Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Honor the resident’s right to a safe, clean, comfortable and homelike environment,
including but not limited to receiving treatment and supports for daily living safely.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation and interview, the facility failed to maintain floors free of a dirty
wax build-up, broken or damaged tiles and dirt and grime. This affected multiple residents
who resided in the affected areas and affected staff’s ability to keep the kitchen floor
clean. The facility had a census of 82.
1. Review of the undated daily cleaning list showed:
– All areas of the building should be monitored on a daily basis and all resident living
areas and non-living areas should be clean and odor free;
– Staff to dust mop or sweep resident rooms daily
Review of the undated deep cleaning policy showed:
– All resident rooms will be deep cleaned once monthly or more often if needed (as in the
case of heavy care rooms);
– Bathroom floor surfaces will be cleaned with a cleaner/disinfectant;
– Bathroom floors will be swept and moped and any dirt, grime or stains will be scrubbed
with a stiff brush or other equipment suitable for removing surface dirt;
– If the stain is not removable, housekeeping staff are to notify maintenance staff with a
maintenance request form.
Review of undated cleaning guidelines showed:
– Prepare Proxy 4D (cleaner) in mop water solution;
– Mop entire room, working your way out the door;
– In heavy odor rooms, use odor counteractant (odor diffuser) at base of toilet.
2. Observation on 1/27/19, at 9:15 A.M., showed dirt and grime on the kitchen floor around
the equipment (work tables, range, dishwasher, steam table, etc). The kitchen floor
contained several broken and missing tiles that prevented proper cleaning of the floor’s
surface.
During an interview on 1/29/19, at 5:55 A.M., Dietary Staff A said they mop the kitchen
floor daily, but it is worn and chipped and very hard to clean.
During an interview on 1/29/19, at 9:23 A.M., the Dietary Manager said staff clean the
kitchen floor daily; but the kitchen floor is worn and will not come clean.
3. Observation on 1/27/19, at 9:25 A.M., showed the doorways to the rooms on the front
center hall (going toward the unit) contained a dark dirty looking area one to two feet
wide and the length of the doorway. The area looked like someone had stripped the center
of the hall and pushed the dirt and wax under the doorways, sealing the dirty and grime
into the floor. Some of the dirty came up when rubbed with a paper towel containing soap
and water.
Observation on 1/27/19, starting at 9:15 A.M., and all days and times of the survey showed
the following:
– Several resident rooms with discolored floor tiles and dirty discolored grout areas
around bathroom stools on the tiles;
– This included resident rooms: 1, 3, 4, 12, 18, 21, 22, 25, 26, 27, 28, 30, 31, 33, 34,
36, 38, 40, 46, 49 and 50.
Observation and interview on 1/27/19, at 11:40 A.M., showed the business office carpet
coated with dirt and debris. The Business Office Manager said they needed to vacuum the
carpet in his/her office.
Observation on 1/30/19, at 10:49 A.M., showed the room adjacent to resident room [ROOM
NUMBER] contained discolored floor tiles in the doorway 3 inches wide and 30 inches long
and multiple dirty discolored floor tiles through out the room.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0584

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 1)
During an interview on 1/30/19, at 8:18 A.M., Maintenance Staff A said they were in the
process of stripping floors and replacing bathroom floor tiles. They have 4 more rooms to
do on the unit then they will do the front area. A contractor came in and stripped the
hallways and failed to seal the doorways and leaked dirty water and wax into the resident
rooms which is why the tiles in the doorways look so dirty.
During an interview on 1/30/19, at 2:36 P.M., the Maintenance Supervisor said he was just
sick about the quality of work the contractor did when they stripped the hallways. The
contractor made a big mess, leaving the doorways full of waxed-in dirt and debris. He and
his staff started replacing bathroom flooring, and as time allows, plan to continue
fixing, replacing and cleaning the facility’s floors. The kitchen floor contains broken
and worn tiles that are hard to clean. He hoped they would be able to replace the kitchen
floor in the future.

F 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Assess the resident when there is a significant change in condition

