Inspection Reports for Middletown Nursing and Rehabilitation Center
131 S 10TH ST, IN, 47356
Back to Facility ProfileDeficiencies per Year
16
12
8
4
0
Severe
High
Moderate
Low
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Complaint Investigation
Census: 13
Deficiencies: 0
Jun 17, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00460963.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00460963 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 13
Medicare residents: 1
Medicaid residents: 5
Other payor residents: 7
Inspection Report
Follow-Up
Census: 10
Capacity: 45
Deficiencies: 2
Feb 11, 2025
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and Licensure Survey originally conducted on 12/16/24 to verify compliance with federal regulations.
Findings
At this PSR survey, Middletown Nursing and Rehabilitation Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinkled except for two detached storage sheds. Fire alarm and smoke detection systems were in place and operational. Some deficiencies related to hazardous area enclosure and fire door maintenance were noted but temporarily waived from 12/16/2024 to 12/16/2025.
Severity Breakdown
SS=E: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Hazardous areas are not fully enclosed with required fire-rated barriers and doors as per NFPA 101 standards. | SS=E |
| Maintenance, inspection, and testing of fire door assemblies not fully compliant with NFPA 80 standards. | SS=E |
Report Facts
Certified beds: 45
Census: 10
Inspection Report
Life Safety
Census: 13
Capacity: 45
Deficiencies: 12
Dec 16, 2024
Visit Reason
The survey was conducted as a Life Safety Code Recertification and Licensure Survey by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with multiple Life Safety Code requirements including emergency preparedness testing documentation, means of egress obstructions, fire alarm system maintenance, sprinkler system inspections, ceiling construction in freezer room, equipment inspection certificates, electrical receptacle safety, fire drill timing, generator fuel testing, building construction firestopping, hazardous area enclosures, and fire door maintenance.
Severity Breakdown
SS=F: 6
SS=E: 4
SS=D: 1
SS=C: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to document emergency preparedness exercises at least twice per year including unannounced drills. | SS=F |
| Failed to maintain 1 of 6 means of egress free of obstructions. | SS=E |
| Failed to maintain fire alarm system; main panel battery failed and semi-annual inspections not itemized by location. | SS=F |
| Failed to provide documentation for quarterly sprinkler system inspections for one quarter. | SS=F |
| Failed to maintain ceiling construction in freezer room; missing ceiling tile delaying sprinkler activation. | SS=F |
| Failed to have current inspection certificates for water heater and boilers. | SS=F |
| Failed to maintain electrical receptacles in Shenandoah Dining Room; cracked outlet and open ground. | SS=D |
| Failed to conduct quarterly fire drills at unexpected times on third shift for 4 of 4 quarters. | SS=C |
| Failed to perform annual fuel quality test for diesel powered emergency generator. | SS=F |
| Failed to maintain building construction type for new dining room; annular space around pipes not firestopped. | SS=E |
| Failed to enclose two hazardous fuel-fired heater rooms with 1-hour fire-rated barrier and 3/4-hour fire-rated doors. | SS=E |
| Failed to maintain proper operation of rolling steel fire door; door not equipped with fusible link and not self-closing. | SS=E |
Report Facts
Certified beds: 45
Census: 13
Fire drills not conducted at unexpected times on third shift: 4
Fire alarm system battery inspection date: 2019
Sprinkler system inspection missing quarter: 1
Inspection Report
Annual Inspection
Census: 12
Capacity: 12
Deficiencies: 2
Nov 26, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00444843.
Findings
The facility was cited for deficiencies including failure to maintain the stove hood in a clean manner affecting all residents, and failure to ensure the use of enhanced barrier precautions (EBP) for three residents and proper dating of a feeding tube piston syringe. No deficiencies were found related to the complaint investigation.
