Average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Morning Breeze Retirement Community And Healthcare during CMS and state inspections, most recent first.
A resident with HTN, HF, orthostatic hypotension, DM, and dementia had an order for Metoprolol 25 mg daily with hold parameters for SBP and HR. The EMAR lacked documentation that BP or HR were obtained before administration, and an LPN stated vitals should be checked and documented before giving a med with hold parameters.
The facility failed to follow physician orders for weight monitoring for two residents with CHF and nutrition-related concerns. One resident had multiple missed weight entries, then showed an 11-lb gain in 24 hours, but there was no documentation of PRN Torsemide administration or physician notification. A second resident with dementia and CHF also had multiple missing weekly weight entries, and staff stated weights were to be documented in the EMAR.
A resident receiving IV antibiotics through a PICC line had a dressing that remained dated and worn, with the ETAR left blank for the scheduled dressing change. The resident was cognitively intact and had diagnoses including infection following a procedure, wound infection, CAD, and CHF. An LPN observed the dressing and stated it should have been changed earlier, while facility policy required central line dressings to be maintained sterile and changed at least every 7 days.
Significant Torsemide Medication Error: A resident with CHF and multiple chronic conditions had overlapping Torsemide orders that resulted in the medication being administered as a routine morning dose plus extra doses at both 2:00 P.M. and 5:00 P.M. The DON stated the resident should have received the routine dose and only one extra afternoon dose if the weight was above the ordered threshold, and later acknowledged a medication error occurred when the 5:00 P.M. order was not discontinued.
A facility failed to accurately document the administration of narcotic pain medication for a resident with moderate cognitive impairment and multiple diagnoses. The resident's Morphine Sulfate administration was not consistently recorded in the EMAR, despite being signed out in the narcotic book. This discrepancy was identified during a review of the resident's medication records and an interview with an RN, highlighting a failure to adhere to the facility's documentation policy.
The facility failed to maintain safe water temperatures in resident rooms, with temperatures exceeding the policy limit of 120 degrees Fahrenheit. This was observed in five rooms, confirmed through interviews and temperature checks. The Maintenance Director only checked temperatures at nurses' stations, and the facility's logs lacked documentation for resident rooms.
A facility failed to properly store medications, as an expired vial of Tuberculin serum was found in the Long Hall medication room refrigerator. The vial had been open for more than 30 days, contrary to the storage directions, and the DON could not determine how many residents might have received the expired medication due to limited documentation. The facility's policy requires outdated drugs to be returned or destroyed, which was not followed.
Failure to Document Vital Signs Before Administering Metoprolol
Penalty
Summary
The facility failed to follow a physician’s order for a resident who was cognitively intact and had diagnoses including metabolic encephalopathy, anemia, heart failure, hypertension, orthostatic hypotension, diabetes, non-Alzheimer’s dementia, anxiety, and depression. The order, started on 04/15/25, directed staff to administer Metoprolol 25 mg once daily and to hold the medication if systolic blood pressure was less than 110 or heart rate was less than 60. Review of the April, May, June, and July 2025 EMAR showed no documentation that the resident’s blood pressure or heart rate was obtained and recorded before Metoprolol was administered. During interview, an LPN stated that vital signs should be obtained before giving a medication with hold parameters, that the medication should be held if the parameters were not met, and that the reason for not giving the medication should be documented in the resident’s record. The facility policy stated that medications are to be administered in a safe and timely manner as prescribed and that vital signs are checked and verified when necessary before administration.
Failure to Complete Ordered Weight Monitoring and Document Weight Changes
Penalty
Summary
The facility failed to follow physician's orders for weight monitoring for two residents with nutrition-related concerns and congestive heart failure. One resident was cognitively intact and had diagnoses including cellulitis, thyroid disorder, arthritis, malnutrition, heart failure, and congestive heart failure. A physician's order required daily weights for congestive heart failure, and another order allowed PRN Torsemide for a 3-pound weight gain in one day or a 5-pound gain over one week. The clinical record lacked documented weights on several dates, and there was no documentation that the resident refused weights on those dates. The resident's weight increased from 229.2 lbs. to 240.2 lbs. in 24 hours, but the record lacked documentation that PRN Torsemide was given or that the physician was notified of the weight gain. For the second resident, who was moderately cognitively impaired and had diagnoses including unspecified dementia, anemia, hypertension, neurogenic bladder, non-Alzheimer's dementia, and depression, an order required weekly weights for congestive heart failure. The clinical record lacked documented weights for multiple scheduled weekly dates. Staff interviews indicated weights were expected to be documented in the EMAR, and the facility policy stated weights are monitored for undesirable or unintended weight loss or gain and recorded in the medical record.
PICC Dressing Change Not Completed as Ordered
Penalty
Summary
The facility failed to provide parenteral/IV site maintenance related to dressing changes for a resident receiving antibiotics through a PICC line in the right arm. The resident was observed with an intact PICC dressing on 07/29/25, and the dressing was still intact but worn and wrinkled on 07/30/25; both observations showed the dressing dated 07/22/25. The resident stated she was receiving antibiotics through the PICC twice a day and that the dressing had not been recently changed. The resident’s record showed she was cognitively intact and had diagnoses including infection following a procedure, wound infection, coronary artery disease, and congestive heart failure. The physician’s order, started 07/28/25, directed the PICC dressing to be changed every Monday afternoon, and the ETAR showed the dressing was due to be changed on 07/28/25 but was left blank. During interview, an LPN stated the PICC dressing should be changed every five to seven days and, after observing the dressing, indicated it should have been changed before then. The facility policy stated central vascular access device dressings are to be maintained sterile and changed at least every 7 days.