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to recognize a
significant change in status for one of 31 sampled residents (Resident #44) when staff
should have determined there was a significant change in the resident’s physical and/or
mental healthh. The facility had a census of 82.
Review of the Resident Assessment Instrument (RAI) manual showed a significant change in
status comprehensive assessment should be completed when a resident has a major
improvement or decline in their status that will not resolve itself without intervention
of staff, impacts more than one area of the resident’s health status and requires
interdisciplinary review and/or revision of the care plan.
1. Review of the Residen# 44’s Monthly Summaries, dated 10/29/18 and 11/7/18, showed
resident had feeling or appeared down, depressed or hopeless.
Review of Resident #44’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 12/4/18, showed the following:
– Independent in decision making;
– Independent with care;
– No depression of feeling of dread or hopeless;
– No significant weight loss or gain;
– Weight 210, height 65 inches;
– [DIAGNOSES REDACTED].
Review of the resident’s medical record showed staff sent a fax to the physician’s office
on 12/6/18. The fax showed the resident had a 12 pound weight increase in a month and
asked that the physician review the physician order [REDACTED]. The physician ordered
staff to weight the resident monthly.
Review of the resident’s Monthly Summaries, dated 12/12/18, showed resident had feeling or
appeared down, depressed or hopeless
Review of the resident’s POS showed the physician ordered [MEDICATION NAME] 15 milligrams
(mg) tablets each evening, starting on 12/18/18, for depression.
Review of the resident’s Monthly Summaries, dated 1/7/19, showed resident had feeling or
appeared down, depressed or hopeless
Review of the resident’s History and Physical, showed Medical Group A saw the resident on
12/19/18, and Physician A saw the resident on 1/8/19, for his/her 19 pound weight gain.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0637

