Benefis Senior Services - Grandview
3015 18th Ave S, Great Falls, MT 59405 · Cascade County · 48 certified beds · avg 29 residents/day · certified since Jul 10, 2024
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)
▲ Immediate jeopardy, one-off · Jun 8, 2026 · F-0686 · triggered by a complaint
The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving.
Why it matters: Bedsores are painful, can become deeply infected, and in serious cases can be life-threatening.
Severity (J): Inspectors found a situation that put a resident's life or safety in immediate danger, affecting one or a few residents. The facility must fix it immediately — these citations often come with large fines.
Corrected: Jun 8, 2026 (Deficient, Provider has date of correction)
All citations in the current public record (26)
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 |
|---|---|---|
| Jun 8, 2026 | ▲ J · Immediate jeopardy, one-off | The facility did not provide proper care for pressure ulcers (bedsores) or did not do enough to prevent new ones from forming. Bedsores develop when residents stay in one position too long without help moving. · from a complaint |
| Jun 8, 2026 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Jun 8, 2026 | 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. · from a complaint |
| Jun 8, 2026 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jun 8, 2026 | 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. · from a complaint |
| Aug 12, 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. · from a complaint |
| May 20, 2025 | E · Potential for harm, repeated | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| May 20, 2025 | E · Potential for harm, repeated | The facility did not provide safe and appropriate respiratory care — such as oxygen, breathing treatments, or care for residents on breathing equipment — for residents who needed it. |
| May 20, 2025 | D · Potential for harm, one-off | The facility did not give residents proper notice about what Medicare or Medicaid covers, or about charges the resident might owe for services that aren't covered. |
| May 20, 2025 | D · Potential for harm, one-off | The facility gave residents unnecessary mind-altering (psychotropic) medications, or used drugs in a way that restrained residents by dulling their ability to think, move, or function. |
| May 20, 2025 | D · Potential for harm, one-off | The facility did not provide required paperwork or notices about a resident's needs, their right to appeal a transfer or discharge, or the facility's bed-hold policy (how long a bed is saved during a hospital stay). |
| May 20, 2025 | D · Potential for harm, one-off | The facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. |
| May 20, 2025 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| May 20, 2025 | D · Potential for harm, one-off | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Oct 2, 2024 | E · Potential for harm, repeated | The facility did not honor residents' individual preferences, choices, values, and beliefs in their daily life and care. · from a complaint |
| Oct 2, 2024 | D · Potential for harm, one-off | The facility did not properly prepare residents for a safe transfer or discharge. Before a resident leaves, the facility must get them ready and make sure the move is safe and orderly. · from a complaint |
| Jun 20, 2024 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Jun 20, 2024 | E · Potential for harm, repeated | 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. |
| Jun 20, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Jun 20, 2024 | E · Potential for harm, repeated | 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. |
| Jun 20, 2024 | 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. |
| Jun 20, 2024 | D · Potential for harm, one-off | The facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. |
| Jun 20, 2024 | D · Potential for harm, one-off | The facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. |
| Jun 20, 2024 | 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. |
| Jun 20, 2024 | D · Potential for harm, one-off | The facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist. |
| Jun 20, 2024 | D · Potential for harm, one-off | The facility did not develop and follow policies and procedures for offering residents flu and pneumonia vaccinations. |
Inspection trend by year
Citations from standard inspections decreased between the last two inspection cycles (8 → 5).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2024 | 12 | 0 | F |
| 2025 | 9 | 0 | E |
| 2026 | 5 | 1 | J ▲ |
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 $48,323.
| Date | Type | Amount / length |
|---|---|---|
| Jun 8, 2026 | Fine | $48,323 |
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | Montana avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 4.66 | 4.82 | 3.95 | top 45% in Montana; top 19% in the U.S. |
| Registered Nurse hours | 1.94 | 1.17 | 0.69 | top 9% in Montana; top 2% in the U.S. |
| Weekend total nurse staffing | 4.57 | 4.26 | 3.50 | top 33% in Montana; top 11% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 1.66 | 0.71 | 0.48 | top 5% in Montana; top 1% in the U.S. |
| Total nursing staff turnover (%) | 0.0 | 54.8 | 45.8 | — |
| RN turnover (%) | 0.0 | 48.3 | 42.9 | — |
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 4.30, RN 1.79, weekend 4.22. Staffing rating: 4/5.
