resident, who also had a urinary catheter due to urinary retention and required extensive assistance with activities of daily living (ADLs) because of a cancer diagnosis, did not have these needs reflected in the baseline care plan. Interviews with staff confirmed that baseline care plans were initiated at admission but did not consistently include all required information for continuity of care. Staff acknowledged that areas such as ADLs, pain, urinary issues, falls, psychotropic medications, and oxygen therapy should be included, but these were sometimes omitted. Additionally, staff noted that some aspects of the computer system used for care plan entry needed to be addressed to ensure thorough completion of baseline care plans.
Deficient Respiratory Care: Incomplete Oxygen Orders, Poor Tubing Documentation, and Infection Control Lapses
Penalty
Summary
The facility failed to ensure that oxygen therapy orders for several residents included a specific rate of oxygen delivery. Observations revealed that multiple residents were receiving oxygen via nasal cannula, but their provider orders only specified to maintain oxygen saturation above a certain percentage, without indicating the exact flow rate. In some cases, contradictory orders were present, and staff interviews confirmed that orders often lacked a defined rate, especially when transferred from hospital records. This omission was noted for four residents, with staff acknowledging the issue and attributing it to the electronic medical record systems used. Additionally, the facility did not maintain proper documentation or labeling to indicate when oxygen tubing was last changed for several residents. During observations, none of the oxygen tubing in use had visible dates or labels showing the last change, despite facility policy requiring weekly changes and documentation. Staff interviews revealed uncertainty about where or if tubing changes were documented, and it was noted that a recent staffing mix-up may have contributed to the lack of labeling. A whiteboard in the nurse's lounge outlined the process, but this was not consistently followed in practice. Furthermore, infection control practices were not adhered to regarding respiratory equipment. One resident's nebulizer machine and mouthpiece were observed on the carpeted floor next to a trash receptacle, with the mouthpiece touching the floor and covered with used tissues. Staff confirmed that this did not meet infection control standards and acknowledged that the resident was unlikely to have placed the equipment there independently. The resident had a current order for nebulized albuterol four times daily, indicating frequent use of the equipment.
Failure to Provide Required SNF Beneficiary Notification for Medicare Services
Penalty
Summary
The facility failed to provide the required Skilled Nursing Facility (SNF) Beneficiary Notification, Form CMS-10055, to one of three sampled residents who received Medicare Part A skilled services. During an interview, a staff member confirmed that the notification form was not completed when the resident was discharged from skilled care services and was unable to explain the omission. Review of facility records showed the resident's Medicare Part A skilled services began on 4/10/25 and ended on 5/12/25, but there was no evidence that the required notification form was provided to the resident.
Failure to Limit PRN Psychotropic Medication Orders to 14 Days
Penalty
Summary
The facility failed to ensure that psychotropic medications prescribed on an as-needed (PRN) basis were limited to 14 days unless there was documented rationale for continued use in the medical record. For one resident, an order for alprazolam 0.25 mg to be given nightly as needed did not include a stop date or a 14-day limitation. Staff confirmed that such orders should have a stop date. For another resident on hospice, there were two active PRN orders for lorazepam with a one-year end date, both exceeding the 14-day limit without documented justification in the medical record. Staff indicated uncertainty about the appropriateness of longer PRN orders for hospice residents.
Failure to Provide Written Bed Hold Policy Notification During Hospital Transfer
Penalty
Summary
The facility failed to provide written notification of its bed hold policy to a resident and/or the resident's representative when the resident was transferred to the hospital. During an interview, a staff member confirmed that there was no documentation of the required notification for this hospitalization. Review of the facility's own policy indicated that written notification of the room hold policy is required for residents and/or their representatives.
Failure to Include Oxygen Therapy and Aspiration Risk in Care Plans
Penalty
Summary
The facility failed to develop and implement a person-centered comprehensive care plan addressing all identified needs for two residents who were receiving oxygen therapy and for one resident with an increased risk of aspiration following a recent hospitalization for aspiration and respiratory failure. Observations confirmed that both residents were receiving oxygen via nasal cannula, and interviews with staff and residents revealed inconsistencies in the monitoring and supervision of meals, particularly for the resident with a history of aspiration. Documentation review showed that the Minimum Data Set (MDS) assessments for both residents indicated the use of oxygen therapy, and for one resident, documented swallowing difficulties and a history of aspiration. Despite these documented needs, the comprehensive care plans for both residents did not include problems, goals, or interventions related to oxygen therapy. Additionally, the care plan for the resident with a history of aspiration did not address the increased risk for aspiration or swallowing difficulties. Staff interviews confirmed that these care areas should have been included in the care plans, as identified by the MDS assessments.
