Morgantown Woods of Journey

In the surveyor’s words

From the most serious findings on record at Morgantown Woods of Journey, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Mar 28, 2024

  Based on observation, interview, and record review, the facility failed to provide adequate supervision to prevent a resident with a history of elopement from walking out the same emergency exit door on 3 consecutive days for 1 of 3 residents reviewed for elopement. Resident B was found 1.1 miles in an empty commercial lot by the police. (Resident B) The Immediate Jeopardy began on March 23, 2024, when Resident B exited the facility without staff supervision. The Administrator and the [NAME] President of Clinical Operations were notified of the Immediate Jeopardy, on March 27, 2024 at 10:45 a.m. […]

• No harm, potential for more than minimal, widespreadF812Apr 9, 2025

  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. […]

• No harm, potential for more than minimal, patternF641Apr 9, 2025

  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 admitted 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. […]

• No harm, potential for more than minimal, patternF604Aug 10, 2023

  Based on observation, interview, and record review, the facility failed to protect the residents' right to be free from physical restraints for 4 of 5 residents reviewed for physical restraints. (Resident 28, Resident 3, Resident 15, Resident 23) Findings include: 1. On the following dates, times, and locations, Resident 28 was observed sitting in a Broda wheelchair (a chaired designed to provide supportive positioning, decrease postural deviations, and enhance patient safety while facilitating safe, frequent repositioning) with restraining straps secured across the resident's upper legs. The straps were unable to be removed by the resident: - On 8/6/23 at 11:00 a.m. and 2:00 p.m. in her room. - On 8/7/23 at 10:54 a.m. and 2:20 p.m. in her room. - On 8/8/23 at 10:10 a.m. and 11:30 a.m. […]

• No harm, potential for more than minimal, patternF689Sep 29, 2022

  Based on observation, interview, and record review, the facility failed to ensure hot water temperatures remained at a safe and comfortable level, below 120 degrees Fahrenheit for 6 out of 11 residents rooms that were assessed for safe water temperatures. (Room 1, Room 2, Room 3, Room 4, Room 5, Room 6) Findings include: Water temperatures were observed on the following dates and times: On 9/27/22 at 10:47 A.M., Room 1's bathroom water temperature was 124 degrees. On 9/27/22 at 10:48 A.M., Room 2's bathroom water temperature was 127 degrees. On 9/27/22 at 10:49 A.M., Room 3's bathroom water temperature was 126 degrees. On 9/27/22 at 10:50 A.M., Room 4's bathroom water temperature was 128 degrees. […]