Morgantown Woods Of Journey

Based on interview and record review, the facility failed to ensure a quarterly Minimum Data Set (MDS) assessment was completed 92 days after the previous MDS assessment for 2 of 3 residents reviewed for Resident Assessment. (Resident 2, Resident 24)Findings include: 1. On 3/10/26 at 11:43 a.m., Resident 2's clinical record was reviewed. The diagnoses included, but were not limited to, diabetes mellitus and hypertension. The quarterly MDS assessment was dated 10/3/25. The clinical record lacked documentation of another assessment since 10/3/25. 2. On 3/10/26 at 11:50 a.m., Resident 24's clinical record was reviewed. The diagnoses included, but were not limited to, schizoaffective disorder and anxiety. The quarterly MDS assessment was dated 10/3/25. The clinical record lacked documentation of another assessment since 10/3/25. During an interview on 3/11/26 at 12:04 p.m., the Corporate MDS nurse indicated Resident 2 and Resident 24's clinical record lacked documentation of a quarterly MDS assessment since 10/3/25. On 3/11/26 at 2:49 p.m., the Administrator provided the facility…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure Minimum Data Set Assessments were accurate for 2 of 14 residents reviewed for comprehensive assessment. (Resident 5, Resident 29) Findings include:1. On 3/10/26 at 11:05 a.m., Resident 5's clinical record was reviewed. The diagnoses included, but were not limited to, bipolar disorder and anxiety disorder. The Preadmission Screening and Resident Review (PASARR), dated 9/14/19, indicated the resident had serious mental illness. Current physician's orders indicated the resident was taking Torsemide (a diuretic) beginning on 7/12/25 and Depakote (an anticonvulsant) beginning on 7/11/25. The annual Minimum Data Set (MDS) Assessment, dated 8/11/25, indicated the resident did not have a serious mental illness and was not taking diuretic or anticonvulsant medications. During an interview on 3/11/26 at 1:50 p.m., the Director of Nursing indicated the 8/11/25 annual MDS assessment was incorrectly coded. 2. On 3/10/26 at 11:53 a.m., Resident 29's clinical record was reviewed. The diagnoses included, but were not limited to,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interview, the facility failed to ensure a resident had an accurate Level I Preadmission Screening and Resident Review (PASARR) for 1 of 3 residents reviewed for PASARR. (Resident 24)Findings include: On 3/10/26 at 10:08 a.m., Resident 24's clinical record was reviewed. The diagnoses included, but were not limited to, schizophrenia and anxiety. Resident 24's PASARR, dated 3/3/25, indicated no Level II required due to no serious mental illness, no mental health symptoms, and no antidepressants or any other mental health medication were prescribed. There was no evidence of a PASARR condition of a serious mental health condition. If changes occur or new information refutes these findings, a new screen must be submitted. Resident 24's admission date was 3/31/25 with the diagnosis of schizophrenia and a diagnosis date of anxiety was 4/17/25. The Order Summary Report dated 3/11/26 indicated the following:- Buspirone (antianxiety medication) 15 milligrams (mg) give a 0.5 tablet twice a day for anxiety, start date 1/9/26. - Paroxetine (antidepressant medication)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to develop a comprehensive care plan related to noncompliance for 1 of 14 residents reviewed for care plans. (Resident 39)Findings include:On 3/9/26 at 2:58 p.m., Resident 39's clinical record was reviewed. The diagnoses included, but were not limited to, COPD (Chronic Obstructive Pulmonary Disease), hypertension, dementia, diabetes mellitus with circulatory complications, and heart failure. A Physician's Order, dated 6/2/24, indicated the resident was prescribed a 2,000 cc (cubic centimeters; equivalent to 1 milliliter) fluid target goal, with 480 cc at breakfast, 480 cc at lunch, 480 cc at dinner, 120 cc each shift, and 120 cc at bedtime. The resident's progress notes indicated the following: - On 12/8/25 at 2:42 p.m., the resident had frothy sputum and asked for 8-10 mugs of ice in one shift. He was educated he was not to have more than 2 mugs of ice per shift. - A Dietitian Evaluation, dated 12/29/25, indicated the resident did not adhere to his prescribed fluid restriction diet and occasionally consumed in excess of the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to protect a resident's right to be free from physical abuse when a male resident punched another male resident in the face for 1 of 3 residents reviewed for abuse. (Resident B, Resident C) Findings include:On 12/17/25 at 