Failure to Update Care Plans After Resident Falls
Penalty
Summary
The facility failed to update and revise care plans to reflect actual falls and implement new interventions for two residents following multiple fall incidents. For one resident, despite a documented unwitnessed fall from bed and noted impulsivity, the care plan did not include the fall event, the resident's impulsive behavior, or any new interventions post-fall. Staff interviews revealed uncertainty about the interventions in place and reliance on care plans for guidance, but the care plan remained outdated. For another resident, multiple falls were documented, including incidents where the resident was found on the floor or partially out of bed and wheelchair, with some resulting in injuries. Although the facility had a process for event reporting and a fall committee that met regularly, the resident's care plan was not updated with new interventions after each fall to address the root causes. The care plan only reflected interventions implemented shortly after admission, with no subsequent updates following the documented falls.
Failure to Use Beard Net During Food Preparation
Penalty
Summary
A staff member was observed preparing four individual residents' breakfast trays in the kitchen area while wearing a hairnet but not a beard net, despite having facial hair. During interviews, the staff member acknowledged that a beard net should have been worn, and other staff confirmed that both a hairnet and beard net are required when preparing food if indicated. Review of the facility's Food & Nutrition Services Dress Code policy confirmed that facial hair longer than 1/4 inch must be restrained with a facial hair covering while in food service areas. This lapse in following established sanitary hygiene practices was directly observed during food preparation.
Delayed Call Light Response and Resident Fall
Penalty
Summary
The facility failed to ensure that call lights were answered in an appropriate timeframe for three residents, leading to significant delays in response times. Resident #10 reported waiting up to 20 minutes for assistance, particularly during shift changes or after 6:00 p.m., and noted that staff would sometimes turn off the call light without addressing all her needs. The facility's call history confirmed that eight out of fifteen call light uses for this resident exceeded 15 minutes, with some waits extending up to an hour. Resident #6 also experienced prolonged wait times, with 13 out of 14 call light uses exceeding 15 minutes, including one instance of a two-hour wait. Resident #5 reported waiting over 45 minutes for assistance, and in one instance, attempted to get up without staff help, resulting in a fall. The call history for this resident showed multiple instances of extended wait times, including a 59-minute wait. The facility's expectation for call lights to be answered was stated to be seven to nine minutes, as per staff member A. However, the documented wait times for the residents significantly exceeded this expectation, indicating a failure in the facility's response system. The delays in responding to call lights not only compromised the residents' ability to have their needs met promptly but also contributed to a fall incident for one resident who attempted to move without assistance due to the prolonged wait.
Failure to Ensure Safe Discharge for Resident
Penalty
Summary
The facility failed to provide a safe and orderly discharge for a resident who was sent home alone without meeting his rehabilitation goals. The resident had a wound/fistula, required multiple medications, and needed ongoing rehabilitation services. Despite these needs, the resident was discharged without the necessary home health services in place, increasing the risk of a poor outcome and safety concerns due to his inability to care for himself. Interviews revealed that the resident was discharged without home health services, physical therapy, or occupational therapy being initiated. The family, who lived nearby but were not planning to provide full-time care, had not seen any home health services since the discharge. The resident struggled with mobility, requiring assistance to reach his apartment, and was unable to manage his medications, leading to concerns about potential medication errors. The facility staff member responsible for setting up these services did not follow up to ensure they were in place, and the family was left without support until a scheduled appointment with a new primary care provider. The resident's discharge paperwork lacked instructions for wound care or fistula management, and he had not met several occupational and physical therapy goals necessary for a safe return home. The resident expressed that he did not feel prepared for discharge, and the facility's failure to ensure necessary services were in place prior to discharge put him at risk for negative outcomes. The facility's actions and inactions led to a deficiency in providing a safe discharge process for the resident.
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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 Great Falls
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Benefis Senior Services - Eastview | 0.3 mi | ★★★★★ | 6 | 0 |
| Park Place Transitional Care And Rehabilitation | 0.5 mi | ★★★★★ | 12 | 0 |
| Benefis Senior Services - Westview | 1.9 mi | ★★★★★ | 0 | 0 |
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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.