Benefis Senior Services - Grandview

In the surveyor’s words

From the most serious findings on record at Benefis Senior Services - Grandview, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Jun 8, 2026

  Based on interview and record review, the facility failed to identify, assess, measure, document, monitor, and obtain physician orders promptly for the treatment and care of an avoidable pressure ulcer, including failing to develop and implement a baseline care plan for pressure ulcer prevention. The pressure ulcer developed within ten days of the resident's admission to the facility and worsened to a Stage IV, causing the resident pain. She did not want to be repositioned and voiced not wanting to live. The resident was placed in Hospice for end-of-life care and services for 1 (#27) of 5 residents sampled for pressure injuries. […]

• No harm, potential for more than minimal, patternF655May 20, 2025

  Based on observation, interview, and record review, the facility failed to develop and implement a baseline care plan which included the minimum necessary instructions needed to provide effective and person-centered care of the resident for 3 (#s 3, 17, and 21) of 17 sampled residents. Findings include: During an observation on 5/17/25 at 3:02 p.m., resident #17 was lying in bed, receiving oxygen via nasal cannula. Review of resident #17's document titled, Baseline Care Plan, dated 4/7/25, did not include a problem, goals, or interventions for oxygen therapy. During an observation on 5/18/25 at 8:35 a.m., resident #3 was lying in bed, receiving oxygen via nasal cannula. […]

• No harm, potential for more than minimal, patternF695May 20, 2025

  Based on observation, interview, and record review, the facility failed to ensure the oxygen rate of delivery was included in the provider's oxygen orders for 4 (#s 3, 17, 78, and 129); failed to ensure a form of documentation was in place for when oxygen tubing was last changed for 5 (#s 3, 17, 21, 78, and 129); and failed to ensure proper infection control practices were adhered to for a respiratory nebulizer mask/mouthpiece for 1 (#17) of 17 sampled residents. These deficient practices had the potential to affect the correct rate of oxygen delivery and increase the risk for infections in residents with prescribed oxygen. Findings include: 1. Oxygen Orders During an observation on 5/17/25 at 3:02 p.m., resident #17 was lying in bed, receiving oxygen via nasal cannula. […]

• No harm, potential for more than minimal, patternF675Oct 2, 2024

  Based on interview and record review, the facility failed to ensure call lights were answered in an appropriate timeframe for 3 (#s 5, 6, and 10) of 4 sampled residents concerning call lights; and the facility failed to prevent falls for 1 resident (#5) requiring help after pushing the call light. This had the potential to result in more falls in the facility with those residents requiring help and pushing the call light button for assistance. Findings include: a. During an interview on 10/2/24 at 10:06 a.m., resident #10 stated she would wait the longest for her call light to be answered when it was shift change or after 6:00 p.m. Resident #10 stated she would often wait 20 minutes for her call light to be answered. […]

• No harm, potential for more than minimal, isolatedF552Jun 8, 2026

  Based on observation, interview, and record review, the facility failed to obtain informed consent to include an explanation of the risks, benefits, and alternatives before the administration of psychotropic medications for 1 (#36) of 18 sampled residents. Findings include: During an observation and interview on 6/1/26 at 2:22 p.m., resident #36 was lying in bed. Resident #36 stated she was admitted to the facility on [DATE], after she had fallen at home and fractured her hip. Resident #36 stated she had increased sleepiness and all she wanted to do right now was sleep. Resident #36 stated she had a history of depression, but was not sure if that was what was causing her sleepiness.Review of resident #36's pharmacy medication regimen review, dated 5/29/26, showed: . […]