Deficiencies (last 11 years)
Deficiencies (over 11 years)
15.1 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
152% worse than Kansas average
Kansas average: 6 deficiencies/yearDeficiencies per year
28
21
14
7
0
Occupancy
Latest occupancy rate
80% occupied
Based on a June 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jul 2, 2025
Visit Reason
An off-site revisit survey was conducted to verify correction of all previous deficiencies cited on 2025-06-04.
Findings
All deficiencies have been corrected as of the compliance date of 2025-06-11, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 8
Date: 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. It outlines corrective actions to address specific concerns identified by surveyors.
Findings
The plan addresses multiple deficiencies related to resident care, staff training, documentation, infection control, and facility maintenance. The facility implemented reeducation, audits, and monitoring to ensure compliance and resident safety.
Deficiencies (8)
F550-D: No immediate correction available for R28. Residents dependent on staff for ADL care are at risk. Staff were reeducated on promoting and maintaining resident dignity.
F637-D: No immediate correction available for R31. Residents newly started on dialysis may be affected. MDS Coordinator was reeducated on Significant Change in Status MDS requirements.
F641-D: Modification completed for MDS ARD 10/28/24. Residents on antipsychotic medications may be affected. MDS Coordinator received reeducation on coding section N.
F684-D: Resident #23 assessed by therapy; footrest extender added to wheelchair. Staff reeducated on safe transport of residents in wheelchairs.
F698-D: Dialysis dressing site for Resident #31 assessed and cared for. Staff reeducated on dialysis dressing care and monitoring.
F732-C: Incomplete staffing information on daily staff posting corrected. Staff reeducated on posting direct care daily staffing numbers.
F812-F: Open, uncovered, or undated food items discarded or repackaged. Staff reeducated on food procurement and storage policy.
F925-F: Flies in kitchen addressed by maintenance repairs. Staff reeducated on pest control policy.
Report Facts
Substantial date of compliance: Jun 11, 2025
Frequency of monitoring: 3
Duration of monitoring: 4
Duration of monitoring: 30
Inspection Report
Annual Inspection
Census: 36
Deficiencies: 8
Date: Jun 4, 2025
Visit Reason
The inspection was a Health Recertification Survey conducted to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including resident dignity, comprehensive assessments after significant changes, accuracy of assessments, quality of care, dialysis care, nurse staffing information posting, food safety and sanitation, and pest control. These deficiencies placed residents at risk for harm, discomfort, or adverse health outcomes.
Deficiencies (8)
F550 Resident Rights: The facility failed to ensure dignified care for a resident when staff failed to cover the resident during care, exposing him to others and risking embarrassment.
F637 Comprehensive Assessment: The facility failed to complete a Significant Change Minimum Data Set assessment for a resident who started dialysis, risking unidentified care needs.
F641 Accuracy of Assessments: The facility failed to accurately complete the Minimum Data Set for a resident, incorrectly documenting psychotropic medication use, risking unidentified care needs.
F684 Quality of Care: The facility failed to ensure appropriate wheelchair positioning for a resident, risking accidents and decreased comfort.
F698 Dialysis: The facility failed to provide necessary dialysis assessment, care, and services for a resident, including incomplete post-dialysis evaluations and failure to notify providers of a soiled catheter dressing.
F732 Posted Nurse Staffing Information: The facility failed to post accurate and complete nurse staffing data, omitting actual hours worked on daily staffing sheets.
F812 Food Safety: The facility failed to maintain sanitary food storage conditions, including undated and uncovered food items and damaged equipment, risking food-borne illness.
F925 Pest Control: The facility failed to maintain an effective pest control program, with an abundance of flies in the kitchen and structural issues allowing pest entry, risking contaminated food and resident discomfort.
Report Facts
Resident census: 36
Residents sampled: 14
Dates dialysis assessments not completed: 7
Dates dialysis communication forms missing: 3
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 2
Date: 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 resident safety during transportation.
Complaint Details
The complaint investigation found immediate jeopardy due to unsafe transportation practices leading to resident injury. The facility implemented corrective actions including staff education, reeducation of drivers, and termination of the responsible transportation staff.
Findings
The facility failed to ensure a resident was safely secured in the transportation vehicle, resulting in the resident sliding out of her wheelchair and sustaining an injury. Staff failed to communicate the injury properly and did not activate emergency services. Corrective actions were implemented prior to the survey.
Deficiencies (2)
The facility failed to ensure Resident 1 was safely secured in the transportation vehicle, causing her to slide out and injure her left ankle. Staff lacked training and competency in securing residents and wheelchairs, and the vehicle was operated unsafely, causing fear for safety.
