Original Inspection report

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Immediately tell the resident, the resident’s doctor, and a family member of situations
(injury/decline/room, etc.) that affect the resident.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to contact the physician for the
need to alter treatment due to significant change for two Residents (#31 and #32) of 14
sampled residents. The facility’s census was 52.
1. Record review of Resident #31’s Admission Minimum Data Set (MDS) (a federally mandated
assessment instrument completed by facility staff), dated 9/29/18, showed [DIAGNOSES
REDACTED].
Record review of the resident’s Face Sheet showed a [DIAGNOSES REDACTED].
Record review of the Treatment Administration Record (TAR), dated 11/1/18, showed the
resident had not worn his/her Bi-level Positive Airway Pressure ([MEDICAL CONDITION]) (a
positive air pressure device that helps with breathing) for15 nights.
During an interview on 11/16/18 at 8:47 A.M., the resident said his/her [MEDICAL
CONDITION] mask does not fit properly and blows air out of the bottom of it. He/she
refuses to wear it because it doesn’t fit.
Record review showed the facility failed to notify the physician of the poor fitting mask
and the [MEDICAL CONDITION] not worn as ordered.
During an interview on 11/19/18 at 4:00 P.M., the Director of Nursing (DON) said she would
expect the charge nurse to notify the physician of any problem with the [MEDICAL
CONDITION] mask.
2. Record review of Resident #32’s monthly weight record showed:
– Admission weight on 3/21/18 of 167.2 pounds (lbs);
– (MONTH) (YEAR) weight of 153.4 lbs (9.02% loss in three months);
– (MONTH) (YEAR) weight of 151.4 lbs;
– (MONTH) (YEAR) weight of 149.0 lbs;
– (MONTH) (YEAR) weight of 154.2 lbs;
– (MONTH) (YEAR) weight of 147.6 lbs (4.28% loss in one month);
– (MONTH) (YEAR) weight of 154.6 lbs;
– (MONTH) (YEAR) weight of 147 then re-weight on 11/15/18 of 152.4 lbs.
Record review of the resident’s Nutrition Progress Notes showed:
– On 5/16/18, noted weight loss, will add Med Pass (dietary supplement to increase
calorie intake) at 60 milliliters (ml) three times daily (TID) with medications;
– On 6/20/18, Registered Dietician (RD) discussed weight loss via telephone with Dietary
Manager (DM);
– On 6/13/18, Pro Shake (a nutritional shake with added calories) added with meals twice
daily;
– On 9/12/18 weight of 147.6 lbs, noted 6.8 % weight loss in past month. Will suggest Med
Pass TID;
– On 11/14/18 weight of 147 lbs, weight fluxes, receiving Med Pass TID, preferences
provided and encouraged. No further dietary changes to recommend.
Record review of the resident’s medical record showed a Nutritional Care Form with a list
of residents with dietary issues. The form had faxed to physician on 9/14/18 and had
dietary recommendations related to weight loss for the resident. The form did not show a
follow up response noted. The facility failed to obtain a response or follow up on the
faxed message.
During an interview on 11/16/18 at 2:00 P.M., the Administrator said the physician had
been faxed a recommendation on 9/14/18. There wasn’t any record of physician response and
she will notify the physician today.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0580

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 1)
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Record review on 11/16/18 at 2:30 P.M. of the resident’s Nurse Progress Notes showed
physician made aware of dietary recommendations and weight loss with fluctuations.
Received telephone order for Med Pass 60 ml TID with medications and will weigh weekly.

F 0582

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Give residents notice of Medicaid/Medicare coverage and potential liability for
services not covered.

Based on interview and record review, the facility failed to issue a Notice of Medicare
Non-Coverage (NOMNC) (a required notice to beneficiaries of covered skilled services
ending) when benefits were not exhausted and the resident discharged to home for three
residents (Resident #149, #150, and #151) out of three sampled residents. The facility’s
census was 52.
Record review of Resident #149’s medical record showed:
– Medicare Part A skilled services start date of 6/15/18 and end date of 8/13/18;
– The facility initiated a discharge on 8/8/18 from Medicare Part A Services when benefit
days were not exhausted;
– There was no NOMNC form issued.
Record review of Resident #150’s medical record showed:
– Medicare Part A skilled services start date of 5/10/18 and end date of 6/8/18;
– The facility initiated a discharge on 6/9/18 from Medicare Part A Services when benefit
days were not exhausted;
– There was no NOMNC form issued.
Record review of Resident #151’s medical record showed:
– Medicare Part A skilled services start date of 6/8/18 and end date of 9/23/18;
– The facility initiated a discharge on 9/17/18 from Medicare Part A Services when benefit
days were not exhausted;
– There was no NOMNC form issued.
During an interview on 11/16/18 at 2:33 P.M., the Social Services Director said she was
not aware that this form should be completed when a resident’s benefits have not been
exhausted.
During an interview on 11/19/18 at 3:00 P.M., the Administrator said she wasn’t aware the
correct form wasn’t being utilized, but would make sure it is in the future.
The facility did not provide a policy.

F 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Not transfer or discharge a resident without an adequate reason; and must provide
documentation and convey specific information when a resident is transferred or
discharged.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to ensure discharge/transfer
documentation was completed to include reasons for the discharge/transfer, discharge plan
and notification of the resident’s responsible party for one sampled resident (Resident
#48), who was discharged to the hospital, out of three sampled closed records and 14

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0622

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 2)
sampled residents. The facility’s census was 52.
Record review of the resident’s Physician’s Order Sheet, dated 9/5/18, showed:
– admitted on [DATE] with rehabilitation to home;
– [DIAGNOSES REDACTED].
Record review of the resident’s Initial Admission Note, dated 9/9/18, showed Add note:
Resident was dcd (discharged ) today to the hospital.
Record review of the resident’s nurse’s notes, dated 9/5/18 through 9/9/18, showed no
documentation of reason for hospital transfer, the hospital transfer notice, or the bed
hold policy.
During an interview on 11/28/18 at 3:35 P.M., the Administrator said:
– The resident had an infection and the family wanted the resident to be transferred to
the hospital;
– The family chose to take the resident home rather than return to the facility upon
hospital discharge.
Record review of the facility policy titled, Resident Transfer/Discharge, Immediate
Discharge, and Therapeutic Leave Policy, dated 5/28/18, showed:
– Before any resident is transferred or discharged under a facility-initiated transfer or
discharge, the facility must notify the resident and the resident representative the
reason for the transfer or discharge in writing in a manner they understand;
– Consent to or agreement with the discharge or transfer means that the resident or their
legally authorized representative has consented to or agreed with the transfer or
discharge;
– Any consent shall be documented in the medical record;
– When a resident is transferred or discharged , the resident’s attending physician must
document the medical record with the reason for the transfer/discharge;
– The facility shall provide sufficient preparation and orientation to ensure that the
resident has a safe and orderly transfer or discharge. This includes informing the
resident where he or she is going and taking steps to minimize anxiety.