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
The physician diagnosed the resident with lower bilateral extremity [MEDICAL CONDITION]
(swelling of both legs) and placed the resident on [MEDICATION NAME] (a diuretic).
Review of the resident’s dietary notes, dated 1/7/19, showed significant weight gain;
weight gain from 203 pounds on 12/12/18, to 223 pounds on 1/7/19. (Weight gain of 20
pounds or 9.1% in less than a month).
During an interview on 1/29/19, at 5:07 P.M., Licensed Practical Nurse (LPN) B said the
resident has had significant weight gain. The resident saw the physician in (MONTH) for
the weight gain and the Nurse Practitioner (NP) this month. They added [MEDICATION NAME]
(40 milligram) twice a day for 10 days for the [MEDICAL CONDITION] in his/her legs and
placed the resident on weekly weights.
Observation and interview on 1/27/19, at 9:54 A.M., showed the resident sat in recliner
with a blanket over his/her legs. The resident looked as if he/she had been crying. The
resident said he/she missed his/her daddy and continued to cry. Homemaker A went into the
resident’s room and he/she told the homemaker why he/she was so tearful.
Observation and interview on 1/27/19, at 2:52 P.M., showed the resident in his/her
recliner with his/her feet up and a blanket up to his/her neck. The resident said he/she
stayed in his/her room most of the time. He/she did not like all of the yelling and
fighting that went on in the facility. There are residents who are mean to staff, yelling
and hitting, residents who yell at each other and the code green’s are all very upsetting
to him/her. He/she said he/she was unable to stop crying when he/she thinks of his/her
daddy. The resident said he/she had a lot of pain but the pain in his/her legs were some
better. The resident showed the surveyor his/her legs and they looked puffy and swollen.
Observation and interview on 1/28/19, at 3:10 P.M., the resident said he/she felt better
today since he/she talked with the tele-psy (Seeing and speaking with the mental health
physician located at a remote location over a computer screen) physician. The physician
ordered mental health therapy sessions so he/she can get some help about missing his/her
daddy so much. The resident’s legs looked swollen and puffy.
Review of the medical record on 1/28/19, at 9:00 A.M., showed the facility addressed the
resident’s increased depression. The resident spoke with Tele-Psy yesterday, 1/27/19. The
physician increased the resident’s [MEDICATION NAME] (used for depression) on 1/28/19 and
gave an order for [REDACTED].
Record review and interview on 1/29/19, at 5:07 P.M., LPN B said the resident has
increased depression in the last month or two over the loss of his/her father. The
resident saw the tele-psy physician this week and counseling was ordered. They also
increased his/her antidepressant medication on 12/18/18 and again on 1/28/19. The
information in the computer and in the resident’s chart confirmed the information.
During an interview on 1/28/19, at 3:55 P.M., the MDS Coordinator said he/she only thought
of health issues when addressing the need for a MDS significant change. Significant weight
gain and increased depression was not something that triggered in her mind for the need to
do an MDS significant change. The resident’s increased weight and increased depression
should have been addressed with a significant change MDS.
During an interview with the Director of Nursing (DON) on 1/31/19, at 2:50 P.M., the DON
said significant weight gain and increased depression should have triggered the need for a
MDS significant change.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure staff
developed and updated a care plan consistent with residents’ specific conditions and needs
which affected three of 18 sampled residents (Resident #13, #44 and #61). The facility
census was 82.
1. Review of the facility’s Comprehensive Care Plans policy, dated (MONTH) 6, 2007,
showed:
– Purpose: To ensure the facility develops a comprehensive care plan for each resident
that includes measurable objectives and time tables to meet a resident’s medical, nursing,
and mental and psychosocial needs that are identified in the comprehensive assessment.
– A registered nurse (RN) has been designated to work with an Inter-Disciplinary Team
(IDT) for the purpose of the Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, and care planning process.
– The Resident Assessment Instrument (RAI) User Manual will be used to look at residents
holistically.
– Daily nursing meetings will occur Monday through Friday with a review of the resident’s
medical, functional, and psychosocial problems and this information will be individualized
to the resident’s plan of care.
– The care plan will be oriented toward preventing avoidable declines in functioning or
functional levels; managing risk factors; addressing residents’ strengths; using current
standards of practice in the care planning process; evaluating treatment objectives and
outcomes of care; respecting the resident’s right to refuse treatment; using an IDT
approach to care plan development to improve the resident’s functional status; involving
resident/family/responsible party; assessing and planning for care sufficient to meet the
care needs of new admissions; involving the direct care staff with the care planning
process relating to the resident’s expected outcomes; addressing additional care planning
areas that could be considered in the facility setting; utilizing the Care Area Assessment
sheets (CAAS, identifies areas of care needed for caring for a resident) process to
identify why areas of concern may have been triggered.
– The care plan will be updated toward preventing declines in functioning, will reflect on
managing risk factors and building on resident’s strengths.
– All treatment objectives will be measureable and corroborate with the resident’s own
goals and wishes when appropriate.
– Care plans will be initiated and revised timely, accurately, and will be individualized.
2. Review of Resident #13’s quarterly Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 11/7/18, showed:
– A Brief Interview for Mental Status (BIMS) score of 15 which indicated he/she made
his/her own decisions;
– No behaviors;
– Independent in all care areas;
– Received antipsychotic medications, antidepressant medications, antianxiety medications
and opioids (narcotic pain medications) seven out of last seven days;
– [DIAGNOSES REDACTED].
Review of the January, 2019 physician’s orders [REDACTED].
– Check mouth after giving each medication to prevent cheeking (holding, not swallowing)
