Moravian Manor

Number of residents sampled: Number of residents cited: Based on observations and interview with staff, it was determined that the facility failed to treat each resident with respect and dignity during meal service in one of two dining rooms (Herrnhut).Findings include:Observation on August 26, 2025, at 11:47 a.m. revealed Employee E4 wearing disposable gloves while feeding Resident 9.Observations on August 27, 2025, at 11:54 a.m. revealed Employee E4 wearing disposable gloves while feeding Resident 19 and Employee E5 wearing disposable gloves while feeding Resident 14.Observations on August 28, 2025, at 11:54 a.m. revealed Employee E6 wearing disposable gloves while feeding Resident 14. Employee E6 was also standing while feeding Resident 14. Employee E3 was standing and wearing disposable gloves while assisting Resident 19. Employee E8 was wearing disposable gloves while feeding Resident 9. An additional observation revealed licensed staff E7 wearing disposable gloves while feeding Resident 37. Interview with the Nursing Home Administrator on August 28, 2025, at 12:55 p.m.…

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 review of the National Fire Protection Agency's (NFPA) 96, observation and interview with staff, it was determined the facility failed to provide an environment free of accident hazards for one of two dining areas. (2nd floor dining room). Findings include: Review of NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations states that open flames are not permitted in health care settings. Observation in the second floor dining room on April 9, 2025 at 11:15 a.m. revealed four hotel pans containing food being warmed by 8 sterno burners (fuel made from denatured and jellied alcohol). Interview with Dietary Employees E3 and E4 on April 9, 2025 at 11:35 a.m. revealed the steam table had broken, and they had been using the sterno to keep the food warm until the steam table was able to be replaced. Further interview revealed the sterno had been used for about a month. Interview with the Nursing Home Administrator on April 9, 2025 at 11:30 confirmed there should not be open flame in the nursing home and instructed the dietary staff 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 a review of the facility's policy, clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of the 18 residents reviewed (Resident 53). Findings include: Review of the facility's policy titled Abuse Investigation, with a review date of May 17, 2023, revealed that all reports of resident abuse, neglect, and injuries of unknown origin are promptly investigated by facility management. The investigation includes interviewing staff members (on all shifts) who had contact with the resident during the alleged incident. Review of Resident 53's diagnosis list includes Alzheimer's Disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and Vascular Dementia with behavioral disturbances. Review of Resident 53's clinical record including the nursing progress notes dated June 20, 2024, at 10:17 p.m., revealed that during the weekly skin assessment, a 20.0 x 9.0 cm (centimeter). yellow bruise area was observed on 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 upon review of clinical records, it was determined the facility failed to ensure resident's code status coincided with resident's wishes and failed to ensure those wishes were identified in resident's medical record for two of 24 residents reviewed (Residents 20 and 49). Findings include: Review of Resident 20's Progress Notes revealed a nursing entry dated June 28, 2023 stating Resident was sent to the hospital on June 26, 2023 at 10:30 p.m. due to a decline in the residents status, residents eyes where rolling in back of head and was very hard to get a response out of, resident heart rate was high as well as blood pressure and the residents hands where blue and arms clenched tight against chest. Resident was belly breathing. Review of Resident 20's POLST (Pennsylvania Orders for Life Sustaining Treatment) signed by the resident and dated March 16, 2018 revealed the resident was a DO Not Resuscitate and wanted comfort measure only including not to send to the hospital for life sustaining treatment only if comfort needs cannot be met. Review of Resident 20's care plan revealed…

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 review of facility policy and procedure, clinical record review and staff interview it was determined that the facility failed to notify resident's representative of medication changes and failed to notify a physician of a resident's weight gain for two out of 24 residents reviewed. (Resident 23 and Resident 225) Findings include: Review of facility policy and procedure titled Protocol for residents with diagnosis of CHF revealed Resident with a diagnosis of CHF will automatically be put on daily weights. Further review of facility policy and procedure revealed the MD [physician] will be notified if there is a three or more pound weight gain in one day or if there is a five or more pound weight gain in one week. Review of Resident 23's diagnosis list revealed diagnoses including Congestive Heart Failure (CHF - excessive body/lung fluid caused by a weakened heart muscle). Review of Resident 23's physician orders dated April 12, 2023, revealed an order for daily weights: notify doctor if there is a 3…