F 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide timely notification to the resident, and if applicable to the resident
representative and ombudsman, before transfer or discharge, including appeal rights.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to notify in writing the
resident and/or family or legal representative of a facility-initiated transfer to the
hospital for five residents (Resident #2, #37, #42, #44, and #45) out of 14 sampled
residents and one closed record for Resident #48. The facility’s census was 52.
1. Record review of the facility’s policy titled Resident Transfer/Discharge, Immediate
Discharge, and Therapeutic Leave Policy, dated 5/28/18, showed before any resident is
transferred or discharged under a facility-initiated transfer or discharge, the facility
must notify the resident and the resident representative the reason for the transfer or
discharge in writing in a manner they understand.
2. Record review of Resident #2’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the resident’s transfer to the hospital.
3. Record review of Resident #37’s medical record showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0623

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 3)
– Resident was transferred to the hospital on [DATE], readmitted on [DATE];
– The resident was transferred to the hospital again on 9/24/18 and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the resident’s transfer to the hospital.
4. Record review of Resident #42’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the resident’s transfer to the hospital.
5. Record review of Resident #44’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the resident’s transfer to the hospital.
6. Record review of Resident #45’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– The resident was transferred to the hospital again on 10/5/18 and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the resident’s transfer to the hospital.
7. Record review of Resident #48’s medical record showed:
– Resident was transferred to the hospital on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the resident’s transfer to the hospital.
8. During an interview on 11/16/18 at 2:30 P.M., the Administrator said they were not
aware they had to notify the resident and the resident’s representative in writing before
transfer to the hospital.

F 0624

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Prepare residents for a safe transfer or discharge from the nursing home.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to prepare and orientate one
resident (Resident #48) for a discharge to the hospital, out of three sampled closed
records and 14 sampled residents. The facility’s census was 52.
Record review of Resident #48’s Physician’s Order Sheet, dated 9/5/18, showed:
– admitted on [DATE];
– [DIAGNOSES REDACTED].
– admitted for rehab to home.
Record review of the resident’s Initial Admission Note, dated 9/9/18, showed Add note:
Resident was dcd (discharged ) today to the hospital.
Record review of the resident’s nurse’s notes, dated 9/5/18 through 9/9/18, showed no
documentation of reason for hospital transfer, transfer/discharge teaching, hospital
transfer notice, or bed hold policy.
During an interview on 11/28/18 at 3:35 P.M., the Administrator said:
– The resident had an infection and the family wanted the resident to be transferred to
the hospital;
– The family chose to take the resident home rather than return to the facility upon
hospital discharge.
Record review of the facility policy titled, Resident Transfer/Discharge, Immediate
Discharge, and Therapeutic Leave Policy, dated 5/28/18, showed:

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0624

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 4)
– Consent to or agreement with the discharge or transfer means that the resident or their
legally authorized representative has consented to or agreed with the transfer or
discharge;
– Any consent shall be documented in the medical record;
– The facility shall provide sufficient preparation and orientation to ensure that the
resident has a safe and orderly transfer or discharge. This includes informing the
resident where he or she is going and taking steps to minimize anxiety;
– Orientation should be documented in the medical record including the resident’s
understanding regarding the transfer or discharge.

F 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Notify the resident or the resident’s representative in writing how long the nursing
home will hold the resident’s bed in cases of transfer to a hospital or therapeutic
leave.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to inform the resident and
family or legal representative of their bed hold policy at the time of transfer to the
hospital for five residents (Resident #2, #37, #42, #44, and #45) out of 14 sampled
residents and one closed record for Resident #48. The facility’s census was 52.
1. Record review of Resident #2’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
2. Record review of Resident #37’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE], and again
on 9/24/18 and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
3. Record review of Resident #42’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
4. Record review of Resident #44’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
5. Record review of Resident #45’s medical record showed:
– Resident was transferred to the hospital on [DATE] and readmitted on [DATE], again on
9/19/18 and readmitted on [DATE], and again on 10/5/18 and readmitted on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
6. Record review of Resident #48’s closed record showed:
– Resident was transferred to the hospital on [DATE];
– No documentation of a letter notifying the resident or the resident’s representative of
the facility’s bed hold policy before transfer to the hospital.
7. During an interview via email on 11/15/18, the Administrator said they give the bed
hold policy on admission, not with each hospitalization .

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0625

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0655

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Create and put into place a plan for meeting the resident’s most immediate needs within
48 hours of being admitted

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop and implement a
baseline care plan (plan for immediate needs) within 48 hours of admission which included
the minimum healthcare information necessary to properly care for the immediate needs of
one residents (Resident #31) out of 14 sampled residents. The facility’s census was 52.
Record review of Resident #31’s Admission Minimum Data Set (MDS) (a federally mandated
assessment instrument required to be completed by facility staff), dated 9/29/18, showed
[DIAGNOSES REDACTED].
Record review of the resident’s Face Sheet showed a [DIAGNOSES REDACTED].
Record review of the Treatment Administration Record, showed Bi-level Positive Airway
Pressure ([MEDICAL CONDITION]) (a positive air pressure device which helps with breathing)
to be worn at bedtime with a start date of 9/18/18.
Record review of the resident’s Initial Care Plan, dated 9/18/18, showed [MEDICAL
CONDITION] not marked as an area of concern.
During an interview on 11/19/18 at 5:15 P.M., the MDS Coordinator said she would expect
the baseline care plan to include [MEDICAL CONDITION] and oxygen therapy if the nurse knew
about it on admission.
The facility did not provide a policy for Baseline Care Plans.

F 0656

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Develop and implement a complete care plan that meets all the resident’s needs, with
timetables and actions that can be measured.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to develop and implement a care
plan with specific interventions for eleven residents (Resident #2, #11, #24, #26, #30,
#31, #32, #37, #43, #44, and #45) out of 14 sampled residents. The facility’s census was
52.
1. Record review of the facility’s policy titled Comprehensive Care Plans, dated 4/6/17,
showed:
– The Facility must develop a comprehensive care plan for each resident that includes
measurable objectives and timetables to meet a resident’s medical, nursing, and mental and
psychosocial needs that are identified in the comprehensive assessment;
– 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 setting;
– Evaluating treatment objectives and outcomes of care;
– Respecting the resident’s right to refuse treatment;
– Offering alternative treatments;
– Using an interdisciplinary team approach to care plan development to improve the
resident’s functional status;