of medications;
– [MEDICATION NAME] 10 milligrams (mg) one tablet daily for [MEDICAL CONDITION];
– [MEDICATION NAME] 1 mg, one tablet BID (twice daily) for [MEDICAL CONDITION] disorder;
– [MEDICATION NAME] 5 mg, one tablet at bedtime (HS) for [MEDICAL CONDITION];
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
– [MEDICATION NAME] 15 mg, two tablets at HS for [MEDICAL CONDITION];
– Trazadone 150 mg, one tablet at HS for [MEDICAL CONDITION];
– Bisopromol [MEDICATION NAME] 5 mg, one tablet daily for hypertension; hold for a
systolic (measures the pressure in your blood vessels when your heart beats) B/P less than
100 or a heart rate less than 60;
– [MEDICATION NAME] 20 mg, one tablet daily for hypertension; hold for a systolic B/P of
less than 100 or a heart rate less than 60;
– [MEDICATION NAME] sodium 100 mg, one capsule BID for bowel regulation;
– [MEDICATION NAME]-S, two tablets at HS for bowel regulation;
– [MEDICATION NAME] 10 mg/15 milliliters (ml), 15 ml daily PRN (as needed) for
constipation;
– Magnesium [MEDICATION NAME], drink on bottle every three days PRN for constipation;
– Milk of Magnesia, 30 ml every other day PRN for constipation;
– Polyethylene [MEDICATION NAME] powder, dissolve one scoopful, 17 grams, in 8 ounces of
liquid and drink BID PRN for constipation;
– Ranitadine 300 mg one tablet BID for reflux disease;
– [MEDICATION NAME] liquid, 30 ml every six hours PRN for reflux or indigestion;
– [MEDICATION NAME] sulfate 2.5 mg/3 ml, inhale one vial per nebulizer (a machine that
changes medication from a liquid to a mist so that it can be more easily inhaled into the
lungs) every six hours PRN for [MEDICAL CONDITION];
– [MEDICATION NAME] APAP (narcotic pain medication) 10/325 mg, one tablet every six hours
for pain.
Review of the care plan last updated on 1/1/19, showed:
– Staff did not develop a plan of care for [MEDICAL CONDITION].
– Staff did not develop a plan of care for [MEDICAL CONDITION] disorder (known as
manic-depressive illness, a brain disorder that causes unusual shifts in mood, energy,
activity levels, and the ability to carry out day-to-day tasks).
– Staff did not develop a plan of care for the use of antipsychotic, antidepressant,
antianxiety, and opioid medications.
– Staff did not develop a plan of care for constipation, hypertension (elevated blood
pressure, B/P), reflux disease (backing up of stomach contents into the throat), [MEDICAL
CONDITION], or [MEDICAL CONDITION] ([MEDICAL CONDITIONS]).
3. Review of Resident #61’s significant change in status MDS, dated [DATE], showed:
– Moderately cognitive impaired;
– Extensive assist of one staff for activities of daily living (ADLs);
– No behaviors;
– Received antipsychotic medications, anxiety medications, antidepressant medications, and
hypnotic medications seven out of the last seven days;
– [DIAGNOSES REDACTED].
Review of the POS [REDACTED]
– Duloxetine 20 mg daily for major [MEDICAL CONDITION];
– [MEDICATION NAME] 50 mg daily for depression;
– [MEDICATION NAME] 1 mg BID for depression;
– [MEDICATION NAME] 0.5 mg three times a day (TID) for anxiety disorder;
– [MEDICATION NAME] 100 mg BID for [MEDICAL CONDITION];
– [MEDICATION NAME] 32.4 mg BID for [MEDICAL CONDITION].
Review of the care plan, revised 1/22/19, showed the facility staff did not develop plans
of care to address the following:
– Major [MEDICAL CONDITION];
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 5)
– Anxiety disorder;
– [MEDICAL CONDITION];
– The use of antipsychotic, antidepressant, antianxiety, [MEDICAL CONDITION], and hypnotic
medications.
4. Review of the Resident #44’s Annual Minimum Data Set (MDS), a federally mandated
assessment instrument completed by facility staff, dated 12/4/18 showed the following:
– Independent in decision making;
– Independent with care;
– No depression of feeling of dread or hopeless;
– No significant weight loss or gain;
– Weight 210, height 65 inches;
– [DIAGNOSES REDACTED].
Review of the resident’s monthly summaries, dated 10/29/18, 11/718, 12/12/18 and 1/7/9,
all showed the resident had been feeling or appeared down, depressed or hopeless.
Review of the resident’s History and Physical, showed Medical Group A saw the resident on
12/19/18. Physician A saw the resident on 1/8/19, for his/her 19 pound weight gain. The
physician diagnosed the resident with lower bilateral extremity [MEDICAL CONDITION] and
placed the resident on [MEDICATION NAME] (diuretic).
Review of the resident’s dietary notes, dated 1/7/19, showed significant weight gain;
weight gain from 203 pounds on 12/12/18, to 223 pounds on 1/7/19. (Weight gain of 20
pounds or 9.1% in less than a month).
Review of the current physician order [REDACTED].>Review of the resident’s care plan
for nutrition under Problems/needs, dated 1/17/19, showed:
– Problems: Resident will stop eating when reaches 200 pounds; Resident will overeat then
vomit; Resident ask for seconds for most meals; Resident does not comed down for
breakfast;
– Goals – I will maintain my weight within 5% of my current weight of 222.
Approaches: – Resident on house supplement TID; Montor weight monthly; Record dietary
intake;
– The care plan did not address the resident’s significant weight gain.
– The care plan did not address the resident’s [MEDICAL CONDITION].
– The care plan addressed house supplement but the resident was not on house supplement.
During an interview on 1/29/19, at 5:07 P.M., Licensed Practical Nurse (LPN) B said the
resident has had a significant weight gain. The resident saw the physician in (MONTH) for
the weight gain and the Nurse Practitioner this month. They added [MEDICATION NAME] (40
milligram) twice a day for 10 days for the [MEDICAL CONDITION] in his/her legs and placed
the resident on weekly weights.
Review of the resident’s care plan for [MEDICAL CONDITION] disorder, dated 1/09/19,
showed:
– Problem: Resident currently taking antipsychotic medications, antidepressant medications
and antianxiety medications to manage mental illness.
– Goal: Resident will have minimal to no adverse effects from medications within the next
three months;
– Resident will have no significant increase in depression or behaviors for the next three
months;
– Approaches: administer medications as ordered; monitor for any possible adverse effects
such as drowsiness, dizziness, tremors, dry mouth etc.;
– The care plan did not address the resident’s increased depression and crying related to
the loss of his/her father before Christmas.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 6)
Observation and interview on 1/27/19 at 9:54 A.M., showed the resident sat in a recliner
