Inspection Report Summary
The most recent inspection on July 2, 2025, found the facility in compliance with all surveyed regulations and no new deficiencies. Prior inspections showed multiple deficiencies related to resident dignity, dialysis care, assessment accuracy, wheelchair safety, food safety, pest control, and staffing information posting. Complaint investigations substantiated issues including an injury due to unsafe transportation practices and medication errors, but corrective actions were implemented promptly, including staff re-education and termination of involved personnel. Enforcement actions such as fines or license suspensions were not listed in the available reports. The facility appears to have addressed recent deficiencies effectively, showing improvement in compliance over time.
Deficiencies (last 11 years)
Deficiencies (over 11 years)
17.9 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
198% worse than Kansas average
Kansas average: 6 deficiencies/year
Deficiencies per year
12
9
6
3
0
Census
Latest occupancy rate
36 residents
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Re-Inspection
Deficiencies: 0
Jul 2, 2025
Visit Reason
An off-site revisit survey was conducted on 07/02/2025 for all previous deficiencies cited on 06/04/2025 to verify correction of cited deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date 06/11/2025, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
Jun 11, 2025
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection, outlining corrective actions and compliance dates for each cited deficiency.
Findings
The plan addresses multiple deficiencies related to resident dignity, dialysis care, MDS coding, wheelchair safety, staffing information, food safety, and pest control. The facility describes reeducation efforts, monitoring plans, and dates of substantial compliance for each issue.
Severity Breakdown
D: 5
C: 1
F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Concerns related to promoting and maintaining resident dignity | D |
| Concerns regarding significant change in status MDS for residents newly started on dialysis | D |
| Concerns with coding of section N for residents receiving antipsychotic medications | D |
| Concerns with wheelchair footrest positioning and safe transport of residents in wheelchairs | D |
| Concerns with dialysis dressing care and monitoring | D |
| Incomplete staffing information on daily staff posting | C |
| Food safety concerns including open, uncovered, or undated food items and damaged cutting board | F |
| Pest control concerns related to flies in the kitchen | F |
Report Facts
Frequency of monitoring: 3
Monitoring duration: 4
Monitoring duration: 30
Date of substantial compliance: Jun 11, 2025
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 8
Jun 4, 2025
Visit Reason
The inspection was a Health Recertification Survey conducted to assess compliance with federal regulations and standards for nursing home care.
Findings
The facility was found deficient in multiple areas including resident dignity and rights, comprehensive assessments after significant changes, accuracy of assessments, quality of care related to wheelchair positioning, dialysis care and monitoring, nurse staffing information posting, food safety and sanitation, and pest control program effectiveness.
Severity Breakdown
SS=D: 5
SS=C: 1
SS=F: 2
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to ensure dignified care for Resident 28 when staff failed to cover the resident during care, risking embarrassment and decreased psychosocial well-being. | SS=D |
| Failed to complete a Significant Change Minimum Data Set assessment for Resident 31 after starting dialysis, risking unidentified care needs. | SS=D |
| Failed to accurately complete the Minimum Data Set for Resident 2, inaccurately documenting medication use, risking unidentified care needs. | SS=D |
| Failed to ensure appropriate wheelchair positioning for Resident 23, risking accidents and decreased comfort. | SS=D |
| Failed to provide necessary dialysis assessment, care, and services for Resident 31, risking adverse outcomes and dialysis complications. | SS=D |
| Failed to post accurate and identifiable nurse staffing information including actual hours worked. | SS=C |
| Failed to provide sanitary food storage conditions, including undated and uncovered food items and damaged equipment, risking food-borne illness. | SS=F |
| Failed to maintain an effective pest control program, resulting in an abundance of flies and structural issues allowing pest entry, risking contaminated food and resident discomfort. | SS=F |
Report Facts
Resident census: 36
Residents sampled: 14
Dates Pre/Post Dialysis Evaluation not completed: 7
Dates Dialysis Communication Form missing: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in findings related to Resident 28 dignity and dialysis care |
| Certified Nurse Aide N | Certified Nurse Aide | Named in findings related to Resident 28 dignity and wheelchair positioning |
| Administrative Nurse D | Administrative Nurse | Named in multiple findings including dignity, assessments, dialysis, and wheelchair positioning |
| Consultant Staff GG | Named in findings related to assessment accuracy | |
| Certified Nurse Aide M | Certified Nurse Aide | Named in wheelchair positioning finding |
| Dietary Manager BB | Dietary Manager | Named in food safety and sanitation findings |
| Administrative Staff A | Named in food safety and pest control findings | |
| Maintenance U | Named in pest control findings |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 4
Mar 20, 2025
Visit Reason
A complaint survey was conducted by the Kansas Department for Aging and Disability Services on behalf of CMS due to concerns about a resident not being properly secured in a facility vehicle, resulting in injury.
Findings
The facility failed to ensure Resident 1 remained free of accident hazards during transportation on 01/21/25. The resident was not properly secured in the vehicle, slid out during a sudden stop, and sustained an injury. Staff failed to communicate the injury accurately or activate emergency services. The driver was terminated and corrective actions were implemented prior to the survey.
Complaint Details
The complaint investigation found that on 01/21/25, Resident 1 was not properly secured in the facility vehicle, leading to a fall and injury. Staff failed to notify the facility properly or call emergency services. The driver was terminated for safety violations.
Severity Breakdown
G: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to ensure Resident 1 was safely secured in the transportation vehicle before operation, resulting in injury. | G |
| CNA securing the resident lacked appropriate training and competency evaluation. | G |
| Transportation staff operated the vehicle unsafely, causing the vehicle to cross rumble strips multiple times and a sudden stop that caused the resident to slide out of the wheelchair. | G |
| Failure to accurately communicate the resident's injury to the facility and failure to activate 911 for emergency assessment. | G |
Report Facts
Census: 34
Speed limit: 40
Distance driven after incident: 50
Date of incident: Jan 21, 2025
Date of driver termination: Jan 27, 2025
Date of corrective education completion: Jan 28, 2025
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Transportation Staff E | Transportation Staff / Driver | Named in findings for unsafe vehicle operation and failure to secure resident; terminated for safety violations |
| Certified Nurse Aide D | CNA | Named in findings for securing resident without training and failure to communicate injury |
| Administrative Nurse B | Administrative Nurse | Documented progress notes and interviewed regarding incident and facility expectations |
| Administrative Staff A | Administrative Staff | Interviewed regarding staff responsibilities and corrective actions |
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 18, 2023
Visit Reason
An offsite revisit survey was conducted on 10/18/2023 for all previous deficiencies cited on 08/31/2023.
Findings
All deficiencies have been corrected as of the compliance date of 09/21/2023, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 11
Aug 31, 2023
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified during the inspection conducted on 8/31/2023 at Moran Manor.
Findings
The plan addresses multiple deficiencies including resident privacy, MDS coding errors, pain management care plans, ADL care, shaving and nail care, wheelchair safety, toileting needs, laboratory monitoring, kitchen sanitation, and infection control. The facility outlines corrective actions, staff reeducation, monitoring processes, and timelines for substantial compliance by 9/21/2023.
