Above average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Morristown Manor during CMS and state inspections, most recent first.
A resident with multiple medication orders was allowed to self-administer medications without the required assessment and documentation by the IDT. Although the resident was cognitively intact and able to take medications independently, the facility did not follow its policy to assess and document the resident's ability to safely self-administer medications.
A resident's call light was repeatedly found out of reach while she was in her wheelchair, with observations showing it placed on the bed or between the wall and bed. The SSD confirmed the call light should have been accessible, and the DON stated there was no specific policy for call light use.
A resident with dementia and mood disturbance exhibited escalating physically abusive and exit-seeking behaviors, including attempts to leave the facility and increased agitation. Although staff and the IDT implemented new interventions such as increased monitoring, medication adjustments, and relocation to a secured unit, these changes were not promptly updated in the resident's care plan, resulting in a lack of individualized documentation for behavior management.
A resident with COPD, hypoxemia, and sleep apnea did not have required monitoring and documentation performed during use of a non-invasive ventilator, as ordered by the physician. The necessary information was not recorded in the MARs or TARs because the order was placed on a respiratory flowsheet that nursing staff could not access, resulting in a lack of documented respiratory assessments and resident tolerance.
A QMA was observed preparing and administering medications to three residents, including those with vascular dementia and hypertension, without performing required hand hygiene before donning gloves or administering medications. The aide touched multiple surfaces and objects during preparation and administration, contrary to facility policy and infection control standards.
The facility failed to follow proper medication administration procedures by preparing medications for multiple residents at a time. Observations revealed that a QMA and an LPN had prepped medications for several residents and left them in the medication carts, contrary to the facility's policy against presetting medications.
The facility failed to ensure that controlled medications for two residents were properly labeled with required information, including the resident's full name, prescribed dose, and route of administration. The medications were obtained from the facility's medication management machine and not from the pharmacy, leading to the absence of proper labeling.
The facility failed to complete the BIMS section of the MDS for three residents with dementia, despite their ability to understand and communicate. This was confirmed by the Social Services Director and the MDS Coordinator, who acknowledged that the assessments should have been completed.
The facility failed to timely initiate transmission-based precautions for a resident with COVID-19. Despite a physician order for isolation dated two days after admission, there was no documentation that the resident was placed in TBP until then, contrary to the facility's COVID-19 policy.
A resident with heart failure, diabetes, and weakness did not receive the annual influenza vaccine as ordered, despite consent being given and facility policy requiring vaccination. The electronic medication administration record showed the vaccine was not signed off as administered, and the Infection Preventionist confirmed the oversight.
The facility failed to protect a resident from physical abuse by another resident, resulting in injuries. Resident D, with dementia and mood disorder, shoved Resident P to the floor, causing a skin tear and hematoma. The incident was captured on camera, and Resident D was placed on one-on-one supervision and sent to a psychiatric facility.
The facility failed to timely report an incident where a resident with dementia inappropriately touched another resident. The incident was reported to the state agency a day later, violating the facility's abuse policy.
The facility failed to thoroughly investigate a reportable incident where a resident with dementia was observed holding another resident's genitalia. The investigation did not include statements from all staff present during the incident, leading to a deficiency.
The facility failed to provide appropriate catheter care and timely monitoring of urine characteristics for two residents, leading to potential health risks. One resident with an indwelling urinary catheter experienced foul-smelling, dark urine and a contaminated urine sample, while another resident reported symptoms of a urinary tract infection and experienced delays in being taken to the bathroom, leading to urinary accidents.
The facility failed to provide adequate supervision for three residents with dementia, leading to multiple incidents of inappropriate behavior and physical altercations. Despite various interventions, one resident continued to wander into other residents' rooms, causing distress and demonstrating the facility's inability to manage her behaviors effectively.
