Benefis Senior Services - Eastview

F 0600 Level of Harm - Actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

the operation.During an interview on 10/22/25 at 11:15 a.m., NF5 stated he had evaluated resident #1 at

the hospital. NF5 stated resident #1 presented with swelling and signs of pain in her left leg. NF5 stated, I called [Resident #1's] daughter, and she was claiming physical and sexual abuse, so I completed a trauma assessment and a genital urinary assessment. I had ordered X-rays, a pan scan (a full body CT scan) to quickly identify any areas of trauma. The left leg was swollen but did not show any bruising and when it was discovered there was a fracture, orthopedics was called, and they would come down and assess the resident. Once orthopedics takes over, my part is complete.During an interview on 10/22/25 at 1:24 p.m., staff member D stated she had walked into resident #1's room about 7:00 a.m., on 10/6/25 to perform morning cares. Staff member D stated that resident #1 was dependent on staff for care, including mobility, and both of resident #1's legs were on the bed. Staff member D stated that resident #1's left leg did not look right, so she had called in staff member J to look at resident #1. Staff member D stated she had attempted to roll resident #1, but resident #1 had cried out. Staff member D stated, That is when we called the nurse to come over and evaluate [Resident #1's Name]. Staff member D stated that resident #1's leg had . been looking awkward for a while; we just thought that was normal for her (resident #1). I never said anything to anybody about it. Staff member D stated resident #1 had a history of putting her legs over the side of the bed in the past, but had not seen resident #1 do that in quite a while.During an interview on 10/22/25 at 1:48 p.m., NF7 stated the Orthopedic team received an Orthopedic consult for resident #1 from the emergency department regarding a femur fracture. NF7 stated he had performed the open reduction internal fixation of the fracture (surgical procedure). NF7 stated there was rotation to the left leg with some swelling. NF7 stated, There was no bruising noted to the left leg. The fracture was not an acute fracture.

The fracture was partially healed. I would estimate the fracture happened at minimum, two to three weeks ago, but could have occurred as long as eight weeks ago. I had a hard time getting the fracture reduced because of the healing. In my professional opinion, this fracture was suspicious. It was just odd that it was not caught sooner. This patient was non-verbal and non-ambulatory. NF7 stated the acute swelling could have been caused by moving resident #1, and some scar tissue around the fracture was damaged by callous formation on the bone. NF7 stated swelling and acute pain could occur when a fracture has already begun to heal.During an interview on 10/22/25 at 3:01 p.m., staff member H stated, I did not look at the operation report. If I would have seen the operation report I would have done more, I would have looked further back and talked to more staff. I definitely would have done more. I was going off of what staff told me, it seemed like it was an acute event. I felt it was a recent fracture. We determined the cause of the injury. Staff member H stated that after the injury investigation, she had called and talked with an orthopedic provider and asked if the scenario they came up with was possible. Staff member H stated they did not feel the injury required an abuse and neglect investigation.Review of resident #1's CT scan, dated 10/6/25, showed a distal femur periprosthetic fracture. The tibia and fibula were intact.Review of resident #1's operation report, dated 10/7/25, showed: . This patient had no bruising on her entire left lower extremity. This fracture would not move with a femoral distractor placed. On manual palpation, this fracture was mostly healed in a malunited position. saw and osteotomes were utilized to free up fracture fragments.

Then, the fracture would mobilize.Review of a facility policy titled, [Facility Names] Abuse/Neglect Allegations [Facility Name], dated 10/2025, showed: . Neglect is the failure of the facility, its employees or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Benefis Senior Services - Eastview

2621 15th Ave S Great Falls, MT 59405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0610 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

down on the bed, in a supine position, put his left foot down next to the heater (about a 3-inch deep by 4 inches high recessed area), and staff member H started to raise the bed up. Staff member G stated he felt some pain and twisting in the knee area of his left leg. Staff member H stated they had talked to staff member D and staff member I about the incident, but had not talked to any other staff, including staff member B who had assessed resident #1 prior to being sent to the Emergency Room. Staff member H stated, He wrote a nursing note, and I felt that was complete and there was no need to interview him. Staff member H stated she had not looked at the operation report. Staff member H stated, If I would have seen

the operation report I would have done more, I would have extended and looked further back and talked to more staff. I definitely would have done more. I was going off of what staff told me, it seemed like it was an acute event. I felt it was a recent fracture. Staff member G stated more interviews were completed, but there was no documentation, and they were completed after the investigation process. Staff member G stated mood and behavior were looked at, but there was no noted change in resident #1's mood or behavior that would have indicated a change in status. Staff member G stated the investigation should have been conducted differently and more thoroughly, I see that now. Staff member G stated resident #1 had a history of putting her legs over the edge of the bed. Staff members G and H did not recognize the fracture as suspicious until after reading a hospital progress note. Review of the facility's complete investigation documents showed no documentation for an investigation involving an injury of unknown origin. There was no documentation showing the results of the facility's re-enactment of the fracture, and no investigation into abuse or neglect involving a fracture until after the initial investigation was completed.Review of resident #1's nursing notes, dated 6/1/25-10/6/25, showed not documentation of the resident putting her legs over

the side of the bed.Review of resident #1's Care Plan, dated 6/1/2025-10/6/2025, contained no documentation resident #1 puts her legs over the side of the bed putting her at risk for injury or falls.Review of resident #1's staff documentation, dated 9/1/25-10/6/25, showed resident #1 was dependent on staff for her ADLS (Activities of Daily Living).Review of a facility policy titled, [Facility Names] Resident Abuse/Neglect Allegations, dated10/2025, showed: . [Facility Name] . protect residents during investigations and report incidents, and investigation results II. The DON or designee initiates an investigation .a. Gather initial written reports from all parties involved or witness to the allegation- this includes residents, family members, staff, co-workers, etc.b. Document preliminary findings including any physical indications related to the allegation, interviews with complainants, residents, witnesses and others, etc III. The DON/Manger (or their Designee) will follow-up on the preliminary findings by continuing the investigation .a. Follow-up with in-person/telephone interviews with complainants, residents . witnesses, etc. Document findings from

these interviews . [sic]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Benefis Senior Services - Eastview