Severity Breakdown
D: 7
E: 2
F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| No immediate correction available for residents R25, R10, or R12 regarding promoting resident privacy. | D |
| Discrepancy with R25's Annual MDS coding at N0450A; coding errors corrected and education provided. | D |
| Lack of non-medicinal pain interventions on resident R32's care plan; care plans updated and education provided. | D |
| Resident care plans updated to include arm immobilizer, grooming preferences, toileting, and leg rests as per surveyor concerns. | E |
| Concerns about shaving and nail care for residents; reeducation and monitoring implemented. | E |
| Resident R23's wheelchair lacked foot pedals; foot pedals added and staff reeducated. | D |
| Resident R18's toileting needs not adequately addressed; incontinence assessment completed and care plans updated. | D |
| Laboratory monitoring orders clarified and reviewed to prevent duplication; staff reeducated. | D |
| Kitchen sanitation concerns addressed; staff reeducated and sanitation inspections scheduled. | F |
| Infection control concerns including staff entering Covid-19 positive room without PPE and catheter care; immediate reeducation and monitoring implemented. | F |
| All concerns addressed immediately upon walk-through; ongoing reeducation and monitoring planned. | F |
Report Facts
Walking rounds frequency: 5
Walking rounds frequency: 3
Walking rounds frequency: 3
Walking rounds frequency: 3
Walking rounds frequency: 3
Walking rounds frequency: 5
Audit frequency: 3
Compliance date: Sep 21, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Shaunna Taylor | Administrator | Administrator submitting the Plan of Correction. |
| Teresa Edwards | Person who added the Plan of Correction. | |
| Evelyn Lacey | Person who modified the Plan of Correction. |
Inspection Report
Routine
Census: 32
Deficiencies: 11
Aug 31, 2023
Visit Reason
The inspection was a health resurvey of Moran Manor to assess compliance with resident rights, care plans, infection control, food safety, and other regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to maintain resident dignity during care, inaccurate assessments and care plans, inadequate toileting programs, failure to follow physician orders for lab monitoring, unsanitary food storage and preparation, improper infection control practices, and unsafe environmental conditions in the kitchen.
Severity Breakdown
SS=D: 7
SS=E: 3
SS=F: 3
Deficiencies (11)
| Description | Severity |
|---|---|
| Failure to maintain resident dignity during peri-care and catheter care, exposing residents inappropriately. | SS=D |
| Failure to complete accurate Minimum Data Set (MDS) assessments regarding antipsychotic medication use. | SS=D |
| Failure to develop and implement comprehensive care plans reflecting current resident needs including pain management and use of assistive devices. | SS=D |
| Failure to review and revise care plans timely to reflect changes in resident condition and needs. | SS=E |
| Failure to provide adequate assistance with activities of daily living (ADL) including grooming and hygiene. | SS=E |
| Failure to ensure an environment free from accident hazards due to lack of foot pedals on wheelchair. | SS=D |
| Failure to develop and implement effective individualized toileting program to maintain bladder function. | SS=D |
| Failure to ensure laboratory blood monitoring as ordered by physician for diabetic resident. | SS=D |
| Failure to properly store, prepare, and distribute food under sanitary conditions in the kitchen. | SS=F |
| Failure to maintain an effective infection prevention and control program including improper PPE use, unsanitary catheter care, and improper handling of nasal inhalers. | SS=F |
| Failure to provide a safe, functional, sanitary, and comfortable environment for residents and staff, including dirty kitchen floors. | SS=F |
Report Facts
Residents sampled: 16
Residents census: 32
Pain rating: 5
Units of insulin: 30
Units of Novolog insulin: 4
Units of Novolog insulin: 6
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in findings related to dignity violations and catheter care |
| Administrative Nurse E | Administrative Nurse | Named in findings related to dignity, care plan accuracy, infection control, and PPE use |
| Certified Nurse Aide P | Certified Nurse Aide | Named in findings related to resident dignity and toileting |
| Certified Nurse Aide N | Certified Nurse Aide | Named in findings related to resident dignity and toileting |
| Consultant Staff GG | Named in findings related to MDS accuracy and care plan updates | |
| Administrative Staff A | Administrative Staff | Named in findings related to kitchen sanitation |
| Dietary Staff BB | Dietary Staff | Named in findings related to PPE noncompliance |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Jun 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#180909) triggered by a medication error incident where a resident received medications not prescribed to them.
Findings
The facility failed to administer medication per physician's orders to Resident 1, resulting in a medication error when Licensed Nurse G administered medications prescribed to another resident. The error was caused by the nurse leaving medications unattended. No adverse effects were noted, and corrective actions including staff re-education and physician notification were implemented prior to the surveyor's arrival.
Complaint Details
The complaint investigation #180909 found that Licensed Nurse G administered medications to Resident 1 that were prescribed to another resident. The medication error occurred on 06/17/23 at 09:25 AM when the nurse left medications unattended. The resident was monitored with no adverse effects. The facility notified the physician and resident's representative and implemented corrective actions including staff re-education.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to administer medication per physician's order resulting in medication error for Resident 1. | D |
Report Facts
Census: 33
Medication error incident date: Jun 17, 2023
Re-education start date: Jun 17, 2023
Re-education completion date: Jun 19, 2023
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in medication error finding for administering wrong medications |
| Administrative Nurse D | Administrative Nurse | Reported and discussed medication error with physician |
| Administrative Staff A | Reported notification of medication error | |
| Administrative Staff B | Notified about medication error |
Inspection Report
Plan of Correction
Deficiencies: 2
Jun 20, 2023
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited as past non-compliance during a prior inspection on 06/20/2023.
Findings
The plan addresses two deficiencies identified as past non-compliance, specifically tags F0000 and F755-D.
Deficiencies (2)
| Description |
|---|
| Deficiency F0000 cited as past non compliance |
| Deficiency F755-D cited as past non compliance |
Inspection Report
Re-Inspection
Deficiencies: 0
Apr 29, 2022
Visit Reason
An offsite revisit survey was conducted on 04/29/2022 for all previous deficiencies cited on 03/16/2022.
Findings
All deficiencies have been corrected as of the compliance date of 04/01/2022, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 5
Mar 16, 2022
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation #169251 to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to complete a significant change Minimum Data Set (MDS) for a resident admitted to hospice, failure to develop and implement a comprehensive care plan for a resident, failure to complete a discharge summary for a discharged resident, failure to provide sanitary dressing changes for a resident's skin tear, and failure to maintain proper food safety standards related to ice machine drainage.
Complaint Details
The visit was triggered by a complaint investigation #169251 as stated in the initial comments section.
Severity Breakdown
SS=D: 4
SS=F: 1
Deficiencies (5)
| Description | Severity |
|---|---|
| Failed to complete a significant change Minimum Data Set (MDS) for one resident admitted to hospice care services. | SS=D |
| Failed to develop and implement a comprehensive care plan for one resident to ensure goals, interventions, and treatments met the resident's needs. | SS=D |
| Failed to complete a discharge summary for one resident following discharge from the facility. | SS=D |
| Failed to ensure dressing change to one resident's skin tear was performed in a sanitary manner to promote healing and prevent infections. | SS=D |
| Failed to ensure a two-inch air gap existed between the ice machine drainage pipes and the sewer drain to prevent backflow of contaminated water and spread of food borne illness. | SS=F |
Report Facts
Census: 20
Residents selected for sample/review: 15
MDS date: Dec 10, 2021
MDS date: Dec 27, 2021
Physician Order Sheet date: Jan 24, 2022
Nurses Note date: Feb 24, 2021
Admission MDS date: Dec 28, 2021
Physician order date: Jan 7, 2022
Admission MDS date: Jan 7, 2022
Physician Order date: Mar 12, 2022
Wound size: 1.5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Stated resident #6 began hospice service on 12/23/21 and resident #22 discharge procedures. |
| Administrative Nurse D | Administrative Nurse | Confirmed hospice status of resident #6, expectations for MDS and discharge summary completion, and food safety concerns. |
| Licensed Nurse G | Licensed Nurse | Observed performing wound care on resident #11 and interviewed regarding dressing change procedures. |
| Maintenance Staff U | Interviewed regarding ice machine drainage pipe installation and potential backflow risk. |
Inspection Report
Plan of Correction
Deficiencies: 5
Mar 16, 2022
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during the inspection conducted on March 16, 2022.