with a blanket over his/her legs. The resident looked as if he/she had been crying. The
resident said he/she missed his/her daddy and continued to cry. Homemaker A went into the
resident’s room and he/she told the homemaker why he/she was so tearful
Observation and interview on 1/27/19, at 2:52 P.M., showed the resident in his/her
recliner with his/her feet up and a blanket up to his/her neck. The resident said he/she
stayed in his/her room most of the time. He/she did not like all of the yelling and
fighting that went on in the facility. There are residents who are mean to staff, yelling
and hitting, residents who yell at each other and the code green’s (A call out for staff
to come help calm a situtation when a resident might be harmful to self or others – verbal
or physicial) are all very upsetting to him/her. He/she said he/she was unable to stop
crying when he/she thinks of his/her daddy. The resident said he/she had a lot of pain but
the pain in his/her legs were some better. The resident showed the surveyor his/her legs
and they looked puffy and swollen.
During an interview on 1/28/19, at 3:10 P.M., the resident said he/she felt better today
since he/she talked with the tele-psy (a visual conference call between the resident and
the mental health pysician who is located at a remote location) physician. The physician
ordered mental health therapy sessions so he/she can get some help about missing his/her
daddy so much. The resident’s legs looked swollen and puffy.
Review of resident’s progress notes writen by the nurses on 1/28/19, at 9:00 A.M., showed
the facility addressed the resident’s increased depression. The resident spoke with
Tele-Psy yesterday. The physician increased [MEDICATION NAME] (used for depression) and
gave order for counseling and for the resident to be reevaluated in 30 days,
Record review and interview on 1/29/19, at 5:07 P.M., LPN B said the resident has had
increased depression in the last month or two over the loss of his/her father. The
resident saw the tele-psy physician this week and counseling was ordered. They also
increased his/her antidepressant medication on 12/18/18, and again on 1/28/19. The
information in the computer and in the resident’s chart confirmed the information.
5. During an interview on 1/28/19, at 3:55 P.M., and on 1/31/19, at 11:00 A.M., the
MDS/Care Plan said
– She thought the care plans were up to date, but when she was the acting Director of
Nursing (DON) for five months, someone else did the care plans.
– She is finding a lot of errors in the care plans and is working to correct them.
– Resident #44 had not been on a supplement for about 4 months so that should not have
been on the care plan. The resident’s increased weight and increased depression should
have been updated on the care plan.
– She had not thought to care plan antipsychotic, antidepressant, or antianxiety
medications.
– All care plans needed to be comprehensive and individualized to each resident’s needs
and issues.
During an interview on 1/31/19, at 2:50 P.M., and at 4:55 P.M., the Director of Nursing
(DON) said:
– Care plans should be comprehensive and all areas should be included in the care plan for
residents.
– Any issues or incidents that happen such as falls, should be care planned immediately.
– Significant weight gain and increased depression should have been addressed on the
resident’s care plan.
– The care plan should not say Resident #44 was on a supplement three times a day.
– She expected the care plan to be current with what is happening to the resident today.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 7)
– They have daily meetings and changes discussed should trigger changes in the resident’s
care plan.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure services provided by the nursing facility meet professional standards of
quality.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to follow
physician’s orders when administering medication to one of 18 sampled residents (Resident
#29) and failed to reconcile a medication order correctly which affected one sampled
resident (Resident #73). The facility census was 82.
1. Review of the facility’s Medication Administration and Monitoring policy, dated
4/16/17, showed:
– Purpose: To ensure for proper administration of medications, techniques of administering
medications, effective monitoring of residents for adverse consequences associated with
side effects to medications. To provide guidelines and systems for following procedures
for medications errors including defining a medication error and levels of medication
errors. To ensure therapeutic guidelines are monitored in drugs that require laboratory
and diagnostic studies.
– Medications are to be given per physicians’ orders. The nurse or certified medication
technician (CMT) will check each medication to the medication administration record (MAR),
noting correct medication, correct resident, correct dose, correct time, and correct
route.
– Dispense the medication, if time is specified, give medication as ordered on time.
Specified medications should be scheduled to best reflect the physician’s order and drug
recommendations.
Review of the facility’s Transcription of Orders/Following Physician’s Orders policy,
dated 4/6/17, showed:
– Purpose: To outline procedures in accurately transcribing physicians’ orders and to
ensure that all physicians’ orders are followed; and that a process is in place to monitor
nurses in accurately transcribing and following physicians’ orders.
– All medication orders are to be transcribed on the MAR or the treatment sdministration
record (TAR).
– The Resident Care Coordinator (RCC) will audit all physicians’ order sheets and
telephone orders daily to ensure all new physicians’ orders are recapped and followed
completely and accurately.
– On weekends, the registered nurse (RN) supervisor will check all charts in the facility
to ensure that all new orders received have been transcribed accurately and implemented.
– Every month when the new change over arrives to the facility the RCC will review the old
physicians’ order sheets (POS) and MARs to verify that all orders are correct on the new
POS, MAR, and TAR records.
– The nurse or CMT in charge of medication administration must review all of their
designated MARs and TARs prior to the end of the shift to ensure that all
medications/treatments scheduled to be given on their shift were administered according to
the physician’s order and that all necessary interventions were taken in the event of an
omission.
2. Review of Resident #29’s significant change in status Minimum Data Set (MDS), a