Failure to Assess and Document Resident's Ability for Self-Administration of Medications
Penalty
Summary
The facility failed to have the interdisciplinary team (IDT) determine and document whether self-administration of medications was clinically appropriate for a resident. The resident, who had diagnoses including hypertension and was assessed as cognitively intact, had multiple physician orders for medications such as magnesium oxide, diltiazem, a calcium supplement, carboxymethylcellulose sodium eye drops, and metoprolol. During a medication administration observation, a Qualified Medication Aide (QMA) prepared the resident's medications and placed them on the bedside table, allowing the resident to take them without direct supervision. The QMA confirmed that the resident was able to take her medications independently. However, the Director of Nursing (DON) stated that the resident had not been assessed by the IDT to determine if she could safely self-administer her medications. The facility's policy requires that each resident who desires to self-administer medication must be assessed by the IDT for cognitive, physical, and visual ability, and that this assessment be documented. In this case, the required assessment and documentation were not completed prior to allowing the resident to self-administer medications.
Call Light Not Accessible to Resident
Penalty
Summary
The facility failed to ensure that a resident's call light was within reach, as observed on multiple occasions. On two separate days, the resident was seen sitting in her wheelchair with the call light either lying across her bed or positioned between the wall and the bed, making it inaccessible. During an interview, the Social Services Director confirmed that the call light should have been within the resident's reach. The Director of Nursing also indicated that the facility did not have a policy specific to the use of call lights.
Failure to Timely Update Care Plan for Resident with Dementia and Behavioral Issues
Penalty
Summary
The facility failed to timely update the care plan for a resident with dementia and mood disturbance, who exhibited physically abusive and exit-seeking behaviors. Despite multiple documented incidents, including verbal aggression, wandering, attempts to leave the building, and increased agitation, the care plan was not revised to include new interventions such as fifteen-minute checks, medication changes, or relocation to a secured dementia unit. Progress and social service notes indicated that staff and the interdisciplinary team (IDT) responded to these behaviors with various interventions and meetings, but these changes were not reflected in the resident's official care plan. The resident's clinical record showed ongoing behavioral issues and a pattern of staff attempting different non-pharmacological and pharmacological interventions, including increased monitoring and environmental changes. However, the care plan remained largely unchanged and did not document the new strategies implemented in response to the resident's evolving needs. Interviews with facility leadership confirmed that care plans were generalized and not sufficiently individualized to reflect the resident's specific behavioral interventions.
Failure to Monitor and Document Non-Invasive Ventilator Use
Penalty
Summary
The facility failed to monitor and document the use of a non-invasive ventilator (NIV) for a resident with chronic obstructive pulmonary disease (COPD), hypoxemia, and sleep apnea. The resident's care plan included interventions such as applying the NIV machine as ordered, listing settings, monitoring oxygen saturation levels, and contacting the physician as needed. A physician's order specified that the NIV should be applied at bedtime with particular settings, and required staff to monitor and document respiratory rate, minute volume, exhaled tidal volume, and the resident's tolerance. Upon review, there was no documentation in the Medication Administration Records (MARs) or Treatment Administration Records (TARs) of the required monitoring when the NIV was used. The Director of Nursing (DON) explained that the order was entered on a respiratory flowsheet that was not visible to nursing staff, resulting in the absence of documentation. The facility's policy required trained personnel to perform equipment setup, monitoring, and documentation as per physician orders, including detailed respiratory assessments and resident tolerance, which was not completed in this case.
Failure to Perform Hand Hygiene During Medication Administration
Penalty
Summary
The facility failed to maintain proper infection control practices during medication administration for three residents. Qualified Medication Aide (QMA) 2 was observed preparing and administering medications without performing hand hygiene at critical points, such as before donning and after doffing gloves, and prior to administering medications. During medication preparation, QMA 2 touched various surfaces and objects, including scissors, storage bags, medication drawers, and a computer mouse, without performing hand hygiene before proceeding to handle medications or interact with residents. For one resident with vascular dementia, QMA 2 prepared and crushed medications, mixed them with pudding, and administered them without hand hygiene before glove use or medication administration. For another resident with hypertension, QMA 2 prepared medications, donned gloves, administered eye drops, and touched the resident's face without hand hygiene before leaving the medication cart or donning gloves. In a third case involving a resident with vascular dementia, QMA 2 prepared oral medications and a medication patch, touched multiple surfaces, and applied the patch without hand hygiene prior to administration. Interviews with QMA 2 and the Infection Preventionist confirmed that hand hygiene should have been performed at these points, and the facility's policy also required hand hygiene before medication pass and before leaving the medication cart.