Findings
The plan addresses multiple deficiencies including significant change MDS completion, care plan revisions, emergency transfer and discharge policies, wound care procedures, and maintenance of the ice machine air gap. The facility outlines corrective actions, staff training, monitoring, and reporting to the Quality Assurance and Assessment Committee with a substantial compliance date of April 1, 2022.
Deficiencies (5)
| Description |
|---|
| Failure to complete a significant change MDS for Resident R(6). |
| Issues with care plan revisions for Resident R(7). |
| Noncompliance with Emergency Transfer or Discharge Policy for Resident R(22). |
| Improper wound care for Resident R(11). |
| Ice machine drain did not have the required 2-inch air gap. |
Report Facts
Substantial compliance date: Apr 1, 2022
Inspection Report
Re-Inspection
Deficiencies: 0
Oct 14, 2020
Visit Reason
An offsite revisit was conducted on 10/14/2020 for all previous deficiencies cited on 08/20/2020.
Findings
All deficiencies have been corrected as of the compliance date of 09/10/2020, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Re-Inspection
Deficiencies: 0
Sep 18, 2020
Visit Reason
An off-site revisit was conducted on 09/18/2020 for all previous deficiencies cited on 06/30/2020.
Findings
All deficiencies have been corrected as of the compliance date of 07/31/2020 and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Plan of Correction
Deficiencies: 6
Aug 20, 2020
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report dated August 20, 2020. It outlines corrective actions to address specific concerns identified during the inspection.
Findings
The plan addresses multiple deficiencies including significant change MDS completion, care plan revisions, wound care, fall interventions, and medication storage. The facility describes corrective actions, staff training, monitoring plans, and dates of substantial compliance for each deficiency.
Severity Breakdown
D: 5
E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to complete significant change MDS timely for resident R(16). | D |
| Resident R(25) comprehensive care plan not revised timely. | D |
| Care plans for residents R(17) and R(16) not revised immediately following a fall. | D |
| Improper wound care for resident R(8), including rinsing off soap and delayed doctor notification. | D |
| Care plans for residents R(17) and R(16) not updated timely for fall risk interventions. | D |
| Undated insulin pens stored in medication room refrigerator posing risk to residents receiving injectable insulin. | E |
Report Facts
Substantial date of compliance: Sep 10, 2020
Substantial date of compliance: Aug 24, 2020
Substantial date of compliance: Aug 25, 2020
Monitoring frequency: 30
Monitoring frequency: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Adams | Administrator | Submitted the Plan of Correction |
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 6
Aug 20, 2020
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation to assess compliance with regulatory requirements and investigate complaints.
Findings
The facility was found deficient in multiple areas including failure to complete significant change Minimum Data Set assessments, failure to develop and implement comprehensive care plans especially for fall prevention, failure to review and revise care plans after falls, inadequate quality of care related to wound treatment and assessment, failure to maintain a safe environment and provide adequate supervision to prevent falls, and failure to properly label and store injectable medications.
Complaint Details
The inspection included a complaint investigation #153562 related to care plan deficiencies, fall prevention, wound care, and medication management.
Severity Breakdown
SS=D: 5
SS=E: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failed to complete a significant change Minimum Data Set for Resident 16 after changes in activities of daily living. | SS=D |
| Failed to develop and implement a comprehensive care plan for Resident 25 for fall prevention and failed to have the baseline care plan available for staff guidance. | SS=D |
| Failed to review and revise care plans with interventions following falls to prevent further falls for Residents 17, 16, and 25. | SS=D |
| Failed to provide appropriate treatment to Resident 8's wound, failed to report changes to the skin condition surrounding the wound, and failed to complete and document weekly wound assessments. | SS=D |
| Failed to ensure resident environment was free of accident hazards and failed to provide adequate supervision and assistance devices to prevent accidents for Residents 17, 16, and 25. | SS=D |
| Failed to provide appropriate labeling and storage of injectable medications for eight residents requiring insulin to ensure safe medication administration. | SS=E |
Report Facts
Residents requiring insulin: 9
Insulin syringes lacking open dates: 8
Resident census: 25
Resident sample size: 12
Resident falls: 13
Fall risk score: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse H | Licensed Nurse | Reported on care plan interventions and wound care. |
| Administrative Nurse D | Administrative Nurse | Provided multiple interviews confirming care plan and wound care deficiencies. |
| Certified Nurse Aide P | Certified Nurse Aide | Reported on resident medication changes and care. |
| Certified Nurse Aide N | Certified Nurse Aide | Reported on resident care and toileting program. |
| Consultant GG | Consultant | Confirmed need for fall interventions. |
| Consultant HH | Consultant | Reported on therapy and resident balance. |
| Licensed Nurse G | Licensed Nurse | Confirmed injectable pens lacked open dates. |
| Certified Nurse Aide LL | Certified Nurse Aide | Reported on Dycem placement for resident. |
| Certified Nurse Aide Q | Certified Nurse Aide | Reported on Dycem placement for resident. |
| Certified Medication Aide R | Certified Medication Aide | Assisted resident to bathroom during observation. |
| Certified Nurse Aide M | Certified Nurse Aide | Reported on fall risk and interventions for resident. |
Inspection Report
Abbreviated Survey
Census: 24
Deficiencies: 2
Jun 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by CMS to assess the facility's compliance with CMS and CDC recommended practices to prepare for COVID-19.
Findings
The facility failed to implement recommended infection control practices, including improper doffing of PPE by staff outside resident rooms and inadequate staff screening, allowing a staff member with a fever and shortness of breath to work.
Severity Breakdown
F 880 SS=F: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to ensure staff correctly doffed PPE in accordance with CDC guidelines, removing PPE in the hallway instead of inside the resident's room. | F 880 SS=F |
| Failure to thoroughly screen staff before reporting to work, including allowing a staff person with a temperature of 100.4F and shortness of breath to work. | F 880 SS=F |
Report Facts
Total residents: 24
Temperature: 100.4
Dates of staff screening failures: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| RN1 | Registered Nurse | Observed doffing PPE incorrectly and interviewed regarding infection control practices |
| NA1 | Nurse Aide | Observed doffing PPE incorrectly and interviewed regarding infection control practices |
| Director of Nursing | Director of Nursing | Provided statements about staff PPE expectations and staff screening procedures |
Inspection Report
Plan of Correction
Deficiencies: 2
Jun 30, 2020
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified during the Moran Manor COVID survey conducted on June 30, 2020.
Findings
The facility was found to have issues related to the location of isolation bins and doffing of PPE within resident rooms, as well as staff wellness sheet completion and competency. The Plan of Correction outlines re-education and monitoring actions to address these deficiencies.
Deficiencies (2)
| Description |
|---|
| Facility staff need re-education on location of isolation bins and doffing PPE within the elder’s room. |
| Staff need re-education on wellness sheet completion and competency. |
Report Facts
Completion date: Jul 31, 2020
Monitoring frequency: 3
Monitoring frequency: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Adams | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Janice VanGotten | Added and modified the Plan of Correction |
Inspection Report
Follow-Up
Deficiencies: 4
May 14, 2019
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously cited deficiencies identified by regulation numbers 483.10(f)(5)(i)-(iv)(6)(7), 483.10(g)(6)-(9), 483.10(j)(1)-(4), and 483.12(c)(1)(4) were corrected as of 04/18/2019.
Deficiencies (4)
| Description |
|---|
| Deficiency related to regulation 483.10(f)(5)(i)-(iv)(6)(7) |
| Deficiency related to regulation 483.10(g)(6)-(9) |
| Deficiency related to regulation 483.10(j)(1)-(4) |
| Deficiency related to regulation 483.12(c)(1)(4) |
Report Facts
Date corrections completed: Apr 18, 2019
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 4
Mar 26, 2019
Visit Reason
The inspection was a health resurvey to assess compliance with resident rights, communication access, grievance handling, and reporting of alleged violations.
