Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Willows Of Greensburg during CMS and state inspections, most recent first.
Mouse Droppings Found in Kitchen Dry Storage: The facility failed to maintain an effective pest control program and the kitchen was not free of mouse droppings. During a kitchen tour with the DM, droppings were seen in a case box of evaporated milk, in a metal tray under the furnace, and in an open bin of plastic lids in the dry storage room. The DM said pest control had treated the facility a couple of weeks earlier, and the Administrator said the facility used a local pest control company, with bait boxes installed and checked every other month.
Failure to Follow Amlodipine Hold Parameters: A resident with HTN had an order for amlodipine 10 mg every morning to be held if systolic BP was below 110, but the EMAR showed the medication was given multiple times when the resident’s systolic BP was below that parameter. An LPN stated she would check BP before giving a cardiac med, would not administer it if out of range, and would document the reason in the EMAR.
Failure to Complete and Document Ordered Wound Care: Two residents had pressure-related wounds that progressed from early skin breakdown to more advanced wounds, including an unstageable pressure ulcer with slough and eschar. One resident had dementia and diabetes, and the other had IAD that progressed to an unstageable wound. The EMAR/ETAR lacked documentation that ordered wound treatments were completed as prescribed, and one resident’s treatment record also did not match the wound progress notes.
A CNA provided catheter care to a severely cognitively impaired resident with a urinary catheter and UTI treatment but did not wear a gown despite enhanced barrier precaution signage requiring gown and gloves. The resident had an open-ended order for enhanced barrier precautions related to the catheter, and the facility policy identified urinary catheter care as a high-contact activity requiring gown and glove use.
The facility failed to obtain documented weights for a resident with severe cognitive impairment, heart failure, and respiratory failure who had a PRN order for Bumetanide for leg swelling or a >3 lb weight gain in one day. The chart and EMAR/ETAR lacked weights over an extended period, and staff stated the resident should have been weighed daily for the PRN order to be followed.
The facility failed to ensure multi-use insulin pens were labeled with an opened-on date in 2 medication carts. An LPN observed an Lantus pen for one resident and a Basaglar pen for another resident that were both in use but not dated, and the facility policy required multi-use medications to include the date they were first opened or accessed.
Unlabeled food items were found in snack refrigerators on the Memory Care Unit and Station 4. A cake container with an expired best-by date, leftovers, an unopened soft drink, and a frozen treat were stored without resident names or dates, despite staff stating that family-provided food should be labeled and dated.
A resident with severe cognitive impairment and multiple medical conditions did not receive appropriate urinary catheter care when a nurse inserted a catheter but failed to document reassessment after no urine return was observed. Blood was later found in the catheter tubing and bag, and hospital imaging revealed the catheter balloon was inflated in the penile urethra rather than the bladder.
A resident with severe cognitive impairment and multiple diagnoses did not receive a prescribed cognition medication for several weeks after an RN accidentally discontinued the order. The error was discovered when the family notified the facility, revealing that the medication had not been administered as required by the physician's order and facility policy.
A resident with severe cognitive impairment and multiple medical conditions experienced an unwitnessed fall. Staff delayed both the documentation of the incident and the initiation of neurological assessments, contrary to facility policy requiring immediate post-fall evaluation and documentation. The required risk management form and neuro checks were not completed promptly after the event.
The facility did not consistently implement or develop required care plan interventions for several residents, including missing or improperly placed fall prevention measures such as call light signage, non-skid strips, clip alarms, and wheelchair safety features, as well as lacking care plans for residents with PTSD. These deficiencies were confirmed through observations, record reviews, and staff interviews.
A resident with severe cognitive impairment and multiple diagnoses had both a signed DNR and POST form indicating DNR status, but also had a current physician's order for CPR. Staff interviews confirmed that the facility's process should ensure consistency between advance directives and physician orders, but this was not followed, resulting in conflicting documentation of the resident's code status.
A resident with hypotension and other medical conditions received midodrine despite physician orders to hold the medication when systolic blood pressure was above 140. The medication was administered multiple times when the resident's blood pressure exceeded this threshold, contrary to both the physician's order and facility policy. An LPN confirmed that such medications should be held and documented appropriately.
A resident with severe cognitive impairment and multiple medical conditions had numerous undocumented meal consumption entries for breakfast and lunch over several days. A CNA confirmed that meal intake should be recorded daily, and facility policy requires this documentation in the medical record.
The facility did not have an RN on duty for eight consecutive hours on two days during the review period. The DON confirmed that only one RN worked night shifts on those days, and their hours did not fulfill the daily requirement. The facility lacked a specific policy for RN coverage, relying instead on State and Federal regulations.