Improper Medication Administration Procedures
Penalty
Summary
The facility failed to ensure proper medication administration procedures were followed by preparing medications for more than one resident at a time. During an observation of the Pine and Juniper units' medication carts, it was found that medications were prepped for multiple residents simultaneously. On the Pine unit, a Qualified Medication Assistant (QMA) was found to have prepared medications for two residents, Resident Q and Resident R, and left them in the medication cart. The QMA acknowledged that medications should not be prepped ahead of time for any residents. Resident Q's medication cup contained Tramadol, gabapentin, acetaminophen, atorvastatin, Lasix, melatonin, pramipexole, and Xarelto, while Resident R's cup contained Aptiom, Lasix, oyster shell calcium, and lamotrigine. Similarly, on the Juniper unit, an LPN was found to have prepared medications for five residents and left them in the medication cart. The LPN identified the medications in each cup, which included various medications such as buspirone, diltiazem, Trazadone, Xanax, depakote, senna, atorvastatin, carvedilol, melatonin, coreg, Cymbalta, Norco, and tramadol. The facility's policy, as provided by the Director of Nursing (DON), explicitly stated that there should be no presetting of medications. This deficiency was related to a complaint investigation (IN00431737).
Failure to Properly Label Controlled Medications
Penalty
Summary
The facility failed to ensure that controlled medications stored in the locked medication storage drawer in the medication refrigerator were properly labeled. During an observation of the main nursing station medication room, it was found that a multi-dose bottle of lorazepam for Resident C and another for Resident P were not labeled with the required information, including the resident's full name, prescribed dose, and route of administration. The medications were obtained from the facility's medication management machine and not from the pharmacy, leading to the absence of proper labeling. The Director of Nursing (DON) confirmed that the medications were not labeled according to the facility's Medication Labeling policy, which mandates that all prescriptions filled by the pharmacy or outside pharmacies must include specific information such as the name of the drug, route of administration, strength, volume, control number, expiration date, and other relevant details. The failure to adhere to these labeling requirements was observed during a survey, highlighting deficiencies in the facility's medication management practices for two residents.
Failure to Complete Cognitive Assessments
Penalty
Summary
The facility failed to accurately complete the cognitive assessment portion of the MDS (Minimum Data Set) Assessment for three residents diagnosed with dementia. Specifically, the BIMS (Brief Interview for Mental Status) section of the MDS was not completed for Residents 28, 54, and 78, despite their ability to understand and make themselves understood. This was confirmed through clinical record reviews and interviews with the Social Services Director and the MDS Coordinator, who both acknowledged that the BIMS assessments should have been completed for these residents. Resident 28 had a Quarterly MDS Assessment completed on 1/29/24, Resident 54 had a Quarterly MDS Assessment completed on the same date, and Resident 78 had a Significant Change of Status MDS Assessment completed on 2/29/24. All three assessments indicated that the residents were usually able to make themselves understood and understand others, yet the BIMS assessments were omitted. The Social Services Director and the MDS Coordinator both confirmed that the residents were capable of answering the BIMS questions and that the assessments should have been conducted as per the facility's policy using the RAI (Resident Assessment Instrument).