Findings
The facility failed to facilitate regular Resident Council meetings, respond to grievances with rationale, provide private telephone access for residents, and promptly report alleged abuse incidents to the state agency. Multiple deficiencies related to resident rights, grievance follow-up, communication privacy, and abuse reporting were identified.
Severity Breakdown
SS=E: 3
SS=D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to facilitate Resident Council meetings regularly and respond to resident concerns with rationale. | SS=E |
| Failed to provide residents reasonable access to private telephone use. | SS=E |
| Failed to make prompt efforts to investigate, resolve, and provide decisions regarding grievances. | SS=E |
| Failed to report alleged abuse incidents to the state agency in a timely manner. | SS=D |
Report Facts
Resident census: 27
Residents sampled for review: 12
Residents without personal phone: 5
Grievances lacking response: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Nurse | Named in abuse allegation involving resident #1 |
| Staff B | Administrative Nursing Staff / Grievance Officer | Verified failure to respond to resident council concerns and grievances |
| Staff H | Social Service Staff / Grievance Official | Verified failure to respond to resident concerns and grievances |
| Staff I | Activity Staff | Documented resident council concerns and lack of investigation follow-up |
| Staff G | Direct Care Staff | Involved in abuse allegation for spanking resident #21 |
| Staff E | Licensed Staff | Investigated abuse allegations and decided not to report to state agency |
Inspection Report
Plan of Correction
Deficiencies: 4
Mar 26, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a prior inspection report dated 03/26/2019 for Moran Manor RS.
Findings
The plan addresses multiple deficiencies including lack of Resident Counsel Meetings, absence of a designated telephone area for residents, inadequate management of resident concerns, and failure to report suspicion of abuse, neglect, or exploitation. Corrective actions include staff re-education, establishment of monthly meetings, monitoring, and ongoing quality assurance processes.
Severity Breakdown
E: 3
D: 1
Deficiencies (4)
| Description | Severity |
|---|---|
| Lack of Resident Counsel Meetings or follow up from the concerns | E |
| Concern regarding an area for the Resident’s to use the telephone | E |
| Concern regarding management of concerns that Residents bring forward, especially during Resident Counsel | E |
| Concern regarding reporting the suspicion of Abuse, Neglect or Exploitation | D |
Report Facts
Dates of staff re-education: Mar 29, 2019
Dates of staff re-education: Apr 18, 2019
Monitoring frequency: 3
Monitoring duration: 30
Monitoring duration: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| DELLARIBORDY | Administrator | Submitted the Plan of Correction and responsible for staff re-education and monitoring |
| JANICE VANGOTTEN | Added Plan of Correction on 03/29/2019 | |
| LACEY HUNTER | Modified Plan of Correction on 05/24/2019 |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 28, 2018
Visit Reason
An offsite revisit survey was conducted on 06/28/2018 for all previous deficiencies cited on 06/12/2018 to verify correction of prior deficiencies.
Findings
All deficiencies cited in the previous inspection have been corrected as of the compliance date of 06/22/2018, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Report Facts
Previous deficiencies cited: 1
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 12, 2018
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found a most serious deficiency at level 'F', widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance effective 06/22/2018.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiency at level 'F', widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Lacey Hunter | Licensure Certification & Enforcement Manager | Named as contact and signatory related to findings and enforcement |
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Jun 12, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation for Moran Manor, triggered by complaints #121638 and #109142.
Findings
The facility failed to timely review and revise care plans for residents at risk of falls and incontinence, and failed to maintain an effective infection prevention and control program, specifically by improperly cleaning the room of a resident with a clostridium difficile infection.
Complaint Details
The visit was complaint-related, investigating complaints #121638 and #109142. The complaint investigation found deficiencies in care plan revisions and infection control practices.
Severity Breakdown
SS=D: 1
SS=F: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to review and revise care plans timely for residents at risk of falls and toileting issues, including lack of interventions such as gait belt use, fall mats, and bed positioning. | SS=D |
| Failure to maintain an effective infection prevention and control program by not properly cleaning and disinfecting a resident's room requiring contact isolation for clostridium difficile infection. | SS=F |
Report Facts
Residents reviewed: 15
Fall assessment scores: 14
Fall assessment scores: 19
BIMS score: 3
BIMS score: 14
BIMS score: 15
Bleach solution ratio: 1.9
Contact time: 10
Inspection Report
Plan of Correction
Deficiencies: 3
Jun 7, 2018
Visit Reason
The document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection, addressing specific care plan and housekeeping issues.
Findings
Deficiencies included inadequate fall interventions and toileting plans for residents, and insufficient cleaning protocols for rooms on isolation for C-diff. The facility implemented corrective actions including care plan updates, staff education, and enhanced cleaning oversight.
Severity Breakdown
D: 2
F: 1
Deficiencies (3)
| Description | Severity |
|---|---|
| Resident #22 care plan lacked appropriate fall interventions; updated to include gait belt, fall mat, and bed in low position. | D |
| Resident #24 care plan did not reflect ability and desire to verbalize need to toilet; updated accordingly. | D |
| Housekeeping staff did not follow policy for cleaning rooms on isolation for C-diff; re-education and observation implemented. | F |
Inspection Report
Follow-Up
Deficiencies: 1
Dec 1, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
The revisit confirmed that the previously cited deficiency with ID Prefix F0309 related to regulation 483.25 was corrected as of 12/01/2016. No other deficiencies were noted.
Deficiencies (1)
| Description |
|---|
| Deficiency with ID Prefix F0309 related to regulation 483.25 |
Inspection Report
Plan of Correction
Deficiencies: 1
Dec 1, 2016
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a complaint investigation for Moran Manor.
Findings
The facility was found deficient in providing necessary care and services to maintain residents' well-being, specifically related to bathing and skin care. The plan outlines monitoring bathing, auditing documentation, re-educating staff on skin care, and ensuring timely treatment of skin impairments.
Complaint Details
Related to complaint Moran Manor complaint 11212016; the plan addresses deficiencies found during that complaint investigation.
Deficiencies (1)
| Description |
|---|
| Failure to provide necessary care and services to maintain highest practicable well-being related to bathing and skin care. |
Report Facts
Substantial date of compliance: Dec 1, 2016
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeanette Oberzan | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact person for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Nov 21, 2016
Visit Reason
An abbreviated survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be a "D" level deficiency, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, resulting in a finding of substantial compliance effective December 1, 2016.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be a "D" level deficiency constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | D |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named as contact and signer of the report |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Nov 21, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#107864) to assess the facility's provision of necessary care and services related to skin problems for residents.
Findings
The facility failed to provide timely and necessary treatment for two residents with extensive skin excoriation areas, including large malodorous wounds and red scratched skin areas, despite care plans and assessments indicating risk. Licensed nursing staff acknowledged lack of skin treatment prior to hospital admissions.
Complaint Details
The complaint investigation (#107864) found substantiated deficiencies related to failure to provide adequate skin care treatment for two residents, resulting in hospital admissions with documented skin wounds and infections.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to ensure necessary treatment and services for residents with skin excoriation areas. | SS=D |
Report Facts
Census: 33
Sample size: 5
Braden score: 18
Weight: 342.8
Skin lesion size: 8
Skin lesion size: 3
Skin lesion size: 2
Skin lesion size: 2
Skin lesion size: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse D | Completed weekly skin assessment on 11/1/16 for resident #2 | |
| licensed nursing staff B | Reported no skin treatment in place for resident #2 prior to hospital transfer and was unaware of skin problems for resident #3 |
Inspection Report
Follow-Up
Deficiencies: 0
Oct 26, 2016
Visit Reason
This post-certification revisit was conducted to verify that previously reported deficiencies on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies related to various regulatory requirements were found to be corrected as of the revisit date.
Report Facts
Deficiencies corrected: 12
Inspection Report
Re-Inspection
Deficiencies: 1
Oct 26, 2016
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to confirm the date such corrective actions were accomplished.