Significant Torsemide Medication Error
Penalty
Summary
The facility failed to prevent a significant medication error involving Torsemide for a resident with heart failure, hypertension, diabetes, seizure disorder, anxiety, depression, and respiratory failure who was cognitively intact. The resident had new cardiology orders for Torsemide 40 mg every morning and an additional dose if the resident's weight was greater than 219 pounds. The record showed multiple overlapping physician orders for daily weights and extra Torsemide doses, including orders that did not specify the amount to be given and later orders for extra doses at 5:00 P.M. and 2:00 P.M. The electronic medication administration record showed the resident received Torsemide daily at 6:00 A.M., 2:00 P.M., and 5:00 P.M. from 07/22/25 through 07/30/25. During interviews, the LPN stated new physician orders would be entered into the resident's clinical record, and the DON stated the resident was supposed to receive a routine morning dose and an extra 40 mg dose in the afternoon if the weight was greater than 219 pounds. The DON said she did not believe the resident was supposed to receive extra doses at both 2:00 P.M. and 5:00 P.M. Observation of the medication cart showed no separate supply of extra Torsemide doses, and the pharmacy representative reported 24 capsules of Torsemide 40 mg had been dispensed. The DON later stated there was a medication error, that a nurse had clarified the PRN order and a second order was added at 2:00 P.M., and that the 5:00 P.M. order should have been discontinued. She also stated the resident had no ill effects or outcomes from the medication error.
Inaccurate Documentation of Narcotic Administration
Penalty
Summary
The facility failed to ensure accurate documentation of a resident's medication administration record, specifically concerning the administration of narcotic pain medication. Resident C, who was moderately cognitively impaired and had diagnoses including anemia, hypertension, diabetes, and seizure disorder, was prescribed 15 mg of Morphine Sulfate to be administered every three hours as needed for severe pain. The Controlled Drug Receipt/Record/Disposition Form indicated that the medication was signed out as given on several occasions. However, discrepancies were noted in the Electronic Medication Administration Record (EMAR), which lacked documentation for the administration of the medication on two specific occasions. During an interview, RN 2 explained the procedure for documenting narcotic administration, which involved recording it in the narcotic book and then in the electronic system. The facility's policy on medication administration documentation, revised in April 2007, required that all medications administered be documented immediately after administration. The failure to document the administration of Morphine Sulfate in the EMAR as per the facility's policy led to the deficiency cited in relation to Complaint IN00444788.
Unsafe Water Temperatures in Resident Rooms
Penalty
Summary
The facility failed to maintain safe water temperatures in resident rooms, as observed during a survey. Water temperatures in five out of nine resident rooms were found to be excessively high, ranging from 120.0 to 124.1 degrees Fahrenheit, which is above the facility's policy limit of 120 degrees Fahrenheit. This was confirmed through interviews, observations, and temperature checks using both probe thermometers and a laser gun. Resident 11 reported that the water in his bathroom was too hot, and this was verified by a temperature reading of 121.5 degrees Fahrenheit. The Maintenance Director indicated that routine checks were only conducted at nurses' stations, not in resident rooms unless a problem was reported. The facility's hot water monitoring logs showed that temperatures were only documented at the nurses' stations, with no records for resident rooms. The facility's policy requires water temperatures to be maintained at or below 120 degrees Fahrenheit to prevent scalding, and any excessive temperatures should be reported and addressed immediately. However, the policy was not followed, leading to the deficiency in maintaining safe water temperatures in resident rooms.
Expired Medication Vial Found in Medication Room
Penalty
Summary
The facility failed to appropriately store medications, specifically an expired medication vial, in one of the two medication rooms reviewed. During an observation of the Long Hall medication room, a refrigerator was found to contain an open vial of Tuberculin (TB) serum with an open date written on the side of the bottle. The vial was over half full and had been opened for more than 30 days, which is beyond the recommended usage period as per the TB serum package insert. The Director of Nursing (DON) confirmed that the TB serum should have been discarded after 30 days from the open date. However, due to limited documentation in their system, the DON could not identify how many residents might have received this expired medication. The facility's current policy on the storage of medications, dated 2020, states that discontinued, outdated, or deteriorated drugs or biologicals should be returned to the dispensing pharmacy or destroyed, 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) |
|---|---|---|---|---|
| Hickory Creek At Greensburg | 1 mi | ★★★★★ | 10 | 0 |
| Willows Of Greensburg | 1.2 mi | ★★★★★ | 15 | 0 |
| Arbor Grove Village | 1.5 mi | ★★★★★ | 18 | 0 |
| Aspen Place Health Campus | 1.6 mi | ★★★★★ | 0 | 0 |
| Waldron Rehabilitation And Healthcare Center | 12 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.