Morning Breeze Retirement Community and Healthcare

In the surveyor’s words

From the most serious findings on record at Morning Breeze Retirement Community and Healthcare, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF921Aug 19, 2024

  Based on interview, observation, and record review, the facility failed to provide safe water temperatures for 5 of 9 resident rooms observed. (Rooms 45, 47, 42, 43, and 1) Findings include: During an interview and observation on 08/13/24 at 12:53 P.M., Resident 11 indicated the water in his bathroom was hot. The water in the resident's bathroom sink was felt and found to be hot. The water stream was to hot to keep a hand under the water flow without discomfort. The water temperature was tested with a probe and was found to be 121.5 degrees Fahrenheit. […]

• No harm, potential for more than minimal, patternF656Jun 28, 2021

  Based on observation, interview, and record review, the facility failed to develop Care Plans in a timely manner for residents who were at risk for falls and at risk for pressure ulcers for 6 of 18 residents reviewed for Care Plans. (Residents 35, 18, 17, 2, 37, and 48) Findings include: 1. During an observation and interview on 06/21/21 at 11:27 A.M., Resident 35 indicated she had fallen in the facility and she had a sore on her right heel. Her right foot was wrapped with a compression wrap all the way to her knee. A SKIN OBSERVATION TOOL record, dated 04/30/21, was provided by the DON (Director of Nursing) on 06/23/21 at 1:22 P.M. The record indicated the resident had an injury to her right heel. The clinical record was reviewed on 06/25/21 at 2:13 P.M. […]

• No harm, potential for more than minimal, patternF686Jun 28, 2021

  Based on interview, observation, and record review, the facility failed to prevent pressure ulcers related to completing wound and skin assessments, and following physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . (Residents 45, 17, 37, and 18) Findings include: 1. During an interview on 06/21/21 at 9:25 A.M., Resident 45 indicated she had a sore on her bottom. The clinical record for Resident 45 was reviewed on 06/22/21 at 3:17 P.M. A Quarterly MDS (Minimum Data Set) assessment, dated 06/01/21, indicated the resident was moderately cognitively impaired. diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident had an unstageable deep tissue injury that was not present on admission. […]

• No harm, potential for more than minimal, isolatedF684Aug 4, 2025

  Based on record review and interview, the facility failed to follow physician's orders related to hold parameters for a hypertensive medication for 1 of 18 residents reviewed for Quality of Care. (Resident 7)Findings include:The clinical record for Resident 7 was reviewed on 07/30/2025 at 10:29 A.M. A Quarterly Minimum Data Set (MDS) assessment, dated 06/17/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, metabolic encephalopathy, anemia, heart failure, hypertension, orthostatic hypotension, diabetes, non-Alzheimer's dementia, anxiety, and depression.An open-ended physician's order, with a start date of 04/15/25, indicated for the staff to administer the resident's Metoprolol 25 milligrams, once a day. […]

• No harm, potential for more than minimal, isolatedF692Aug 4, 2025

  Based on record review and interview, the facility failed to follow physician's orders for weight monitoring for 2 of 5 residents reviewed for nutrition. (Residents 38 and 49)Findings include:1.The clinical record for Resident 38 was reviewed on 07/30/2025 at 1:53 P.M. An admission Minimum Data Set (MDS) assessment, dated 06/14/25, indicated the resident was cognitively intact. The resident's diagnoses included, but were not limited to, cellulitis, thyroid disorder, arthritis, and malnutrition.The resident had a diagnosis of heart failure, dated 06/15/25 and congestive heart failure, dated 06/25/25.A physician's order, dated 06/30/25 through 07/30/25, indicated the resident was to be weighed daily for congestive heart failure.A current open-ended physician's order, with a start date of… […]