Willows of Greensburg

In the surveyor’s words

From the most serious findings on record at Willows of Greensburg, in the surveyor’s own words.

• Actual harm, isolatedF686Apr 19, 2021

  Based on observation, interview, and record review, the facility failed to prevent pressure ulcers and follow physician's orders for 4 of 4 residents reviewed for pressure ulcers. (Residents 27, 34, 42, 28). Residents 27 and 34 with decreased mobility related to hip fractures developed unstageable wounds on the heels of their affected legs. Findings include: 1. Resident 27's wound was observed on 04/15/21 at 2:21 P.M. The resident was seated in the recliner and was wearing a pressure relieving boot on her left foot. LPN 5 removed the boot and the dressing on the wound. She indicated this was her first observation of the wound that day. The wound was an unstageable (wound was covered with dead tissue) pressure ulcer, measuring 4.5 centimeters (cm) x (by) 4.5 cm. […]

• No harm, potential for more than minimal, patternF925May 20, 2026

  Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was maintained and the kitchen was free of mouse droppings. This deficient practice had the potential to affect 71 of 71 residents residing in the facility. Findings include:During the initial kitchen tour with the Dietary Manager (DM), on 05/14/2026 at 10:45 A.M., the following was observed in the dry storage room: -Scattered mouse droppings in a case box of cans of evaporated milk that was sitting on a wire shelf rack,-Scattered mouse droppings in a metal tray under the furnace, and-Scattered mouse droppings in an open clear rectangular bin full of plastic lids that was sitting on a wire shelf rack. […]

• No harm, potential for more than minimal, patternF656Apr 7, 2025

  Based on record review, observation, and interview, the facility failed to ensure care planned interventions were followed related to fall interventions and care plans were in place for residents with a diagnosis of Post Traumatic Stress Disorder (PTSD) for 6 of 16 residents reviewed for Care Plans. (Residents 48, 18, 260, 51, 22, 7) Findings include: 1. Resident 48's clinical record was reviewed on 04/03/25 at 3:23 P.M. A Quarterly Minimum Data Set (MDS) assessment, dated 03/09/25, indicated the resident was moderately cognitively impaired. The resident used a walker and a wheelchair and required partial to moderate assist from staff for mobility. The resident's diagnoses included, but were not limited to, Parkinson's disease, hypertension, and dementia. […]

• No harm, potential for more than minimal, patternF758Mar 7, 2022

  Based on record review and interview, the facility failed to provide [CONDITION(S)] medications per physician's orders in a timely manner and failed to monitor for ASE (Adverse Side Effects) to [CONDITION(S)] medications for 4 of 5 residents reviewed. (Residents 20,12, 53, and 14) Findings include: 1. The clinical record for Resident 20 was reviewed on 03/07/22 at 1:41 P.M. An Annual MDS (Minimum Data Set) assessment, dated 12/07/21, indicated the resident was severely cognitively impaired. Diagnoses included, but were not limited to, dementia with behavioral disturbances and [CONDITION(S)]. The resident received antipsychotic medications on a routine basis. The EMAR (Electronic Medication Administration Record) was provided by the DON (Director of Nursing) on 03/07/22 at 1:44 P.M. […]

• No harm, potential for more than minimal, patternF757Apr 19, 2021

  Based on observation, record review, and interview, the facility failed to follow physician's orders related to monitoring residents' vital signs prior to medication administration and obtaining laboratory values for 5 of 8 residents reviewed for unnecessary medications. (Residents 37, 17, 5, 2, and 13) Findings include: 1. Resident 37 was observed on 04/14/21 at 12:07 P.M., in the main dining room eating lunch with ease and had no signs or symptoms of adverse side effects from medications or acute distress. A Quarterly MDS (Minimum Data Set) assessment, dated 03/05/21, indicated the resident was cognitively intact. […]