Transportation Staff and CNA failed to communicate the resident's injury to the facility and did not activate 911 for emergency assessment, continuing to the appointment and then returning to the facility.
Report Facts
Resident census: 34
Miles driven after incident: 50
Date of incident: Jan 21, 2025
Date of survey: Mar 20, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Transportation Staff E | Transportation Staff | Named in findings for unsafe vehicle operation and failure to secure resident |
| Certified Nurse Aide D | CNA | Named in findings for lack of training and failure to secure resident |
| Administrative Nurse B | Administrative Nurse | Reviewed progress notes and facility investigation |
| Administrative Staff A | Administrative Staff | Responsible for ensuring residents were secured and reported corrective actions |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 18, 2023
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2023-08-31.
Findings
All deficiencies have been corrected as of the compliance date of 2023-09-21, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 11
Date: Aug 31, 2023
Visit Reason
This document is a Plan of Correction submitted by Moran Manor in response to deficiencies identified during the inspection visit on 8/31/2023.
Findings
The plan addresses multiple deficiencies related to resident care plans, ADL assistance, pain management, infection control, laboratory monitoring, and facility sanitation. Immediate corrections were made where possible, and staff reeducation and ongoing monitoring processes were implemented.
Deficiencies (11)
F550-D: No immediate correction available for residents R25, R10, or R12 regarding ADL care dependency. Staff will be reeducated and monitoring rounds conducted.
F641-D: Discrepancy found in resident R25's Annual MDS coding at N0450A; corrections made and education provided to MDS Coordinator.
F656-D: Resident R32's care plan lacked non-medicinal pain interventions; care plans updated and staff educated.
F657-E: Resident care plans updated for R15, R25, R18, and R23 to include immobilizer use, grooming preferences, toileting, and leg rests.
F677-E: Residents R25, R15, R2, R11, and R26 received shaving and nail care after surveyor notification; staff reeducation and monitoring planned.
F689-D: Foot pedals placed on resident R23's wheelchair; staff reeducated and monitoring rounds scheduled.
F690-D: Incontinence assessment and care plan updated for resident R18; staff reeducation and monitoring planned for toileting plans.
F755-D: Laboratory orders clarified with PCP for resident; staff reeducation and monitoring of lab orders planned.
F812-F: All kitchen sanitation concerns addressed; dietary staff reeducated and sanitation inspections scheduled.
F880-F: Infection control concerns including PPE use and catheter care addressed with immediate reeducation and ongoing monitoring.
F921-F: All concerns addressed during walk-through; dietary staff reeducated and sanitation inspections planned.
Report Facts
Walking rounds frequency: 5
Walking rounds frequency: 3
Walking rounds frequency: 3
Reeducation date: Sep 20, 2023
Inspection Report
Re-Inspection
Census: 32
Deficiencies: 11
Date: Aug 31, 2023
Visit Reason
Health resurvey inspection to evaluate 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, inaccurate assessments, incomplete care plans, inadequate ADL care, unsafe environment hazards, improper infection control practices, and unsanitary food handling.
Deficiencies (11)
F 550 Resident Rights: The facility failed to provide dignity to residents by not closing blinds during peri-care, exposing residents during catheter care, and not assisting with clothing adjustment in common areas.
F 641 Accuracy of Assessments: The facility failed to complete an accurate Minimum Data Set (MDS) for one resident regarding antipsychotic medication use.
F 656 Develop/Implement Comprehensive Care Plan: The facility failed to develop and implement comprehensive care plans for residents regarding pain management and other care needs.
F 657 Care Plan Timing and Revision: The facility failed to review and revise care plans timely for multiple residents to reflect current care needs such as use of immobilizers, toileting programs, and grooming.
F 677 ADL Care Provided: The facility failed to provide adequate grooming and hygiene care including shaving and nail care for multiple dependent residents.
F 689 Free of Accident Hazards: The facility failed to ensure a safe environment for a resident by not providing foot pedals on her wheelchair, causing feet to skim the floor during transport.
F 690 Bowel/Bladder Incontinence: The facility failed to develop and implement an effective individualized toileting program to maintain bladder function for one resident.
F 755 Pharmacy Services: The facility failed to obtain ordered laboratory blood monitoring (A1C, CBC, CMP) for a diabetic resident as per physician orders.
F 812 Food Procurement, Storage, Preparation, and Service: The facility failed to maintain sanitary food handling and storage practices including dirty kitchen equipment, food debris, and improper thawing of food.
