Benefis Senior Services - Westview

Inspectors wroteBased on interview and record review, the facility failed to ensure there were eight consecutive (onsite) hours of registered nursing coverage provided each day, seven days a week. This failure affected all residents in the facility when an RN was not available on-site.

Inspectors wroteBased on interview and record review, the facility failed to submit two reportable events in the designated required timeline for 2 (#s 20 and 23) out of 19 sampled residents. Resident #20 had an injury of unknown origin identified on 5/24/26, and it wasn't initially reported to the State Survey Agency until 5/26/26. Resident #23 was a victim of physical abuse that occurred on 7/22/25, and it was not initially reported until 9/19/25.

Inspectors wroteBased on interview and record review, the facility failed to revise a care plan for a resident who had documented safety concerns related to leaving the facility without supervision for 1 (#40) of 21 sampled and supplemental residents. This failure resulted in the resident exiting the facility unsupervised, placing the resident at risk of harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to independently carry out activities of daily living (ADL) for self-grooming was provided assistance with removal of facial hair for 1 (#1) of 19 sampled residents. This had the increased risk of negatively affecting the residents self-esteem when in a public area.

Inspectors wroteBased on interview and record review, the facility failed to ensure social services was provided to one resident needing assistance with transitioning to a long-term care facility and managing the resident's finances for 1 (#1); and ensuring psychosocial well-being was assessed for a resident following a physical altercation for 1 (#23) of 19 sampled residents. The failure could result in undue stress for the residents related to the lack of social service assistance.

Inspectors wroteBased on observation and interview, the facility failed to ensure safe food labeling and storage in accordance with professional standards of practice. These deficient practices affected all residents receiving food services from the facility, placing all residents at risk for a foodborne illness or negative outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident was free from mental abuse by depriving a resident their rights to private visitations (see F563 & F583) and isolating the resident from social interactions for staff convenience, causing the resident to experience ongoing feelings of being dull, bored, and frustrated which resulted in the resident expressing feelings of being a prisoner, for 1 (#78) of 13 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consistently assess, measure, and monitor a resident's pressure ulcer; and failed to ensure wound dressings were provided as ordered by the physician, and failed to ensure sufficient wound documentation was completed, to prevent the progression of a worsening Stage III pressure ulcer for 1 (#75). This deficient practice had the potential to cause worsening wounds and infection for the resident; and the facility failed to ensure 1 (#7) of 13 sampled residents properly received perineal care to prevent the occurrence of a wound related to the use of an indwelling catheter.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan that reflected the care needs, and to attain or maintain the residents' highest practicable physical, mental, and psychosocial well-being, for 2 (#s 14 and 68) of 13 sampled residents, which included failing to ensure interventions were in place and documented for dialysis and dialysis related emergencies and monitoring of the resident for #14; failed to ensure interventions were in place to prevent identified elopement risks and/or review and revise interventions in place following elopements for #68.

Inspectors wroteBased on observation, interview, and record review, the facility failed to timely identify elopement risks and implement sufficient preventative interventions for a resident with repeated elopement(s), for 1 resident (#68) and the resident had severe cognitive impairments, of 13 sampled residents. There continued to be elopement hazards for this resident, and it was identified necessary staff were not aware of how to identify or classify an elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staffing contributing to a worsening pressure ulcer injury for 1 (#75), ADLs not being completed for 2 (#s 5 and 83), long call light times and low staffing concerns reported by residents for 3 (#s 13, 79 and 83), and repositioning not being completed for 3 (#s 7, 13 and 83) of 13 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, implement, and inform residents, to include 1 (#78) of 13 sampled residents, of their policy and procedure for resident visitations. This deficient practice had the potential to affect all residents and their visitors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident privacy during visits for 1 (#78); and failed to provide privacy curtain or a door for a resident's bathroom for 1 (#2) of 13 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from restraints, unless there had been a documented medical symptom, for 1 (#68) of 13 sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure pre-poured medications were given timely for 3 (#s 7, 79, and 80) of 13 sampled residents. This deficient practice had the potential to result in late medication administration, and time sensitive medications given too closely together, possibly resulting in a high half-life concentration of medication in the body.

Inspectors wroteBased on observation and interview, the facility failed to ensure basic ADLs were being completed for 2 (#s 5 and 83) of 13 sampled residents. This deficient practice had the potential to result in residents feeling unclean and unkept.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were getting turned to prevent skin breakdown throughout the day, for 3 (#s 7, 13, and 83) of 13 sampled residents. This deficient practice increased the risk of skin breakdown for any resident who did not get turned frequently enough.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who received dialysis were provided services, consistent with professional standards of practice, to include physician orders for the dialysis and appropriate nutrition and per the resident's preferences, for 1 (#14) of 13 sampled residents. The deficient practice placed the resident at risk for pre-dialysis and post-dialysis complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure prescribed medications were given for 2 (#s 7 and 79) and failed to follow physician ordered parameters for one medication, digoxin, for 1 (#80) of 13 sampled residents. The facility's medication error rate was calculated at nine percent. This deficient practice had the potential to cause harm for a resident if their pulse was too low and the medication was given, or if the medications were not given at all.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a referral for an orthopedic consult was followed up on, and there was a delay of three months, where the facility did not follow up on it, for 1 (#2) of 4 residents sampled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide residents with food at a safe and appetizing temperature for 4 (#s 101, 104, 117, and 121) of 16 sampled residents, this this could affect more residents who received food from the kitchen.

Inspectors wroteBased on interviews and record review, the facility failed to provide residents' choices related to the timing and frequency of showers for 3 (#s 104, 114, and 126) of 16 sampled residents.

Inspectors wroteBased on interviews and record review, the facility failed to provide residents assistance with bathing, which resulted in dependent residents going extended periods of time without a bath or shower, for 3 (#s 119, 121, and 127) of 16 sampled residents.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement a comprehensive care plan for a resident with concerns related to skin, nutrition, activities of daily living, mobility, and urinary concerns, for 1 (#128) of 16 sampled residents.