Findings
The revisit inspection confirmed that the previously cited deficiency related to regulation 28-39-158(a) was corrected as of 10/26/2016. No other deficiencies or uncorrected issues were noted in this report.
Deficiencies (1)
| Description |
|---|
| Deficiency related to regulation 28-39-158(a) previously cited and corrected |
Inspection Report
Plan of Correction
Deficiencies: 12
Oct 26, 2016
Visit Reason
This document is a Plan of Correction submitted by Moran Manor in response to deficiencies identified in a prior inspection, outlining corrective actions to address various compliance issues.
Findings
The plan addresses multiple deficiencies including housekeeping and maintenance, accurate resident status documentation, care plan revisions, vital signs monitoring, personal hygiene services, incontinent care, fall interventions, blood sugar monitoring, nursing staff sufficiency, medication availability, and maintenance services. The facility commits to staff re-education, audits, and ongoing monitoring to ensure compliance.
Deficiencies (12)
| Description |
|---|
| Inadequate housekeeping and maintenance services to maintain sanitary, orderly, and comfortable resident areas. |
| Transcription error in resident #39's MDS regarding PASSR status. |
| Care plans not properly reviewed and revised, including toileting plans. |
| Failure to provide necessary care and services to maintain highest practicable well-being, including vital signs monitoring. |
| Inadequate services to maintain good personal hygiene through bathing. |
| Inadequate treatment for residents incontinent of bladder, including toileting plans and voiding diaries. |
| Failure to implement timely interventions following falls. |
| Failure to notify physician of blood sugars outside established parameters. |
| Insufficient nursing staff to provide consistent nursing and related services. |
| Medications not always available to administer as ordered by physician. |
| Failure to ensure vital signs are monitored as ordered by physician. |
| Inadequate maintenance services to maintain sanitary, orderly environment for staff. |
Report Facts
Substantial date of compliance: Oct 26, 2016
Blood sugar monitoring frequency: 3
Vital signs audit frequency: 4
Medication audit frequency: 3
Call light audits: 3
Inspection Report
Re-Inspection
Deficiencies: 1
Sep 28, 2016
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be an 'F' level deficiency, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction which was accepted, and the facility was found to be in substantial compliance based on the credible allegation of compliance.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found to be an 'F' level deficiency, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed letter regarding survey findings and plan of correction acceptance. |
Inspection Report
Plan of Correction
Census: 37
Deficiencies: 1
Sep 28, 2016
Visit Reason
The inspection was conducted as a licensure resurvey combined with a complaint investigation covering multiple complaint numbers.
Findings
The facility failed to retain the services of a full-time certified dietary manager to oversee dietary staff and maintain a clean and sanitary dietary department for food storage, preparation, and service to residents.
Complaint Details
The inspection included complaint investigations with complaint numbers 104762, 103931, 101763, 100263, 99368, 99371, 98982, and 98683.
Severity Breakdown
SS=C: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to retain the services of a full-time certified dietary manager to perform managerial duties overseeing dietary staff and maintaining a clean and sanitary dietary department. | SS=C |
Report Facts
Census: 37
Inspection Report
Life Safety
Deficiencies: 1
Aug 1, 2016
Visit Reason
A Life Safety Code survey was conducted on August 1, 2016, by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies at the facility to be at an "F" level, indicating no harm but with potential for more than minimal harm that is not immediate jeopardy. Remedies including denial of payments and possible termination of provider agreement were recommended if substantial compliance is not achieved.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Deficiencies cited at "F" level with no harm but potential for more than minimal harm that is not immediate jeopardy. | F |
Report Facts
Effective date for denial of payments: Nov 1, 2016
Provider agreement termination date: Feb 1, 2017
Plan of correction submission timeframe: 10
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and mentioned in relation to enforcement and certification |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 4
Feb 11, 2016
Visit Reason
The inspection was conducted as a complaint investigation covering multiple complaint numbers (#96544, #96560, #96654, #95537, and #95056).
Findings
The facility failed to review and revise the care plan for a resident with wandering behavior, resulting in unsafe wandering into other residents' rooms. Additionally, the facility failed to provide necessary care and services to prevent wandering behaviors, and failed to meet nutritional needs by not providing adequate portion sizes or physician-ordered therapeutic diets.
Complaint Details
The inspection was triggered by complaint investigations #96544, #96560, #96654, #95537, and #95056. The complaints involved issues with care planning and wandering behaviors leading to resident safety concerns.
Severity Breakdown
SS=D: 2
SS=E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to review and revise the plan of care for a resident with wandering behavior into other residents' rooms. | SS=D |
| Failed to provide necessary care and services to prevent wandering into other residents' rooms. | SS=D |
| Failed to provide menus meeting nutritional needs according to recommended dietary allowances. | SS=E |
| Failed to provide therapeutic diets as prescribed by physicians for multiple residents. | SS=E |
Report Facts
Census: 37
Residents reviewed: 7
Residents on mechanical soft diets: 6
Residents on ground meat diets: 2
Residents on pureed diets: 1
Residents on regular texture diets: 26
Residents with 1800 calorie ADA diet: 2
Residents with 2000 calorie ADA diet: 1
Residents with cardiac diets: 2
Residents with low concentrated sweets/consistent carbohydrate diets: 5
Elopement risk assessment score: 20.5
Deficiency count: 4
Serving size measured: 1.45
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative nursing staff B | Received family complaint about resident wandering and stated stop sign was ordered but back-ordered | |
| Direct care staff J | Witnessed resident #8 strike resident #2 and separated residents | |
| Direct care staff K | Intervened when resident #9 grabbed resident #2's wrists | |
| Direct care staff M | Reported resident did not wander into rooms often and usually redirected | |
| Direct care staff N | Reported resident wandered into other rooms and became upset when redirected | |
| Direct care staff O | Reported resident constantly redirected with books or activities | |
| Social service staff D | Reported resident liked folding clothes and staff redirected wandering | |
| Licensed nursing staff E | Reported resident wandered until midnight and used other residents' bathrooms | |
| Licensed nursing staff F | Documented behaviors and noted wandering as behavior only if entering other rooms | |
| Dietary staff G | Interviewed about diet orders and serving sizes, found inadequate diet management | |
| Dietary staff I | Observed serving meals, did not weigh portions, served less than planned meat portions | |
| Consultant H | Advised facility to follow physician ordered diets and appropriate serving sizes |
Inspection Report
Plan of Correction
Deficiencies: 4
Feb 11, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a complaint investigation related to wandering behavior, dietary management, and patient diet orders.
Findings
The facility identified deficiencies related to individualized care plans for wandering residents, dietary serving utensil recommendations, and liberalized diet orders. The Plan of Correction outlines staff reeducation, monitoring, and individualized care adjustments to address these issues.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified as Moran Manor complaint 02112016.
Severity Breakdown
D: 2
E: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to individualize monitoring and activities for wandering behavior patients | D |
| Failure to revise activity program and behavior monitoring for wandering residents | D |
| Failure to ensure and maintain adequately recommended dietary allowance and serving utensil recommendations | E |
| Failure to review patient diet orders and educate staff on liberalized diets | E |
Report Facts
Completion date: Mar 2, 2016
Reeducation dates: Feb 11, 2016
Reeducation dates: Feb 22, 2016
Reeducation dates: Feb 19, 2016
Monitoring period: 30
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeanette Oberzan | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance | |
| Irina Strakhova | Modified the Plan of Correction document |
Inspection Report
Follow-Up
Deficiencies: 0
Sep 18, 2015
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
All previously cited deficiencies listed with their regulation numbers were corrected as of the revisit date, indicating compliance with the required standards.