A resident with multiple chronic conditions did not have their increased Fluoxetine dose correctly transcribed after returning from a hospital stay, resulting in the administration of a lower dose than prescribed for several months. Nursing staff and the DON confirmed the error occurred during the order transcription process, contrary to facility policy requiring accurate medication order transcription.
Surveyors found that the medication refrigerator contained opened vials of TB serum that were not labeled with the date they were first used. An LPN confirmed that the vials should have been dated upon opening, and facility policy requires this practice. The issue was identified during a review of the medication room and associated records.
A resident with an indwelling urinary catheter and multiple medical conditions experienced a significant delay in obtaining a urinalysis with culture and sensitivity after a physician's order was placed. Despite repeated attempts by the lab to collect the sample, it was not available on several visits, resulting in cancellation of the original order and a delay in both laboratory results and initiation of antibiotic treatment. Facility policy requires timely laboratory services, which was not met in this case.
Three residents were found to have lapses in infection control, including a resident whose PICC line dressing was not changed as ordered or per facility policy, and two residents with indwelling urinary catheters whose drainage bags or tubing were repeatedly observed touching the floor. Staff acknowledged these practices did not meet facility policy for catheter care and infection prevention.
Survey results were not made easily accessible for residents and visitors on multiple days, with no clear posting near the entrance and missing documents in the designated location. The Administrator acknowledged that survey results should be available without needing to ask staff, in accordance with facility policy.
A resident experienced an unwitnessed fall, and the facility failed to document or report the incident, leading to delayed medical intervention. The resident, who was severely cognitively impaired, was later found to have a fractured hip after being sent to the hospital. The LPN involved did not follow the facility's fall management policy, resulting in a deficiency.
A resident's fall was not documented or reported by an LPN, leading to a delay in treatment for a fractured hip. The resident, who was severely cognitively impaired, showed signs of distress but the incident was not recorded in medical records. The facility's policy on fall management was not followed, resulting in a lack of timely care.
A facility failed to report an abuse allegation within the required timeframe. A staff member was observed engaging in inappropriate behavior with a resident, who has a history of inappropriate touching and severely impaired cognition. Despite the facility's policy requiring immediate reporting, the incident was not reported to the state in a timely manner.
A facility failed to accurately complete MDS assessments for a resident with behavioral symptoms. Despite observations and staff notes indicating aggressive behaviors, such as grabbing and hitting, these were not documented in the MDS assessments. The resident's care plan noted manipulative behaviors but lacked updated interventions, and behavior logs were incomplete.
A facility failed to update the behavior plan for a resident with severe cognitive impairment and ongoing aggressive behaviors, including inappropriate touching and physical aggression. Despite existing care plans, interventions were not revised to address persistent issues, leading to multiple incidents requiring staff intervention. Facility policies on behavior management and care plans were not effectively implemented.
A facility failed to monitor and address a resident's aggressive and inappropriate behaviors, which included grabbing and hitting staff, particularly targeting female staff members. The behavior log and clinical records lacked consistent documentation of these incidents, and the care plans in place were ineffective in managing the resident's behaviors. Staff interviews revealed ongoing challenges in handling the resident's conduct, highlighting a deficiency in the facility's behavioral health care services.
The facility failed to follow guidelines for insulin pen usage and physician's orders for blood pressure medication. A nurse did not cleanse insulin pens before use, and another resident's blood pressure was not documented before administering lisinopril, contrary to orders.
The facility failed to provide adequate education to a resident regarding urinary catheter care and proper placement of the catheter bag. The resident consistently placed the catheter bag improperly, and there was no documentation of education or a care plan for the resident's self-care practices. This deficiency was identified during a survey, highlighting the facility's failure to ensure proper catheter care and education, potentially contributing to the resident's recurrent UTIs.
The facility failed to follow infection control guidelines for a resident with an indwelling urinary catheter. The catheter drainage bag was observed resting on the floor or in a plastic wash basin on multiple occasions. The DON acknowledged the lack of a specific policy on catheter bag placement, although staff were aware that the bags should not touch the floor.
Mouse Droppings Found in Kitchen Dry Storage
Penalty
Summary
The facility failed to maintain an effective pest control program and the kitchen was not free of mouse droppings. During an initial kitchen tour with the Dietary Manager, mouse droppings were observed in a case box of evaporated milk on a wire shelf rack, in a metal tray under the furnace, and in an open clear rectangular bin containing plastic lids on a wire shelf rack in the dry storage room. The Dietary Manager stated the pest control company had been at the facility for treatment a couple of weeks earlier. The Administrator stated the facility used a local pest control company, that the last service was the monthly treatment and spring treatment, and that mice bait boxes had been installed in February 2026 and were checked every other month for bait.