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 – Some

(continued… from page 6)
– 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, and;
– Addressing additional care planning areas that could be considered in the facility
setting, and;
– Utilizing the Care Area Assessment Summary (CAAS) 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 objective will be measurable and corroborate with the resident’s own goals
and wishes when appropriate.
2. Record review of Resident #2’s (MONTH) (YEAR) physician’s orders [REDACTED].
Record review of the resident’s Significant Change Minimum Data Set (MDS) (a federally
mandated assessment instrument required to be completed by facility staff), dated 8/6/18,
showed:
– [DIAGNOSES REDACTED].>- Activities to be very important.
Record review of the resident’s comprehensive care plan, dated 11/6/18, showed no care
plan for dementia, urinary catheter care, or activities.
3. Record review of Resident #11’s (MONTH) (YEAR) POS, showed:
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s Quarterly MDS, dated [DATE], showed frequent, moderate
pain.
Record review of the resident’s comprehensive care plan, dated 8/16/18, showed no care
plan for pain.
4. Record review of Resident #24’s (MONTH) (YEAR) POS, showed orders for wound care to
coccyx.
Record review of the resident’s significant change MDS, dated [DATE], showed:
– One Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow
open ulcer with a red pink wound bed);
– Activities to be very important.
Record review of the resident’s comprehensive care plan, dated 11/3/18, showed no care
plan for wound care or activities.
5. Record review of Resident #26’s admission MDS, dated [DATE], showed activities to be
very important.
During an interview on 11/14/18 at 10:39 A.M., the resident said they don’t do too much,
sometimes on Sundays they have church and they played bingo today. He/she would like to do
more.
Record review of the resident’s comprehensive care plan, dated 11/6/18, showed no care
plan for activities.
6. Record review of Resident #30’s admission MDS, dated [DATE], showed:
– Activities to be very important;
– Moisture Associated Skin Damage.
Record review of the resident’s (MONTH) (YEAR) POS, showed an order for
[REDACTED].>Record review of the resident’s comprehensive care plan, dated 9/18/18,
showed the staff did not update the care plan to address wound care.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 – Some

(continued… from page 7)
During an interview on 11/14/18 at 11:00 A.M., the resident said he/she wishes there were
more things to do like crafts. It is boring here.
Record review of the resident’s comprehensive care plan, dated 9/18/18, showed no care
plan for activities.
7. Record review of Resident #31’s (MONTH) (YEAR) POS, showed an order for [REDACTED].
Record review of the resident’s comprehensive care plan, dated 9/18/18, showed no care
plan for oxygen therapy or [MEDICAL CONDITION] care.
Record review of the resident’s admission MDS, dated [DATE], showed activities as very
important.
Record review of the resident’s comprehensive care plan, dated 9/18/18, showed no care
plan for activities.
During an interview on 11/14/18 at 11:15 A.M., the resident said we need more than bingo.
We are not allowed to go to church on Sundays because it is only for the people on the
unit.
8. Record review of Resident #32’s monthly record of weights showed:
– Admission weight on (MONTH) 21, (YEAR) of 167.2 pounds (lbs);
– (MONTH) (YEAR), 168.6 lbs;
– (MONTH) (YEAR), 153.4 lbs;
– (MONTH) (YEAR), 151.4 lbs;
– (MONTH) (YEAR), 149 lbs;
– (MONTH) (YEAR), 154.3 lbs;
– (MONTH) (YEAR), 147.6 lbs;
– (MONTH) (YEAR), 154.6 lbs;
– (MONTH) (YEAR), 147 lbs;
– (MONTH) (YEAR), re weight of 152.4 lbs.
Record review of the resident’s nutrition progress notes showed:
– (MONTH) 8, (YEAR), Resident does not eat much at meals;
– (MONTH) 16, (YEAR), Noted weight loss in Resident;
– (MONTH) 20, (YEAR), More weight loss noted in Resident, Pro Shake (a dietary
supplement) added with meals twice daily;
– (MONTH) 12, (YEAR), Noted 6.8 lb. weight loss over past month;
– (MONTH) 14, (YEAR), weight fluxes, receiving Med Pass (a nutritional supplement) three
times daily for extra calories.
Record review of the resident’s care plan, last updated 10/02/18, showed weight loss not
addressed in the care plan.
9. Record review of Resident #37’s (MONTH) (YEAR) POS, showed:
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
Record review of the resident’s comprehensive care plan, dated 11/11/18, showed no care
plan for oxygen.
10. Record review of Resident #43’s (MONTH) (YEAR) POS, showed:
– [DIAGNOSES REDACTED].>- an order written [REDACTED].M. and 500 mg at bedtime for
[MEDICAL CONDITION].
Record review of the resident’s comprehensive care plan, updated 11/10/18, showed no care
plan for [MEDICAL CONDITION].
11. Record review of Resident #44’s (MONTH) (YEAR) POS, showed:
– [DIAGNOSES REDACTED]. Symptoms are worse at the end of the day and may produce [MEDICAL
CONDITION]);
– an order written [REDACTED].
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 – Some

(continued… from page 8)
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s significant change MDS, dated [DATE], showed activities
very important to the resident.
Record review of the resident’s comprehensive care plan, dated 10/20/18, showed no care
plan for depression, anxiety, [MEDICAL CONDITION], or activities.
12. Record review of Resident #45’s (MONTH) (YEAR) POS, showed:
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].M. to 8:00 P.M.;
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s significant change MDS, dated [DATE], showed:
– The resident to be on regular and as needed (PRN) pain medications;
– Unstageable pressure ulcer;
– Activities to be very important.
Observation on 11/14/18 at 3:12 P.M. showed the resident:
– Yelled out and cursed during care;
– Wore a brace around his/her torso, removed by Certified Nurse Aide (CNA) to do care.
During an interview on 11/14/18 at 3:15 P.M., Licensed Practical Nurse (LPN) A, CNA B and
Nurse Aide (NA) C said the resident yells every time he/she is touched.
Record review of the resident’s comprehensive care plan, dated 10/31/18, showed no care
plan for a brace, pain, wound care, pressure ulcer prevention, or activities.
12. During an interview on 11/19/18 at 5:00 P.M., the MDS Coordinator said she would
expect all areas, (such as oxygen, pain, activities of daily living, nutrition,
activities, pressure injuries, depression, anxiety, [MEDICAL CONDITIONS] and weight loss)
that trigger or cause issues to be care planned. She would care plan side effects of
medications within other other care plans, not a separate care plan.

