Health inspection·March 26, 2024

F 0602 Protect each resident from the wrongful use of the resident's belongings or money. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review the facility failed to ensure resident's-controlled medications were accounted for and not subjected to misappropriation or diversion for 2 of 6 residents (R3 and R4) reviewed for controlled medications in a sample of 7. This failure has the potential to affect all residents residing at the facility who receive controlled medications. Residents Affected - Few Past Noncompliance: no plan of correction required. This past non-compliance occurred between 03/01/24 and 03/09/24. Findings include: 1. R3's Face Sheet, with an admission date of 01/06/23, documents R3 has diagnoses of but not limited to Acute hematogenous osteomyelitis, left humerus, Gastroesophageal reflux disease (GERD), acute kidney failure, Diabetes Mellitus, chronic pain syndrome, and other specified arthritis. R3's Minimum Data Set, (MDS), dated [DATE], documents R3 is cognitively intact with a Brief Interview for Mental Status, (BIMS), of 15 out of 15. It further documents R3 requires substantial/maximal assistance with oral hygiene, shower/bathe, upper body dressing, bed mobility, dependent with lower body dressing, personal hygiene, transfer, and she is always incontinent of bladder and always continent of bowel. R3's Care Plan, with print date of 03/26/24, documents R3 experiences the presence of frequent pain, goal is to have full pain relief, and interventions are, teach distraction techniques, monitor for worsening of pain symptoms and notify physician of changes, assess pain daily using 1-10 scale, and administer pain medication as needed. R3's Physician's Order, dated 05/28/2023 at 1:34 PM, documents hydrocodone 10 milligrams (mg)-acetaminophen 325 mg tablet:1 tab by mouth (PO) every 4 hours as needed (PRN) for pain. R3's Controlled Drug Record, dated from 02/15/24 through 03/25/24, was reviewed and shows on 03/01/24 at 1:45 AM, R3 was given one tab of her hydrocodone 10mg-acetaminophen 325mg PRN pain medication by V9, Registered Nurse (RN). The pain medication was marked off which then left 43 tablets of R3's PRN pain medication. It also has the date 03/01/24 at 11:45 written underneath the previous entry with just the initials of V3, Licensed Practical Nurse (LPN). The 43 was not marked off, indicating no PRN pain medication was given and there should still be 43 tablets left. R3's Medication Administration Record, (MAR), dated 03/2024, was reviewed and shows R3 received her PRN her hydrocodone 10mg-acetaminophen 325mg pain medication by V9, RN at 1:42 AM on 03/01/24 and (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 3 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 03/26/2024 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)