Failure to Follow Hold Parameters for Amlodipine
Penalty
Summary
The facility failed to follow the physician’s hold parameters for amlodipine, a medication ordered for hypertension, for one resident. The resident’s current order, started 03/31/2023, directed that amlodipine 10 mg be given every morning but held if systolic blood pressure was below 110. The resident’s quarterly MDS dated 12/17/2025 identified hypertension among the diagnoses. Review of the April and May 2026 EMAR showed the medication was administered on multiple days when the resident’s systolic blood pressure was below the ordered hold parameter, including readings of 90, 103, 108, 107, 106, 105, 108, 105, 108, 104, and 106. During interview, an LPN stated that if a resident had hold parameters for a cardiac medication, she would assess blood pressure before administration, would not give the medication if anything was out of range, and would document the reason in the EMAR. The facility policy on Physician Medication Orders stated medications should be administered only upon the signed order of a person lawfully authorized to prescribe.
Failure to Document and Complete Ordered Wound Treatments
Penalty
Summary
The facility failed to ensure wound treatments were completed as ordered for two residents with pressure-related skin conditions. For one resident, the clinical record showed a right ischium pressure ulcer that began as a Stage 1 injury and progressed to an unstageable wound with eschar and slough. The resident had dementia and diabetes and was severely cognitively impaired. Although an order was in place for the wound to be cleansed, packed with calcium alginate, and covered with bordered gauze, the February 2026 EMAR/ETAR lacked documentation that this treatment was completed during the ordered period. During observation, the Assistant Director of Nursing prepared and completed the wound treatment for the first resident, and the wound was noted to be approximately tennis-ball size with measurable depth, slough, and gray tissue. Record review showed the wound had worsened over time from a small dry Stage 1 pressure ulcer to an unstageable pressure ulcer with drainage and tissue breakdown. The ADON stated the resident had a rapid decline and that the treatment should have been checked off in the EMAR/ETAR when completed, but the record did not show that the calcium alginate treatment was documented as administered as ordered. For the second resident, the wound on the right buttock/lower back area was observed as a circular wound about 5 cm in diameter and 2 cm deep, with a pink wound bed and no drainage or signs of infection. Record review showed the area began as incontinence-associated dermatitis and later developed into an unstageable pressure ulcer with slough and eschar. The resident had intermittent incontinence, slept in a recliner, and refused some pressure-relieving interventions. The February 2026 EMAR/ETAR showed the wound treatment was changed from medical grade honey to a zinc oxide-based hydrophilic paste mixed with collagen particles, but the record lacked indication that the treatment should have been changed on that date, and the treatment documentation did not align with the wound progress notes showing honey was to continue daily.
Failure to Follow Enhanced Barrier Precautions During Catheter Care
Penalty
Summary
The facility failed to follow infection control guidelines for enhanced barrier precautions for one resident with a urinary catheter. During observation, a CNA provided catheter care and hygiene to the resident while wearing gloves and closing the curtain, but did not don a gown even though the resident’s door had a sign indicating that gown and gloves were required for care under enhanced barrier precautions. When interviewed, the CNA stated that when a resident required enhanced barrier precautions, she would wear a gown and gloves, and acknowledged that she had forgotten to wear a gown while providing the catheter care. Resident 25 was severely cognitively impaired and had diagnoses including neurogenic bladder and a urinary catheter. The clinical record showed an open-ended physician’s order for enhanced barrier precautions related to the catheter, with a start date of 03/19/2025. The record also showed the resident was prescribed and administered Macrobid for a UTI from 05/11/2026 through 05/21/2026. The facility policy stated that enhanced barrier precautions include targeted gown and glove use during high-contact resident care activities, including device care or use such as urinary catheters.
Failure to Obtain Required Weights for Resident with PRN Diuretic Order
Penalty
Summary
The facility failed to obtain weights for 1 of 3 residents reviewed for nutrition. Resident 7’s clinical record showed a Significant Change MDS assessment dated 04/22/2026 indicating severe cognitive impairment, with diagnoses including heart failure and respiratory failure. The resident also had an open-ended physician’s order, starting 04/22/2026, for Bumetanide 2 mg every 24 hours as needed for leg swelling or a weight gain of greater than 3 pounds in one day. The clinical record and the April and May 2026 EMAR/ETAR did not show documented weights from 04/23/2026 through 05/19/2026. During interview, an RN stated that a resident with an order for a PRN medication for weight gain should be weighed daily. The ADON stated the resident had been on daily weights before hospice admission, that the daily weight order must have been discontinued, and that the PRN medication order could not be followed if the resident was not weighed daily. The facility policy titled Weight Monitoring stated that if clinically indicated, weight should be monitored daily.