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 8)
federally mandated assessment instrument completed by facility staff, dated 11/17/18,
showed:
– A Brief Interview for Mental Status (BIMS) score of 8 which indicated supervision needed
in decision making;
– Mechanically altered diet;
– [DIAGNOSES REDACTED].
Review of the January, 2019, POS showed:
– NAME] DR (used to treat GERD) 40 milligrams (mg), one twice daily (BID) before meals,
give on an empty stomach.
Review of the January, 2019, MAR showed:
– Staff hand recorded NAME] DR, 40 mg, 1 tablet by mouth BID and did not record before
meals, on an empty stomach.
– Administration times were 8:00 A.M. and 4:00 P.M.
Observation and interview on 1/29/19, at 8:56 A.M., CMT A did and said:
– Administered NAME] DR, 40 mg to the resident;
– Said he/she administered the medication after the resident ate his/her breakfast meal;
– Said the MAR did not show to administer before meals, on an empty stomach;
– He/she did not know who recorded the medication on the MAR.
During an interview on 1/30/19 at 2:49 P.M., RCC A said:
– NAME] DR should be given before meals.
– Breakfast was scheduled to be served at 8:00 A.M. and the NAME] DR should be given at
7:00 A.M.;
– If staff administered the medication at 8:56 A.M., it was not given before breakfast or
on an empty stomach;
– The POS showed to give the NAME] DR before meals and on an empty stomach.
– The pharmacy should have printed the medication and instructions on the January, 2019
MAR and he/she did not know why times were not printed.
– The times printed on the January, 2019 were 7:00 A.M. and 4:00 P.M., not 8:00 A.M. as
hand written by staff.
– CMTs and nurses could record orders on the MAR.
3. Review of Resident #73’s December, (YEAR), POS showed:
– Licensed Practical Nurse (LPN) A hand recorded Humalog insulin sliding scale (an amount
of insulin given related to the blood sugar level assessed) as verbally ordered by Family
Nurse Practitioner (FNP) on 12/16/18;
– Blood Sugar (BS) 151 milligrams (mg)/deciliter (dl) to 200 mg/dl give 2 units of Humalog
insulin.
Review of the resident’s quarterly MDS, dated [DATE], showed:
– A BIMS score of 15, which indicated he/she made his/her own decisions;
– [DIAGNOSES REDACTED].
– Therapeutic diet;
– Received insulin injection seven out of last seven days.
Review of the January, 2019, POS showed:
– Humalog insulin sliding scale: BS 151 mg/dl to 200 mg/dl, administer 1 unit of Humalog
insulin with a physician order date of 9/9/18;
– The most recent verbal and handwritten order, dated 12/16/18, for Humalog sliding scale
insulin was not printed on the January, 2019, POS.
Review of the January, 2019, Weekly Diabetic Report/Flow Sheet showed:
– Humalog insulin per sliding scale before meals and at bedtime: BS 151 mg/dl to 200 mg/dl
administer 2 units of Humalog insulin;
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
– BS 182 mg/dl, Humalog 2 units administered.
Observation on 1/30/19, at 11:59 A.M., showed:
– LPN A administered Humalog 2 units to the resident for a BS of 182 mg/dl.
Review of the January, 2019, MAR showed:
– The sliding scale listed as Humalog insulin 1 unit for a BS of 151 mg/dl to 200 mg/dl;
– Staff handwrote See DM (diabetes mellitus) Flow Sheet;
– No insulin administration charted on the MAR, only on the Weekly Diabetic Report/Flow
Sheet.
During an interview on 1/30/19, at 2:30 P.M., LPN A said:
– The order changed from 1 unit to 2 units for a BS of 151 mg/dl to 200 mg/dl on 12/16/18,
and showed the surveyor the written order for the change of dose;
– The Weekly Diabetic Report/Flow Sheet, dated January, 2019, showed the change of dose to
Humalog 2 units for a BS of 151 mg/dl to 200 mg/dl;
– He/she administered the latest, correct dose of insulin to the resident;
– He/she did not know why the printed POS did not show the changed sliding scale dose.
During an interview on 1/30/19, at 2:33 P.M., RCC A said:
– The sliding scale order was changed in December, (YEAR), but did not get carried over to
the January, 2019 POS;
– He/she reconciled the POS and MAR at the end of each month, but missed the changed order
and did not get it corrected.
4. During an interview on 1/31/19, at 4:55 P.M., the Director of Nursing (DON) said:
– She expected physicians’ orders to be followed.
– RCC A always reconciles POS, MAR, and Weekly Diabetic Record/Flow Sheets monthly.
– The pharmacy did not print the correct times on the January, 2019, and she did not know
why.
– She expected RCC A to reconcile all medications and orders correctly.

