Above average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
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 Hickory Creek At Greensburg during CMS and state inspections, most recent first.
Failure to Follow Ordered Wound Treatment: A resident with severe cognitive impairment, paraplegia, and multiple wounds had a left ischial wound treatment order that included cleansing with Dakin's solution and packing with Calcium Alginate with silver, but the EMTAR documentation did not include the Calcium Alginate with silver. The DON stated the wound NP provided weekly orders and that the June order should have included the Calcium Alginate for the wound.
Inaccurate NP progress notes and medication documentation were found for two residents. One resident’s NP note listed the wrong facility name, and another resident’s NP notes incorrectly listed Xanax 1 mg TID instead of the ordered BID dose. The DON said the notes were reviewed in the morning meeting and that the errors should have been caught; the facility also had no policy for reviewing documentation.
Delayed Lab Specimen Collection for Wound and Urine Cultures: The facility failed to obtain wound and urine specimens in a timely manner for two residents with signs and symptoms of infection. One resident had an infected arterial wound with erythema and heavy drainage, but the wound culture was collected two days after it was recommended and antibiotics were started six days after symptom onset. Another resident had repeated UTI symptoms, and UA C&S specimens were not obtained promptly during two separate episodes, with antibiotics started before culture review and later changed when the culture showed Cipro was not susceptible.
A resident with an indwelling urinary catheter was observed multiple times propelling himself in a wheelchair with catheter tubing dragging on the floor, including in the hallway, dining room, and his room. During one observation, an LPN entered the room to give medication while several inches of tubing and part of the catheter bag were touching the floor. The resident was cognitively intact and had diagnoses including HTN and obstructive uropathy, and the DON stated the tubing should not be touching the floor.
The facility failed to keep the State Survey binder current and accessible for public review. An observation found the binder at the front door, but it only contained a notice directing people to the Administrator's office to view the previous 3 years of survey reports, and the most recent survey in the binder was dated 10/18/2022. The Administrator stated the binder should have been up to date and reported there was no policy for the State Survey binder.
The facility failed to maintain the required RN coverage for eight consecutive hours a day on multiple occasions. The DON was the only RN available, leading to insufficient coverage. The facility's records confirmed several days with inadequate RN hours, and the Administrator admitted there was no policy for RN coverage.
A resident with a history of UTIs experienced a delay in receiving antibiotic treatment due to late lab results and medication unavailability. Despite symptoms of burning and pain with urination, the resident's urine sample collected on 09/04/24 confirmed E. coli, but the antibiotic Bactrim was not administered until 09/12/24. The facility's policy required starting antibiotics within three days of obtaining a urine sample, but the lab's out-of-state location caused delays in result reporting.
A resident with diabetes received insulin despite physician's orders to hold it if blood sugar was below 120. The LPN administered insulin after meals without updating the order, contrary to facility policy on medication administration.
A resident in an LTC facility received incorrect medication dosages due to errors by an LPN. The LPN administered 15 ml of lactulose instead of the prescribed 30 ml and gave 25 units of Lispro insulin without rechecking the resident's blood sugar, which was below the threshold for insulin administration. The LPN relied on undocumented verbal instructions from a Nurse Practitioner, contrary to the facility's policy requiring verification of medication details.
Failure to Follow Ordered Wound Treatment
Penalty
Summary
Provide appropriate pressure ulcer care and prevent new ulcers from developing was not met when the facility failed to follow a physician's wound treatment order for a resident with a left ischial wound. The resident's record showed severe cognitive impairment, diagnoses including an unspecified open wound of the lower back and pelvis, obstructive uropathy, paraplegia, depression, and bipolar disorder, and dependence on staff for most care. A wound NP note indicated the left ischial wound was to be cleansed with Dakin's solution, lightly packed with Calcium Alginate with silver including the undermining, and covered with a bordered gauze dressing once daily. A physician's order for the same wound directed staff to cleanse the left ischium with Dakin's solution, pack it with Dakin's moist fluffed gauze, and cover it with a border gauze dressing. However, the June 2025 EMTAR documentation for the treatment period lacked the Calcium Alginate with silver required by the wound order. During interview, the DON stated the resident had wounds to the coccyx and ischium, the wound NP visited weekly, and the facility wound nurse or DON transcribed the orders into the clinical record for floor nurses to follow in the ETAR; the DON also stated the June order should have included the Calcium Alginate for the left ischium.
