Cycle 1
Health 2025-08-04 · Fire 2025-08-04
4 health deficiencies
Top issue: Quality of Life and Care (3 deficiencies)
4 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Greensburg, IN
Morning Breeze Retirement Community And Healthcare
5-star overall rating with 4-star inspections with 4 recent health deficiencies with 4 fire-safety deficiencies in the latest cycle
950 N Lakeview Dr, Greensburg, IN
(812) 662-7778
Overall
5 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
5 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
64
Certified beds
Average residents
54
Average occupied residents
Ownership
Non-Profit
Publicly displayed owner type
Chain
Exceptional Living Centers
Operator or chain grouping
Approved since
2000-07-21
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
10 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.72
Registered nurse staffing · state 0.66 · national 0.68
LPN hours / resident day
0.67
Licensed practical nurse staffing · state 0.77 · national 0.87
Aide hours / resident day
2.23
Nurse aide staffing · state 2.27 · national 2.35
Total nurse hours
3.62
All reported nurse hours · state 3.71 · national 3.89
Licensed hours
1.39
RN + LPN hours · state 1.44 · national 1.54
Weekend hours
3.31
Weekend nurse staffing · state 3.24 · national 3.43
Weekend RN hours
0.51
Weekend registered nurse coverage · state 0.45 · national 0.47
Physical therapist
0.01
Reported PT staffing · state 0.06 · national 0.07
Adjusted RN hours
0.65
CMS adjusted RN staffing hours
Adjusted total hours
3.29
CMS adjusted total nurse staffing hours
Case-mix index
1.51
Higher values indicate more complex resident acuity
RN turnover
22%
Annual RN turnover · state 42% · national 45%
Total nurse turnover
49%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
7,137
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
30.63
Composite VBP score used to determine payment impact.
Payment multiplier
0.9861
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
Not reported
This facility did not meet this measure's case minimum policy requirement and therefore no measure data is publicly reported.
Healthcare-associated infections
2.28
Baseline 5.68% · Performance 7.15% · Measure score 2.28 · Achievement 2.28 · Improvement 0
Total nurse turnover
5.63
Baseline 52.83% · Performance 40.68% · Measure score 5.63 · Achievement 5.63 · Improvement 3.84
Adjusted total nurse staffing
1.29
Baseline 2.98 hours · Performance 3.44 hours · Measure score 1.29 · Achievement 1.29 · Improvement 1.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 11.66% |
10.72%
0.9 pts worse
|
No Different than the National Rate · Eligible stays 65 · Observed rate 13.85% · Lower 95% interval 7.8% |
| Discharge to community | 59.35% |
50.57%
8.8 pts better
|
No Different than the National Rate · Eligible stays 39 · Observed rate 58.97% · Lower 95% interval 47.53% |
| Medicare spending per beneficiary | 1.35 |
1.02
0.3 pts worse
|
|
| Drug regimen review with follow-up | 97.06% |
95.27%
1.8 pts better
|
Numerator 33 · Denominator 34 |
| Falls with major injury | 2.94% |
0.77%
2.2 pts worse
|
Numerator 1 · Denominator 34 |
| Discharge self-care score | 63.64% |
53.69%
10 pts better
|
Numerator 14 · Denominator 22 |
| Discharge mobility score | 59.09% |
50.94%
8.2 pts better
|
Numerator 13 · Denominator 22 |
| Pressure ulcers or injuries, new or worsened | 0% |
2.29%
2.3 pts better
|
Numerator 0 · Denominator 34 · Adjusted rate 0% |
| Healthcare-associated infections requiring hospitalization | 7.15% |
7.12%
About the same
|
No Different than the National Rate · Eligible stays 32 · Observed rate 6.25% · Lower 95% interval 3.82% |
| Staff COVID-19 vaccination coverage | 80.72% |
8.2%
72.5 pts better
|
Numerator 67 · Denominator 83 |
| Staff flu vaccination coverage | 93.88% |
42%
51.9 pts better
|
Numerator 92 · Denominator 98 |
| Discharge function score | 77.27% |
56.45%
20.8 pts better
|
Numerator 17 · Denominator 22 |
| Transfer of health information to provider | Not Available |
95.95%
|
Numerator Not Available · Denominator 11 · Too few residents or stays to report publicly. |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | Not Available |
25.2%
|
Numerator Not Available · Denominator 15 · Too few residents or stays to report publicly. |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.1 |
1.6
0.5 pts better
|
1.9
