Benefis Senior Services - Eastview

In the surveyor’s words

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

• Immediate jeopardy, isolatedF880May 24, 2022

  Based on observation, interview, and record review, the facility failed to ensure transmission-based precautions were implemented for residents with an unknown vaccination status, or unvaccinated residents when they were admitted to the facility, and residents were then diagnosed with COVID-19, for 2 (#s 405 and 406) and; a hospitalization was necessary for 1 (#405) after the resident developed a cough and complained of a burning in his chest, of 9 sampled residents; and the potential spread of COVID-19 from the lack of implementation of transmission-based precautions for other residents residing on the same unit, and failed to implement transmission-based precautions for 1 (#90) of 1 sampled resident. […]

• Actual harm, isolatedF600Oct 23, 2025

  Based on observation, interview, and record review, the facility failed to identify and investigate a major injury of unknown origin in a timely manner for a cognitively impaired resident, which was found to be a femur fracture, even though a staff member thought the resident's leg looked awkward for a while but neglected to address the concern. The surgeon treating the resident found the fracture was already healing and difficult to repair due to the delay in treatment for the injury of unknown origin, for 1 (#1) of 4 sampled residents. […]

• Actual harm, isolatedF684May 23, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident's venous statis ulcer was assessed routinely; treated promptly; and treatment orders were received and monitored routinely, to demonstrate healing and prevent discomfort for 1 (#124) of 1 sampled resident. Findings include: During an observation on 5/22/23 at 10:23 a.m., staff member S was completing routine wound care for resident #124 to her right posterior lower extremity. Resident #124 had bandages on her right foot, left foot, and left calf. During wound care resident #124 stated she had a lot of pain in the left foot and calf. During an assessment of the left foot and leg, staff member S noted bandages on the back of the resident's calf, and on her left foot, just below the great toe. […]

• Actual harm, isolatedF692May 23, 2023

  Based on observation, interview, and record review, the facility failed to ensure a resident's nutrition status was maintained by providing the needed assistance with meals to prevent a severe weight loss for 1 (#78); and failed to provide meal assistance and interventions to prevent a significant weight loss for 1 (#59) of 3 sampled residents. Findings include: 1. During an interview on 5/23/23 at 9:07 a.m., staff member P stated resident #78 was to receive a regular diet with finger foods. Staff member P stated she met with the residents on admission. Staff member P stated she would get a physician consult for pharmacological interventions as needed. Staff member P stated she saw the resident quarterly, including family of the resident if they chose to participate. […]

• Actual harm, isolatedF689May 13, 2021

  Based on observations, interview, and record review, the facility failed to implement on-going interventions attempting to prevent 10 falls, one with a fracture, for 1 (#34); and failed to identify and assess the needs of a morbidly obese resident, and prevent a fall with fracture for 1 (#69) for 6 sampled and supplemental residents. Findings include: 1. During an observation on 5/12/21 at 3:06 p.m., resident #34 was in bed. The resident had regular socks on, and the fall mat was propped against the wall. Review of resident #34's Care Plan, dated 3/17/21, showed staff were to assist the resident with wearing non-skid footwear. Review of resident #34's Risk Manager Worksheets showed the resident fell 10 times from 12/07/20 through 5/3/21. […]