Inspection visit
Health inspection
4 citations recorded
Inspector’s narrative
What the inspector wrote
This survey cited 4 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.
F 0690
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Few
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate
catheter care, and appropriate care to prevent urinary tract infections.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. R11's
Minimum Data Set (MDS) dated [DATE] documents R11 is occasionally incontinent of urine and he is
always incontinent of bowel. R11's MDS dated [DATE] documents R11 has a urinary catheter.
R11's bowel and urinary incontinence care plan did not address providing incontinent care.
On 07/28/22 12:26 PM, V14, CNA, wet three wash cloths with no rinse peri wash and water. V14 wiped the
resident by folding the towel. V14 only wiped the rectal anus area not the buttocks. V14 did not dry the
resident, after cleaning him. R11 was incontinent of feces.
On 7/29/22 at 10:05 AM, V2, DON, stated, During incontinent care, I would expect the CNAs to wipe the
females front to back using soap and wash rags.
Based on interview, observation and record review, the facility failed to provide appropriate catheter care
and complete incontinent care for 2 of 3 residents (R11, R46) reviewed for catheters and incontinence in
the sample of 25.
Findings include:
1. On 07/28/2022 at 10:30 AM, V12, Certified Nurse Aide (CNA), provided catheter and incontinent care for
R46. V12 washed hands prior to giving catheter care. V12 cleansed the right and left side of labia in
downward motions. The catheter tubing had slight amount of feces near insertion site. V12 did not clean the
tubing, the feces remained. V12 rolled R46 over on her right side, feces noted on incontinent pad. V12 used
wet soapy washcloth and cleansed right, and left side of buttocks, then inner buttocks in downward motion
(back to front). Inner thighs were not cleansed in front or back. None of the areas were rinsed or dried. R46
continued having a bowel movement, V12 cleansed buttocks again with wet soapy wash cloth. No areas
were dried during the entire procedure. V12 transferred R46 to her wheelchair. V12 hung the urinary
drainage bag on the wheelchair frame, bag, and tubing touching the floor. V12 did not put urinary drainage
bag in a cover. V12 wheeled R46 to the dining room.
R46's Face Sheet documents medical diagnosis to include Obstructive and reflux uropathy, dementia,
Alzheimer's.
R46's Care Plan, dated Onset: 04/30/2019, documents: I use an indwelling catheter I will experience no
infections from catheter use 12/23/2020
*Ongoing assessment of color, clarity and character of my urine
(continued on next page)
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other
safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the
date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER
REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Facility ID:
If continuation sheet
Page 1 of 5
Event ID:
145909
Printed: 05/15/2026
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
145909
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenville Nursing & Rehab
400 East Hillview Avenue
Greenville, IL 62246
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 0690
*Assess me for symptoms of urinary tract infection (UTI)
Level of Harm - Minimal harm
or potential for actual harm
*Observe me for acute behavioral changes that may indicate UTI
*Change my catheter tubing/bag every ___________
Residents Affected - Few
*Catheter care for me every (Q) shift
*Encourage my fluid intake
*Monitor my catheter tubing for kinks or twists in tubing
*F/C (foley catheter) CARE Q SHIFT. DX (diagnosis): BLADDER OUTLET OBSTRUCTION
*MAY FLUSH F/C BID (twice a day) PRN (as needed), CALL PCP (primary care physician) IF WORSENED
S/S (signs/symptoms) OR UNABLE TO IRRIGATE.
*#18FR (french) WITH 30CC (cubic centimeter) BALLOON CHANGE F/C Q MONTH AND PRN PER
STERILE TECHNIQUE AND POLICY
R46's Physician Order Sheet (POS) dated, 7/25/2022, documents, MAINTAIN #18 FR FOLEY WITH 30CC
BULB. DX: OBSTRUCTIVE AND REFLUX UROPATHY
R46's Physician Order Sheet (POS) dated, 5/15/2022, documents, #18FR WITH 30CC BALLOON
CHANGE F/C Q MONTH AND PRN PER STERILE TECHNIQUE AND POLICY
R46's Lab Report dated, 9/25/2021, documents, Urine Culture, organism - Klebsiella Pneumoniae.