Complaint Details
Complaint IN00444843 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=F: 1
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to maintain the stove hood in a cleanly manner, with cobwebs and debris observed above the stove. | SS=F |
| Facility failed to ensure the use of enhanced barrier precautions (EBP) for 3 of 3 residents reviewed and failed to ensure a feeding tube piston syringe was dated for 1 resident. | SS=D |
Report Facts
Census: 12
Total Capacity: 12
Residents requiring EBP: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerrod Moore | Administrator | Signed the report |
| Dietary Manager | Interviewed regarding stove hood cleaning and kitchen sanitation | |
| Dietary Aide 5 | Interviewed regarding stove hood cleaning | |
| Maintenance Director | Provided service report for stove hood cleaning and involved in corrective action plan | |
| Certified Nursing Assistant 2 | Interviewed regarding use of enhanced barrier precautions | |
| Director of Nursing | DON | Interviewed regarding EBP use and policies |
| Registered Nurse 1 | RN | Provided enteral nutrition policy and interviewed regarding EBP |
Inspection Report
Annual Inspection
Deficiencies: 0
Nov 26, 2024
Visit Reason
The inspection was a paper compliance review related to the Annual Recertification and State Licensure survey.
Findings
Middletown Nursing and Rehabilitation Center was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 based on the paper review for the Recertification and State Licensure survey.
Inspection Report
Renewal
Deficiencies: 1
Jul 9, 2024
Visit Reason
The inspection was conducted as an offsite Licensure Investigation Survey to review the facility's compliance with license renewal requirements.
Findings
The facility failed to timely renew their license to operate as a health care facility before the expiration date of May 30, 2024, as the renewal application and payment were received after the required 45-day prior deadline.
Deficiencies (1)
| Description |
|---|
| Facility failed to ensure timely renewal of license before expiration on May 30, 2024. |
Report Facts
Days prior to license expiration required for renewal application: 45
License expiration date: May 30, 2024
Date renewal application signed: Apr 23, 2024
Date renewal application and payment postmarked: Jun 25, 2024
Date payment received notification: Jul 1, 2024
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerrod Moore | Administrator | Signed as facility representative on the report. |
Inspection Report
Complaint Investigation
Census: 11
Capacity: 45
Deficiencies: 0
May 10, 2024
Visit Reason
The visit was conducted as an Emergency Preparedness Survey including a complaint investigation (Complaint Number IN00434001). The complaint investigation was to determine compliance with Medicare/Medicaid participation requirements and Life Safety Code standards.
Findings
The facility was found in compliance with Emergency Preparedness Requirements and Life Safety Code regulations. The complaint investigation was unsubstantiated, and the facility was compliant with all applicable requirements.
Complaint Details
Complaint Number IN00434001 was investigated and found to be unsubstantiated.
Report Facts
Certified beds: 45
Census: 11
Inspection Report
Plan of Correction
Deficiencies: 0
Jan 16, 2024
Visit Reason
The visit was a paper compliance review of the Post Survey Revisit (PSR) that exited on 12/22/23 for the Life Safety Code Recertification and State Licensure Survey that exited on 11/06/23.
Findings
Middletown Nursing and Rehabilitation Center was found in compliance with Requirements for Participation in Medicare/Medicaid, Life Safety from Fire, and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code, Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2.
Inspection Report
Re-Inspection
Census: 12
Capacity: 45
Deficiencies: 1
Dec 22, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted to review Emergency Preparedness and Life Safety Code compliance following prior surveys on 11/06/23.
Findings
The facility was found in compliance with Emergency Preparedness requirements but was not in compliance with Life Safety Code requirements due to one corridor door failing to self-close and latch properly, potentially allowing smoke passage. The door latch was repaired on 12/28/23.
Severity Breakdown
SS=E: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failed to ensure 1 of over 30 corridor doors had no impediment to closing and latching into the door frame, which would resist the passage of smoke. | SS=E |
Report Facts
Certified beds: 45
Census: 12
Number of corridor doors: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerrod Moore | Administrator | Signed report |
| Environmental Services Director | Interviewed regarding door deficiency; name not provided |
Inspection Report
Life Safety
Census: 10
Capacity: 45
Deficiencies: 9
Nov 6, 2023
Visit Reason
The Indiana Department of Health conducted an Emergency Preparedness Survey and a Life Safety Code Recertification and Licensure Survey to assess compliance with federal and state regulations including emergency preparedness, fire safety, and facility safety codes.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements, Life Safety Code requirements including emergency power system maintenance, egress door accessibility, hazardous area door self-closing devices, corridor door latching, fire drills scheduling, fire door annual inspections, and essential electrical system fuel quality testing.