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.1 · Observed 0.9 · Expected 1.5 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.3 |
1.5
0.2 pts better
|
1.8
0.5 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.3 · Observed 1.1 · Expected 1.4 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 87.8% |
93.6%
5.8 pts worse
|
93.4%
5.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 93.2% · Q2 93.3% · Q3 88.9% · Q4 76.1% · 4Q avg 87.8% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 98.0% |
95.4%
2.6 pts better
|
95.5%
2.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 98.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.9% |
3.8%
0.1 pts worse
|
3.3%
0.6 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.3% · Q2 4.4% · Q3 2.2% · Q4 6.5% · 4Q avg 3.9% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 9.9% |
24.6%
14.7 pts better
|
11.4%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.3% · Q2 9.1% · Q3 6.8% · Q4 7.3% · 4Q avg 9.9% |
| Percentage of long-stay residents who lose too much weight | 3.6% |
5.6%
2 pts better
|
5.4%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 4.9% · Q3 7.3% · Q4 2.3% · 4Q avg 3.6% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 38.9% |
23.5%
15.4 pts worse
|
19.6%
19.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 43.9% · Q2 36.6% · Q3 40.5% · Q4 34.9% · 4Q avg 38.9% |
| Percentage of long-stay residents who received an antipsychotic medication | 10.6% |
14.8%
4.2 pts better
|
16.7%
6.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 13.5% · Q2 11.4% · Q3 8.8% · Q4 8.3% · 4Q avg 10.6% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.0%
About the same
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 7.6% |
13.3%
5.7 pts better
|
16.3%
8.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.2% · Q2 7.5% · Q3 3.4% · Q4 7.3% · 4Q avg 7.6% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 11.4% |
11.7%
0.3 pts better
|
14.9%
3.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 2.4% · Q2 2.4% · Q3 4.8% · Q4 35.7% · 4Q avg 11.4% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.4%
0.4 pts better
|
1.0%
1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.1% |
1.2%
0.1 pts better
|
1.7%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 2.3% · Q4 2.2% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 36.2% |
24.2%
12 pts worse
|
19.8%
16.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 50.5% · Q2 32.7% · Q3 32.5% · Q4 29.9% · 4Q avg 36.2% |
| Percentage of long-stay residents with pressure ulcers | 2.1% |
4.1%
2 pts better
|
5.1%
3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.9% · Q3 3.1% · Q4 2.3% · 4Q avg 2.1% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 61.3% |
81.6%
20.3 pts worse
|
81.7%
20.4 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 87.8% · Q2 72.3% · Q3 56.7% · Q4 33.9% · 4Q avg 61.3% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 10.5% |
10.5%
About the same
|
12.0%
1.5 pts better
|
Short Stay · 20240701-20250630 · Adjusted 10.5% · Observed 10.3% · Expected 11.0% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.7% |
1.3%
0.6 pts better
|
1.6%
0.9 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 2.5% · 4Q avg 0.7% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 57.1% |
79.0%
21.9 pts worse
|
79.7%
22.6 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 57.1% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 29.1% |
22.4%
6.7 pts worse
|
23.9%
5.2 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 29.1% · Observed 27.6% · Expected 22.6% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-08-19 · Fire 2024-08-19
3 health deficiencies
Top issue: Environmental (1 deficiency)
2 fire-safety deficiencies
Top issue: Emergency Preparedness (1 deficiency)
Cycle 3
Health 2023-07-03 · Fire 2023-07-03
3 health deficiencies
Top issue: Quality of Life and Care (2 deficiencies)
7 fire-safety deficiencies
Top issue: Smoke (3 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-08-04
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-08-04
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-08-04
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2025-12-12
E · Potential for more than minimal harm
2025-08-04
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2025-12-12
F · Potential for more than minimal harm
2024-08-19
E41 · Emergency Preparedness Deficiencies
Fire Safety
Implement emergency and standby power systems.