Report Facts
Deficiency corrections: 9
Inspection Report
Enforcement
Deficiencies: 1
Aug 25, 2015
Visit Reason
A Health survey was conducted to determine if the facility is in compliance with Federal participation requirements for nursing homes participating in the Medicare and/or Medicaid program.
Findings
The survey found the most serious deficiencies to be 'F' level, widespread, constituting no actual harm but with potential for more than minimal harm that is not immediate jeopardy. The facility submitted a plan of correction and was found to be in substantial compliance based on the credible allegation of compliance and the plan.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies were 'F' level, widespread, constituting no actual harm with potential for more than minimal harm that is not immediate jeopardy. | F |
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed the enforcement decision letter |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 10
Aug 25, 2015
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigations #89971 and #90285 to investigate complaints and assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including failure to adequately monitor residents receiving dialysis, failure to timely assess residents after condition changes, inadequate nutritional interventions, failure to monitor bowel movements and administer medications as ordered, improper medication storage and monitoring, failure to maintain sanitary food preparation and storage conditions, improper infection control practices during blood glucose testing and wound care, failure to maintain functioning call light systems, and failure to maintain a quality assessment and assurance committee with physician participation.
Complaint Details
The inspection included complaint investigations #89971 and #90285.
Severity Breakdown
SS=D: 3
SS=E: 3
SS=C: 1
SS=F: 3
Deficiencies (10)
| Description | Severity |
|---|---|
| Failure to adequately monitor vital signs, weights, and dialysis site for resident receiving dialysis. | SS=D |
| Failure to timely assess resident after being informed by hospice staff the resident was actively dying. | SS=D |
| Failure to implement interventions to prevent weight loss for a resident. | SS=E |
| Failure to monitor bowel movements and administer laxatives as ordered for multiple residents. | SS=C |
| Failure to post nurse staffing data in a prominent place accessible to residents and visitors. | SS=F |
| Failure to store, prepare, and serve food under sanitary conditions including unlabeled food, food stored on floor, and dirty kitchen equipment. | SS=D |
| Failure to adequately monitor expiration dates of medications including insulin pens and stock medication. | SS=E |
| Failure to ensure proper infection control practices during blood glucose testing and wound care. | SS=E |
| Failure to maintain functioning call light system in multiple bathrooms and resident room. | SS=F |
| Failure to maintain a quality assessment and assurance committee with physician attendance at meetings. | SS=F |
Report Facts
Residents reviewed for sample: 15
Residents with dialysis: 1
Residents with weight loss reviewed: 3
Residents with unnecessary drug monitoring: 5
Residents requiring glucometer testing: 6
Residents affected by call light system failure: 11
Weight loss in pounds: 2.6
Days without bowel movement: 7
Days without bowel movement: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff D | Named in findings related to dialysis monitoring, wound care, glucometer cleaning, and bowel movement monitoring. | |
| Administrative nursing staff B | Named in findings related to dialysis monitoring, bowel movement monitoring, glucometer cleaning, medication monitoring, staffing posting, and wound care oversight. | |
| Direct care staff J | Named in dialysis monitoring findings. | |
| Direct care staff I | Named in dialysis monitoring and bowel movement monitoring findings. | |
| Licensed nursing staff N | Named in dialysis monitoring findings. | |
| Licensed nursing staff E | Named in dialysis monitoring findings. | |
| Licensed nursing staff L | Named in medication expiration and bowel movement monitoring findings. | |
| Dietary staff F | Named in food sanitation findings. | |
| Consultant staff K | Named in nutritional monitoring findings. | |
| Maintenance staff M | Named in call light system findings. | |
| Administrative staff A | Named in QAA committee findings. |
Inspection Report
Plan of Correction
Deficiencies: 9
Aug 20, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report, outlining corrective actions and compliance dates.
Findings
The plan addresses multiple deficiencies including monitoring of patients with peritoneal dialysis, nutrition care planning, bowel management, nurse staffing information posting, food storage and labeling, medication expiration monitoring, infection control practices, resident call system maintenance, and quality assurance committee activities.
Severity Breakdown
C: 1
D: 3
E: 3
F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Inadequate monitoring of patients with peritoneal dialysis including daily blood pressure, weight, access site, and exchanges. | D |
| Failure to ensure nutrition strategies for elders are care planned and implemented to reduce risk of significant weight loss. | D |
| Inadequate bowel management policy and monitoring of residents' bowel routines. | E |
| Failure to post nurse staffing information in a clear and readable format accessible to residents and visitors. | C |
| Improper food storage practices including uncovered food, unlabeled or undated food, and food stored directly on the floor. | F |
| Failure to monitor medication expiration dates including insulin pens. | D |
| Inadequate infection control practices to prevent cross contamination during glucose testing and dressing changes. | E |
| Resident call systems not maintained as functioning call light systems with insufficient inspection frequency. | E |
| Failure to maintain a quality assessment and assurance committee with appropriate membership and meeting frequency. | F |
Report Facts
Completion date: Sep 18, 2015
Reeducation dates: Aug 27, 2015
Reeducation dates: Sep 2, 2015
Monitoring frequency: 2
Monitoring frequency: 3
QA Committee meeting frequency: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jeanette Oberzan | Administrator | Administrator named as submitter of the Plan of Correction and involved in monitoring and reeducation. |
| Shirley Boltz | Contact person for Plan of Correction assistance. |
Inspection Report
Life Safety
Deficiencies: 1
May 5, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine if the facility was in compliance with Federal requirements for nursing homes participating in Medicare and/or Medicaid programs.
Findings
The survey found the most serious deficiencies to be an "F" level deficiency, widespread, with no harm but potential for more than minimal harm, not constituting immediate jeopardy.
Severity Breakdown
F: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Most serious deficiencies found were an "F" level deficiency, widespread, with no harm but potential for more than minimal harm. | F |
Report Facts
Days to submit plan of correction: 10
Effective date for denial of payments: Aug 5, 2015
Provider agreement termination date: Nov 5, 2015
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Signed as Enforcement Coordinator for the Survey, Certification and Credentialing Commission. |
| Brenda McNorton | Director of Fire Prevention Division | Contact person for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 8
Jun 27, 2014
Visit Reason
This is a post-certification revisit conducted to verify that previously cited deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies identified by regulation or LSC provision numbers were corrected as of the revisit date, June 27, 2014.
Deficiencies (8)
| Description |
|---|
| Deficiency related to regulation 483.15(h)(2) |
| Deficiency related to regulation 483.25(a)(3) |
| Deficiency related to regulation 483.25(h) |
| Deficiency related to regulation 483.25(l) |
| Deficiency related to regulation 483.25(m)(2) |
| Deficiency related to regulation 483.35(i) |
| Deficiency related to regulation 483.65 |
| Deficiency related to regulation 483.70(h) |
Report Facts
Deficiencies corrected: 8
Inspection Report
Re-Inspection
Deficiencies: 1
Jun 27, 2014
Visit Reason
This report documents a revisit inspection to verify that previously reported deficiencies have been corrected and to record the dates when corrective actions were accomplished.
Findings
The revisit report confirms that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 06/27/2014.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited |
Inspection Report
Plan of Correction
Deficiencies: 9
Jun 12, 2014
Visit Reason
This document is a Plan of Correction submitted by Moran Manor in response to deficiencies cited during a regulatory inspection, outlining corrective actions to address specific findings.
Findings
The plan details multiple corrective actions including maintenance repairs, staff re-education on resident care and medication administration, infection control, dietary sanitation, and compliance monitoring, with specified completion dates and oversight responsibilities.