Failure to Timely Initiate Transmission-Based Precautions for COVID-19 Resident
Penalty
Summary
The facility failed to ensure timely initiation of transmission-based precautions (TBP) for a resident with COVID-19. Resident 255, who had diagnoses including COVID-19, cough, and hypertension, was admitted to the facility from the hospital on 3/16/24. Despite a physician order dated 3/18/24 indicating the need for droplet/contact isolation and in-room services with isolation precautions, there was no documentation in the progress notes or physician orders that the resident was placed in TBP until 3/18/24. The facility's COVID-19 Policy and Procedure, dated 8/6/23, required healthcare personnel to wear additional PPE when providing direct care within 6 feet of a resident in a Red Zone, but this was not followed for Resident 255 until two days after admission.
Failure to Administer Annual Influenza Vaccine
Penalty
Summary
The facility failed to ensure the annual influenza immunization was administered per physician orders for one resident. The clinical record for the resident, who had diagnoses including heart failure, diabetes mellitus, and weakness, showed that consent for the influenza vaccine was given. However, the electronic medication administration record indicated that the dose of the flu vaccine was not signed off as administered on the specified date. An interview with the Infection Preventionist confirmed that the vaccine had not been administered, and a new order was obtained to administer it within the appropriate window for the annual influenza vaccine. The facility's policy on influenza immunization, revised in 2020, stated that all residents would be offered the influenza vaccination starting October 1 and continuing through the influenza season, following CDC recommendations. Despite this policy, the resident did not receive the vaccine as ordered. The CDC document provided by the facility indicated that September and October are generally good times for vaccination, ideally by the end of October. This discrepancy between policy and practice led to the identified deficiency.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident's right to be free from physical abuse by another resident. Resident D, who had diagnoses including dementia and mood disorder, was involved in a physical altercation with Resident P. The incident occurred in a common area where Resident D forcefully shoved Resident P to the floor after throwing a metal drinking cup at her. This resulted in Resident P sustaining a skin tear to her right hand and a hematoma to the back of her head. The incident was captured on camera, and staff arrived approximately 30 seconds later to assess and care for Resident P. Resident D was placed on one-on-one supervision immediately following the incident and was later sent to a psychiatric facility for evaluation and treatment. Interviews with Resident D and the Social Services Director confirmed that Resident D's discharge from the facility was related to the abusive behavior. Resident D had a history of aggressive behaviors, including hiding knives and scissors, which posed a risk to other residents. The facility's policy on Abuse, Neglect, and Misappropriation Prohibition and Prevention was reviewed, which stated that the facility would not condone resident abuse by anyone, including other residents. Despite this policy, the facility failed to prevent the abusive incident between Resident D and Resident P, leading to physical harm and distress for Resident P.
Failure to Timely Report Abuse Incident
Penalty
Summary
The facility failed to timely report a reportable incident involving two residents with dementia and psychotic disturbances. Resident 94, who was severely impaired, touched Resident E inappropriately on the outside of his pants in his lap area. This incident occurred on the morning of 2/26/24 but was not reported to the Indiana Department of Health until 2/27/24. The Executive Director initially did not consider the incident reportable but later realized the necessity of reporting it. The clinical records and social services notes indicate that both residents were severely impaired and had difficulty recalling the incident. Resident E did not express distress over the incident, and Resident 94 did not remember the event. Despite this, the facility's abuse policy mandates immediate reporting of such incidents to state agencies. The delay in reporting the incident was a clear violation of this policy, as the incident was not reported within the required timeframe of 24 hours.
Incomplete Investigation of Reportable Incident
Penalty
Summary
The facility failed to thoroughly investigate a reportable incident involving two residents with dementia and psychotic disturbances. Resident 94, who was severely impaired, was observed by a CNA holding Resident E's genitalia through his clothing in the hallway. The CNA intervened and called for assistance from an RN, who helped separate the residents and assessed Resident E for injuries, finding none. However, the investigation did not include statements from all staff present during the incident, specifically the RN who assisted but was not asked for a written statement. The facility's abuse policy requires a thorough investigation, including interviews with all staff who had contact with the residents before, during, and immediately after the incident. Despite this, the investigation was deemed complete by the Clinical Specialist without obtaining all necessary staff statements. This incomplete investigation process led to the deficiency noted in the report.
