Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 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 Woods Of Journey during CMS and state inspections, most recent first.
A resident with a history of aggression physically assaulted another resident experiencing psychosis by punching him multiple times in the face, resulting in visible injury. Staff intervened to separate the residents, but the incident revealed a failure to prevent abuse as required by facility policy.
A sanitation bucket in the kitchen was found to have a sanitizing solution concentration below the required level, as determined by the Assistant Dietary Manager using a test strip. The staff member was unsure of the correct concentration and later confirmed it was lower than the facility's policy requirement, potentially affecting all residents served from the kitchen.
Surveyors identified that MDS assessments for four residents were inaccurately coded, including errors in documenting admission source, daily use of limb restraints, anticoagulant medication use, and prognosis related to hospice care. Staff interviews and record reviews confirmed these discrepancies, and it was noted that the facility lacked a specific policy for MDS coding, relying instead on the RAI manual.
Staff assisted a resident with dementia and psychosis during meals by standing rather than sitting, and failed to engage with the resident, instead conversing with other staff. The resident, who was fully dependent on staff for eating, was not treated in accordance with dignity and respect policies.
A resident with a history of stroke, hemiplegia, and schizophrenia was admitted without their POST form being properly documented or communicated to staff. The POST form, indicating a request for CPR and full medical attention, was not found in the EHR or at the nurse's station as required by facility policy, and was only located later in a scanned pile not accessible to staff.
A resident with dementia and other conditions was repeatedly observed secured in a Broda chair with leg straps to prevent self-transfer. Although there was a physician order for the restraint and instructions for periodic release, the clinical record lacked required documentation of daily use, specific release schedules, and quarterly re-evaluations. The DON confirmed that ongoing assessments were not completed as required by facility policy.
The facility failed to protect residents from improper use of restraints. A resident was observed in a Broda chair with leg straps not ordered by a physician, and there was no documentation of regular release and repositioning. Another resident was restrained without prior informed consent, and documentation of release and repositioning was lacking. A third resident was observed straining against restraints, with no documentation of being released every two hours. Interviews revealed staff uncertainty about restraint protocols.
A resident with Alzheimer's disease was prescribed antipsychotic medications without an adequate diagnosis or attempt at gradual dose reduction (GDR). The facility's policy requires GDR to determine if symptoms can be managed with a lower dose, but the resident's medication regimen was not evaluated for GDR, and antipsychotics were prescribed for longer than 14 days without proper evaluation.
The facility did not ensure that daily posted nurse staffing information accurately reflected the actual hours worked by staff over five consecutive days. Observations showed that the staffing sheets lacked actual hours worked, and the Clinical Support Nurse confirmed the need for updates. The facility also lacked a policy on staffing sheet requirements.
A resident with a history of elopement exited the facility unsupervised on three consecutive days due to inadequate supervision and a malfunctioning door alarm. Despite being placed on 15-minute checks, the resident managed to leave through the same emergency exit door, which was not connected to the internal alarm system. The facility's failure to provide continuous supervision and secure the door led to repeated elopements, posing a significant risk to the resident's safety.
Failure to Protect Resident from Physical Abuse by Another Resident
Penalty
Summary
A deficiency occurred when a male resident physically assaulted another male resident by punching him in the face multiple times. On the day of the incident, the aggressor had been agitated and displayed verbal and physical aggression toward staff, while the victim was experiencing an episode of psychosis and was not easily redirected. Staff witnessed the assault in the facility's front lobby area, where the aggressor struck the victim with a closed fist, resulting in a small, bluish-purple, swollen area and a cut under the victim's right eye. The two residents were immediately separated by staff, and the victim received ice for his injury. The clinical records indicated that the victim had diagnoses including Alzheimer's disease, schizophrenia, and anxiety, and was cognitively intact according to a recent assessment. The aggressor had diagnoses of dementia, anxiety, and depression, and was noted to be severely cognitively impaired. The facility's policy, which was in place at the time, required the prevention of abuse, but the incident demonstrated a failure to protect a resident from physical abuse by another resident.