Severity Breakdown
D: 4
E: 3
F: 2
Deficiencies (9)
| Description | Severity |
|---|---|
| Slow draining resident bathroom sink on east hallway and bulging baseboards | E |
| Ensuring proper fitting clothing and personal hygiene for dependent residents | D |
| Policy and procedure on accidents and incidents, care plan communication | D |
| Bowel management program and documentation | D |
| Proper procedure to pass medication and medication error correction | D |
| Cleaning and sanitation of food containers, storage bins, kitchen equipment | F |
| Proper cleaning of glucometer and infection tracking logs | E |
| Removal of outside biohazard storage shed and purchase of new storage building | E |
| Employment of qualified Dietary Manager and ongoing sanitation oversight | F |
Report Facts
Completion date: Jun 23, 2014
Completion date: Jun 27, 2014
Completion date: Mar 30, 2015
Medication error correction date: May 21, 2014
In-service training date: Jun 13, 2014
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Christine Kuhn | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Re-Inspection
Census: 30
Deficiencies: 8
May 28, 2014
Visit Reason
The inspection was a Health Resurvey to evaluate compliance with previously cited deficiencies and overall facility conditions.
Findings
The facility failed to maintain a sanitary environment, provide adequate assistance with activities of daily living, prevent repeated falls, monitor medications properly, maintain sanitary food storage and preparation areas, and ensure infection control practices including proper sanitization of glucometers and infection tracking.
Severity Breakdown
SS=E: 4
SS=D: 4
SS=F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failed to provide housekeeping and maintenance services to maintain a safe and sanitary environment in resident hallways and bathrooms. | SS=E |
| Failed to provide necessary assistance for activities of daily living including grooming and dressing for a cognitively impaired resident. | SS=D |
| Failed to ensure adequate supervision and assistive devices to prevent repeated falls for a resident with a history of multiple falls. | SS=D |
| Failed to monitor medications for constipation and provide PRN medication as ordered for a resident. | SS=D |
| Failed to monitor and administer Lamotrigine medication as ordered, resulting in a significant medication error. | SS=D |
| Failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen and dry storage areas. | SS=F |
| Failed to adequately sanitize the common use glucometer and maintain thorough infection control tracking and trending. | SS=E |
| Failed to provide a safe and sanitary environment in the biohazard storage shed and kitchen areas. | SS=E |
Report Facts
Census: 30
Medication error doses: 24
Fall risk score: 17
Fall risk score: 14
Lamotrigine blood level: 1.5
Bowel movement gap: 5
Bowel movement gap: 4
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Maintenance Staff | Interviewed regarding environmental and maintenance deficiencies |
| Staff P | Dietary Staff | Interviewed regarding kitchen sanitation and cleaning schedules |
| Staff J | Licensed Nursing Staff | Provided information on resident care, medication administration, and glucometer use |
| Staff B | Administrative Nursing Staff | Interviewed regarding medication errors, infection control, and fall interventions |
| Staff F | Direct Care Staff | Observed assisting resident with ADLs and interviewed about resident care |
| Staff E | Direct Care Staff | Interviewed about resident care and toileting |
| Staff D | Direct Care Staff | Interviewed about resident toileting and documentation |
| Staff H | Direct Care Staff | Observed administering medication |
Inspection Report
Follow-Up
Deficiencies: 4
Oct 30, 2013
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all deficiencies previously cited under regulations 483.25, 483.25(d), 483.25(i), and 483.30(a) were corrected by 09/18/2013.
Deficiencies (4)
| Description |
|---|
| Deficiency under regulation 483.25 |
| Deficiency under regulation 483.25(d) |
| Deficiency under regulation 483.25(i) |
| Deficiency under regulation 483.30(a) |
Report Facts
Deficiencies corrected: 4
Date of revisit: Oct 30, 2013
Date of follow-up survey: Aug 19, 2013
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 4
Aug 19, 2013
Visit Reason
The inspection was conducted as a complaint investigation (#67332) regarding concerns about resident care and services.
Findings
The facility failed to adequately assess and timely notify the physician regarding a resident's change in condition related to gastrointestinal bleeding requiring blood transfusion. Additionally, the facility failed to provide adequate toileting plans for multiple residents, failed to implement nutrition strategies to prevent further weight loss for one resident, and failed to provide sufficient nursing staff to meet resident care needs.
Complaint Details
The inspection was triggered by complaint investigation #67332 concerning inadequate care and services.
Severity Breakdown
SS=E: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failed to adequately assess a change in condition and seek timely treatment for a resident with signs of gastrointestinal bleeding requiring blood transfusion. | SS=E |
| Failed to provide adequate toileting plans for 4 residents reviewed for toileting. | SS=E |
| Failed to provide nutrition strategies as care planned for 1 resident to prevent further weight loss. | SS=E |
| Failed to provide sufficient nursing staff to ensure resident well-being and provision of care. | SS=E |
Report Facts
Resident census: 34
Residents reviewed: 6
Weight loss percentage: 6.19
Resident weight: 106
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Physician L | Physician | Named in relation to delayed response to lab results and resident care. |
| Staff E | Direct Care Staff | Mentioned in relation to resident care and toileting deficiencies. |
| Staff I | Direct Care Staff | Mentioned in relation to resident care and toileting deficiencies. |
| Staff B | Licensed Nursing Staff | Mentioned in relation to resident care and toileting deficiencies. |
| Staff J | Direct Care Staff | Mentioned in relation to resident care and toileting deficiencies. |
| Staff G | Direct Care Staff | Mentioned in relation to resident care and toileting deficiencies. |
| Staff H | Direct Care Staff | Mentioned in relation to staffing and resident care. |
| Staff O | Direct Care Staff | Mentioned in relation to resident care and toileting deficiencies. |
| Staff A | Administrative Nursing Staff | Mentioned in relation to resident care and communication failures. |
| Staff C | Administrative Nursing Staff | Mentioned in relation to resident care and communication failures. |
| Staff M | Direct Care Staff | Mentioned in relation to staffing and resident care. |
| Staff Q | Administrative Staff | Mentioned assisting resident with meals. |
| Staff K | Dietary Manager | Mentioned in relation to nutrition care and restorative services. |
| Staff P | Activity Staff | Mentioned in relation to passing snacks and drinks. |
| Care Practitioner S | Care Practitioner | Mentioned in relation to resident weight loss and contributing factors. |
Inspection Report
Plan of Correction
Deficiencies: 4
Aug 13, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to a complaint investigation related to deficiencies found during an inspection.
Findings
The facility identified deficiencies related to resident care including assessment and notification of changes in condition, individualized toileting plans, nutrition strategies, and sufficient nursing staff to meet resident needs. The Plan of Correction outlines specific corrective actions, staff education, monitoring, and oversight to address these issues.
Complaint Details
This Plan of Correction is in response to a complaint investigation identified by Event ID 6OFT11 and Complaint ID Moran Manor 081913.
Deficiencies (4)
| Description |
|---|
| Failure to provide necessary care and services to maintain highest practicable well-being, including timely notification to physician regarding changes in resident condition and adverse side effects. |
| Failure to develop and implement individualized toileting plans to maintain bladder function and reduce urinary tract infections. |
| Failure to ensure nutrition strategies are care planned and implemented to reduce risk of significant weight loss or gain. |
| Failure to provide sufficient nursing staff to meet resident needs, including timely response to call lights and respecting resident preferences. |
Report Facts
Dates for corrective actions: Sep 18, 2013
Dates of staff education: Aug 29, 2013
Audit frequency: 5
Audit frequency: 2
Audit frequency: 3
Audit frequency: 7
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Vogel | Administrator | Submitted the Plan of Correction and involved in oversight and education. |
| Shirley Boltz | Contact person for Plan of Correction assistance. | |
| Mary Jane Kennedy | Modified the Plan of Correction document. | |
| Irina Strakhova | Added the Plan of Correction document. |
Inspection Report
Follow-Up
Deficiencies: 1
May 10, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.20(l)(3) with ID prefix F0284 was corrected as of 05/10/2013. No other deficiencies or issues are noted.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 483.20(l)(3) previously cited and corrected. |
Report Facts
Deficiency correction date: May 10, 2013
Inspection Report
Plan of Correction
Deficiencies: 1
May 10, 2013
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Moran Manor.