Severity Breakdown
SS=C: 1
SS=E: 4
SS=F: 4
Deficiencies (9)
| Description | Severity |
|---|---|
| Emergency Preparedness Plan failed to include the role of the LTC facility under a waiver declared by the Secretary. | SS=C |
| Failed to implement emergency power system inspection, testing, and maintenance requirements; no documentation of annual fuel quality test for diesel generator. | SS=F |
| Means of egress door (Lounge exit) was magnetically locked without the code posted for emergency access. | SS=E |
| Hazardous area door (Covid Room) lacked a properly working self-closing device. | SS=E |
| Business office pass-through windows greater than 20 square inches were not protected by electrically supervised automatic smoke detection. | SS=E |
| Corridor doors (Resident Room #104 and double door near Nurses station) failed to latch properly. | SS=E |
| Failed to conduct quarterly fire drills on unexpected days and times as required. | SS=F |
| Failed to ensure annual inspection and testing of all fire door assemblies in accordance with NFPA 80. | SS=F |
| Failed to ensure annual fuel quality test for the facility's diesel-powered generator. | SS=F |
Report Facts
Certified beds: 45
Census: 10
Deficiencies cited: 9
Fire drills conducted near month end: 7
Fire drills per quarter: 12
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Environmental Services Director | Interviewed regarding emergency preparedness plan, fire door inspections, and generator fuel testing; acknowledged findings | |
| Administrator | Interviewed and present at exit conference; acknowledged findings | |
| Maintenance Director | Responsible for monitoring generator fuel testing and maintenance |
Inspection Report
Renewal
Census: 12
Capacity: 12
Deficiencies: 2
Sep 22, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from September 18 to 22, 2023.
Findings
The facility was found deficient in developing and implementing comprehensive care plans for certain residents, and failed to report required nursing staffing data to the payroll based journal for the quarter April 1 to June 30, 2023.
Severity Breakdown
SS=D: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failed to develop or update care plans for the use of Prolia, new skin impairments, a bolster mattress, and antidepressant for Resident 9, affecting 3 of 11 residents reviewed. | SS=D |
| Failed to report required nursing staffing data to the payroll based journal for April 1-June 30, 2023. | SS=F |
Report Facts
Census Bed Type: 12
Medicaid Census: 6
Other Payor Census: 6
Deficiencies cited: 2
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jerrod Moore | Administrator | Signed the report and mentioned in interview |
| Director of Nursing | Interviewed regarding care plan deficiencies for Residents 2, 4, and 9 | |
| Business Office Manager | Interviewed regarding failure to report payroll based journal staffing data | |
| LPN 3 | Interviewed regarding Resident 4's skin impairments |
Inspection Report
Renewal
Deficiencies: 0
Sep 22, 2023
Visit Reason
The inspection was conducted for recertification and state licensure of the Middletown Nursing and Rehabilitation Center.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding recertification and state licensure.
Inspection Report
Follow-Up
Census: 12
Capacity: 45
Deficiencies: 0
Dec 15, 2022
Visit Reason
A Post Survey Revisit (PSR) was conducted to the Emergency Preparedness Survey and the Life Safety Code Recertification and Licensure Survey originally conducted on 09/14/22 by the Indiana Department of Health.
Findings
At this PSR Emergency Preparedness survey and Life Safety Code survey, Middletown Nursing and Rehabilitation Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements, including fire safety and sprinkler systems.
Report Facts
Certified beds: 45
Census: 12
Inspection Report
Renewal
Deficiencies: 0
Oct 20, 2022
Visit Reason
The inspection was conducted for recertification and state licensure compliance of Middletown Nursing and Rehabilitation Center.