F 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Develop the complete care plan within 7 days of the comprehensive assessment; and
prepared, reviewed, and revised by a team of health professionals.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to revise and
update comprehensive care plans with specific interventions to meet the individual needs
of one resident (Resident #44) out of 14 sampled residents. The facility’s census was 52.
Record review of Resident #44’s (MONTH) (YEAR) physician’s orders [REDACTED].
– Weekly weights;
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s Registered Dietician’s (RD) Nutrition Progress Notes
showed:
– On /17/18, noted weight loss in resident. Will put on weekly weights;
– On 9/2/18, noted six pound (lb) weight loss in resident over the past month. Med pass

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0657

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 9)
three times daily and [MEDICATION NAME] to help increase appetite.
Record review of the resident’s Minimum Data Set (MDS) (a federally mandated assessment
instrument completed by facility staff), showed:
– Significant change MDS, dated [DATE], resident’s weight as 146 pounds (lbs);
– Significant change MDS, dated [DATE], resident’s weight as 137 lbs (6.1% loss in less
than 30 days).
Record review of the resident’s comprehensive care plan, last updated 10/20/18, showed:
– Weight is fairly stable at this time;
– Weigh monthly.
During an interview on 11/19/18 at 5:00 P.M., the MDS Coordinator said she would expect
all areas, such as oxygen, pain, activities of daily living, nutrition, activities,
pressure injuries, depression, anxiety, [MEDICAL CONDITIONS] and weight loss, that trigger
or cause issues to be care planned. She updates and reflects changes in condition as soon
as she is told.

F 0658

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

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

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to follow physician’s orders for
four residents (Resident #17, #30, #31, and #44) out of 14 sampled residents. The
facility’s census was 52.
1. Record review of Resident #17’s (MONTH) (YEAR) Physician’s Order Sheet (POS), showed:
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].= 3 u; BS 201-250 = 6 u; 251-300 = 9 u; 301-350 = 12 u;
350-400 = 15 u; greater than 400 = call physician) as directed.
Observation on 11/14/18 at 12:30 P.M. showed the resident eating lunch.
Observation on 11/14/18 at 1:43 P.M., showed Certified Medication Technician (CMT) D
performed a finger stick blood sugar test, then administered 7 u of [MEDICATION NAME].
Record review of the Medication Administration Record [REDACTED]
– ProAir three doses missed on 11/14/18 and three doses on 11/15/18, one morning dose
missed on 11/16/18;
– Three doses of [MEDICATION NAME] missed on 11/14/18.
During an interview on 11/14/18 at 1:45 P.M., CMT D said:
– They have a one hour window of time to give medication, so he/she does not think it is a
problem to check a resident’s blood sugar after meals instead of before because they still
get their insulin on time;
– The resident’s inhaler is not available. He/she ordered it from the pharmacy on 11/13/18
but it has not arrived to the facility;
– He/she administered the last available dose of [MEDICATION NAME] during the morning

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 – Some

(continued… from page 10)
medication pass and there isn’t any available.
During an interview on 11/16/18 at 7:54 A.M., the Administrator said she would expect to
be notified if a resident is out of a medication so that there are no missed doses. The
[MEDICATION NAME] is in the facility now and she will notify the pharmacy today to get the
ProAir.
During an interview on 11/16/18 8:24 A.M., the Administrator said she talked with the
pharmacy and Resident #17’s insurance no longer covers ProAir but they will cover
[MEDICATION NAME] (a medication that relaxes muscles in the airways and increases air flow
to the lungs). The pharmacy claims they notified the facility but the Administrator said
they did not. The [MEDICATION NAME] will be in the building today.
2. Record review of Resident 30’s (MONTH) (YEAR) POS, showed:
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].= zero u; 131-240 = 4 u; 241-300 = 10 u; 301-350 = 12 u;
351-400 = 16 u; 401-450 = 25 u; 451-500 = 30 u.
Observation on 11/14/18 at 12:30 P.M. showed the resident eating lunch.
Observation on 11/14/18 at 1:43 P.M. showed CMT D performed a finger stick blood sugar
test and administered 4 u of [MEDICATION NAME].
During an interview on 11/19/18 at 5:15 P.M., the Director of Nursing (DON) said she would
expect finger stick blood sugar to be checked prior to meals if that is how it is ordered
because it could affect the sliding scale insulin dose.
3. Record review of Resident #31’s (MONTH) (YEAR) POS, dated showed:
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
During an interview on 11/16/18 at 8:47 A.M., the resident said the [MEDICAL CONDITION]
mask does not fit and he/she won’t wear it because it blows air out of the bottom of it.
Record review of the resident’s (MONTH) (YEAR) Treatment Administration Record (TAR)
showed the resident has not worn the [MEDICAL CONDITION] for 15 nights.
Record review of the resident’s medical record showed the facility failed to notify the
physician that the resident does not wear his/her [MEDICAL CONDITION] as ordered.
During an interview on 11/19/18 at 5:15 P.M., the DON said she would expect the charge
nurse to notify the physician that the resident is not using the [MEDICAL CONDITION]
system as ordered.
4. Record review of Resident #44’s (MONTH) (YEAR) POS, showed:
– [DIAGNOSES REDACTED].
– Cardiac diet since 4/17/18;
– House shakes (supplemental shakes) three times daily since 10/10/18;
– Weekly Weights.
Record review of the resident’s Nutrition Progress Notes, dated 1/17/18, showed:
– Noted weight loss in resident;
– Will put on weekly weights.
Record review of the resident’s monthly weight record showed the resident being weighed
monthly instead of weekly.
During an interview on 11/19/18 at 4:00 P.M., the DON said she would expect physician’s
orders to be followed as they are written. If a resident was an order for [REDACTED].
5. Record review of the facility’s policy titled Blood Glucose Monitoring, dated 4/6/17,
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 – Some

(continued… from page 11)
showed:
– The blood sugar monitoring/accucheck orders will be obtained from the physician,
including the recommended time and frequency of the monitoring;
– At the scheduled time, the Licensed Nurse/ Insulin Certified Certified Medication
Technician (CMT) will complete the blood sugar/accucheck.
6. Record review of the facility’s policy titled Medication Administration and Monitoring,
dated 4/6/17, showed:
– Medications are to be given per doctors’ orders;
– The nurse or CMT should note if the medication is refused or not available;
– The DON or Registered Nurse (RN) designee will be notified immediately regarding the
resident not receiving the medication;
– It will then become the DON or RN responsibility to ensure that the medication is
received and that the Licensed Practical Nurse (LPN) or CMT distributes the medication to
the resident;
– The back-up pharmacy or primary pharmacy will be notified and medication will be
received;
– The physician will be notified if medication is given late and the nurse’s notes will
indicate why medication has a discrepancy;
– This will include not only medications, but treatments as well as examples (eye/ear
ointment/drops, elastic anti-embolism hose, creams, inhalers, dressings, etc.).

F 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide activities to meet all resident’s needs.