Findings
The plan addresses discharge planning deficiencies, requiring a pre-discharge care plan involving an interdisciplinary team and confirmation of discharge services with the resident and family.
Complaint Details
This plan of correction is related to a complaint investigation at Moran Manor, as indicated by the reference to Complaint Revised and the complaint event ID.
Severity Breakdown
D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to conduct discharge planning upon admission and prior to discharge including an interdisciplinary team and confirmation of post-discharge services. | D |
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
May 2, 2013
Visit Reason
The inspection was conducted as a complaint investigation related to complaint #65030 concerning the facility's discharge planning and post-discharge care.
Findings
The facility failed to develop a post-discharge plan of care for a resident discharged home, resulting in lack of coordination of necessary services and equipment such as home health care, oxygen therapy, and mobility devices to ensure continuity of care after discharge.
Complaint Details
The complaint investigation was triggered by complaint #65030. The facility was found to have discharged a resident without ensuring post-discharge services and equipment were in place, substantiating the complaint.
Severity Breakdown
SS=D: 1
Deficiencies (1)
| Description | Severity |
|---|---|
| Failure to develop a post-discharge plan of care to ensure services to meet the resident's care needs after discharge. | SS=D |
Report Facts
Census: 34
Residents selected for discharge: 3
Brief mental interview score: 8
Oxygen treatment: 2
Breathing treatment dosage: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff A | Reported resident's desire to go home and was involved in discharge planning calls. | |
| Licensed nursing staff E | Commented on discharge planning timing and resident awareness. | |
| Licensed nursing staff F | Commented on discharge frequency and discharge planning process. |
Inspection Report
Re-Inspection
Deficiencies: 1
Apr 20, 2013
Visit Reason
This revisit inspection was conducted to verify that previously reported deficiencies had been corrected and to document the dates such corrective actions were accomplished.
Findings
The report confirms that the previously cited deficiency under regulation 28-39-158(a) with ID prefix S0600 was corrected as of 04/20/2013.
Deficiencies (1)
| Description |
|---|
| Deficiency under regulation 28-39-158(a) previously cited and now corrected |
Inspection Report
Follow-Up
Deficiencies: 3
Apr 20, 2013
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit confirmed that corrections were completed for deficiencies related to regulations 483.10(c)(7), 483.25(c), and 483.35(i) as of 04/20/2013.
Deficiencies (3)
| Description |
|---|
| Deficiency related to regulation 483.10(c)(7) |
| Deficiency related to regulation 483.25(c) |
| Deficiency related to regulation 483.35(i) |
Report Facts
Deficiencies corrected: 3
Inspection Report
Plan of Correction
Deficiencies: 4
Apr 1, 2013
Visit Reason
This document is a Plan of Correction submitted by Moran Manor in response to deficiencies cited in a prior inspection report (Event ID UO6Q11). It outlines corrective actions the facility will take to address identified issues.
Findings
The plan addresses deficiencies including ensuring proper surety bond coverage for residents' personal funds, staff education on skin care policies, and hiring and training a qualified Dietary Manager to ensure sanitary food preparation and service.
Severity Breakdown
B: 1
D: 1
F: 2
Deficiencies (4)
| Description | Severity |
|---|---|
| Surety Bond needed for the Security of Personal Funds to cover the total balance of residents' personal fund account. | B |
| Staff education on the facility's skin care policy including repositioning, off-loading, dressing changes, monitoring, and nutrition and hydration. | D |
| Employment of a qualified Dietary Manager within 12 months and staff education on proper storage, preparation, and service of food to prevent food borne illness. | F |
| Employment of a qualified Dietary Manager within 12 months and staff education on proper storage, preparation, and service of food to prevent food borne illness (duplicate of above). | F |
Report Facts
Plan of Correction completion date: Apr 20, 2013
Plan of Correction submission date: Apr 1, 2013
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Greta Wakefield | Administrator | Submitted the Plan of Correction to KDADS |
Inspection Report
Census: 35
Deficiencies: 4
Mar 25, 2013
Visit Reason
The inspection was conducted to evaluate compliance with dietary services regulations, including staffing qualifications and food safety practices.
Findings
The facility failed to employ a full-time certified dietary manager to oversee dietary services, served non-pasteurized soft fried eggs to residents, and allowed food service staff in the memory care unit to serve food without hairnets, risking food contamination.
Severity Breakdown
SS=F: 4
Deficiencies (4)
| Description | Severity |
|---|---|
| Failure to employ a full-time qualified dietary manager to oversee dietary services. | SS=F |
| Serving soft runny eggs with noncongealed yolks using non-pasteurized eggs. | SS=F |
| Food service staff in the memory care unit served food without hairnets, risking contamination. | SS=F |
| Improper storage of kitchen pans with water droplets between stacked pans. | SS=F |
Report Facts
Census: 35
Residents served soft runny eggs: 8
Residents served from buffet style crock pots: 10
Inspection Report
Follow-Up
Deficiencies: 2
Dec 15, 2012
Visit Reason
This post-certification revisit was conducted to verify that previously identified deficiencies reported on the CMS-2567 Statement of Deficiencies and Plan of Correction have been corrected.
Findings
The revisit report confirms that the deficiencies identified under regulations 483.13(b), 483.13(c)(1)(i), and 483.13(c)(1)(ii)-(iii), (c)(2)-(4) were corrected as of 12/15/2012.
Deficiencies (2)
| Description |
|---|
| Deficiency related to regulation 483.13(b), 483.13(c)(1)(i) |
| Deficiency related to regulation 483.13(c)(1)(ii)-(iii), (c)(2)-(4) |
Inspection Report
Plan of Correction
Deficiencies: 2
Dec 15, 2012
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a complaint investigation.
Findings
The facility was found to have deficiencies related to abuse/involuntary seclusion and failure to properly investigate and report allegations involving inappropriate touching with a sexual nature by another resident.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Moran Manor 111612 Complaint.
Deficiencies (2)
| Description |
|---|
| Facility shall remain free from abuse/involuntary seclusion. |
| Facility shall investigate and report allegations/individuals. |
Report Facts
Plan of Correction completion date: Dec 15, 2012
Staff in-service dates: 112612
Staff in-service dates: 113012
Notification timeframe: 5
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Nov 16, 2012
Visit Reason
The inspection was conducted as a complaint investigation regarding allegations of sexual abuse by one resident toward other cognitively impaired residents.
Findings
The facility failed to protect two cognitively impaired residents from sexual abuse by another resident and failed to thoroughly investigate and report these allegations to the state agency. Multiple staff and residents reported inappropriate touching incidents by resident #1 toward residents #2 and #3, which were not properly documented or reported.
Complaint Details
The complaint investigation #61653 was triggered by allegations that resident #1 sexually abused residents #2 and #3. The facility failed to document incidents in residents' charts and did not notify the state agency as required.
Severity Breakdown
SS=D: 2
Deficiencies (2)
| Description | Severity |
|---|---|
| Facility failed to protect residents from sexual abuse by another resident. | SS=D |
| Facility failed to investigate and report allegations of sexual abuse to the state agency. | SS=D |
Report Facts
Census: 31
Residents selected for review: 6
BIMS score: 3
Dates of incidents: Oct 6, 2012
Dates of incidents: Nov 8, 2012
Date of survey completion: Nov 16, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Administrative staff E | Reported observations of inappropriate touching and notified police and DPOA | |
| Administrative nursing staff A | Reported witnessing inappropriate touching and reviewed resident #2's MDS | |
| Direct care staff B | Witnessed resident #1 touching other residents inappropriately | |
| Direct care staff C | Reported moving resident #1 away from other residents after inappropriate touching | |
| Administrative nursing staff D | Reported being informed of inappropriate touching and physician's medication order |
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