Inaccurate NP Progress Notes and Medication Documentation
Penalty
Summary
The facility failed to verify the accuracy of physician/NP assessments related to residents’ current medication regimens for 2 of 13 resident records reviewed. For Resident 13, the clinical record showed a Quarterly MDS assessment dated 08/27/2025 indicating the resident was cognitively intact and diagnoses including heart failure, hypertension, COPD, anxiety, and depression. A Facility NP progress note dated 09/11/2025 stated the resident resided in a different facility, and the note lacked the correct facility name for the resident’s current residence. The DON stated the NP progress notes were reviewed during the morning meeting and that the error should have been caught. For Resident 27, the clinical record showed an Annual MDS assessment dated 07/02/2025 indicating severe cognitive impairment and diagnoses including Alzheimer’s disease, anxiety, aphasia, and COPD. An open-ended physician’s order dated 10/10/2024 directed Xanax 1 mg twice daily for anxiety, but Facility NP progress notes dated 08/21/2025, 09/04/2025, and 09/18/2025 documented Xanax 1 mg three times daily in the medication list. The DON stated the NP progress notes were reviewed in the morning meeting, that any new order would have been written on a telephone order form, and that the documentation error should have been caught; the resident received the correct twice-daily dosage, but the progress notes were inaccurate. The DON also stated the facility did not have a policy related to reviewing documentation.
Delayed Lab Specimen Collection for Wound and Urine Cultures
Penalty
Summary
The facility failed to obtain laboratory specimens in a timely manner for two residents who had signs and symptoms requiring testing. One resident had a right lower extremity arterial ulcer with periwound erythema and heavy drainage. The wound nurse practitioner recommended a wound culture after assessing the wound and speaking with the facility NP, but the wound specimen was not collected until two days later. The culture later showed the wound was infected with bacteria, and the resident was not started on Levaquin until six days after symptom onset. Another resident had repeated urinary symptoms consistent with a possible UTI, including increased frequency, burning, pain with urination, dark yellow foul-smelling urine, and later continued burning and frequency. On the first episode, a UA C&S was ordered after the resident reported symptoms, but the record showed the specimen was collected the next day and staff were still awaiting results several days later before an on-call triage order led to Bactrim. On the later episode, the resident again reported urinary symptoms and a UA C&S was ordered, but the urine was not obtained until later that day and the lab did not receive it until the following day. The resident was started on Cipro before the culture results were reviewed, and later the NP was notified that the culture and sensitivity was not susceptible to Cipro, prompting a change in antibiotic. During interview, the Infection Preventionist stated that when residents had signs or symptoms of a UTI, staff would obtain vital signs, assess symptoms, and contact the physician, and that urine or wound cultures would be obtained in the facility and picked up by the lab. She also stated the lab had recently switched to coming only on Monday, Wednesday, and Friday, with other specimens sent by mail carrier service. The facility policy for lab tracking stated that daily order checks and daily lab tracking reports were to ensure ordered tests were entered and, if not resulted as expected, investigated to obtain the results.
Indwelling Catheter Tubing Touched the Floor
Penalty
Summary
The facility failed to follow infection control guidelines related to indwelling urinary catheter management for one resident. During multiple observations, the resident was seen propelling himself in a wheelchair with catheter tubing dragging on the floor, including while going from his room to the Main Dining Room, while traveling in the hallway, and while returning to his room. On one observation, the resident also had a mechanical lift harness in the wheelchair underneath him while four to five inches of catheter tubing were dragging on the floor. During another observation, an LPN entered the resident’s room to administer medication after a staff member exited, and four to six inches of the urinary catheter tubing were touching the floor while about an inch of the catheter bag was touching the floor. The resident’s record showed he was cognitively intact and had diagnoses including hypertension and obstructive uropathy. The DON stated the tubing should not be touching the floor. The facility’s infection control policy stated that urinary drainage bags should have a barrier such as a cover or wash basin underneath them to prevent catheter bags or tubing from touching the ground.
State Survey Results Not Kept Current for Public Review
Penalty
Summary
The facility failed to have recent State survey results available and accessible for public review. During an observation and record review on 09/17/2025 at 1:32 P.M., the State Survey binder was present at the front door, but the binder contained a notice stating that the previous 3 years of State Department of Health surveys were available in the Administrator's office and that the Administrator should be contacted to view the reports. The last survey dated in the binder was 10/18/2022. During an interview on 09/17/2025 at 1:38 P.M., the Administrator stated the State Survey binder should have been up to date. During a later interview on 09/18/2025 at 9:53 P.M., the Administrator stated there was no policy referencing the State Survey binder.
