Willows Of Greensburg

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.

Based on record review and interview, the facility failed to provide appropriate urinary catheter care for 1 of 3 residents reviewed for urinary catheter care. (Resident C)Findings Include:The clinical record for Resident C was reviewed on 8/14/2025 at 11:30 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 5/22/2025, indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, hypertension, atrial fibrillation, End-stage renal disease, and Alzheimer's disease. A Progress Note, dated 8/7/2025 at 8:50 A.M., created by Registered Nurse (RN) 2, indicated the Nurse Practitioner (NP) was made aware of Resident C's increase fatigue. New orders were obtained to anchor a urinary catheter and administer a normal saline bolus of 500 cubic centimeter (cc) over two hours and then decrease to 100cc every hour for 48 hours. A Progress Note, dated 8/7/2025 at 2:30 P.M., created by RN 3, indicated Resident C had a 16 French indwelling urinary catheter with a 15 milliliter (ml) balloon. Upon insertion of the urinary catheter there was no urine return. A Progress Note, dated 8/7/2025 at 8:29 P.M., created by RN 3, indicated a Qualified Medical Assistant from another unit reported to them the presence of blood in Resident C's urinary catheter bag. Bright red blood was noted in the catheter tubing and bag.

Emergency Medical Services (EMS) arrived and transported the resident to the hospital.The clinical record lacked documentation to indicate the resident's catheter placement was reassessed prior to the presence of blood in the catheter bag. A Hospital Transfer Report, dated 8/7/2025, indicated Resident C had an Abdomen/Pelvis Computed Tomography (CT) Scan. A Radiology Impression indicated a urinary catheter balloon was inflated within the penile urethra. During an interview, on 8/14/2025 at 3:08 P.M., RN 3 indicated that after inserting a urinary catheter the nurse would need to make sure there was urine return in

the tubing. If there was no urine return, the urinary catheter would need to be monitored to ensure urine return began. The current facility policy titled, Validation Checklist Catheterization (Male), dated 2023, was provided by the Director of Nursing (DON) on 8/14/2025 at 3:53 P.M. The policy indicated, .Inserted the catheter gently into the meatus or until urine began to flow from the bladder .if resistance continued, do not force entry . This citation relates to Complaints 2574159 and 2572941. 3.1-41(a)(2)

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/14/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Willows of Greensburg

410 Park Rd Greensburg, IN 47240

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

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Based on record review, and interview the facility failed to provide an ordered medication for 1 of 3 resident's reviewed. (Resident B)Findings Include: The clinical record for Resident B was reviewed on 8/14/2025 at 11:18 A.M. The record indicated the resident was severely cognitively impaired. The resident's diagnoses included, but were not limited to, non-Alzheimer's dementia, atrial fibrillation, and hypertension.

A physician's order, dated 6/22/2025, indicated Resident B was to receive Memantine (a cognition medication) 5 milligram (mg), one tablet twice a day.The order was discontinued on 7/7/25 with a note stating, Meds from home no interchange needed. The resident's medication administration record was reviewed. The resident had not received the prescribed Memantine from 7/8/25 through 7/28/25.A Health Status Note, dated 8/08/25 at 3:11 P.M., indicated the family notified the facility of discontinuance of memantine on 7/07/2025. The writer confirmed and notified the Nurse Practitioner (NP). During an interview, on 8/14/2025 at 1:28 P.M., RN 2 indicated that on 7/07/25 she discontinued Resident B's Memantine medication on accident, and the family notified her of the missing medication on 7/28/2025. The medication was restarted on 7/29/2025. A current physician's order, with a start date of 7/29/2025, indicated Resident B was to receive Memantine extended release 14 mg daily. The current facility policy titled, Physician Medication/ Ancillary Order Policy & Procedure, dated 07/2023, was provided by the Director of Nursing (DON) on 8/14/2025 at 3:15 P.M. The policy indicated, .Ensure medications/treatments are provided to residents . in accordance with the order . This citation relates to Complaint 2587102. 16.2-5-6 (l) (2)

Event ID:

Facility ID:

If continuation sheet