Unlabeled Multi-Use Insulin Pens in Medication Carts
Penalty
Summary
The facility failed to ensure multi-use insulin pens were labeled with an opened-on date for 2 of 3 medication carts reviewed, including the Long Hall Medication Cart and the L Hall Medication Cart. On the Long Hall Medication Cart, an Lantus insulin pen for Resident 1 was observed to be about eighty percent full and not labeled with an opened-on date. An LPN stated that whoever placed the pen in the cart should have dated it and said she used the pen to administer 50 units of insulin to Resident 1 that morning. On the L-Hall Medication Cart, a Basaglar insulin pen for Resident 73 was observed to be half full and also not labeled with an opened-on date. The facility policy titled Labeling of Medications stated that all medications and biologicals must be labeled in accordance with applicable federal and state requirements and that labels for multi-use vials must include the date the vial was initially opened or accessed.
Unlabeled Food Stored in Snack Refrigerators
Penalty
Summary
The facility failed to store foods appropriately for 2 of 3 snack refrigerators reviewed, including the Memory Care Unit and Station 4. During observation, the Memory Care Unit snack refrigerator contained a gray plastic grocery bag with a double-layer white cake in a plastic container on the top shelf, and the container had a best if purchased by date of 05/18/2026. There was no name on the container or bag, and QMA 4 stated that food items brought in by families should be labeled with the resident's name and a date. The Station 4 snack refrigerator and freezer contained multiple unlabeled food items. These included a gray plastic bag with a plastic container of leftovers on the second shelf, a gray plastic bag with two plastic containers of leftovers in the door, an unopened carbonated soft drink with no name or date, and a medium-sized to go cup with a chocolate frozen treat in the freezer with no name or date. CNA 5 stated that if there was no name on the containers, they probably belonged to an employee. The facility's policy stated that food brought in by visitors should be labeled with the resident's name and dated received.
Failure to Provide Appropriate Urinary Catheter Care
Penalty
Summary
A deficiency occurred when a resident with severe cognitive impairment and multiple diagnoses, including end-stage renal disease and Alzheimer's disease, was not provided with appropriate urinary catheter care. After a nurse inserted a 16 French indwelling urinary catheter, there was no urine return observed. Despite this, the clinical record did not show that the catheter placement was reassessed prior to the discovery of blood in the catheter tubing and bag. The facility's policy required that the catheter be inserted until urine flow was observed and not to force entry if resistance was met. Later, a medical assistant reported the presence of bright red blood in the resident's catheter bag, prompting emergency transport to the hospital. Imaging at the hospital revealed that the catheter balloon had been inflated within the penile urethra, rather than the bladder. The lack of documentation regarding reassessment of catheter placement after the absence of urine return contributed to the deficiency in providing appropriate catheter care.
Failure to Administer Ordered Medication Due to Accidental Discontinuation
Penalty
Summary
A resident with severe cognitive impairment and diagnoses including non-Alzheimer's dementia, atrial fibrillation, and hypertension had a physician's order for Memantine 5 mg twice daily. The order was discontinued on 7/7/25 with a note referencing medications from home, but the resident did not receive the prescribed Memantine from 7/8/25 through 7/28/25. Documentation shows that the family notified the facility of the discontinuation, and the nurse confirmed the medication was stopped in error. The medication was not administered for approximately three weeks due to this accidental discontinuation, despite the physician's order requiring its administration. Facility policy requires that medications be provided in accordance with physician orders, which was not followed in this instance.
Failure to Timely Document Fall and Initiate Neurological Assessments
Penalty
Summary
The facility failed to document a fall and initiate neurological assessments in a timely manner for a resident who was severely cognitively impaired and had multiple diagnoses, including stroke, heart failure, hypertension, dementia, anxiety, and depression. The resident, who used a walker and required staff assistance for ADLs, experienced an unwitnessed fall during the night shift. After the fall, the CNA alerted the nurse, who checked the resident's vital signs and assisted her back to bed. The resident subsequently complained of pain multiple times, but the nurse only checked vital signs and provided medication, without immediate documentation or a thorough assessment. The nurse did not complete the required risk management form for the unwitnessed fall until the following day, and the neurological assessment was not started until over an hour after the incident. Facility policy required immediate assessment and documentation following any fall, including a head-to-toe assessment, pain assessment, and timely initiation of neurological checks. The delay in both documentation and neurological assessment constituted a failure to follow established protocols for post-fall management.