Deficiency in RN Coverage
Penalty
Summary
The facility failed to provide the required Registered Nurse (RN) coverage for eight consecutive hours a day for 12 out of 29 days reviewed. This deficiency was identified through interviews and record reviews. The Director of Nursing (DON) admitted that they were the only RN working at the facility, which sometimes resulted in the absence of an RN for the required hours. The Regional Director of Clinical Services and the Manager of Financial Operations confirmed that the facility had one day with zero RN hours and 21 days with less than eight RN hours during the fiscal year quarter 3. The facility's nursing schedules for April, May, June, September, and October 2024 showed specific dates when an RN was not on duty for the required hours. The Facility Assessment indicated that an average of four RNs was needed for direct care, but the facility lacked a policy related to RN coverage. The Administrator acknowledged the absence of such a policy during an interview.
Delayed Antibiotic Treatment for UTI
Penalty
Summary
The facility failed to obtain laboratory results and start an antibiotic in a timely manner for a resident who was reviewed for urinary tract infections. The resident, who was cognitively intact, had a history of cerebral infarction, UTI, seizure disorder, anxiety, depression, and psychotic disorder. On 09/01/24, the resident complained of burning with urination, and staff encouraged fluid intake. By 09/03/24, the resident continued to experience symptoms, prompting a Nurse Practitioner to order a urinalysis and culture and sensitivity test. The urine sample was collected on 09/04/24 and sent to the lab on 09/06/24. However, the facility did not receive the culture results until 09/08/24, which confirmed the presence of E. coli. Despite the confirmation of a UTI, the resident did not receive the prescribed antibiotic, Bactrim, until 09/12/24, due to the medication being unavailable on 09/11/24. The facility's policy required that if a resident had an order for a UA C&S and ended up having a UTI, they should have been started on an antibiotic within three days of obtaining the urine. Interviews with staff revealed that the lab used by the facility was out of state and had been taking five days to return culture results. The Director of Nursing acknowledged that the resident should have been started on an antibiotic sooner. The facility's policies on infection prevention and lab tracking were reviewed, but no additional policies related to lab services were available.
Failure to Follow Insulin Hold Parameters
Penalty
Summary
The facility failed to adhere to a physician's order regarding insulin administration for a resident diagnosed with diabetes, hypertension, and depression. The resident, who was cognitively intact, was prescribed insulin lispro with specific hold parameters indicating that the insulin should not be administered if the resident's blood sugar was less than 120. However, the resident received insulin on multiple occasions when their blood sugar levels were below the specified threshold, as documented in the EMAR/ETAR records for July, August, and September. During an interview, an LPN admitted to checking the resident's blood sugar and administering insulin after the resident had eaten, despite the hold parameters. The LPN had communicated with a Nurse Practitioner about the order but had not updated the instructions to reflect any changes. The facility's policy on medication administration emphasized verifying the correct medication, dose, route, rate, time, and resident each time a medication is administered, which was not followed in this case.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate of less than 5% due to errors in medication administration for one resident. On the morning of October 9, 2024, an LPN was observed preparing and administering medications for a resident. The LPN incorrectly administered 15 ml of lactulose instead of the prescribed 30 ml. Additionally, the LPN administered 25 units of Lispro insulin without rechecking the resident's blood sugar, which was initially recorded as 106. The facility's policy required holding the insulin if the blood sugar was below 120, but the LPN proceeded based on a verbal instruction from a Nurse Practitioner, which was not documented in the resident's EMAR or progress notes. The resident involved was cognitively intact and had diagnoses including diabetes, hypertension, and depression. The resident's clinical records indicated regular insulin administration, with specific instructions to hold insulin if blood sugar levels were below 120. The LPN acknowledged the error in lactulose dosage and the failure to update the EMAR with the new insulin administration instructions. The facility's policy on medication administration emphasized verifying the correct medication, dose, route, rate, time, and resident, which was not adhered to in this instance.
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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.
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Nursing homes near Greensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Aspen Place Health Campus | 0.7 mi | ★★★★★ | 0 | 0 |
| Morning Breeze Retirement Community And Healthcare | 1 mi | ★★★★★ | 0 | 0 |
| Arbor Grove Village | 1.1 mi | ★★★★★ | 18 | 0 |
| Willows Of Greensburg | 1.7 mi | ★★★★★ | 15 | 0 |
| Waldron Rehabilitation And Healthcare Center | 12.3 mi | ★★★★★ | 7 | 0 |
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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.