Based on observation, interview and record review, the facility failed to provide an
ongoing program of activities designed to meet the interests of each resident. This
practice affected six residents (Resident #11, #26, #30, #31, #42, and #43) out of 14
sampled residents and one resident (Resident #28) outside the sample and had potential to
affect all the residents in the facility. The facility’s census was 52.
1. Record review of the facility’s (MONTH) (YEAR) Activity Calendar showed:
– On 11/14/18, The Main Unit-at 8:45 A.M., Concerns; 9:30 A.M., Bingo; 10:30 A.M. Exercise
and Fitness; 3:00 P.M., Bible Study; 7:00 P.M. Greenville Baptist;
– On 11/14/18, The Behavioral Unit-8:45 A.M., Concerns; 9:30 P.M., Bingo; 11:00 A.M.,
Exercise and Fitness; 2:00 P.M., World Day of Diabetes Day Update; 7:00 P.M., Greenville
Baptist;
– On 11/16/18, The Main Unit-8:45 A.M., Concerns; 9:30 A.M., Bingo; 3:00 to 6:00 P.M.,
Setting Up For Dinner; 6:00 to 8:00 P.M., Thanksgiving Dinner;
– On 11/16/18, The Behavoral Unit-8:45 A.M., Concerns; 9:30 A.M., Bingo; 11:00 A.M.,
Stress Management and Lower Back Pain; 2:00 P.M., WOF Safety and Security; 3:00 to 6:00
P.M., Preparing For Dinner; 6:00 to 8:00 P.M., Thanksgiving Dinner;
– On 11/19/18, The Main Unit-8:45 A.M., Concerns; 9:30 A.M., Bingo; 11:00 A.M.,
Alzheimer’s Awareness; 2:00 P.M., Crafts; 3:00 P.M., Bean Quiz;
– On 11/19/18, The Behavioral Unit-8:45 A.M., Concerns; 11:00 A.M., Dressing For The Job;
2:00 P.M., Alzheimer’s Awareness; 3:00 P.M., Bean Quiz.
During an interview on 11/14/18 at 10:39 A.M., Resident #26 said they don’t do too much,
sometimes on Sundays they have church and they played bingo today. He/she would like to do
more.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 12)
During an interview on 11/14/18 at 11:00 A.M., Resident #30 said he/she wishes there were
more things to do like crafts. It is boring here.
During an interview on 11/14/18 11:15 A.M., Resident #31 said he/she needs more than
bingo. We are not allowed to go to church on Sundays because it is only for the people on
the unit.
During a resident group interview on 11/16/18 at 9:10 A.M., Resident #28 said they got to
go to the movies and the zoo, but he/she wished they had more activities.
During an interview on 11/16/18 at 2:03 P.M., the Activity Director said she did not have
Bingo today because the State Agency was using the dining room for Resident Council (from
9:10 A.M.-9:50 A.M.) but she would make it up another day and surprise the residents.
Observation on 11/19/18 at 11:40 A.M., showed four residents sitting at the nurse’s
station in wheelchairs.
Observation on 11/19/18 at 2:35 P.M., showed seven residents on the locked unit
participating in Alzheimer’s Awareness Activity. The main unit did not have activities
going on for the residents as scheduled.
Observation on 11/19/18 at 3:11 P.M. showed seven residents on the locked unit in the
commons area and some with cards. The activity schedule showed Bean Quiz as activity for
both locked and unlocked units. The main unit without activities going on for the
residents as scheduled.
During an interview on 11/19/18 at 11:15 A.M., the Activity Director said there was a
conflict on the schedule due to having activities for both the main unit and locked unit.
Only the locked unit had activities during this time.
2. Record review of Resident #42’s comprehensive care plan, last updated 11/10/18, showed:
– Activities to visit with resident and assist with selection of activity to attend;
– Post Activities calendar in resident room and circle activities that are of interest to
resident.
During an interview on 11/19/18 at 11:30 A.M., Resident #42 said they only play Bingo and
nothing else on the calendar.
3. Record review of Resident #11’s comprehensive care plan, last updated 8/16/18, showed:
– Activities to visit with resident and assist with selection of activity to attend;
– Post Activities calendar in resident room and circle activities that are of interest to
resident.
4. Record review of Resident #43’s comprehensive care plan, last updated 11/10/18, showed:
– Activities to visit with resident and assist with selection of activity to attend;
– Post Activities calendar in resident room and circle activities that are of interest to
resident.
5. Observation on 11/19/18 at 2:30 P.M. showed:
– No Activity calendar posted in Resident #11’s room;
– No Activity calendar posted in Resident #42’s room;
– No Activity calendar posted in Resident #43’s room.
6. During an interview on 11/19/18 at 2:35 P.M., Certified Nurse Aide (CNA) E said the
residents had activities in the dining room or commons area but there was no specified
activities room. He/she said some residents just do things in their room.
During an interview on 11/19/18 at 5:00 P.M., the Administrator said she would expect
activities to be tailored to meet the resident’s preferences and to occur as scheduled.
7. Record review of the facility’s policy titled Activity, undated, showed the purpose is
to ensure that all residents in the facility are provided an on going program of
activities designed to meet, in accordance with the comprehensive assessment, their
interests and their physical, mental and psychosocial well being.
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0679

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

F 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to ensure that a
resident received care to prevent and promote healing of pressure ulcers for one resident
(Resident #24) out of 14 sampled residents. The facility’s census was 52.
Record review of Resident #45’s significant change Minimum Data Set (MDS) (a federally
mandated comprehensive assessment tool completed by the facility staff), dated 8/26/18,
showed:
– At risk of pressure ulcer;
– Urinary catheter;
– Always incontinent of bowel;
– One Stage II pressure ulcer (partial thickness loss of dermis presenting as a shallow
open ulcer with a red pink wound bed).
Record review of the resident’s (MONTH) (YEAR) physician’s orders [REDACTED].
Observation on 11/16/18 12:10 P.M., showed a wound to coccyx approximately 2 to 3
centimeters (cm), round, open red area, without a dressing.
During an interview on 11/16/18 at 12:15 P.M., Licensed Practical Nurse (LPN) G said the
Treatment Administration Record (TAR) showed wound healed, no wound care. She said she
would fax an order to the physician to tell him it was not healed and to get orders.
Record review of the resident’s Nutrition Progress Note, dated 10/18/18, showed resident
has a decub to coccyx that is treated per nursing and healing. No dietary change to
recommend at this time.
Record review of the TAR, dated (MONTH) (YEAR), showed the wound to be healed on (MONTH)
28, (YEAR).
Record review of the resident’s nurse progress notes, dated 10/28/18 through 11/3/18,
showed no notes regarding the wound.
Record review of the resident’s Comprehensive Care Plan, updated 11/3/18, showed the care
plan not updated for healed or Stage II pressure ulcer.
Record review of the resident’s nurse progress notes, dated 11/7/18, 11/8/18, and
11/14/18, showed dressing dry and intact to coccyx. Note dated 11/7/18 showed complaints
of pain to coccyx.
Record review of the resident’s skin assessments, dated 10/23/18 through 11/13/18, showed
a wound to the coccyx 2 cm in length and 1 cm in width with granulation (pink tissue
beginning to heal), treated with [MEDICATION NAME] (a product used to manage wounds),
cover with island dressing (an absorbent pad).
Record review showed physician order [REDACTED].
During an interview on 11/19/18 at 10:25 A.M., LPN I said he/she marked the wound as
healed on 10/28/18 because it was no longer open, it was superficial so they began putting
[MEDICATION NAME] ointment on it. He/she did not notify the physician because they had the
order for [MEDICATION NAME] as needed. He/she said it was not opened the last time he/she
worked and looked at it, it doesn’t look any different than it did when he/she marked it
healed but he/she hasn’t worked for days. He/she has worked in (MONTH) and did not note
any change in the wound. The resident is supposed to be turned every 2 hours, but he/she
will not say that he is turned every 2 hours. The resident likes to be up most of the
time. There is a pressure relieving pillow on his/her wheelchair.
During observation on 11/19/18 at 4:04 P.M., the resident lay on his/her back in bed,