Failure to Implement and Develop Required Care Plan Interventions for Falls and PTSD
Penalty
Summary
The facility failed to ensure that care planned interventions were implemented and that comprehensive care plans were developed for residents with specific needs, including fall prevention and management of PTSD. Multiple residents with a history of falls did not have the required interventions in place as outlined in their care plans. For example, one resident with Parkinson's disease and dementia, who had experienced multiple falls, did not have the prescribed call light signage or properly placed non-skid strips in their room, despite these being documented interventions following previous falls. Observations confirmed the absence or incorrect placement of these items during several checks, and staff interviews acknowledged the deficiencies. Another resident with severe cognitive impairment and a history of falls was supposed to have a clip alarm in use as a fall intervention. However, during observation, the alarm was attached to the resident's wheelchair rather than being in use while the resident was in bed, as required. Staff interviews revealed that hospice staff had failed to move the alarm after assisting the resident, and education on this intervention had previously been provided. Similarly, a third resident with severe cognitive impairment and a recent fall was supposed to have non-skid strips in front of their recliner, but repeated observations showed these strips were not present, and staff confirmed the intervention was missing. Additionally, the facility did not develop care plans for residents diagnosed with PTSD, as required. Two residents with PTSD lacked any care plan or interventions addressing this diagnosis, despite facility policy and staff acknowledgment that such care plans should be in place. Other deficiencies included the absence of anti roll back tippers and bright colored tape on a resident's wheelchair, both of which were documented fall prevention interventions. These failures were identified through record review, direct observation, and staff interviews, demonstrating a pattern of not following or implementing care planned interventions for multiple residents.
Failure to Document and Implement Advance Directive Consistently
Penalty
Summary
The facility failed to properly document and implement an appropriate advance directive for one resident. The resident, who was severely cognitively impaired and had diagnoses including hypertension, diabetes, and non-Alzheimer's dementia, had both a signed Out of Hospital Do Not Resuscitate (DNR) Declaration and Order, as well as a Physician Orders for Scope of Treatment (POST) form indicating DNR status. Despite these documents, the resident's clinical record contained a current, open-ended physician's order for Cardiopulmonary Resuscitation (CPR). Interviews with staff revealed that the process for completing and transcribing POST forms and DNR orders involved both nursing and social services staff, with an expectation that the POST form and physician's orders would match. The Director of Nursing confirmed that if a resident had an Out of Hospital DNR, there should not be a physician's order for CPR. The facility's policy required adherence to residents' rights to formulate advance directives and procedures to communicate code status, but this was not followed in this instance.
Failure to Follow Hold Parameters for Cardiac Medication Administration
Penalty
Summary
The facility failed to follow physician orders regarding the administration of midodrine, a medication prescribed for hypotension, for one resident. The physician's order specified that the medication should be held if the resident's systolic blood pressure was greater than 140. Despite this, the resident's electronic medication administration record showed that the medication was administered multiple times when the systolic blood pressure exceeded the prescribed threshold, with readings ranging from 141 to 180. These administrations occurred on several dates over a two-month period. The resident involved was cognitively intact and had diagnoses including anemia, orthostatic hypotension, and disorders of the autonomic nervous system. During an interview, an LPN confirmed that medications with hold parameters should not be given if vital signs are outside the specified range and should be documented as held with a reason. The facility's medication administration policy also required staff to obtain and record vital signs and to hold medications when vital signs were outside physician-prescribed parameters.
Failure to Document Meal Consumption for Cognitively Impaired Resident
Penalty
Summary
The facility failed to document meal consumption for a resident who was severely cognitively impaired and had multiple diagnoses, including dementia, hypertension, diabetes, stroke, anxiety, and depression. Review of the resident's clinical record revealed numerous instances where meal consumption values were missing for both breakfast and lunch across several dates. During an interview, a CNA confirmed that meal consumption should be recorded daily in the computer at the end of each shift. The facility's current policy also requires staff to document meal consumption in the medical record.
Failure to Provide Required RN Coverage
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for eight consecutive hours a day for two of the seven days reviewed. According to the as-worked nursing schedule, there was no RN present for the required eight consecutive hours on both Saturday and Sunday during the review period. The Director of Nursing (DON) confirmed that only one RN worked the night shift on those days, and their hours did not meet the eight consecutive hour requirement for each day. Additionally, the DON stated that the facility did not have a specific policy for RN coverage and instead followed State and Federal regulations.
Failure to Accurately Transcribe Medication Orders on Admission
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including diabetes, anemia, heart failure, hypertension, seizure disorder, non-Alzheimer's dementia, and depression, did not have their medication orders correctly transcribed upon return from a hospital stay. The resident's psychiatric provider had increased the dose of Fluoxetine to 80 mg daily due to increased behavioral symptoms, and the hospital discharge instructions also specified this dosage. However, upon readmission, the facility transcribed the order as 40 mg daily instead of the intended 80 mg. As a result, the resident received only 40 mg of Fluoxetine daily from the time of readmission through several months, as documented in the electronic medication administration records. Interviews with nursing staff and the DON confirmed that the error occurred during the transcription process when the resident returned from the hospital, and the facility's policy required accurate transcription and clarification of medication orders.