Sanitizing Solution in Kitchen Below Required Concentration
Penalty
Summary
During an initial kitchen tour, the Assistant Dietary Manager tested the sanitizing solution in the sanitation bucket at the three-compartment sink and found the concentration to be 170, as indicated by the test strip. The Assistant Dietary Manager was unsure of the correct color on the test strip bottle that should be matched. Later, she acknowledged that the sanitizing solution was low and that the required concentration should have been between 272-700, according to facility policy. The facility's policy, revised recently, states that cleaning and sanitizing buckets must be prepared at the start of each shift and replaced as needed to maintain proper concentration. This deficiency was identified for 1 of 1 sanitation bucket reviewed and had the potential to affect all 35 residents served from the kitchen.
Inaccurate MDS Assessments for Multiple Residents
Penalty
Summary
The facility failed to ensure the accuracy of Minimum Data Set (MDS) assessments for four residents, resulting in incorrect coding of key clinical information. For one resident with Alzheimer's disease, the admission source was inaccurately coded as a nursing home, despite documentation and staff interviews confirming the resident was admitted from a private home after living with a family member. Another resident with dementia and COPD had daily use of limb restraints in a Broda chair, as ordered by a physician, but the MDS assessment did not reflect this use during the required look-back period. A third resident with COPD, dementia, and schizophrenia was incorrectly coded as receiving anticoagulant medication on the MDS, even though the medication had been discontinued prior to the assessment period. Additionally, a resident with Alzheimer's and Parkinson's disease was coded as not having a life expectancy of less than six months, despite being admitted to hospice care, which was documented in the medical record. Interviews with staff confirmed these inaccuracies and revealed a lack of facility policy on MDS coding, with reliance on the RAI manual for guidance.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
Staff failed to maintain a resident's dignity during meal assistance, as observed on two separate occasions. On the first occasion, a CNA stood to the left of a resident with dementia and psychosis while assisting with the meal, placing her hand on the resident's forehead to hold her head up and feeding her without engaging in conversation. The CNA instead conversed with other staff members during the meal. On the second occasion, the Activity Director also stood in front of the same resident while assisting with eating. The resident's care plan indicated a total dependence on staff for meal assistance due to dementia. Staff interviews confirmed that proper protocol requires sitting and engaging with residents during meal assistance, rather than standing and conversing with other staff. The facility's Resident Rights policy emphasized the right to a dignified existence and being treated with respect and consideration, which was not upheld during these observed meal times.
Failure to Communicate Resident Advance Directive to Care Staff
Penalty
Summary
The facility failed to communicate a resident's advance directive choice to the staff responsible for their care. A review of the clinical record for a resident with diagnoses including cerebral infarction, left side hemiplegia, and schizophrenia revealed that documentation of the Indiana Physician Orders for Scope of Treatment (POST) form was missing from both the electronic health record (EHR) and the binder at the nurse's station. The Director of Nursing (DNS) confirmed that the POST form, which indicated the resident requested CPR and full medical attention, was not available in the expected locations and was only later found in a scanned pile not accessible at the nurse's station. Facility policy requires that advance directives be copied, placed on the chart, and communicated to staff upon admission, but this was not done for the resident in question.
Failure to Document and Re-Evaluate Use of Physical Restraints
Penalty
Summary
A resident with diagnoses including dementia, COPD, anxiety, and psychosis was observed multiple times seated in a Broda chair with leg straps securing both legs, preventing her from getting out of the chair. These observations occurred in various locations, including the hallway and her room, both while awake and asleep. Staff were seen releasing and repositioning the leg straps at intervals. The resident's clinical record included a physician order for the use of the Broda chair with straps for safety and positioning, with instructions for release and repositioning every two hours and quarterly review for continued use. However, documentation in the resident's record was incomplete. The Minimum Data Set (MDS) assessment did not document daily use of limb restraints, and the care plan referenced the use of the Broda chair with straps but lacked specific details. The informed consent form for restraint use did not specify the recommended duration or release schedule. Additionally, the quarterly adaptive device review noted the device's initiation and rationale but lacked evidence of previous quarterly reviews. The Director of Nursing Services confirmed that no further evaluations had been completed, despite facility policy requiring ongoing re-evaluation of restraint need.