Corrected 2024-09-24
F · Potential for more than minimal harm
2024-08-19
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2024-09-24
F · Potential for more than minimal harm
2023-07-03
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2023-08-10
F · Potential for more than minimal harm
2023-07-03
K341 · Smoke Deficiencies
Fire Safety
Install a fire alarm system that can be heard throughout the facility.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-07-03
K271 · Egress Deficiencies
Fire Safety
Have exits that are accessible at all times.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-07-03
K325 · Smoke Deficiencies
Fire Safety
Have properly installed hallway dispensers for alcohol-based hand rub.
Corrected 2023-08-10
E · Potential for more than minimal harm
2023-07-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-08-10
C · Minimal harm
2023-07-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-08-10
C · Minimal harm
2023-07-03
K712 · Miscellaneous Deficiencies
Fire Safety
Have simulated fire drills held at unexpected times.
Corrected 2023-08-10
Inspection history
Recent health citations
D · Potential for more than minimal harm
2025-08-04
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-04
F692 · Quality of Life and Care Deficiencies
Health
Provide enough food/fluids to maintain a resident's health.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-04
F694 · Quality of Life and Care Deficiencies
Health
Provide for the safe, appropriate administration of IV fluids for a resident when needed.
Corrected 2025-08-22
D · Potential for more than minimal harm
2025-08-04
F760 · Pharmacy Service Deficiencies
Health
Ensure that residents are free from significant medication errors.
Corrected 2025-08-22
D · Potential for more than minimal harm
2024-10-18
F842 · Resident Assessment and Care Planning Deficiencies
Health
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Corrected 2024-10-31
E · Potential for more than minimal harm
2024-08-19
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-09-05
D · Potential for more than minimal harm
2024-08-19
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2024-09-05
D · Potential for more than minimal harm
2023-07-03
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-07-03
F686 · Quality of Life and Care Deficiencies
Health
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Corrected 2023-07-19
D · Potential for more than minimal harm
2023-07-03
F698 · Quality of Life and Care Deficiencies
Health
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Corrected 2023-07-19
Penalties and ownership
What sits behind the stars
Ownership
Ae Greensburg Facility Company LLC
5% Or Greater Mortgage Interest · Organization
American Eagle Morning Breeze LLC
Operational/Managerial Control · Organization
Campbell, Brenda
Contracted Managing Employee · Individual
Cook, Steven
Operational/Managerial Control · Individual
Craig, David
Operational/Managerial Control · Individual
Decatur County Memorial Hospital
5% Or Greater Direct Ownership Interest · Organization
Decatur County Memorial Hospital
Operational/Managerial Control · Organization
Exceptional Living Centers, LLC
Operational/Managerial Control · Organization
Hughes, April
Operational/Managerial Control · Individual
Keck, Catherine
Operational/Managerial Control · Individual
Keck, Catherine
Corporate Officer · Individual
Lexington Health Management LLC
5% Or Greater Direct Ownership Interest · Organization
Mccullough, Mary
Operational/Managerial Control · Individual
Mckinney, Rex
Operational/Managerial Control · Individual
Mckinney, Rex
Corporate Officer · Individual
Medical Rehabilitation Centers, LLC
Operational/Managerial Control · Organization
Sutton, Angela
Operational/Managerial Control · Individual
Turner, Stacie
Contracted Managing Employee · Individual
Warren, Sarah
Operational/Managerial Control · Individual
Watts, Amy
Operational/Managerial Control · Individual
Watts, Walter
Operational/Managerial Control · Individual
Wenzler, Annette
Operational/Managerial Control · Individual
Witkemper, Holly
Operational/Managerial Control · Individual
Wright, Morgan
Operational/Managerial Control · Individual
Yurt, Thomas
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
#1
Hickory Creek At Greensburg
Greensburg, IN
5-star overall rating with 4-star inspections with 5 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#2
Willows Of Greensburg
Greensburg, IN
2-star overall rating with 2-star inspections with 13 recent health deficiencies with 14 fire-safety deficiencies in the latest cycle
#3
Arbor Grove Village
Greensburg, IN
3-star overall rating with 4-star inspections with 6 recent health deficiencies with 7 fire-safety deficiencies in the latest cycle
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