Failure to Date Opened TB Serum Vials in Medication Room
Penalty
Summary
Surveyors observed that the medication refrigerator in the Station 4 medication room contained multiple vials of TB (tuberculin) serum that were not labeled with the date they were opened. Specifically, an opened vial of TB serum was found in a box received from the pharmacy, and another opened vial was found in a clear plastic bag with two boxes of TB serum, both lacking an 'opened on' date. The LPN present confirmed that the TB serum should have been dated when first used and acknowledged that several residents had been admitted since the medication was delivered. Review of the TB serum package insert and facility policy confirmed that opened vials must be dated and discarded after 30 days, but this procedure was not followed.
Delay in Obtaining Urinalysis for Resident with Indwelling Catheter
Penalty
Summary
The facility failed to obtain a urinalysis (UA) in a timely manner for one resident with multiple diagnoses, including anemia, orthostatic hypotension, renal insufficiency, neurogenic bladder, and disorders of the autonomic nervous system. The resident, who had an indwelling urinary catheter and was cognitively intact, had a physician's order for a UA with culture and sensitivity. Despite this order, the urine sample was not collected until several days later. Health status notes indicated the order was placed, but the sample remained pending for several days before collection. Interviews revealed that the laboratory made multiple attempts to collect the sample, but it was not available on three separate visits, leading to the cancellation of the original order. A nurse from the facility signed off on the cancellation. A new sample was eventually collected and processed, but this resulted in a significant delay in obtaining laboratory results and initiating antibiotic treatment for a urinary tract infection. The facility's policy requires timely provision of laboratory services, but this was not followed in this instance.
Failure to Follow Infection Control Guidelines for PICC Lines and Urinary Catheters
Penalty
Summary
The facility failed to follow infection control guidelines for three residents with either a peripherally inserted central catheter (PICC) line or indwelling urinary catheters. One resident with a PICC line had a physician's order and facility policy requiring the dressing to be changed every seven days, but the dressing was not changed for at least 13 days after placement. The resident and an LPN confirmed that the dressing had not been changed since the initial placement, despite the policy and order. Two other residents with indwelling urinary catheters were repeatedly observed with their catheter drainage bags or tubing touching or resting on the floor, both while in bed and in a wheelchair. Staff interviews confirmed that catheter bags should not touch the floor, and one CNA noted that the dignity sleeves used were too large, causing the bags to slide out and touch the floor. Facility policy required appropriate catheter care and maintenance of dignity and privacy, but these standards were not met during multiple observations.
Survey Results Not Readily Accessible to Residents and Visitors
Penalty
Summary
The facility failed to ensure that State Survey Results were readily available for residents and visitors to view on three out of five days during the survey period. Observations revealed that there was no posting near the front entrance indicating the location of the survey results, and on one occasion, a sign in the hallway by the therapy department directed individuals to a wall pocket where the results were supposed to be, but the documents were not present. The Administrator confirmed that the survey results should be accessible without requiring visitors to ask staff. The facility's policy states that a readable copy of the most recent survey results should be maintained in a binder in the main lobby and be readily accessible without staff assistance.
Failure to Document and Respond to Resident Fall
Penalty
Summary
The facility failed to provide timely and appropriate care to a resident following an unwitnessed fall. On the morning of 12/11/24, a CNA observed the resident stand up from his recliner and subsequently found him on the floor. The CNA and an LPN assisted the resident back to bed, but the LPN did not document the fall or report it to other staff members. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia and COPD, did not initially express pain but was later observed rubbing his thigh and not acting like himself. The resident's condition worsened over the next day, with swelling observed in his right leg and hip. The NP assessed the resident and ordered monitoring and elevation of the leg. However, the resident's condition continued to deteriorate, leading to a STAT X-ray order due to concerns about swelling and leg shortening. Before the X-ray could be performed, the resident's respiratory status worsened, and he was sent to the hospital, where a fracture was confirmed. The facility's policy required immediate assessment and documentation of falls, which was not followed in this case. The LPN involved denied knowledge of the fall, and the incident was not documented in the resident's record. The DON confirmed that the LPN was no longer employed at the facility. The lack of documentation and communication regarding the fall led to a delay in appropriate medical intervention for the resident.