Failure to Protect Residents from Improper Use of Restraints
Penalty
Summary
The facility failed to protect the rights of residents to be free from physical restraints, as observed in three residents. Resident 16 was repeatedly observed in a Broda chair with leg straps, which were not ordered by the physician, and there was no documentation of the resident being released and repositioned every two hours as required. The care plan and informed consent indicated the need for regular release and repositioning, but this was not documented in the clinical record. Resident 3 was also observed in a Broda chair with lap straps, without prior informed consent for the use of restraints. The consent form was signed after the resident was already restrained, and there was no documentation of the resident being released and repositioned every two hours. The Director of Nursing confirmed the lack of prior consent and documentation for the release and repositioning of the resident. Resident 27 was observed straining against restraints in a Broda chair, with no documentation of being released every two hours. The care plan required regular release and repositioning, but this was not documented. Interviews with CNAs revealed uncertainty about the frequency of releasing the resident from restraints. The facility's policy did not require documentation of repositioning or informed consent prior to restraint use.
Failure to Implement Gradual Dose Reduction for Antipsychotic Medication
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medications, specifically regarding the use of antipsychotic medications. A resident was observed sitting in a broda chair with lower limb restraints and was prescribed olanzapine and prochlorperazine maleate, both antipsychotic medications. The resident's clinical record indicated diagnoses of Alzheimer's disease, a personal history of traumatic brain injury, insomnia, and anxiety. However, the record lacked an adequate diagnosis for the continued use of antipsychotics, and there was no attempt at a gradual dose reduction (GDR) for these medications, nor was it documented as contraindicated. The facility's policy on GDR, which was revised earlier in the year, outlines the need for stepwise tapering of psychotropic drugs to determine if symptoms can be managed with a lower dose or if the medication can be discontinued. Despite this policy, the resident's medication regimen was not evaluated for GDR, and the antipsychotic medication was prescribed for longer than 14 days without proper evaluation. The Clinical Support Nurse acknowledged that antipsychotic medication should not be used for dementia without behaviors and suggested that the resident's hospice care might have been a reason for not attempting a GDR.
Inaccurate Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that the daily posted nurse staffing information accurately reflected the actual hours worked by staff over a period of five consecutive days. Observations made on June 26, 27, 28, July 1, and July 2, 2024, revealed that the posted nurse staffing sheets did not include the actual hours worked by the nursing staff. During an interview on July 2, 2024, the Clinical Support Nurse acknowledged that the facility should have been updating the staffing sheets to reflect the actual hours worked by licensed staff the following day. It was also noted that the facility lacked a policy specifying the requirements for the nurse staffing sheets.
Failure to Prevent Resident Elopement
Penalty
Summary
The facility failed to provide adequate supervision to prevent a resident with a history of elopement from exiting the facility on three consecutive days. Resident B, who had a history of elopement and was diagnosed with non-traumatic brain dysfunction, schizophrenia, psychotic disorder, and bilateral hand amputation, was able to leave the facility unsupervised on three separate occasions. On the first occasion, Resident B was found 1.1 miles away in an empty commercial lot by the police. Despite being placed on 15-minute checks after the first elopement, Resident B managed to exit the facility again on the following two days through the same emergency exit door in the dining room, which was not connected to the internal alarm system and had a malfunctioning battery-operated alarm. The emergency exit door in the dining room was observed to be shut but not secured, with a small, battery-operated door alarm that was not functioning properly. Staff interviews revealed that Resident B was not on 1-on-1 supervision during the night shift following the initial elopement and that the staff were not adequately informed or trained to handle the situation. The Vice President of Clinical Operations (VPCO) and other staff members were not promptly notified of the subsequent elopements, and the necessary documentation was not completed. Additionally, the facility's policy on elopements and wandering residents was not effectively implemented, as alarms are not a replacement for necessary supervision. Resident B's clinical record indicated a history of elopement and a court order appointing a guardian due to incapacity to make healthcare decisions. Despite this, the facility did not take appropriate measures to ensure Resident B's safety. The care plan for Resident B, which included monitoring the placement and function of a bracelet alarm, was not adequately followed. The facility's failure to provide continuous supervision and secure the emergency exit door led to Resident B's repeated elopements, posing a significant risk to the resident's safety.
Removal Plan
- Inserviced the staff on supervision
- Ensured the unsecured door was under supervision until it could be replaced
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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) |
|---|---|---|---|---|
| Grand Valley Health & Rehab | 8 mi | — | 0 | 0 |
| Waters Of Martinsville, The | 11 mi | — | 17 | 0 |
| Brown County Health And Living Community | 11.9 mi | — | 2 | 0 |
| Franklin Meadows | 12.3 mi | — | 8 | 0 |
| Otterbein Franklin Seniorlife Comm Res & Com Care | 12.6 mi | — | 17 | 2 |
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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.