Failure to Provide Appropriate Catheter Care and Urine Monitoring
Penalty
Summary
The facility failed to ensure that a resident with an indwelling urinary catheter received appropriate treatment and services to prevent urinary tract infections and to monitor the urine characteristics of a resident being evaluated for a urinary tract infection. Resident H, who had diagnoses including urinary tract infection, acute pyelonephritis, and neuromuscular dysfunction of the bladder, had an indwelling urinary catheter. Despite a physician's order for daily catheter care, there was no documentation verifying that catheter care was performed every shift from January 15 to February 5, 2024. Additionally, the facility lacked a specific policy for indwelling urinary catheter care, relying instead on a general bed bath/perineal care procedure that did not adequately address catheter care specifics. This led to Resident H experiencing foul-smelling, dark urine and a contaminated urine sample, which delayed appropriate treatment and monitoring for a urinary tract infection. The resident's care plan also indicated the need for catheter care every shift, which was not documented as being followed consistently. The Clinical Specialist confirmed the absence of documentation for catheter care during the specified period, highlighting a significant lapse in care and monitoring for Resident H. Resident L, who had a diagnosis of cerebral infarct and dysuria, was also affected by the facility's failure to provide timely and appropriate care. Despite being cognitively intact and reporting symptoms of a urinary tract infection, Resident L experienced delays in being taken to the bathroom, leading to urinary accidents. A urine sample collected for analysis was reported as possibly contaminated, and there was no documentation of the urine's color, characteristics, or odor. The Director of Nursing confirmed that a repeat urine sample was ordered and collected using an in-and-out catheter, but the nursing progress notes lacked detailed assessments of the urine. This deficiency in documentation and timely care contributed to Resident L's ongoing discomfort and potential urinary tract infection. The facility's failure to provide appropriate catheter care and timely monitoring of urine characteristics for both residents highlights significant lapses in care and documentation, leading to potential health risks for the affected residents.
Inadequate Supervision and Behavioral Management for Dementia Patients
Penalty
Summary
The facility failed to provide adequate supervision for three residents diagnosed with dementia, leading to multiple incidents of inappropriate behavior and physical altercations. Resident E, who was severely cognitively impaired, was involved in an incident where Resident 94, also severely cognitively impaired, touched him inappropriately in the hallway. Despite being on 15-minute checks, Resident 94 was able to approach and grab Resident E's genitalia through his clothing. Staff intervened to separate the residents, but the incident highlighted a lack of effective supervision and monitoring for Resident 94's behaviors. Resident 94 exhibited multiple behavioral issues, including wandering into other residents' rooms, taking their belongings, and displaying hypersexual behaviors. Despite various interventions such as medication adjustments, 15-minute checks, and the use of stop signs on doors, Resident 94 continued to enter other residents' rooms and cause distress. On one occasion, Resident 94 wandered into Resident 15's room and was struck in the back by Resident 15 before staff could intervene. This incident further demonstrated the facility's inability to manage Resident 94's behaviors effectively. The facility's behavioral health management program aimed to identify, monitor, and manage disruptive behaviors using the least invasive approach. However, the repeated incidents involving Resident 94 indicated that the interventions in place were insufficient to prevent her from causing distress to other residents. The facility's failure to provide adequate supervision and effective behavioral management for Resident 94 resulted in multiple incidents of resident-to-resident altercations and inappropriate behavior, highlighting a significant deficiency in the care provided to cognitively impaired residents.
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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 Morristown
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Ashford Place Health Campus | 8.5 mi | ★★★★★ | 0 | 0 |
| Brickyard Healthcare - Brandywine Care Center | 9.5 mi | ★★★★★ | 11 | 0 |
| Aperion Care Greenfield | 10.3 mi | ★★★★★ | 25 | 0 |
| Springhurst Health Campus | 10.4 mi | ★★★★★ | 1 | 1 |
| Greenfield Healthcare Center | 10.4 mi | ★★★★★ | 11 | 0 |
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