Failure to Document and Report Resident Fall
Penalty
Summary
The facility failed to document and report a resident's fall, which resulted in a delay in appropriate care and treatment. A Certified Nurse Aide (CNA) witnessed the resident stand up and subsequently fall, but the incident was not documented or reported by the Licensed Practical Nurse (LPN) who assisted the resident afterward. The resident, who was severely cognitively impaired and had multiple diagnoses including dementia and heart failure, did not initially show signs of pain but later exhibited symptoms such as rubbing his thigh and not eating. The Director of Nursing (DON) discovered the fall only after the resident was sent to the hospital with a fractured right hip. The resident's leg was noted to be swollen by the night shift nurse, and a Nurse Practitioner (NP) assessed the resident the following day, advising monitoring and elevation of the leg. However, the resident's condition worsened, leading to a hospital transfer where the fracture was diagnosed. The LPN involved denied knowledge of the fall, and the incident was not recorded in the resident's medical records. The facility's policy required immediate assessment and documentation of falls, including notifying medical staff and family, and updating care plans. However, these procedures were not followed, as evidenced by the lack of documentation and communication regarding the fall. The failure to adhere to these protocols resulted in a delay in identifying and treating the resident's injury.
Failure to Report Abuse Allegation Timely
Penalty
Summary
The facility failed to report an allegation of abuse to the Indiana Department of Health within the required two-hour timeframe. The incident involved a staff member, identified as Staff Member 11, who was observed by multiple staff members engaging in inappropriate behavior with a resident, referred to as Resident F. Staff members reported witnessing Staff Member 11 lying in bed with Resident F, allowing the resident to fondle her breasts and grab her buttocks without redirection. Despite these observations, the facility administrator did not report the allegations to the state prior to an internal investigation conducted by a corporate staff member. Resident F, who has a history of inappropriate touching and sexual gestures towards female staff, was noted to have severely impaired cognition due to conditions such as aphasia, hypertension, depression, and stroke. The resident's care plan included interventions to address these behaviors, such as stopping care immediately if inappropriate behavior occurred and preserving the resident's dignity and safety. However, the staff member involved did not adhere to these interventions, as evidenced by the lack of redirection and inappropriate interactions with the resident. The facility's policy mandates immediate reporting of such incidents, but this protocol was not followed, resulting in a deficiency.
Inaccurate MDS Assessment for Resident's Behavioral Symptoms
Penalty
Summary
The facility failed to ensure accurate completion of the Minimum Data Set (MDS) assessments for a resident, identified as Resident F, particularly concerning behavioral symptoms. During an observation, Resident F was seen punching the side of his wheelchair, and interviews with the Director of Nursing revealed that the resident had a history of grabbing behaviors. However, the Quarterly MDS assessments dated 06/06/24 and 08/30/24 did not document any behaviors such as hitting, kicking, or grabbing, despite evidence from behavior logs and staff notes indicating otherwise. The behavior logs showed that Resident F exhibited grabbing behaviors on multiple occasions between May 30, 2024, and June 6, 2024, but these were not reflected in the MDS assessments. Additionally, incidents on 08/24/24 and 08/27/24, where the resident displayed aggressive behaviors, were not documented in the behavior log. The resident's care plan, initiated on 5/24/24, noted manipulative behaviors but lacked updated interventions for ongoing behaviors. The facility did not provide a policy but used the Resident Assessment Instrument (RAI) as a guide for MDS assessments.
Failure to Update Behavior Plan for Resident with Aggressive Behaviors
Penalty
Summary
The facility failed to revise the behavior plan of care for Resident F, who exhibited ongoing inappropriate and aggressive behaviors. Resident F, with severe cognitive impairment and diagnoses including aphasia, hypertension, depression, and stroke, had a care plan initiated in April 2024 addressing sexual gestures and inappropriate touching, and another in May 2024 for manipulative behaviors. Despite these plans, the interventions were not updated to address the resident's persistent behaviors, such as hitting the wheelchair, grabbing staff, and causing a skin tear during a shower. Multiple incidents were documented where Resident F displayed aggressive and inappropriate behaviors, including an event where the resident was uncooperative on a facility bus, leading to damage and requiring staff intervention. Other notes indicated increased agitation, restlessness, and physical aggression towards staff, with ineffective distraction methods. Staff interviews confirmed the resident's persistent inappropriate behavior, such as grabbing female staff, which was not mitigated by existing interventions. The facility's policies on behavior management and comprehensive care plans were not effectively implemented, as the care plans lacked updated interventions for the resident's ongoing behaviors.