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: 2/5 · short-stay residents: 3/5
Who owns this facility
Non profit - Corporation
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Baker, Jeffrey | Individual | Corporate Director | NOT APPLICABLE | 08/01/2018 |
| Benefis Health System, INC. | Organization | Operational/Managerial Control | NOT APPLICABLE | 07/16/2008 |
| Borland, Judy | Individual | Corporate Director | NOT APPLICABLE | 03/01/2012 |
| Ehlinger, Forrest | Individual | W-2 Managing Employee | NOT APPLICABLE | 06/03/2014 |
| Ehlinger, Forrest | Individual | Corporate Officer | NOT APPLICABLE | 06/03/2014 |
| Ferrin, William | Individual | Corporate Director | NOT APPLICABLE | 10/01/2008 |
| Goodnow, John | Individual | W-2 Managing Employee | NOT APPLICABLE | 12/02/2002 |
| Goodnow, John | Individual | Corporate Officer | NOT APPLICABLE | 12/02/2002 |
| Harris, Patricia | Individual | W-2 Managing Employee | NOT APPLICABLE | 06/18/2012 |
| Hill, Kathy | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/11/2015 |
| Houlihan, Bruce | Individual | W-2 Managing Employee | NOT APPLICABLE | 11/30/2015 |
| Houlihan, Bruce | Individual | Corporate Officer | NOT APPLICABLE | 01/09/2022 |
| Jones, Llewelyn | Individual | Corporate Director | NOT APPLICABLE | 06/01/2016 |
| Lacey, Tammy | Individual | Corporate Director | NOT APPLICABLE | 08/01/2018 |
| Loucks, Brian | Individual | Corporate Director | NOT APPLICABLE | 05/01/2012 |
| Margaris, Melchisedek | Individual | Corporate Director | NOT APPLICABLE | 06/01/2015 |
| Richards, Phillip | Individual | Corporate Director | NOT APPLICABLE | 01/01/2015 |
| Rose, Marilyn | Individual | Corporate Director | NOT APPLICABLE | 10/01/2008 |
| Tierney, Gregory | Individual | W-2 Managing Employee | NOT APPLICABLE | 01/01/2021 |
| Tierney, Gregory | Individual | Corporate Officer | NOT APPLICABLE | 01/01/2021 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "How do you prevent bedsores for residents who can't move themselves, and how often are at-risk residents repositioned?"
- "How do you explain health changes and treatment options to residents and their families?"
- "When abuse or theft is suspected, who do you notify, how fast, and how do you inform the family?"
- "What does the care plan for a brand-new resident cover in the first 48 hours, and who writes it?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "How many residents here use oxygen or breathing equipment, and who checks that equipment each shift?"
- "Before any service that isn't covered by Medicare or Medicaid, how will you notify us and get our agreement?"
- "What percentage of your residents are on antipsychotic or sedating medications, and how do you work to reduce that?"
- "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 |
|---|---|---|---|---|---|
| Benefis Senior Services - Eastview | 0.3 mi | Great Falls, MT | ★★☆☆☆ | 2/5 | abuse |
| Park Place Transitional Care and Rehabilitation | 0.5 mi | Great Falls, MT | ★★☆☆☆ | 2/5 | |
| Benefis Senior Services - Westview | 1.9 mi | Great Falls, MT | ★☆☆☆☆ | 2/5 | abuse |
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Facility data as of CMS processing date 2026-08-01. CCN 275157.