8:14 a.m., the Administrator provided a copy of a facility reportable incident, dated 12/1/25 at 6:05 p.m. A review of the facility reportable incident indicated Resident B had been agitated the entire day and displayed verbal and physical aggression toward staff. Resident C had been experiencing an episode of psychosis, had not been easily redirected, and had displayed numerous psychotic behaviors over the previous several days. Staff observed Resident B make contact with Resident C's face with a closed fist.During an interview on 12/17/25 at 8:23 a.m., Qualified Medication Aide (QMA) 1 indicated, on 12/1/25 at approximately 6:00 p.m., she walked to the front of the facility near the kitchen and heard a loud noise. When she looked in the direction of the noise, QMA 1 witnessed Resident C sitting on a bench…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the sanitation bucket in the kitchen was at the correct level required for 1 of 1 sanitation bucket reviewed during the kitchen initial tour. This has the potential to affect 35 of 35 residents served from the kitchen. Findings include: During the initial kitchen tour on 4/7/25 at 10:15 a.m., the Assistant Dietary Manager tested the sanitizing solution in the sanitation bucket on the three compartment sink. She used the test strip and dipped the strip in the sanitizing solution. She read the test strip color to the color chart on the bottle which indicated it was 170. She was unsure what color on the test strip bottle, the test strip should of been. On 4/7/25 at 10:36 a.m., the Assistant Dietary Manager indicated the sanitizing solution was low. It should of been 272-700. On 4/9/25 at 4:15 p.m., the Regional Registered Dietician provided the facility's policy, The Sanitizing Buckets, revised 3/31/25, and indicated it was the policy currently being used by the facility. A review of the policy indicated,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the accuracy of the Minimum Data Set assessment for 4 of 12 residents reviewed. The admission from location, daily use of limb restraints, anticoagulant medications, and prognosis were coded incorrectly. (Resident 35, Resident 27, Resident 18, Resident 1). Findings include: 1. Resident 35's clinical record was reviewed on 4/8/25 at 11:24 a.m. The diagnosis included, but was not limited to, Alzheimer's Disease. Resident 35's admission date was 1/15/25. A review of nursing progress notes indicated Resident 35 had been staying with his sister in another state but had recently moved back to this area to be closer to where his brother lived. Resident 35's admission Minimum Data Set (MDS) assessment, dated 1/28/25, indicated the resident had admitted from a nursing home. During an interview on 4/8/25 at 11:32 a.m., the Administrator indicated the resident had been living out of state with his sister prior to being admitted to the facility. During an interview on 4/8/25 at 1:58 p.m., the MDS Coordinator indicated the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain resident's dignity while assisting residents with the meal for 2 of 2 dining observations. Staff stood while assisting the resident. (Resident 27) Findings include: During a dining room observation on 4/7/25 at 12:23 p.m. until 12:40 p.m., CNA 1 was observed to stand to the left of Resident 27 to assist the resident with the meal. CNA 1 then placed her hand on the forehead of Resident 27 to hold her head up while she placed a spoon in the resident's mouth. CNA 1 did not talk with Resident 27, she was observed to talk with other staff members while they assisted residents during the noon meal. During an observation on 4/8/25 at 12:20 p.m., Resident 27 was observed eating with assistance of the Activity Director (AD). The AD was observed to be standing in front of the resident while assisting with the meal. On 4/8/25 at 1:39 p.m., Resident 27's clinical record was reviewed. The diagnoses included, but were not limited to, dementia and psychosis (when people lose some contact with reality). The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to communicate the resident's choice of advance directive to the staff responsible for the resident's care for 1 of 1 residents reviewed for Advance Directive. (Resident 186) Findings include: On [DATE] at 2:28 p.m., Resident 186's clinical record was reviewed. The diagnoses included, but were not limited to, cerebral infarction (stroke), left side hemiplegia (paralysis on one side), and schizophrenia. Resident 186's admission date was [DATE]. The clinical record lacked documentation of the Indiana Physician Orders for Scope of Treatment (POST) form. During an interview on [DATE] at 10:55 a.m., the Director