F 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Have a plan that describes the process for conducting QAPI and QAA activities.

Based on observation, interview and record review, the facility failed to provide
documentation that the Quality Assessment and Assurance (QAA) met on a quarterly basis and
included the appropriate attendees; failed to identify, develop, implement, monitor and
evaluate system problems. This had the potential to affect all residents. The facility
census was 82.
Review of the facility’s undated Quality Assurance Performance Improvement (QAPI) plan
showed:
– Purpose: to provide quality excellence in resident care and do a root cause analysis for
identified areas of concern and improvement;
– The QAA committee will review data from areas the facility believes it needs to monitor
on a monthly basis to assure systems are being monitored and maintained to achieve the
highest level of quality for our organization.
– The administrator has responsibility and is accountable to our facility and corporation
for ensuring that QAPI is implemented throughout the organization.
– All department managers, the administrator, the Director of Nursing (DON), antibiotic
steward, the infection control and prevention officer, medical director, consulting
pharmacist, resident and/or family representative, and three additional staff will provide

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0865

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 10)
QAPI leadership by being on the QAA committee.
– The administrator will facilitate discussion on QAPI activities at the quarterly QAA
meetings.
– The organization will conduct performance improvement projects (PIP) that are designed
to take a systematic approach to revise and improve care or services in areas that we
identify as needing attention.
During an interview on 1/31/19, at 3:50 P.M., the DON and administrator said:
– They have been in their positions for the last three months and have not fully developed
and implemented the QAA/QAPI.
– The corporation is scheduled to do training on the QAA/QAPI soon in the facility.
– QAA should meet monthly and quarterly with the interdisciplinary team (IDT), medical
director, and pharmacist.
– They met with the medical director this fall to go over some of the QAPI but have no
documentation.
– There is no documentation from the meeting or signature sheet of who attended.
– The DON stated labs have been an issue they are addressing through the QAA.
– The DON stated the committee should be identifying, developing, implementing,
monitoring, evaluating, and documenting issues and care areas to provide quality of care.

F 0908

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Keep all essential equipment working safely.

Based on observation, interview and record review, the facility failed to maintain
wheelchairs in good condition when they did not repair or replace wheelchair arms that had
the plastic coverings which were cracked, torn, and/or ripped from the arms and residents
rested their arms on foam padding or cracked, torn plastic which had the potential to
cause wounds to the skin. This affected five of 18 sampled residents (Resident #72, #50,
#45, #61 and #10). This had the potential to affect wheelchairs in the facility used by
residents. The facility census was 82.
1. The facility did not provide a policy to repair wheelchairs.
2. Observation on 1/30/19, at 10:33 A.M., showed:
– Resident #10’s plastic covered wheelchair arms were torn and plastic was ripped off both
arms and foam was visible.
– The resident said the arms were torn for a long time.
Observation on 1/30/19, at 10:50 A.M., showed:
– Resident #72’s wheelchair arms were torn and ripped with foam visible.
– Resident #50’s wheelchair arms were torn and ripped with foam visible.
– Resident #45’s wheelchair arms were torn and ripped with foam visible.
– Resident #61’s wheelchair arms were torn and ripped with foam visible.
During an interview on 1/30/19, at 12:39 P.M., Certified Nurse’s Aide (CNA) A said:
– He/she did not know about the poor condition of the wheelchair arms.
– Staff should fill out a maintenance work slip, place it on the hook by the medication
room, for all equipment that is need of repair and maintenance will perform the repairs.
– Often staff forget to fill out the maintenance work slip.
During an interview on 1/31/19, at 2:15 P.M., the Maintenance Supervisor (MS) said:
– Maintenance repaired wheelchairs when needed.
– Staff should fill out a maintenance work slip and place on the hook by the medication

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0908

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 11)
door.
– He was not aware of any wheelchairs that needed to be repaired.
During an interview on 1/30/19, at 10:33 A.M., and on 1/31/19, at 4:55 P.M., the Director
of Nursing (DON) said:
– Staff should fill out maintenance work slips when they see issues that need to be
addressed.
– She did not know about the poor condition of the wheelchair arms on any wheelchairs.
– Maintenance could repair or replace the wheelchair arms.

F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Make sure that the nursing home area is safe, easy to use, clean and comfortable for
residents, staff and the public.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure staff
provided a clean comfortable homelike environment when staff did not notice, were not
aware, and did not correct a very strong odor of urine coming from a resident’s mattress
and mattress cover which was very noticeable in the resident’s room, the entire hallway on
which the resident lived and at the entrance of the hallway near the dining room. This
affected one of 18 sampled residents (Resident #7). The facility census was 82.
1. The facility did not provide a policy for cleaning mattresses and mattress covers.
Review of the undated daily cleaning list showed:
– All areas of the building should be monitored on a daily basis and all resident living
areas and non-living areas should be clean and odor free:
– Staff to dust mop or sweep resident rooms daily
Review of the undated deep cleaning policy showed:
– All resident rooms will be deep cleaned once monthly or more often if needed (as in the
case of heavy care rooms).
2. Review of Resident #7’s annual Minimum Data Set (MDS), a federally mandated assessment
instrument completed by facility staff, dated 10/24/18, showed:
– A Brief Interview for Mental Status (BIMS) score of four which indicated he/she did not
make his/her own decisions;
– Extensive assist of two or more staff for bed mobility, transfers, and toileting;
– Always incontinent of bladder;
– Occasionally incontinent of bowel;
– [DIAGNOSES REDACTED].
Review of the care plan, updated 1/7/19, showed:
– Required moderate assist with all activities of daily living;
– Assist with hygiene and pericare daily and as needed (PRN);
– Incontinent of bowel and bladder;
– Special toileting program; offer assist to the toilet before and after meals, at
bedtime, and PRN (as needed) at his/her request;
– Assist with pericare after episodes of incontinence and changing briefs as needed;
– Offer bed pan and urinal when needed.
Observations on all days of the facility survey, 1/27/19 through 1/31/19, showed:
– The resident’s room, mattress, entire hallway and the entrance to the hallway near the
dining room smelled of a strong odor of stale urine.
Observation and interview on 1/30/19, at 10:30 A.M., Certified Nurse’s Aide (CNA) A did

