Inspection Reports for Morgantown Woods of Journey
140 W Washington St, Morgantown, IN 46160, IN, 46160
Back to Facility ProfileInspection Report Summary
The most recent inspection on June 19, 2025, found the facility in compliance with life safety and emergency preparedness requirements and identified no deficiencies. Earlier inspections showed a pattern of life safety and emergency preparedness deficiencies, including failures in testing emergency lighting, fire drills, sprinkler inspections, and emergency exercises, as well as issues with kitchen safety and oxygen storage. Prior reports also cited resident care concerns such as improper use of physical restraints, failure to maintain resident dignity during meals, and inaccuracies in resident assessments, but no fines or license actions were listed in the available reports. Multiple complaint investigations were conducted, most of which were unsubstantiated, except for one substantiated complaint in March 2024 involving inadequate supervision that led to elopement and an immediate jeopardy situation that was later resolved. The facility’s recent inspections indicate improvement in life safety and emergency preparedness compliance following earlier citations.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
13.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
217% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
90% occupied
Based on a June 2025 inspection.
Census over time
Inspection Report
Re-Inspection
Census: 35
Capacity: 39
Deficiencies: 0
Jun 19, 2025
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 04/29/25 was performed by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
At this Life Safety Code survey, Morgantown Woods of Journey was found in compliance with Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers, 42 CFR 483.73, and with Requirements for Participation in Medicaid, 42 CFR Subpart 483.90(a), Life Safety from Fire and the 2012 Edition of the National Fire Protection Association (NFPA) 101, Life Safety Code (LSC), Chapter 19, Existing Health Care Occupancies and 410 IAC 16.2. The facility is fully sprinklered with a fire alarm system and smoke detection in corridors and resident sleeping rooms.
Report Facts
Certified beds: 39
Census: 35
Inspection Report
Annual Inspection
Deficiencies: 0
May 13, 2025
Visit Reason
The inspection was conducted as a paper compliance review for the Annual Recertification and State Licensure survey.
Findings
Morgantown Woods of Journey 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
Life Safety
Census: 34
Capacity: 39
Deficiencies: 10
Apr 29, 2025
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal and state regulations.
Findings
The facility was found in substantial compliance with Emergency Preparedness Requirements but failed to conduct required emergency preparedness exercises. Multiple life safety deficiencies were identified including failure to test emergency lighting, battery operated smoke alarms, fire alarm system inspections, sprinkler system inspections, fire drills, patient care related electrical equipment inspections, and issues with kitchen hood extinguishing system and oxygen storage room door latch.
Severity Breakdown
SS=C: 1
SS=E: 2
SS=F: 7
Deficiencies (10)
| Description | Severity |
|---|---|
| Failed to conduct required emergency preparedness exercises including annual full-scale community-based exercises and unannounced staff drills. | SS=C |
| Failed to ensure 16 battery backup lights were tested monthly for 30 seconds and annually for 90 minutes with documentation. | SS=F |
| Failed to ensure documentation for preventative maintenance of 20 battery operated smoke alarms in resident rooms was complete. | SS=F |
| Failed to provide an approved method for returning cooking appliances to approved design location under kitchen hood extinguishing system. | SS=E |
| Failed to maintain fire alarm system with required semi-annual visual inspections and smoke detector sensitivity testing every two years. | SS=F |
| Failed to provide documentation for quarterly sprinkler system inspections for 2 of 4 quarters. | SS=F |
| Failed to ensure 6 of 12 fire drills included verification of transmission of fire alarm signal to monitoring station. | SS=F |
| Failed to conduct quarterly fire drills for 2 of 4 quarters on all shifts. | SS=F |
| Failed to conduct required maintenance and maintain documentation for Patient Care Related Electrical Equipment (PCREE). | SS=F |
| Failed to ensure oxygen storage and transfilling room door fully closed and latched to secure against unauthorized entry. | SS=E |
Report Facts
Certified beds: 39
Census: 34
Battery backup lights: 16
Battery operated smoke alarms: 20
Fire drills missing verification: 6
Fire drills missing: 2
Oxygen containers: 6
Oxygen cylinders: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Phil Ford | Executive Director | Signed report and involved in corrective action oversight |
| Maintenance Director | Interviewed regarding deficiencies and corrective actions for emergency preparedness, fire safety, and equipment maintenance | |
| Dietary Manager | Involved in corrective action for kitchen hood appliance placement |
Inspection Report
Renewal
Census: 35
Capacity: 35
Deficiencies: 7
Apr 9, 2025
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted on April 7, 8, and 9, 2025.
Findings
The facility was found deficient in several areas including failure to maintain resident dignity during meals, failure to communicate advance directives, failure to protect residents' rights to be free from physical restraints, failure to provide written notification for transfers/discharges, inaccuracies in Minimum Data Set assessments, improper sanitation bucket levels in the kitchen, and failure to conduct employee reference checks prior to hire.
Severity Breakdown
SS=D: 4
SS=E: 1
SS=F: 1
F9999: 1
Deficiencies (7)
| Description | Severity |
|---|---|
| Failed to maintain resident's dignity while assisting residents with meals; staff stood while assisting Resident 27 during dining. | SS=D |
| Failed to communicate resident's choice of advance directive to staff responsible for care for Resident 186. | SS=D |
| Failed to protect resident's right to be free from physical restraints; documentation of re-evaluation of restraint use was not completed for Resident 27. | SS=D |
| Failed to ensure written notification of transfer/discharge was given to resident and representative for Residents 8 and 19. | SS=D |
| Failed to ensure accuracy of Minimum Data Set assessments for 4 residents; errors in admission location, limb restraint use, anticoagulant medication, and prognosis coding. | SS=E |
| Failed to ensure sanitation bucket in kitchen was at correct sanitizer concentration level during initial tour. | SS=F |
| Failed to conduct employee reference checks prior to start date for 5 employees reviewed. | F9999 |
Report Facts
Census Bed Type: 35
Sanitizer concentration: 170
Sanitizer concentration: 272
Audit frequency: 6
Audit frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Phil Ford | Executive Director | Signed the inspection report |
| CNA 1 | Named in dignity during meal assistance deficiency | |
| CNA 3 | Interviewed regarding meal assistance practices | |
| Director of Nursing Services | DNS | Provided policies and interviews related to multiple deficiencies |
| Assistant Director of Nursing Services | ADNS | Involved in audits and interviews related to deficiencies |
| Regional Registered Dietician | Provided kitchen sanitation policy | |
| Payroll Benefits Coordinator | Interviewed regarding lack of employee reference checks | |
| Regional Human Resource Partner | Provided facility policy on background checks |
Inspection Report
Complaint Investigation
Census: 30
Capacity: 30
Deficiencies: 0
Feb 19, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00453611.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00453611 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicaid residents: 29
Other residents: 1
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Jan 30, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00450301.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00450301 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 31
Census Payor Type - Medicaid: 28
Census Payor Type - Other: 3
Inspection Report
Complaint Investigation
Census: 28
Capacity: 28
Deficiencies: 0
Nov 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00445786.
Findings
No deficiencies related to the allegations in Complaint IN00445786 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00445786 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census: 28
Total Capacity: 28
Medicaid Census: 23
Other Payor Census: 5
Inspection Report
Complaint Investigation
Census: 28
Capacity: 28
Deficiencies: 0
Sep 12, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00442985.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00442985 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Bed Type: 28
Census Payor Type: 28
Inspection Report
Re-Inspection
Census: 29
Capacity: 39
Deficiencies: 0
Aug 22, 2024
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 07/16/24 was performed to verify compliance with previous findings.
Findings
At this PSR survey, Morgantown Woods of Journey was found in compliance with Requirements for Participation in 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. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Inspection Report
Annual Inspection
Deficiencies: 0
Aug 6, 2024
Visit Reason
Paper compliance review to the Annual Recertification and State Licensure Survey was completed.
Findings
Morgantown Woods of Journey 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
Life Safety
Census: 33
Capacity: 39
Deficiencies: 4
Jul 16, 2024
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code standards, including failure to conduct annual 90-minute testing of battery-operated emergency lights, semiannual inspection of kitchen exhaust systems, verification of fire alarm transmission during fire drills, and proper securing of oxygen cylinders.
Severity Breakdown
SS=F: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to ensure 15 battery backup lights were tested annually for 90 minutes and maintain written records of inspections and tests. | SS=F |
| Failed to ensure 1 of 1 kitchen exhaust systems was inspected semiannually for grease buildup and maintain documentation. | SS=E |
| Failed to ensure 4 of 12 fire drills included verification of transmission of the fire alarm signal to the monitoring station. | SS=F |
| Failed to ensure 1 of 3 cylinders of nonflammable gases such as oxygen were properly secured from falling. | SS=E |
Report Facts
Certified beds: 39
Census: 33
Battery backup lights: 15
Fire drills missing verification: 4
Oxygen cylinders improperly secured: 1
Inspection Report
Annual Inspection
Census: 31
Capacity: 31
Deficiencies: 3
Jul 2, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of Complaint IN00434506.
Findings
The facility was found deficient in protecting residents' rights to be free from physical restraints without proper documentation and consent for 3 residents. Additionally, the facility failed to post accurate nurse staffing data for 5 days and did not ensure residents were free from unnecessary psychotropic medications, including lack of gradual dose reductions and inadequate diagnoses.
Complaint Details
Complaint IN00434506 was investigated and no deficiencies related to the allegations were cited.
Severity Breakdown
SS=D: 2
SS=C: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to protect residents' right to be free from physical restraints for 3 of 5 residents reviewed; lacked documentation of releasing restraints and repositioning every 2 hours and informed consent prior to restraint use. | SS=D |
| Failed to post daily nurse staffing data reflecting actual hours worked for 5 of 5 days reviewed. | SS=C |
| Failed to ensure residents were free from unnecessary psychotropic medications; as needed antipsychotic medications prescribed for longer than 14 days without gradual dose reductions and lacked adequate diagnosis for antipsychotics for 1 of 5 residents reviewed. | SS=D |
Report Facts
Survey dates: 5
Residents reviewed for restraints: 5
Residents with restraints observed: 3
Days nurse staffing data lacked actual hours: 5
Residents reviewed for psychotropic medication: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dale W. Hartman | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Apr 24, 2024
Visit Reason
This visit was for the Investigation of Complaint IN00431748 and was conducted in conjunction with the Post Survey Revisit to the Investigation of Complaint IN00431134 completed March 28, 2024.
Findings
No deficiencies related to allegations were cited for Complaint IN00431748, and Complaint IN00431134 was corrected. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00431748 was investigated with no deficiencies cited. Complaint IN00431134 was corrected as of the prior revisit.
Report Facts
Census: 32
Total Capacity: 32
Medicaid Census: 24
Other Payor Census: 8
Inspection Report
Re-Inspection
Census: 32
Capacity: 32
Deficiencies: 0
Apr 24, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00431134 completed on March 28, 2024, conducted in conjunction with the Investigation of Complaint IN00431748.
Findings
Complaint IN00431134 was corrected, and no deficiencies related to Complaint IN00431748 were cited. The facility was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1.
Complaint Details
Complaint IN00431134 was corrected. Complaint IN00431748 had no deficiencies related to the allegations cited.
Report Facts
Census: 32
Total Capacity: 32
Medicaid Census: 24
Other Payor Census: 8
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 1
Mar 26, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00431134 regarding substandard quality of care and elopement incidents involving Resident B.
Findings
The facility failed to provide adequate supervision to prevent Resident B, who had a history of elopement, from leaving the facility through an unsecured emergency exit door on three consecutive days. Immediate Jeopardy was identified but removed after staff inservicing and door security improvements, though noncompliance remained at a lower severity due to lack of a fully implemented systemic plan.
Complaint Details
Complaint IN00431134 was substantiated with federal and state deficiencies cited at F689 related to substandard quality of care and elopement incidents involving Resident B. Immediate Jeopardy began on 2024-03-23 and was removed on 2024-03-28.
Severity Breakdown
SS=J: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to provide adequate supervision to prevent elopement of Resident B on three consecutive days. | SS=J |
Report Facts
Census: 31
Elopement incidents: 3
Haloperidol dosage: 15
Haloperidol decanoate dosage: 150
1-on-1 direct care duration: 24
Survey dates: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Michelle Russell | Interim Administrator | Named as facility representative on the report |
| LPN 1 | Licensed Practical Nurse | Received police call about Resident B elopement and changed door alarm batteries |
| CNA 1 | Certified Nursing Aide | Knew Resident B had left the facility on multiple occasions and provided testimony about supervision |
| CNA 2 | Certified Nursing Aide | Observed Resident B pacing and returning to facility after elopement |
| CNA 3 | Certified Nursing Aide | Located Resident B three blocks from facility and returned him |
| VPCO | Vice President of Clinical Operations | Provided information about elopement incidents and facility policies |
| DON | Director of Nursing | Responsible for documenting door alarm malfunctions and elopement incidents |
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 0
Dec 13, 2023
Visit Reason
This visit was conducted to investigate complaints IN00421574, IN00423396, and IN00420566 at Morgantown Health Care.
Findings
No deficiencies related to the allegations were cited for any of the three complaints investigated. The facility was found to be in compliance with relevant federal and state regulations.
Complaint Details
Complaints IN00421574, IN00423396, and IN00420566 were investigated with no deficiencies found related to the allegations.
Report Facts
Census Bed Type: 32
Census Payor Type - Medicaid: 26
Census Payor Type - Other: 6
Inspection Report
Re-Inspection
Census: 33
Capacity: 39
Deficiencies: 0
Nov 20, 2023
Visit Reason
A second Post Survey Revisit (PSR) was conducted to the Emergency Preparedness survey and Life Safety Code Recertification Survey previously conducted to verify compliance.
Findings
At this PSR survey, Morgantown Health Care was found in compliance with Emergency Preparedness Requirements and Life Safety Code Requirements including fire safety and sprinkler systems.
Report Facts
Certified beds: 39
Census: 33
Inspection Report
Re-Inspection
Census: 32
Capacity: 39
Deficiencies: 3
Oct 23, 2023
Visit Reason
Post Survey Revisit (PSR) to the Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey conducted on 08/29/23 by the Indiana Department of Health.
Findings
The facility was found not in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. Deficiencies included failure to maintain documentation and analysis of emergency drills, incomplete railings on an exit ramp creating a safety hazard, and a corridor door held open with a hook and eye holder preventing proper smoke containment.
Severity Breakdown
SS=F: 1
SS=E: 2
Deficiencies (3)
| Description | Severity |
|---|---|
| Failed to analyze the LTC facility's response to and maintain documentation of all drills, tabletop exercises, and emergency events, and revise the emergency plan as needed. | SS=F |
| Failed to ensure 1 of 2 exit ramps with drop-offs was provided with complete railings, creating a trip hazard and safety risk. | SS=E |
| Failed to ensure 1 corridor door was provided with a means suitable for keeping the door closed, had no impediment to closing, latching and would resist the passage of smoke; door was held open with a hook and eye holder. | SS=E |
Report Facts
Certified beds: 39
Census: 32
Ramp length: 18
Ramp drop-off height: 1.5
Ramp missing handrail length: 9
Deficiency completion date: Nov 6, 2023
Inspection Report
Complaint Investigation
Census: 33
Capacity: 33
Deficiencies: 0
Sep 28, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00418045.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with relevant regulations.
Complaint Details
Complaint IN00418045 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Census Medicaid residents: 28
Census other residents: 5
Inspection Report
Annual Inspection
Deficiencies: 0
Sep 20, 2023
Visit Reason
The visit was conducted as a paper compliance review for the Annual Recertification and State Licensure Survey.
Findings
Morgantown Health Care 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
Routine
Census: 33
Capacity: 39
Deficiencies: 12
Aug 29, 2023
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with federal regulations.
Findings
The facility was found not in compliance with Emergency Preparedness requirements including failure to maintain and update emergency preparedness plans, policies, communication plans, and conduct required emergency exercises. Life Safety Code deficiencies included failure to ensure self-closing corridor doors latch properly, incomplete sprinkler system inspection documentation, missing quarterly fire drills, combustible decorations exceeding allowed coverage on resident room doors, and incomplete electrical receptacle testing documentation.
Severity Breakdown
SS=F: 9
SS=E: 2
SS=D: 1
Deficiencies (12)
| Description | Severity |
|---|---|
| Failed to maintain an emergency preparedness plan reviewed and updated at least annually. | SS=F |
| Failed to maintain an Emergency Preparedness Plan based on a documented facility-based and community-based risk assessment. | SS=F |
| Failed to develop and implement emergency preparedness policies and procedures reviewed and updated at least annually. | SS=F |
| Failed to review and update emergency preparedness policies and procedures to include emerging infectious diseases. | SS=F |
| Failed to develop and maintain an emergency preparedness communication plan. | SS=F |
| Failed to conduct exercises to test the emergency plan at least twice per year including unannounced staff drills. | SS=F |
| Failed to ensure corridor door to linen room had a self-closing device that latches properly. | SS=E |
| Failed to document sprinkler system inspections in accordance with NFPA 25. | SS=F |
| Failed to ensure corridor door to resident room 26 latches properly and resists passage of smoke. | SS=D |
| Failed to ensure combustible decorations on resident room door #23 did not exceed 30 percent coverage. | SS=E |
| Failed to ensure complete documentation was available for all nonhospital-grade electrical receptacles tested at least annually. | SS=F |
| Failed to conduct quarterly fire drills for 1 of 4 quarters on third shift. | SS=F |
Report Facts
Certified beds: 39
Census: 33
Weeks missing sprinkler gauge inspection documentation: 4
Months missing sprinkler valve inspection documentation: 4
Fire drills missing: 1
Resident rooms with combustible door decorations exceeding allowed coverage: 1
Resident room doors failing to latch: 1
Linen room doors failing to latch: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dale W. Hartman | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Administrator | Interviewed regarding emergency preparedness plan and documentation | |
| Environmental Services Director | Interviewed and provided documentation and observations regarding emergency preparedness, sprinkler system, fire drills, door latching, and electrical receptacle testing | |
| Maintenance | Responsible for door latch adjustments, sprinkler gauge checks, receptacle testing, and documentation |
Inspection Report
Annual Inspection
Census: 32
Capacity: 32
Deficiencies: 5
Aug 10, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 6 to August 10, 2023.
Findings
The facility was found deficient in multiple areas including failure to protect residents' rights to be free from physical restraints, failure to provide required written notification for facility-initiated transfers, failure to provide written notice of bed-hold policy upon transfer, failure to use a registered nurse for at least 8 consecutive hours a day 7 days a week, and failure to submit complete and accurate staffing information to CMS.
Severity Breakdown
SS=E: 1
SS=D: 3
SS=C: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failure to protect residents' right to be free from physical restraints for 4 of 5 residents reviewed. | SS=E |
| Failure to ensure written notification required for facility-initiated transfers were given to residents or representatives for 3 of 3 residents reviewed. | SS=D |
| Failure to provide notifications of bed hold policy required for residents transferred to hospital for 2 of 2 residents reviewed. | SS=D |
| Failure to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, based on payroll and other verifiable data for Quarter 2 of fiscal year 2023. | SS=C |
| Failure to electronically submit to CMS complete and accurate direct care staffing information for Quarter 2 of fiscal year 2023. | SS=D |
Report Facts
Survey dates: 5
Census: 32
Total capacity: 32
Residents reviewed for physical restraints: 5
Residents affected by restraint deficiency: 4
Residents reviewed for transfer notification: 3
Residents reviewed for bed hold notification: 2
RN coverage missing days: 6
Licensed nursing coverage missing days: 4
Staffing rating: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dale W. Hartman | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
| Assistant Director of Nursing | Interviewed regarding restraint orders, transfer notifications, and bed hold policy | |
| Director of Nursing | DON | Interviewed regarding restraint use and side rail placement |
| Certified Nursing Assistant 1 | CNA | Interviewed regarding Resident 23's use of side rail |
| Business Office Manager | BOM | Interviewed regarding Payroll Based Journal staffing data submission |
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Jul 26, 2023
Visit Reason
This visit was for Investigation of Complaint IN00413732.
Findings
No deficiencies related to the allegations were cited. Morgantown Health Care was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the Investigation of Complaint IN00413732.
Complaint Details
Complaint IN00413732 - No deficiencies related to the allegations were cited.
Report Facts
Census Bed Type: 32
Census Payor Type - Medicaid: 29
Census Payor Type - Other: 3
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Jun 20, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00410865.
Findings
No deficiencies related to the allegations in Complaint IN00410865 were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Investigation of Complaint IN00410865 found no deficiencies related to the allegations.
Report Facts
Medicaid residents: 29
Other payor residents: 3
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Apr 28, 2023
Visit Reason
This visit was for the investigation of complaints IN00406835 and IN00406886.
Findings
No deficiencies related to the allegations were cited for either complaint. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 regarding the investigation of these complaints.
Complaint Details
Investigation of Complaints IN00406835 and IN00406886 found no deficiencies related to the allegations.
Report Facts
Census: 32
Total Capacity: 32
Medicaid Residents: 28
Other Residents: 4
Inspection Report
Complaint Investigation
Census: 31
Capacity: 31
Deficiencies: 0
Apr 19, 2023
Visit Reason
This visit was conducted for the investigation of Complaint IN00406172.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Complaint Details
Complaint IN00406172 was investigated and found to have no deficiencies related to the allegations.
Report Facts
Medicaid residents: 27
Other payor residents: 4
Inspection Report
Re-Inspection
Census: 29
Capacity: 39
Deficiencies: 0
Dec 13, 2022
Visit Reason
A Post Survey Revisit (PSR) to the Life Safety Code Recertification and State Licensure Survey conducted on 11/01/22 was performed by the Indiana Department of Health to verify compliance with life safety and licensure requirements.
Findings
At this PSR survey, Morgantown Health Care was found in compliance with Requirements for Participation in 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. The facility was fully sprinklered with appropriate fire alarm and smoke detection systems.
Report Facts
Facility capacity: 39
Census: 29
Inspection Report
Complaint Investigation
Census: 32
Capacity: 32
Deficiencies: 0
Nov 3, 2022
Visit Reason
This visit was for the Investigation of Complaint IN00393383 and was conducted in conjunction with the Post Survey Revisit to the Recertification and State Licensure Survey completed September 29, 2022.
Findings
The complaint IN00393383 was found to be unsubstantiated due to lack of evidence. Morgantown Health Care was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the complaint investigation.
Complaint Details
Complaint IN00393383 was unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 32
Census Payor Type - Medicaid: 27
Census Payor Type - Other: 5
Inspection Report
Re-Inspection
Census: 32
Capacity: 32
Deficiencies: 0
Nov 3, 2022
Visit Reason
This visit was for a Post Survey Revisit (PSR) to the Recertification and State Licensure Survey completed on September 29, 2022, and was conducted in conjunction with the Investigation of Complaint IN00393383.
Findings
Morgantown Health Care was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Recertification and State Licensure Survey. The complaint investigation was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00393383 was investigated and found to be unsubstantiated due to lack of evidence.
Report Facts
Census Bed Type: 32
Census Payor Type Medicaid: 27
Census Payor Type Other: 5
Inspection Report
Life Safety
Census: 32
Capacity: 39
Deficiencies: 6
Nov 1, 2022
Visit Reason
An Emergency Preparedness Survey and a Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively.
Findings
The facility was found in compliance with Emergency Preparedness Requirements but not in compliance with Life Safety Code requirements. Deficiencies included failure to document monthly testing of battery-operated emergency lights, incomplete documentation of preventative maintenance for battery-operated smoke alarms, a corridor door that did not latch properly, failure to enforce smoking policies, improper disposal of cigarette butts in smoking areas, and use of a multi-plug adapter not compliant with electrical codes.
Severity Breakdown
SS=F: 4
SS=D: 1
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to document monthly testing for all battery backup lights as required by Life Safety Code. | SS=F |
| Failed to ensure documentation for preventative maintenance of battery operated smoke alarms in 20 of 20 resident rooms was complete. | SS=F |
| One corridor door to resident room 19 did not latch properly, failing to resist passage of smoke. | SS=D |
| Failed to enforce smoking policies; observed staff smoking on facility property contrary to policy. | SS=F |
| Smoking area was not maintained with proper disposal containers for cigarette butts. | SS=F |
| Use of a multi-plug adapter in the Activities office not compliant with electrical code; flexible cords used as substitute for fixed wiring. | SS=E |
Report Facts
Certified beds: 39
Census: 32
Deficiencies cited: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Dale W. Hartman | HFA | Laboratory Director's or Provider/Supplier Representative's signature on report |
Inspection Report
Annual Inspection
Census: 30
Capacity: 30
Deficiencies: 2
Sep 29, 2022
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the investigation of Complaint IN00386189.
Findings
The facility was found to have deficiencies related to improper use of physical restraints on a resident and unsafe hot water temperatures in multiple resident rooms. The complaint investigation was unsubstantiated due to lack of evidence.
Complaint Details
Complaint IN00386189 was investigated and found to be unsubstantiated due to lack of evidence.
Severity Breakdown
SS=D: 1
SS=E: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to follow physician orders for physical restraint use for Resident 22, who was restrained outside of meal times contrary to orders. | SS=D |
| Failure to ensure hot water temperatures remained at a safe and comfortable level below 120 degrees Fahrenheit in 6 out of 11 resident rooms assessed. | SS=E |
Report Facts
Census: 30
Total Capacity: 30
Water temperature readings: 124
Water temperature readings: 127
Water temperature readings: 126
Water temperature readings: 128
Water temperature readings: 132
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Resident 22 | Resident | Subject of physical restraint deficiency |
| Certified Nursing Assistant 1 | CNA | Provided interview regarding Resident 22's behavior and restraint use |
| Licensed Practical Nurse 1 | LPN | Provided interview regarding Resident 22's Broda chair use |
| Assistant Director of Nursing | ADON | Provided interview confirming restraint orders for Resident 22 |
| Environmental Services Director | ESD | Conducted water temperature measurements and provided interview |
| Maintenance Director | Maintenance Director | Provided interview about water heater settings and corrective actions |
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