R46's Lab Report dated, 8/12/2021, documents, Urine Culture, organism Escherichia Coli (bacteria
typically found in intestines and feces).
On 07/29/2022 at 10:13 AM, V2, Director of Nursing (DON), stated she expects the CNAs to cleanse the
catheter tubing from the insertion site and four inches downward on tubing.
The facility's Catheter Care, Urinary Policy and Procedure, dated September 2014, documents, The
purpose of this procedure is to prevent catheter-associated urinary tract infections. It continues, Use a
clean washcloth with warm water and soap to cleanse and rinse the catheter from insertion site to
approximately four inches outward.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145909
If continuation sheet
Page 2 of 5
Printed: 05/15/2026
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
145909
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenville Nursing & Rehab
400 East Hillview Avenue
Greenville, IL 62246
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 0755
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a
licensed pharmacist.
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on
observation, interview, and record review, the Facility failed to discard expired medication. This failure has
the potential to affect all 55 residents living in the Facility.
Findings Include:
On [DATE] at 11:19 AM, there was an opened vial of Tuberculin Purified Protein Derivative (Mantoux) dated
[DATE].
On [DATE] at 1:45 PM, V2, DON, stated, I threw away that Tuberculin vial.
On [DATE] at 1:34 PM, V1, Administrator, stated, I heard about the expired Tubersol (Tuberculin) in the med
room. I would expect them to follow our (medication storage) policies.
The Center for Disease Control's Mantoux Tuberculin Skin Test dated [DATE] documents, The label should
indicate the expiration date. If it's been open more than 30 days or the expiration date has passed, the vial
should be thrown away and a new vial used.
The Facility's Storage of Medications Policy with revision date of [DATE] documents, The facility shall not
use discontinued, outdated, or deteriorated drugs or biologicals. All such drugs shall be returned to the
dispensing pharmacy or destroyed.
The Facility's Resident Census and Conditions of Residents (CMS 672) dated [DATE] documents there are
55 residents living in the Facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145909
If continuation sheet
Page 3 of 5
Printed: 05/15/2026
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
145909
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenville Nursing & Rehab
400 East Hillview Avenue
Greenville, IL 62246
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 0812
Level of Harm - Minimal harm
or potential for actual harm
Residents Affected - Many
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve
food in accordance with professional standards.
Based on observation, interview, and record review, the facility failed to ensure food was stored in a manner
which prevents potential contamination. This failure has the potential to affect all 55 residents living in the
facility.
Findings include:
On 7/26/22 at 8:07 AM in the storeroom there were two bags of Italian rolls. Several of the rolls were
covered with green and black spots and were being stored beside other packages of bread products.
On 7/26/22 at 8:09 AM in the small standing freezer there was a gallon size plastic bag full of individually
wrapped burritos with no label or date and a quart size plastic bag of green peas with no label or date.
There were seven plastic bags of broccoli cuts with no label or date and seven vacuum sealed bags of
spinach that were dated, but not labeled.
On 7/26/22 at 8:15 AM in the walk in refrigerator there was a clear three quart tub containing ham,
cucumber, and sliced peppers with no label or date. There was a six quart tub labeled polish sausage with
approximately fifteen sausages inside and use by date of 7/23/22 on label which was three days prior.
There was a gallon freezer bag on the bottom shelf containing approximately fifteen hot dogs that was not
dated, labeled, or sealed, and the hot dogs were open to air. There was a large metal container of liquid
and fruit that was covered in plastic wrap with no label or date. There was a clear container with slices of an
unknown meat that was dated 12/22/21 on the lid in black marker.