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
and said:
– Pulled back the linens on the resident’s mattress and the surveyor smelled the mattress
cover and mattress;
– Both the mattress and cover smelled of strong urine;
– CNA A said that housekeeping cleaned the mattresses of residents daily after CNAs
stripped the beds, then the CNAs would remake the beds for the residents;
– Said the mattress covers should be able to be removed because there were buckles to hold
the covers in place; he/she did not know if housekeeping removed and washed the mattress
covers or not;
– Removed an incontinent pad from a seat cushion in a recliner and the chair and cushion
did not smell of urine;
– CNA A said the facility got rid of a recliner that Resident #7 used to have because it
smelled of urine and the new recliner was gifted to Resident #7 by his/her roommate’s
family;
– CNA A said they now use the incontinent pad in the chair at all times.
During an interview on 1/31/19, at 2:33 P.M., the Housekeeping/Laundry Manager (HLM) said:

– Staff check Hot Spots at least three times a day or more if a resident is a heavy
wetter.
– Hot Spots are beds and bathrooms that are used by residents who are heavy wetters or had
continual smells of urine.
– She usually came in around 8:00 A.M. and started cleaning hot spots.
– Resident #7’s room was a hot spot and she normally started with his/her room first.
– He/she got up for breakfast, the CNAs strip the bed, housekeeping washed the mattress
and let the mattress dry, and the CNAs remake the bed.
– She used cleaners Proxy 40 and Urine Digester to clean the mattresses.
– Proxy 40 was used most of the time because the product was cheaper to purchase and
killed a lot of bacteria.
– She used Urine Digester when she had it in the facility.
– Resident #7’s mattress was newer, less than two months old.
– She never removed the mattress covers to wash them, and thought it would be difficult to
remove.
– There were zippered covers that could be ordered to put over mattresses and the facility
might have to look into that.
– She walks the halls and cleans hot spots all day; if there is an odor, she informed
staff and they immediately go and clean the area if necessary.
During an interview on 1/31/19, at 4:55 P.M., the Director of Nursing (DON) said:
– She expected staff to clean hot spots daily and as needed.
– She thought housekeeping cleaned hot spots on one hall one day, and one hall the next
day.
– If housekeeping staff were not in the facility, she expected nursing staff to wipe down
the hot spot mattresses.
2. Observation on 1/27/19, at 9:15 AM., showed a strong order of urine when one entered
the facility. Residents were in the dining room area.
Observation on 1/27/19, at 9:45 A.M., showed a strong odor of urine and bowel on center
hall around resident rooms [ROOM NUMBERS].
Observation on 1/28/19, at 7:15 A.M., showed a strong odor of urine when one entered the
facility.
Observation on 1/28/19, at 7:44 A.M., showed a eye watering odor of urine and fecal

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/16/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265730

(X2) MULTIPLE CONSTRUCTION
A. BUILDING ___________
B. WING ___________
(X3) DATE SURVEY COMPLETED

01/31/2019

NAME OF PROVIDER OF SUPPLIER

EASTVIEW MANOR CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

1622 EAST 28TH STREET
TRENTON, MO 64683

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 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 13)
material on center hall near rooms [ROOM NUMBERS].
Observation on 1/29/18, at 2:30 P.M., showed the odors on center hall remain strong and
unpleasant.
Observation on 1/30/19, at 7:55 A.M., showed strong urine and fecal material odors of
urine and fecal material down center hall.
During an interview on 1/30/19, at 8:01 A.M., Licensed Practical Nurse (LPN) B said he/she
could smell the urine odor today and a hot odor from the copy machine on center hall. The
odor on center hall is not consistent.
Observation on 1/30/19, between 5:30 A.M. and 6:00 P.M., showed off and on odors in
resident rooms when residents or staff placed soiled briefs or pull-up in uncovered trash
cans in the bathrooms.
Observation on 1/30/19 at 10:55 a.m., showed an odor in the hallways; upon inspection
soiled briefs were found in resident rooms; such as in resident room [ROOM NUMBER] and
resident room [ROOM NUMBER].
During an interview on 1/30/19, at 2:55 P.M., the Director of Nursing said they really
thought they were managing odors. Bathroom trash cans are residents who provide their own
incontinence needs. She had staff check the rooms and pull the trash which reduced the
odors greatly.
During an interview on 1/30/19, at 3:10 P.M., the Administrator said the resident who
resides in room [ROOM NUMBER] has a medical condition that caused the strong odor of fecal
material and odor. The room is cleaned and deodorized often but she cannot prevent the
odor.