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0686

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 14)
wound care provided by LPN I and observed by the Administrator. Wound measured 3.8 x 2.4
cm with a peeling scab with red to purple colored area approximately 5 x 6 cm around
wound.
During an interview on 11/19/18 at 4:05 P.M., LPN I said the wound did not look like that
on 11/16/18. He/she said it was only a pink area.
Record review of the facility’s policy titled Pressure Ulcers, dated 4/6/17, showed:
– A pressure ulcer is defined as an area of skin breakdown that develops when the skin and
soft tissue is squeezed between the bones and the surface that is within contact of the
body;
– Stage II is superficial ulceration of the skin, appearing as an abrasion, a blister, or
a crater, partial thickness skin loss;
– Upon admission, weekly and as needed, the resident will have a skin assessment completed
by licensed nursing personnel;
– Residents that present with a stage II pressure area can have the following implemented
but not limited to:
– Notification of the Interdisciplinary Team;
– Pressure relieving device;
– Turn and repositioning schedule.

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**
Based on observation, interview, and record review, the facility failed to discontinue an
indwelling urinary catheter (a tube inserted in the bladder to drain urine) as soon as
clinically warranted for one resident (Resident #2) out of 14 sampled residents. The
facility’s census was 52.
Record review of Resident #2’s (MONTH) (YEAR) physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– Catheter Care every shift starting on 10/26/18;
– an order written [REDACTED].
Record review of the resident’s nurse progress notes showed:
– Dated 10/31/18, showed an order for [REDACTED].>- Dated 11/5/18, showed physician
made rounds with new orders written;
– No notes documented after 11/5/18.
Observation on 11/14/18 at 10:30 A.M., showed the resident to have an urinary catheter
which drained to a bag.
During an interview on 11/16/18 at 9:25 A.M., the Director of Nursing (DON) said the
resident does have a catheter and she would find out why it had not been removed.
Observation on 11/19/18 at 4:37 P.M., showed the resident sat in a wheelchair in the
hallway without a catheter.
During interview on 11/19/18 at 4:38 P.M., Licensed Practical Nurse (LPN) I said he/she
removed the catheter on 11/14/18 and the resident is voiding without difficulty.
Record review of the facility’s Nurse Schedule showed LPN I was not scheduled to work on
11/14/18.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 15)
During an interview on 11/29/18 at 12:10 P.M., the Administrator said they do not keep
assignment sheets, they use a dry erase board for assignments. The schedule is accurate.

F 0755

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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 ensure the
pharmacy delivered one resident’s (Resident #17) ProAir Inhaler (a medication that relaxes
muscles in the airways and increases air flow to the lungs) and [MEDICATION NAME] (a
medication used to reduce blood ammonia levels) to the facility out of 14 sampled
residents. The facility’s census was 52.
Record review of Resident #17’s (MONTH) (YEAR) Physicians Order Sheet (POS), showed:
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s Medication Administration Record [REDACTED]
– Three ProAir doses missed on 11/14/18 and three doses on 11/15/18, one morning dose
missed on 11/16/18;
– Three doses of [MEDICATION NAME] missed on 11/14/18.
During an interview on 11/14/18 at 1:45 P.M., Certified Medication Technician (CMT) D
said:
– The resident’s inhaler is not available, he/she ordered it from the pharmacy on
11/13/18, but it has not arrived to the facility;
– He/she administered the last available dose of [MEDICATION NAME] during the morning
medication pass, there isn’t any available.
During an interview on 11/16/18 at 7:54 A.M., the Administrator said she would expect to
be notified if a resident is out of a medication so that there are no missed doses. The
[MEDICATION NAME] is in the facility now and she will notify the pharmacy today to get the
ProAir.
During an interview on 11/16/18 8:24 A.M., the Administrator said she talked with the
pharmacy and Resident #17’s insurance no longer covers ProAir but they will cover
[MEDICATION NAME] (a substitute medication for ProAir). The pharmacy claims they notified
the facility but the Administrator said they did not. The [MEDICATION NAME] will be in the
building today.
Record review of the facility’s policy titled Medication Administration and Monitoring,
dated 4/6/17, showed:
– Medications are to be given per doctors’ orders;
– The nurse or CMT should note if the medication is refused or not available;
– The Director of Nursing (DON) or Registered Nurse (RN) designee will be notified
immediately regarding the resident not receiving the medication;
– It will then become the DON or RN responsibility to ensure that the medication is
received and that the Licensed Practical Nurse (LPN) or CMT distributes the medication to
the resident;
– The back-up pharmacy or primary pharmacy will be notified and medication will be
received;
– The physician will be notified if medication is given late and the nurse’s notes will

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 – Few

(continued… from page 16)
indicate why medication has a discrepancy;
– This will include not only medications but treatments as well as examples (eye/ear
ointment/drops, elastic anti-embolism hose, creams, inhalers, dressings, etc.).

F 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure medication error rates are not 5 percent or greater.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview, and record review, the facility failed to maintain an
error rate of less than five percent (%) when medications were given. There were 27
opportunities with two errors made, for an error rate of 7.41%. This affected one resident
(Resident #17) and had the potential to affect all residents. The facility’s census was
52.
Record review of Resident #17’s (MONTH) (YEAR) physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
Record review of the resident’s Medication Administration Record [REDACTED]
– Three ProAir doses missed on 11/14/18 and three doses on 11/15/18, one morning dose
missed on 11/16/18;
– Three doses of [MEDICATION NAME] missed on 11/14/18.
During an interview on 11/14/18 at 1:45 P.M., Certified Medication Technician (CMT) D
said:
– The resident’s inhaler is not available, he/she ordered it from the pharmacy on 11/13/18
but it has not arrived to the facility;
– He/she administered the last available dose of [MEDICATION NAME] during the morning
medication pass, there isn’t any available.
During an interview on 11/16/18 at 7:54 A.M., the Administrator said she would expect to
be notified if a resident is out of a medication so that there are no missed doses. The
[MEDICATION NAME] is in the facility now and she will notify the pharmacy today to get the
ProAir.
During an interview on 11/16/18 8:24 A.M., the Administrator said she talked with the
pharmacy and Resident #17’s insurance no longer covers ProAir but they will cover
[MEDICATION NAME] (a substitute medication for ProAir). The pharmacy claims they notified
the facility but the Administrator said they did not. The [MEDICATION NAME] will be in the
building today.
Record review of the facility’s policy titled Medication Administration and Monitoring,
dated 4/6/17, showed:
– Medications are to be given per doctors’ orders;
– The nurse or CMT should note if the medication is refused or not available;
– The Director of Nursing (DON) or Registered Nurse (RN) designee will be notified
immediately regarding the resident not receiving the medication;
– It will then become the DON or RN responsibility to ensure that the mediation is
received and that the Licensed Practical Nurse (LPN) or CMT distributes the medication to
the resident;
– The back-up pharmacy or primary pharmacy will be notified and medication will be
received;
– The physician will be notified if medication is given late and the nurses notes will