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 clinical record review, review of facility policy and procedure, and review of documentation provided by the facility, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of 24 residents reviewed (Resident 37). Findings include: Review of the facility policy titled Injuries of Unknown Origin, dated January 2021, states, 2. Statements must be obtained from the person reporting the injury and from the caregivers during the past 24 hours and documented. Review of Resident 37's clinical record, reveals a nursing note dated July 20, 2023, an abrasion noted on the top of the right foot measures .5cm x 1 cm, Reddened areas on right great toe measures 0.3 cm and 0.2 cm and l foot 2nd toe 0.2 x0.2 cm. was reported. There was only one documentation from a caregiver in the past 24 hours. Further review of Resident 37's clinical record revealed a nursing note on August 18, 2023, the certified nursing assistant (CNA) alerted the nurse of a bruised area noted on the resident's left buttock, The area measures 3cmx1.7cm in size and is…

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 upon clinical record review, it was determined the facility failed to notify the State Ombudsman's office of hospitalization of a resident for one of 24 residents reviewed (Resident 51). Findings include: Review of Resident 51's clinical record revealed Resident 51 was hospitalized on [DATE] and August 5, 2023. Interview with the Director of Nursing on September 15, 2023 at 10:00 a.m. confirmed the State Ombudsman's office was not notified of Resident 51's hospitalization. This interview further confirmed the facility failed to notify the State Ombudsman's office of any hospitalizations or discharges of any resident from September 2022 through August, 2023. 28 Pa. Code 201.18(a)(b)(1)(3) Management

Based on clinical record review and interviews with staff it was determined that the facility failed to ensure assessments accurately reflect the resident's status for one of two closed records reviewed (Resident 73). Findings include: Review of Resident 73's clinical record revealed a nursing note dated June 30, 2023, indicating the resident was discharged to home with home health services. Further review of the clinical record revealed a discharge Minimum Data Set (MDS-periodic assessment of the residents care needs) was coded as acute hospitalization. Interview conducted with licensed Employee E3 on September 14, 2023 at 1:15 p.m. revealed the discharge MDS assessment was not completed correctly. The facility failed to ensure assessments accurately reflect the resident status for Resident 73. 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(c) Nursing services 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based upon clinical record review, it was determined the facility failed to update and revise care plans to reflect resident's current status for one of 24 residents reviewed (Resident 52). Findings include: Review of Resident 52's diagnosis list revealed diagnoses including retention of urine. Review of Resident 52's clinical record revealed Resident 52 was admitted to the facility with a Foley catheter [catheter place to help remove urine]. Further review of Resident 52's clinical record revealed Resident 52's Foley catheter was removed on September 13, 2023. Review of Resident 52's physician orders dated September 13, 2023, revealed Bladder Scan TID [three times per day]; straight cath [catheter utilized for one time use; not to be permanently inserted] with 16F [catheter size] if > [greater than] 350 cc [cubic centimeters]. Review of Resident 52's active plan of care revealed a care plan for Resident 52's Foley catheter. Further review of Resident 52's care plan failed to reveal evidence the care plan was updated to reflect the removal of the Foley catheter and the physician's…

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 clinical record review and staff interview it was determined the facility failed to follow recommendation by a would specialist consultant for one of four residents reviewed for pressure ulcers. (Resident 41) Review of Resident 41's progress notes revealed an entry dated July 18 2023 at 11:38 p.m. stating resident with SDTI (Suspected Deep Tissue Injury- brown or black tissues caused by damage due to pressure that is under the skin). Review of Resident 41's Wound care consultant report dated July 21, 2023 revealed the resident had a SDTI and recommended to have an Albumin level (blood test to determine protein in the blood needed for healing). Review of Resident 41's clinical record revealed there was no documented evidence resident 41 had the blood test drawn as recommended by the wound specialist. Interview with the Director of Nursing on September 15, 2023 at 10:35 a.m. confirmed The blood test was not completed as recommended by the wound specialist on July 21, 2023. 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28. Pa. Code…

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.