On 7/26/22 at 8:27 AM, V5, Dietary Manager, pointed to the container of unknown meat and stated, Those
are pork chops. They are from last night. I will get a label on it. That other container is fruited (gelatin), and
it's for today. I know about the moldy bread. That is sitting there so we can exchange it with our wholesale
company. I have told my staff it is there, and they know not to use it.
On 7/28/22 at 1:34 PM, V1, Administrator, stated, I expect staff to follow our policies.
The Facility's Food Storage (Dry, Refrigerated, and Frozen) Policy dated 2016 documents, All food items
will be labeled. The label must include the name of the food and the date by which it should be sold,
consumed, or discarded. Discard food that has passed the expiration date. Leftover contents of cans and
prepared food will be stored in covered, labeled and dated containers in refrigerators and/or freezers.
The Resident Census and Condition of Residents Form (CMS 672) dated 7/26/2022 documents there are
55 residents living in the facility.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145909
If continuation sheet
Page 4 of 5
Printed: 05/15/2026
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
145909
B. Wing
A. Building
(X3) DATE SURVEY
COMPLETED
07/29/2022
NAME OF PROVIDER OR SUPPLIER
STREET ADDRESS, CITY, STATE, ZIP CODE
Greenville Nursing & Rehab
400 East Hillview Avenue
Greenville, IL 62246
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 0880
Provide and implement an infection prevention and control program.
Level of Harm - Minimal harm
or potential for actual harm
Based on interview, Record Review and observation the facility failed to perform hand hygiene to prevent
the spread of infection for 2 of 25 residents (R11, R46) reviewed for infection control in the sample of 25.
Residents Affected - Few
Findings include:
1. On 07/28/22 at12:26 PM, V14, Certified Nursing Assistant (CNA), provided incontinent care for fecal
incontinence for R11. V14 did not wash his hands before donning gloves, and he did not change gloves
after cleaning feces. V14 then adjusted R11's pillow and pillow case. R11 had a pillow between his legs and
a small amount of stool was on this pillow, and V14 did not clean off or remove the pillow.
On 7/29/22 at 10:05 AM, V2, Director of Nursing (DON), stated During incontinent care, she would expect
them to changed gloves, when the gloves are soiled.
2. On 07/28/2022 at 10:30AM, V12, CNA, provided incontinent care for fecal incontinence for R46. V12 did
not wash hands or use hand sanitizer between glove changes, after incontinent care, or before transferring
R46 to her wheelchair. V12 did not wash hands or use hand sanitizer before leaving the room. V12 wheeled
R46 to the dining room and touched the dining room table.
On, 07/29/2022 at 9:12AM, V2, DON, stated she expects the CNA's to wash hands before care. Wash
hands, or use hand sanitizer between glove changes, after care, and prior to leaving resident's room.
The facility's Handwashing/Hand Hygiene Policy and Procedure dated August 2015, documents,
The facility considers hand hygiene the primary means to prevent the spread of infections.
FORM CMS-2567 (02/99)
Previous Versions Obsolete
Event ID:
Facility ID:
145909
If continuation sheet
Page 5 of 5
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Back to topCitations
4 citations recorded*CMS
What do CMS severity letters mean?
Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.
General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.
Each letter combines severity with scope: how many residents the deficiency affected.
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
F812 - Food safety requirements
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
F880 - Infection Control
Provide and implement an infection prevention and control program.
FAQ · About this visit
Common questions about this visit
What happened during the July 29, 2022 survey of GREENVILLE NURSING & REHAB?
This was a inspection survey of GREENVILLE NURSING & REHAB on July 29, 2022. The surveyor cited 4 deficiencies, recorded on the federal Form 2567 statement of deficiencies.
Were any deficiencies cited at GREENVILLE NURSING & REHAB on July 29, 2022?
Yes, 4 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, an..."
What type of survey was this?
This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.
SourceView on CMS Care Compare
Next steps
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Data from CMS Care Compare public records. Dataset last refreshed . If you believe any information is inaccurate, report it here.