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0759

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 17)
indicate why medication has a discrepancy;
– This will include not only medications but treatments as well as examples (eye/ear
ointment/drops, elastic anti-embolism hose, creams, inhalers, dressings, etc.).

F 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

Ensure that residents are free from significant medication errors.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to ensure that two
residents (Resident #17 and #30) out of 14 sampled residents were free from significant
medication errors. The facility’s census was 52.
1. Record review of Resident #17’s (MONTH) (YEAR) physician’s orders [REDACTED].
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED]. Insulin works by lowering levels of glucose in the blood)
30 units (u) every morning;
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].= 3 units (u); BS 201-250 = 6 u; 251-300 = 9 u; 301-350 = 12
u; 350-400 = 15 u; greater than 400 = call physician).
Observation on 11/14/18 at 12:30 P.M. showed the resident eating lunch.
Observation on 11/14/18 at 1:43 P.M. showed Certified Medication Technician (CMT) D
performed a finger stick blood sugar test, result 112, and administered 7 u of [MEDICATION
NAME].
During an interview on 11/14/18 at 1:45 P.M., CMT D said:
– They have a one hour window of time to give medication so he/she does not think it is a
problem to check resident’s blood sugar after meals instead of before because they still
get their insulin on time.
2. Record review of Resident 30’s (MONTH) (YEAR) POS, showed:
– [DIAGNOSES REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].
– an order written [REDACTED].= zero u; 131-240 = 4 u; 241-300 = 10 u; 301-350 = 12 u;
351-400 = 16 u; 401-450 = 25 u; 451-500 = 30 u.
Observation on 11/14/18 at 12:30 P.M. showed the resident eating lunch.
Observation on 11/14/18 at 1:48 P.M. showed CMT D performed a finger stick blood sugar
test, result 170, and administered 4 u of [MEDICATION NAME].
3. During an interview on 11/19/18 at 5:15 P.M., the Director of Nursing (DON) said she
would expect finger stick blood sugar to be checked prior to meals if that is how it is
ordered because it could affect the sliding scale insulin dose.
4. Record review of the facility’s policy titled Blood Glucose Monitoring, dated 4/6/17,
showed:
– The blood sugar monitoring/accucheck orders will be obtained from the physician,
including the recommended time and frequency of the monitoring;
– At the scheduled time, the Licensed Nurse/ Insulin Certified CMT will complete the blood

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 0760

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

(continued… from page 18)
sugar/accucheck.
Record review of the facility’s policy titled Medication Administration and Monitoring,
dated 4/6/17, showed medications are to be given per doctors’ orders.

F 0880

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Provide and implement an infection prevention and control program.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on observation, interview and record review, the facility failed to maintain
adequate infection control practices to prevent the spread of infection for seven
residents (Resident #9, #17, #24, #30, #31, #43, and #44) out of 14 sampled residents and
five residents (Resident #1, #14, #16, #19 and #34) outside the sample. The facility’s
census was 52.
1. Observation on 11/14/18 between 12:52 P.M. and 1:34 P.M. during medication
administration showed Certified Medication Technician (CMT) D failed to sanitize his/her
hands before and after administering medications to Resident #1, Resident #9, Resident
#16, Resident #17, Resident #30, Resident #31, and Resident #34.
During an interview on 11/14/18 at 1:35 P.M., CMT D said he/she should have washed his/her
hands after giving medication and before giving medication to another resident.
2. Manufacturer’s cleaning recommendations for the glucometer showed:
– Professional Disposables International (PDI) wipes (hospital-grade disinfectant wipes)
and/or Clorox (bleach) wipes as approved cleaning agents;
– Glucometers need to be cleaned after each use;
– Keep the glucometer wet with the wipe for at least two minutes.
Observation on 11/14/18 at 1:40 P.M. showed CMT D performed a finger stick blood sugar
(fsbs) test for Resident #16:
– CMT D wore gloves;
– Picked up glucometer (a device use to monitor blood sugar);
– Used a lancet to obtain blood from the resident’s finger;
– Dropped blood onto the glucometer stick and obtained blood sugar results;
– Placed the soiled glucometer on medication cart;
– Sanitized hands and put gloves on;
– Went through insulin medication cart with gloved hands;
– With soiled gloves, prepared the syringe with insulin and administered the injection to
the resident;
– Did not clean the glucometer as per manufacturers instructions after each use.
Observation on 11/14/18 at 1:43 P.M., showed CMT D performed a fsbs test for Resident
#17:
– CMT D put on gloves and picked up soiled glucometer;
– Used a lancet to obtain blood from the resident’s finger;
– Dropped blood onto the glucometer stick and obtained blood sugar results;
– Placed the soiled glucometer on the medication cart;
– Removed gloves and re-gloved;
– Went through insulin medication cart with gloved hands;
– With soiled gloves, prepared the insulin syringe and administered injection to the
resident;
– Removed gloves and wiped the glucometer with an alcohol swab;
– Did not clean the glucometer as per manufacturers instructions after each use.