Findings
The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding recertification and state licensure requirements.
Inspection Report
Routine
Census: 11
Capacity: 45
Deficiencies: 13
Sep 14, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but had multiple deficiencies related to Life Safety Code including emergency power system testing, exit door accessibility, exit discharge surfaces, hazardous area door self-closing devices, kitchen fire safety training, fire alarm system installation and testing, sprinkler system maintenance, corridor door smoke resistance, smoke barrier door gaps, and improper use of power strips in patient care areas.
Severity Breakdown
SS=C: 3
SS=E: 7
SS=F: 2
Deficiencies (13)
| Description | Severity |
|---|---|
| Failed to provide documentation of a three-year 4-hour emergency generator load bank test. | SS=C |
| Three exit doors within the means of egress were magnetically locked without posted access codes. | SS=E |
| Two exit discharges had uneven surfaces with a 5-7 inch drop off, not providing a level walking surface free of obstructions. | SS=E |
| Two hazardous area doors (storage rooms) lacked properly working self-closing devices. | SS=E |
| Kitchen staff were not instructed in the use of the UL 300 hood fire extinguishing system; roll up serving door did not seal properly. | SS=E |
| Smoke detector located within 3 feet of an air supply where air flow would prevent proper operation. | SS=E |
| Fire alarm system lacked documentation of a required semi-annual visual inspection. | SS=C |
| Sprinkler system had dry sprinklers over 10 years old without replacement or testing; spare sprinklers were not properly stored. | SS=F |
| Pass-through window in copy room larger than 20 square inches without electrically supervised smoke detection. | SS=E |
| Seven corridor doors had deficiencies including holes, sagging panels, and failure to self-close and latch properly. | SS=E |
| Smoke barrier doors had a 1/3 inch gap exceeding the maximum 1/8 inch allowed for smoke resistance. | SS=E |
| Failed to ensure annual fuel quality test for diesel generator; no documentation of three-year 4-hour load bank test. | SS=F |
| Power strips in patient care vicinity lacked required UL rating; power strip used as substitute for fixed wiring to power high current equipment. | SS=E |
Report Facts
Certified beds: 45
Census: 11
Deficiencies cited: 12
Load bank test duration: 4
Load bank test interval: 3
Exit doors with issues: 3
Exit discharges with uneven surfaces: 2
Hazardous area doors without self-closing devices: 2
Corridor doors with deficiencies: 7
Smoke barrier door gap: 0.33
Smoke detector clearance: 3
Residents affected by power strip deficiency: 6
Inspection Report
Annual Inspection
Census: 11
Capacity: 11
Deficiencies: 6
Aug 5, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted August 2-5, 2022.
Findings
The facility was found deficient in multiple areas including visitation rights, catheter care, RN coverage, infection control practices, COVID-19 testing and vaccination compliance, and personnel record maintenance.
Severity Breakdown
SS=D: 4
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to provide visitation between 6 p.m. and 9 a.m. for 1 of 1 resident reviewed for visitation (Resident 12). | SS=D |
| Failed to keep Resident 7's urinary catheter bag off the floor for 1 of 1 residents reviewed for indwelling urinary catheters. | SS=D |
| Failed to provide 8 hours of consecutive RN coverage for 2 of the last 30 days reviewed. | SS=D |
| Failed to adhere to infection control policy by having unvaccinated staff member not wear required eye protection during resident care. | SS=E |
| Failed to assure weekly COVID-19 testing for staff member not up-to-date on vaccination. | SS=D |
| Failed to maintain personnel records consistent with regulatory guidelines including timely criminal background checks, physical exams, TB screening, dementia training, and resident rights training for 8 of 10 employee files reviewed. | — |
Report Facts
Census: 11
Total Capacity: 11
Survey Dates: 4
Deficiency Completion Dates: 3
Staff COVID-19 Tests: 3
RN Coverage Failures: 2
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