Failure to Address Resident's Aggressive and Inappropriate Behaviors
Penalty
Summary
The facility failed to adequately monitor, document, and address the behavioral health needs of Resident F, who exhibited aggressive and inappropriate behaviors. During observations and interviews, it was noted that Resident F frequently engaged in grabbing and hitting behaviors, particularly targeting female staff members. These behaviors included grabbing at staff's breasts and other private areas, causing physical harm such as dislocated thumbs and ripped clothing. Despite these incidents, the facility's documentation and interventions were insufficient, as evidenced by the lack of effective strategies to manage the resident's behaviors. The clinical records and behavior logs for Resident F revealed a pattern of aggressive and sexually inappropriate behaviors that were not consistently documented or addressed. The behavior log failed to record several incidents of aggression and inappropriate conduct, indicating a gap in the facility's monitoring and documentation processes. Additionally, the care plans in place for Resident F included interventions that were not effective in managing his behaviors, such as redirecting or stopping care, which did not prevent further incidents. Interviews with staff members highlighted the challenges they faced in managing Resident F's behaviors, with reports of physical aggression and inappropriate touching being common. The facility's policy on behavior management required tracking and documentation of ongoing behaviors, but this was not consistently followed. The lack of social service follow-up and revised interventions further contributed to the deficiency, as the facility did not adequately address the resident's behavioral health needs, leading to repeated incidents of aggression and inappropriate conduct.
Failure to Follow Insulin Pen Guidelines and Physician's Orders for Blood Pressure Medication
Penalty
Summary
The facility failed to follow manufacturer's guidelines related to insulin pen usage and physician's orders for blood pressure medication administration. During an observation, a nurse administered insulin to a resident without cleansing the rubber seals of the insulin pens with an alcohol wipe before attaching the needles, contrary to the facility's policy. The resident, who was moderately cognitively impaired with diagnoses including diabetes and stroke, received insulin without proper priming and cleansing procedures as per the manufacturer's guidelines and facility policy. The nurse admitted to not following the correct procedure during an interview after the medication administration. Additionally, the facility did not adhere to physician's orders for another resident who was severely cognitively impaired with diagnoses including stroke, hypertension, and diabetes. The resident's physician had ordered that a blood pressure medication, lisinopril, be held if the resident's systolic blood pressure was less than 110. However, the resident's electronic medication administration records showed that the medication was administered daily without documenting the resident's blood pressure prior to administration for 52 out of 69 days reviewed. A Qualified Medication Aide confirmed that vital signs should be checked and documented before administering medications with hold parameters, as per the facility's policy.
Failure to Provide Adequate Urinary Catheter Care Education
Penalty
Summary
The facility failed to provide adequate education to a resident regarding urinary catheter care and the proper placement of the urinary catheter bag. Observations revealed that the resident consistently placed the catheter bag on the side of her wheelchair under the armrest, above her waist, which is not the recommended placement. Interviews with the resident and staff confirmed that the resident performed her own catheter care and preferred the bag's placement for easier access. However, there was no documentation of education provided to the resident about the risks associated with improper catheter bag placement. The Director of Nursing (DON) admitted that education was usually given verbally and not documented, and there was no care plan for the resident's self-catheter care and bag placement. The resident's clinical record indicated a history of urinary tract infections (UTIs) and issues with catheter leakage and sediment. Despite physician orders for staff to provide Foley catheter care every shift, the resident's preference for self-care and improper bag placement were not adequately addressed or documented. The facility's policy on catheter care was not followed, as there was no evidence of documented education or a care plan for the resident's self-care practices. This deficiency was identified during a survey, highlighting the facility's failure to ensure proper catheter care and education for the resident, potentially contributing to the resident's recurrent UTIs.
Failure to Follow Infection Control Guidelines for Urinary Catheters
Penalty
Summary
The facility failed to follow infection control guidelines related to the management of indwelling urinary catheters for Resident 51. On multiple occasions, the resident's catheter drainage bag was observed either resting directly on the floor or in a plastic wash basin on the floor. Specifically, on 05/23/24, the drainage bag was in a dignity pouch but was hanging from the wheelchair with the bottom of the pouch resting on the dining room floor. On 05/24/24, the drainage bag was not in a dignity pouch and was resting directly on the floor. On 05/28/24, the drainage bag and pouch were laying in a plastic wash basin on the floor. On 05/30/24, the drainage bag was observed hanging out of the dignity pouch and resting on the floor mat, which was corrected by CNA 2 upon observation. The resident's medical history included Parkinson's disease, dementia, diabetes, BPH, and a history of bladder cancer, and he had an open-ended order for an indwelling urinary catheter due to obstructive uropathy. During an interview, the DON indicated that the facility did not have a specific policy on catheter bag placement, but staff were aware that catheter bags should not touch the floor. Despite this knowledge, the observations indicated a failure to consistently follow infection control guidelines, leading to the deficiency noted in the report.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 168 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Morning Breeze Retirement Community And Healthcare | 1.2 mi | ★★★★★ | 0 | 0 |
| Arbor Grove Village | 1.4 mi | ★★★★★ | 18 | 0 |
| Hickory Creek At Greensburg | 1.7 mi | ★★★★★ | 10 | 0 |
| Aspen Place Health Campus | 2.3 mi | ★★★★★ | 0 | 0 |
| Waldron Rehabilitation And Healthcare Center | 12.9 mi | ★★★★★ | 7 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.