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 19)
Observation on 11/14/18 at 1:45 P.M. showed CMT D performed a fsbs test for Resident #9:
– CMT D sanitized his/her hands and put on gloves;
– Used a lancet to obtain blood from the resident’s finger;
– Dropped blood onto the glucometer stick and obtained blood sugar results;
– Placed the soiled glucometer on the medication cart;
– Did not clean the glucometer as per manufacturers instructions after each use.
Observation on 11/14/18 at 1:48 P.M. showed CMT D performed a fsbs test for Resident #30:
– CMT D wiped glucometer with a bleach wipe and did not follow the manufacturer’s
recommendations;
– Put on gloves and picked up soiled glucometer;
– Used a lancet to obtain blood from the resident’s finger;
– Dropped blood onto the glucometer stick and obtained blood sugar results;
– Placed the soiled glucometer on the medication cart;
– With soiled gloves, prepared the insulin syringe and administered injection to the
resident;
– Removed gloves and wiped the glucometer with an alcohol swab;
– Did not clean the glucometer as per manufacturers instructions after each use.
During an interview on 11/14/18 at 1:30 P.M., CMT D said they are told to use alcohol to
clean the glucometer. There are purple top and orange top wipes in the medication room but
not on the medication cart. He/she thinks the purple wipes are the strong ones.
During an interview on 11/19/18 at 5:00 P.M., the Administrator said she would expect
staff to wash or sanitize hands between residents and the glucometers to be cleaned with
the purple top wipes and allowed to dry. The CMT’s get one in-service a year about how to
clean them.
6. Observation on 11/16/18 at 10:45 A.M. showed:
– Licensed Practical Nurse (LPN) G used a measuring container to empty the urinary
catheter of Resident #44;
– The measuring container was placed in a clear, plastic bag with no name or label and
hung on the handrail in the bathroom to the left of another clear bag with container and
no label;
– Bathroom was shared by Resident #14, Resident #19, Resident #43, and Resident #44;
During an interview on 11/16/18 at 10:47 A.M., LPN G said she believed the containers
were placed on the handrail from left to right to determine who they belong to. He/she
said normally they would have a name on the bags, but he/she just started working at the
facility three days ago and was unsure what the policy was.
During an interview on 11/19/18 at 5:00 P.M., the Administrator said she would expect
measuring containers that were left in the bathroom to be labeled.
7. Observation on 11/16/18 at 12:10 P.M. showed:
– Certified Nurse Aide (CNA) E and CNA F provided incontinent care for Resident #24;
– CNA E washed his/her hands and re-gloved;
– CNA E applied [MEDICATION NAME] ointment (a skin barrier that is used to treat and
prevent skin irritations) to the resident’s coccyx;
– CNA E and CNA F with soiled gloves, put an incontinent brief on the resident along with
pants and house shoes;
– CNA E and CNA F with soiled gloves transferred the resident with a gait belt (a device
placed around the waist to use for assistance with transfers and walking) to his/her
wheelchair and taken to the dining room;
– CNA E and CNA F did not wash their hands after care or before leaving the room.
8. During an interview on 11/19/18 at 5:00 P.M., the Administrator said she would expect
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

(continued… from page 20)
staff to wash or sanitize hands between residents.
9. Record review of the facility’s undated Infection Control Policy showed good
handwashing always before and after any procedure with patient care involved.
Record review of the facility’s policy titled Blood Glucose Monitoring, dated 4/6/17,
showed to follow the cross contamination of equipment policy.
The facility did not provide a policy for cross contamination of equipment.

F 0881

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Some

Implement a program that monitors antibiotic use.

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**
Based on interview and record review, the facility failed to implement an antibiotic
stewardship program to include an infection surveillance program and antibiotic use
protocols. This deficient practice had the potential to affect all residents in the
facility. The facility’s census was 52.
Record review of the facility’s Infection Prevention and Control Program (IPCP) showed the
facility did not establish an Antibiotic Stewardship Program which includes antibiotic use
protocols and a system to monitor antibiotic use. The facility did not have the following:
– No infection surveillance program;
– No protocols to review clinical signs and symptoms and lab reports to determine if the
antibiotic is indicated or if adjustments to therapy should be made and to identify what
infection assessment tools or management algorithms are used for one or more infections;
– No process for periodic review of antibiotic use by prescribing practitioners;
– No protocols to optimize the treatment of [REDACTED].
– No system for the provision of feedback reports on antibiotic use, antibiotic resistance
patterns based on lab data, and prescribing practices for the prescribing practitioners
and for the Quality Assurance and Assessment (QAA) committee.
Record review of the facility’s Census and Conditions of Residents, dated 11/16/18, showed
seven residents currently receiving antibiotics.
During an interview on 11/19/18 at 2:00 P.M., the Administrator said the facility doesn’t
have an antibiotic stewardship program other than a policy for it.

F 0921

Level of harm – Minimal harm or potential for actual harm

Residents Affected – Few

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

Based on observation and interview, the facility failed to maintain all areas of the
facility in a safe, functional, sanitary, and comfortable environment for two residents
(Resident #30 and #31) out of 14 sampled residents and two additional residents (Resident
#4 and #20) outside of the sample. The facility’s census was 52.
1. Observation on 11/14/18 at 10:40 A.M., showed Resident #4’s room door had to be lifted
to open or close because it dragged on the floor.
Record review of the resident’s Quarterly Minimum Data Set (MDS) (a federally mandated
assessment instrument required to be completed by facility staff), dated 8/12/18, showed

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
PRINTED: 7/23/2019
FORM APPROVED
OMB NO. 0938-0391
STATEMENT OF DEFICIENCIES
AND PLAN OF CORRECTION
(X1) PROVIDER/SUPPLIER/CLIA
IDENNTIFICATION NUMBER:

265547

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

11/19/2018

NAME OF PROVIDER OF SUPPLIER

GREENVILLE HEALTH CARE CENTER

STREET ADDRESS, CITY, STATE, ZIP

117 SYCAMORE STREET, PO BOX 108
GREENVILLE, MO 63944

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 – Few

(continued… from page 21)
the resident to use a walker or wheelchair for mobility.
2. Observation on 11/14/18 at 10:45 A. M,. showed Resident #20’s room:
– Had a broken corner on the wall by bathroom with metal and crumbling sheetrock exposed;
– Had a blanket draped over window and attached to the curtain hooks with binder clips.
3. Observation on 11/14/18 at 11:00 A.M. showed Residents #30 and #31’s room:
– Toilet not flushable and water to the toilet turned off;
– Bedside commode sat in the bathroom. The removable bucket contained urine and feces;
– Personal items stacked on the bedside commode lid and on the bathroom floor;
– The headboard of Resident #30’s bed pushed through the wall which caused a hole
approximately six inches by four inches;
– Paint on the south and east walls peeled;
– The wardrobe closet with a handle missing on the bottom drawer;
– The plastic casing missing on the call light for Resident #31.
During an interview on 11/14/18 at 11:05 A.M., Resident #30 said he/she doesn’t like that
there is a hole in the wall, the paint is peeling and the furniture needs handles. The
toilet has never worked since the resident was admitted . He/she has requested those
things be fixed but they have not been fixed. The resident was unsure how the staff dumped
the contents of the bedside commode since the toilet did not flush.
4. Observation on 11/14/18 at 12:52 P.M. showed a six inch by eight inch hole in the
dining room wall next to the door which lead to the kitchen.
5. During an interview on 11/19/18 at 5:15 P.M. the Administrator said she would expect
holes in walls to be repaired, all toilets to be in working order and doors to freely open
and close without dragging the floor. A new toilet has been installed in Residents #30 and
#31’s room as of 11/19/18 and the maintenance staff are aware of the needed repairs to
walls and doors.