2621 15th Ave S Great Falls, MT 59405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

repositioned in a 24-hour time period, and-On 10/5/25, documentation showed resident #1 was repositioned one time in 24 hours at 6:00 p.m.Review of a facility document titled, Documentation of Toileting and Check and Change, dated 10/1/25-10/6/25, showed:- . 10/1/25- 0200 (2:00 a.m.) Activity did not occur. 1100 (11:00 a.m.) Total assistance. 1930 (7:30 p.m.) Total assistance. Resident #1 was checked and changed two times in a 24-hour period.- . 10/2/25-1415 (2:15 p.m.) Total assistance. 1930 (7:30 p.m.) Total assistance. Resident #1 was checked and changed two times in a 24-hr period.- .10/3/25-0545 (5:45 a.m.) Total assistance. 1115 (11:15 a.m.) Total assistance. Resident #1 was checked and changed two times in a 24-hour period.- . 10/4/25-0430 (4:30 a.m.) Activity did not occur. 1915 (7:15 p.m.) Total assistance. 2215 (10:15 p.m.) Activity did not occur. Resident #1 was checked and changed one time in a 24-hour period.- . 10/5/25-1400 (2:00 p.m.) Total assistance. 1915 (7:15 p.m.) Total assistance. Resident #1 was checked and changed two times in a 24-hour period.- . 10/6/25-0200 (2:00 a.m.) Activity did not occur.

Resident #1 was not checked and changed in a 24-hour period.Review of a facility policy titled, [Facility Names] Activities of Daily Living/Needs and Choices, dated 6/2025, showed: . I. Resident needs for assistance with Activities of Daily Living.1. Bed mobility. 7. ToiletingReview of a facility policy titled, [Facility Initials] Pain Management, dated 10/2025, showed: . [Facility Name] assesses residents for pain and treat, as necessary Skilled Patients are assessed for pain at minimum daily and the long stay resident are assessed at minimum of weekly. [sic]8. Personal Hygiene Ability . III. Nursing ensures assistance with ADL is provided as directed in the care plan or as needed.A. Provision of assistance with ADL is regularly documented in the medical record. [sic]

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/23/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Benefis Senior Services - Eastview

2621 15th Ave S Great Falls, MT 59405

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG

SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0744

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Level of Harm - Minimal harm or potential for actual harm

Based on observation, interview, record review, the facility failed to identify and respond to increased behaviors indicative of pain or distress in a cognitively impaired resident for 1 (#1) of 4 sampled residents.

Findings include: During an interview on 10/22/25 at 12:15 p.m., staff member C stated when a dementia resident exhibits an increase in behaviors, she would assess possible causes such as pain, positioning, incontinence, and perform a general head-to-toe assessment for other physical causesDuring an interview

on 10/22/25 at 1:24 p.m., staff member D stated resident #1 exhibited scratching and pinching. Staff member D stated resident #1 had had done that since she was admitted , and it was usually only in the morning during cares. Staff member D stated there had been an increase in behaviors lately for resident #1 but could not say exactly when the behaviors started to increase.During an interview on 10/22/25 at 2:35 p.m., staff members E and F stated that behavior monitoring was done every shift. Staff member F stated if

a resident was unable to verbalize the problem and was demonstrating behaviors such as yelling out, pinching, hitting, etc., she would look at basic needs first. Staff member F stated she would start by looking at the last time the resident ate, or the last time the resident was toileted. Staff member E stated, Sometimes the behaviors are just that the resident wants attention. A review of resident #1's behavior monitoring showed, between 9/1/25 and 10/6/25, resident #1 exhibited behaviors including pinching, scratching, and yelling/screaming 15 times.Review of resident #1's pain assessments, dated 9/1/25-10/6/25, showed: three pain assessments were completed, and only one of the pain assessments was completed on a day resident #1 had exhibited behaviors.A review of resident #1s care plan, with a with

a start date 10/18/24 and end date 10/9/25, showed, Intervention: Identify stressors that lead to inappropriate behavior. Assess pain. [sic] Resident #1's electronic medical record did not contain evidence that pain was assessed as a possible cause of her increased behaviors.A review of resident #1's Quarterly MDS, with an assessment reference date of 6/29/25, showed: . E0200. Behavioral Symptoms.Physical behavioral symptoms directed towards others.1-behavior of this type occurred 1 to 3 days Section J: Health ConditionsPain management. Received PRN pain medications or was offered or declined? The response marked was 0-no A review of resident #1's Quarterly MDS, with an assessment reference date of 9/27/25, showed: . E0200. Behavioral Symptoms.Physical behavioral symptoms directed towards others, and this occurred 4 to 6 days. Section J: Health Conditions, for pain management, showed the question for if the resident received PRN pain medications or was offered or declined them. The response marked was 0-no.

Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet