Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Morgantown Care & Rehabilitation Center during CMS and state inspections, most recent first.
The facility failed to inform residents or resident representatives and/or provide written information about the right to refuse treatment and formulate an advance directive. Records for multiple residents showed incomplete legal document checklists, MOST forms with blank sections, and no documented advance directives, even when residents had intact cognition or representatives stated they had not been given information. Staff interviews showed inconsistent understanding of whether the MOST form counted as an advance directive and confirmed that written advance directive information was not provided.
A resident with dementia, contractures, and dysphagia was observed sitting up in bed while a CNA fed the resident from a standing position at the bedside. The resident’s MDS showed severe cognitive impairment and dependence on staff for eating, and facility policy required meal assistance to be provided with attention to safety, comfort, and dignity. The UM stated the CNA should have been sitting, and the Administrator said staff should not stand at the bedside feeding a resident unless it was care planned as a preference.
Failure to Follow EBP PPE Requirements: A resident with a wound and EBP order was observed receiving direct care from a CNA who wore gloves but did not don the gown required by the room signage. The CNA handled a urine-filled bedpan, emptied and rinsed it, and later stated she did not know whether a gown was required or whether she had seen the signage. The DON and Administrator stated staff should wear the appropriate PPE, including gowns and gloves, for direct care under EBP.
The facility failed to store food safely in the walk-in freezer, which had significant frost and ice accumulation and food particles on the floor. Staff interviews revealed the freezer was malfunctioning, and cleaning schedules were delayed due to staffing shortages. The freezer's compromised seals allowed outside air to enter, causing moisture buildup. Despite the Administrator's belief that the ice on the floor posed no risk, the facility did not meet its policy standards for food storage.
The facility failed to make its most recent survey results readily accessible to residents, families, and visitors. During a Resident Council Meeting, residents were unaware of the survey results' location. The survey binder was found behind the nursing station and was outdated, missing the latest recertification survey results. The Administrator was responsible for maintaining the binder but admitted it was not up to date.
The facility did not post daily nurse staffing information for two out of three days during a survey. The staffing data was outdated and not visible, and on one day, it was not posted at all. The Scheduler was responsible for this task but was unaware of the missing postings. The DON and Administrator confirmed the expectation for daily postings, highlighting a lapse in policy adherence.
The facility failed to maintain cold food temperatures during a meal service, with coleslaw, cucumber salad, and banana pudding left out without an ice bath, resulting in unsafe temperatures. The Dietary Manager and Cook acknowledged the oversight, which occurred due to a staff shortage. The DON and Administrator expected proper temperature checks, but the deficiency still occurred.
A facility failed to store drugs according to professional standards, as observed in a medication cart with expired medications prescribed to several residents. Interviews with staff, including an LPN and the DON, revealed inconsistencies in the process of checking and removing expired medications, despite expectations for regular audits by nurses and pharmacy representatives.
Failure to Provide Advance Directive Information and Document Resident Choices
Penalty
Summary
The facility failed to inform residents or resident representatives and/or provide written information about the right to accept or refuse medical or surgical treatment and, at the resident’s option, formulate an advance directive. The deficiency affected 6 of 29 sampled residents: R8, R22, R45, R63, R110, and R123. Facility policy stated residents had the right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive, and that information about refusing treatment and advance directives would be provided during admission in a manner easily understood by the resident or representative. For R8, the record showed intact cognition with a BIMS of 15/15, but the Resident Legal Document Checklist was incomplete and blank where advance directive information should have been indicated. R8’s MOST form was completed for CPR and full treatment, but sections for antibiotics and IV fluids were left blank, and there was no documented evidence of an advance directive. R8 stated he did not recall being asked about or provided information regarding a living will or advance directive. For R22, the Resident Legal Document Checklist was also blank, the MOST form showed DNR status with other sections left blank, and there was no documented evidence of an advance directive. R22 had severe cognitive impairment with a BIMS of 3/15, and the spouse stated R22 did not have a living will or advance directive and did not recall being asked or given information about one. For R45, the Resident Legal Document Checklist was blank, the MOST form showed DNR status and other treatment sections, but the patient preferences section was left blank, and there was no documented evidence of an advance directive. R45 had intact cognition with a BIMS of 15/15 and stated she did not recall being asked about or provided information regarding a living will or advance directive. For R63, the baseline care plan documented that the resident did not have an advance directive, while the MOST form showed CPR with limited additional interventions and blank sections for fluids/nutrition and antibiotics. The checklist indicated the resident had a POA and living will, but those documents were not located in the medical record or submitted for review. For R110, the MOST form showed DNR and comfort measures, but sections for antibiotics, fluids/nutrition, and patient preferences were blank; the facility’s Advance Directives/Informed Consent form marked a health care surrogate but left the date blank. For R123, the Resident Legal Document Checklist was blank, the MOST form showed CPR with full treatment, and the baseline care plan stated the resident had an advance directive and wished to formulate one, yet no advance directive was documented in the medical record. Interviews with the Admissions Coordinator, SSD, DON, and Administrator showed inconsistent understanding of whether the MOST form was an advance directive and confirmed that written information about advance directives was not provided to residents or representatives.
Dignity Concern During Meal Assistance
Penalty
Summary
The facility failed to ensure that a resident had the right to a dignified existence for 1 of 29 sampled residents reviewed for dignity and resident rights. During mealtime observation, a staff member was standing at the bedside while feeding the resident, rather than sitting while providing meal assistance. Facility policy stated that residents who cannot feed themselves will be fed with attention to safety, comfort, and dignity, and that employees providing meal assistance will be trained and demonstrate competency in providing meal assistance. Resident R27 was admitted with diagnoses including unspecified dementia, contractures of both hips, and dysphagia. The annual MDS showed severe cognitive impairment and dependence on staff for eating. The care plan stated R27 was independent with eating after tray set-up assistance. On observation, R27 was sitting up in bed while CNA1 fed the resident from a standing position. CNA1 stated she usually sat while feeding residents but there was no chair in the room at the time the tray was delivered. The Unit Manager stated the staff member should have been sitting down, and the Administrator stated staff should not stand at the bedside feeding a resident unless it had been care planned as a preference.
Failure to Follow EBP PPE Requirements
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 sampled residents reviewed for Enhanced Barrier Precautions (EBP). R44 was admitted with diagnoses including type 2 diabetes mellitus with foot ulcer, type 2 diabetes mellitus with diabetic neuropathy, and cognitive communication deficit, and had an annual MDS assessment showing a BIMS score of 15 out of 15. A physician order dated 02/18/2026 placed the resident on EBP related to a wound, and the care plan identified infection control needs related to EBP, including personal protective equipment as indicated. During observation, CNA6 entered R44's room where signage at the entrance indicated bed B was on EBP and required gowns and gloves for direct care. CNA6 was observed at the bedside and then handling a bedpan full of urine without wearing a gown, although she was wearing gloves. She emptied the bedpan into the toilet, rinsed it, bagged it, and performed hand hygiene before leaving the room. When interviewed, CNA6 stated she did not know whether a gown was required and did not know whether she had seen the signage. R44 stated staff did not wear gowns when providing care. The Staff Development Coordinator/Infection Preventionist stated staff were expected to follow doorway signage and that she educated staff constantly on PPE, while the DON and Administrator stated staff should wear the appropriate PPE, including gowns and gloves, when providing direct care to a resident on EBP.
Improper Food Storage in Walk-In Freezer
Penalty
Summary
The facility failed to store food in a safe and sanitary manner, as observed during a survey. The walk-in freezer had significant frost and ice accumulation, along with food particles on the floor, which could potentially affect all residents consuming food stored there. The facility's policy required all Time and Temperature Control for Safety (TCS) foods to be stored according to FDA guidelines, wrapped, labeled, and dated to prevent cross-contamination. However, the freezer's condition did not meet these standards. Interviews with staff revealed that the walk-in freezer had been malfunctioning, and a work order was placed prior to the survey. The Dietary Accounts Manager acknowledged the issue and stated that the freezer was scheduled for weekly cleaning, but staffing shortages had caused delays. The Regional Dietary Accounts Manager confirmed that the freezer required regular cleaning with a special chemical to prevent ice buildup, but the dietary manager had fallen behind due to being short-staffed. The Maintenance Director and Service Manager provided further insights into the freezer's condition, noting that compromised seals and gaskets allowed outside air to enter, causing moisture buildup. The Registered Dietician, who conducted a sanitation audit shortly before the survey, did not observe any issues at that time but acknowledged the ongoing problem. The Administrator believed the ice accumulation on the floor posed no risk to the food, as it was not directly on the food items. Despite these observations, the facility's failure to maintain the freezer in a sanitary condition was evident.
Survey Results Accessibility Deficiency
Penalty
Summary
The facility failed to ensure that the results of its most recent certification and complaint survey were readily accessible to residents, their families, and visitors. This deficiency was identified during a Resident Council Meeting where four residents, including the resident council president, expressed that they were unaware of the location of the facility's survey results book. The facility's policy on Resident Rights, revised in January 2025, states that residents have the right to examine the facility's survey results. However, the survey binder was found behind the nursing station and was not up to date, missing the most recent recertification survey results from May 2024. Interviews with the Director of Nursing and the Administrator revealed that the responsibility for maintaining and updating the survey binder lay with the Administrator. Both the DON and the Administrator had started working at the facility in August 2024, and the DON mentioned that updating the binder had been overlooked. The Administrator acknowledged that the binder should not have been stored behind the nursing station and admitted it was not up to date, although he did not provide a specific reason for this oversight.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information for two out of the three days during the State Survey Agency (SSA) Survey. The facility's policy, revised on 01/31/2025, mandates that staffing data be posted daily to ensure adequate nursing support for residents. However, observations on 02/26/2025 revealed that the posted staffing information was outdated, showing data from 01/30/2025, and was placed in a location not easily visible. On 02/27/2025, no staffing data was posted at all. Interviews with the facility's staffing Scheduler and the Director of Nursing (DON) confirmed that the Scheduler was responsible for posting the staffing data daily. The Scheduler acknowledged the importance of this task but was unaware of why the postings were missing. The DON had previously discussed the issue with the Scheduler and emphasized the necessity of daily postings. The Administrator also confirmed the expectation for daily postings, indicating a lapse in adherence to the facility's policy.
Cold Food Temperature Deficiency During Meal Service
Penalty
Summary
The facility failed to provide foods at a safe and appetizing temperature during the noon meal service for the residents of Serenity Hall. On the specified date, observations revealed that coleslaw, cucumber salad, and banana pudding were left out on a tray without being placed in an ice bath, resulting in temperatures of 61°F, 66°F, and 71°F respectively, which exceeded the required cold holding temperature of 41°F or less. The facility's policy and the Kentucky Food Guide 2013 Food Code both mandate that cold foods be held at temperatures of 41°F or less, but this was not adhered to during the meal service. Interviews with the Dietary Manager and Dietary Cook revealed that the cold foods were not placed in an ice bath due to being in a rush, as a staff member had to leave for a family emergency. The Dietary Manager acknowledged that the cold foods should have been held at 41°F, and the Dietary Cook admitted that the trays were not placed in an ice bath prior to serving. The Director of Nursing and the Administrator both expressed expectations that food temperatures should be checked and maintained at safe levels, but the deficiency occurred nonetheless, potentially putting residents at risk of consuming food at unsafe temperatures.
Expired Medications Found on Medication Cart
Penalty
Summary
The facility failed to ensure that drugs and biologicals were stored in accordance with the manufacturer's specifications and accepted professional nursing principles. During an observation of a medication cart servicing specific rooms, it was found that seven cards of medications were beyond their expiration dates. These expired medications were prescribed to four residents, including medications for gastroesophageal reflux disease, high blood pressure, and antihistamines, among others. The facility's policy requires that medications be administered as prescribed and that expiration dates be checked to prevent the administration of expired medications. Interviews with staff revealed a lack of clarity and consistency in the process of checking and removing expired medications. An LPN assigned to the medication cart on the day of the observation stated that she was not usually responsible for that cart and was unsure of the frequency of pharmacy audits for expired medications. The Assistant Director of Nursing and the Director of Nursing both expressed expectations that floor nurses and pharmacy representatives would ensure expired medications were removed, but there was a discrepancy in the frequency and effectiveness of these checks, as evidenced by the presence of expired medications on the cart.
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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 Morgantown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Beaver Dam Nursing & Rehab Center, Inc | 13.6 mi | — | 0 | 0 |
| Signature Healthcare Of Hartford Rehab & Wellness | 19.3 mi | — | 0 | 0 |
| Signature Healthcare Of Bowling Green | 21.1 mi | — | 0 | 0 |
| Colonial Nursing And Rehabilitation Center | 21.6 mi | — | 2 | 0 |
| Bowling Green Nursing And Rehabilitation Center | 21.9 mi | — | 4 | 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 August 2026) and official state health department websites.