of Nursing (DNS) indicated Social Services would complete the POST form on admission, the nurse practitioner would review and sign, and then scan the POST form into the electronic health record (EHR) with a copy going in a binder at the nurse's station. The DNS could not locate the POST form in the EHR. With the DNS, the binder at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to protect the residents right to be free from physical restraints for 1 of 3 residents reviewed for restraints. Documentation of re-evaluation of the need for restraints was not completed. (Resident 27) Findings include: On 4/7/25 at 11:35 a.m., Resident 27 was observed sitting in a Broda chair awake in the hallway with leg straps over both legs to prevent her from getting out of the chair. On 4/7/25 at 2:40 p.m., Resident 27 was observed sitting in a Broda chair asleep in her room with leg straps over both legs to prevent her from getting out the chair. On 4/8/25 at 9:32 a.m., Resident 27 was observed sitting in a Broda chair asleep in her room with leg straps over both legs to prevent her from getting out of the chair On 4/8/25 at 10:00 a.m., Resident 27 observed sitting in a Broda chair in her room. Two patient care staff members released and repositioned the leg straps at that time. On 4/9/25 at 11:08 a.m., Resident 27 observed sitting in a Broda chair asleep in her room with leg straps over both legs to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to ensure the written notification required for a transfer and discharge was given to the resident and resident's representative for 2 of 2 residents reviewed for hospitalization. (Resident 8, Resident 19). Findings include: 1. On 4/8/25 at 2:00 p.m., Resident 8's clinical record was reviewed. The diagnoses included, but were not limited to, chronic obstructive pulmonary disease, hypertension, and heart failure. Resident 8's progress notes, dated 1/17/25 at 7:50 a.m., indicated Resident 8 was to go to the emergency room due to resident chest x-ray results indicated possible pneumonia. The SNF/NF (skilled nursing facility/nursing facility) to Hospital Transfer form, dated 1/17/25 at 7:30 a.m., indicated Resident 8 was transferred to the hospital. The progress notes and transfer form lacked documentation of a written notification of the transfer and discharge was given the resident or the resident's representative. 2. On 4/8/25 at 2:19 p.m., Resident 19's clinical record was reviewed. The diagnoses included, but were not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to protect the residents right to be free from physical restraints for 3 of 5 residents reviewed for restraints. Documentation of releasing the restraint and repositioning was not completed and informed consent for the use of restraints was not completed prior to placing the resident in restraints. (Resident 3, Resident 16, Resident 27) Findings include: 1. On 6/26/24 at 2:11 p.m., Resident 16 was observed sitting in a broda chair asleep in the hallway with lap straps around her legs to prevent her from getting out of the chair. On 6/28/24 at 9:10 a.m., Resident 16 was observed sitting in the broda chair asleep in the hallway with leg straps around her legs to prevent her from getting out of the chair. On 6/28/24 at 10:24 a.m., Resident 16 was observed sitting in the broda chair asleep in her room with leg straps around her legs to prevent her from getting out of the chair. On 6/28/24 at 11:29 a.m., Resident 16 was observed sitting in the broda chair asleep in her room with leg straps around her legs to prevent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure residents were free from unnecessary medications for 1 of 5 residents reviewed. As needed antipsychotic medications were prescribed for longer than 14 days, gradual dose reductions (GDR) were not completed, and antipsychotic medications did not have an adequate diagnosis. (Resident 3) Findings include: During an observation on 6/27/24 at 9:49 a.m., Resident 3 was observed sitting upright in a broda chair with lower limb restrains in place. The resident repeatedly shouted, Come here!, in a loud and intelligible voice. On 6/27/24 at 10:17 a.m., Resident 3's clinical record was reviewed. The diagnoses included, but were not limited to, Alzheimer's disease, personal history of traumatic brain injury, insomnia, and anxiety. A 5/9/24 physician's order indicated the resident was prescribed olanzapine (antipsychotic medication) 2.5 milligrams, two times a day, related to Alzheimer's disease and prochlorperazine maleate (antiemetic and antipsychotic medication) 1 tablet by mouth every six hours as needed for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.