F 880 Infection Prevention and Control: The facility failed to ensure proper infection control including staff not donning PPE for COVID isolation, unsanitary catheter care, and improper handling of nasal inhalers.
F 921 Safe/Functional/Sanitary/Comfortable Environment: The facility failed to maintain a clean and sanitary kitchen environment with sticky floors and heavy dirt and grime buildup.
Report Facts
Resident census: 32
Residents sampled: 16
Insulin units: 4
Insulin units: 6
Insulin units: 10
Insulin units: 12
Insulin units: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in catheter care and dignity findings |
| Administrative Nurse E | Administrative Nurse | Named in dignity, catheter care, infection control, and care plan findings |
| Certified Nurse Aide P | Certified Nurse Aide | Named in dignity and ADL care findings |
| Certified Nurse Aide N | Certified Nurse Aide | Named in dignity and toileting findings |
| Consultant Staff GG | Named in MDS and care plan accuracy findings | |
| Dietary Staff BB | Dietary Staff | Named in infection control PPE finding |
| Administrative Staff A | Administrative Staff | Named in kitchen sanitation findings |
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Jun 20, 2023
Visit Reason
The inspection was conducted as a complaint investigation (#180909) triggered by a medication error incident involving Resident 1 receiving medications not prescribed to them.
Complaint Details
The complaint investigation #180909 was substantiated. The medication error occurred on 06/17/23 when Licensed Nurse G left medications unattended and Resident 1 took medications prescribed to Resident 2. The facility notified the physician and resident's representative, monitored the resident, and implemented corrective actions including staff re-education.
Findings
The facility failed to administer medication per physician's order to Resident 1, resulting in a medication error where Licensed Nurse G administered medications intended for another resident. The resident experienced no adverse effects, and corrective actions including staff re-education were implemented prior to the surveyor's arrival.
Deficiencies (1)
F755 Pharmacy Services: The facility failed to administer medication per physician's order to Resident 1, resulting in a medication error when Licensed Nurse G administered medications prescribed to another resident.
Report Facts
Census: 33
Date of medication error: Jun 17, 2023
Date of survey: Jun 20, 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 medication error notification | |
| Administrative Staff B | Notified about medication error |
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 20, 2023
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during a prior inspection of Moran Manor on June 20, 2023.
Findings
The Plan of Correction addresses past noncompliance issues identified under tags F0000 and F755-D during the inspection.
Deficiencies (2)
Tag F0000 was cited as past noncompliance on 06/20/2023.
Tag F755-D was cited as past noncompliance on 06/20/2023.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Apr 29, 2022
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2022-03-16.
Findings
All deficiencies have been corrected as of the compliance date of 2022-04-01, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 5
Date: 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 related to significant change MDS completion, care plan revisions, discharge policies, wound care, and facility maintenance issues such as the ice machine air gap. The facility outlines corrective actions, staff training, and monitoring plans with a substantial compliance date of April 1, 2022.
Deficiencies (5)
F637-D: The MDS Coordinator will complete a significant change MDS for Resident R(6) by April 1, 2022. The DON/designee will monitor weekly for 30 days to ensure compliance.
F656-D: No immediate correction was possible as Resident R(7) was discharged at the time of survey. The DON/designee will re-educate staff on care plan policies and monitor revisions weekly for 30 days.
F661-D: No immediate correction was possible as Resident R(22) was discharged at the time of survey. Training on emergency transfer and discharge policies will be provided by April 1, 2022.
F684-D: The charge nurse re-dressed Resident R(11)'s wound after providing a clean surface for supplies. Training on non-sterile dressing changes will be provided and monitored weekly.
F812-F: The maintenance director raised the ice machine to provide the required 2-inch air gap. Staff training and signage were added to ensure compliance.
Inspection Report
Complaint Investigation
Census: 20
Deficiencies: 5
Date: Mar 16, 2022
Visit Reason
Health Resurvey and Complaint Investigation #169251 conducted to assess compliance with regulatory requirements and investigate complaints.
Complaint Details
The inspection was triggered by a complaint investigation #169251.
Findings
The facility failed to complete a significant change Minimum Data Set (MDS) for a resident admitted to hospice, did not develop a comprehensive care plan for another resident, failed to complete a discharge summary for a discharged resident, failed to ensure sanitary dressing changes for a resident's skin tear, and failed to maintain proper food safety standards related to ice machine drainage.
Deficiencies (5)
F637: The facility failed to complete a significant change Minimum Data Set for one resident admitted to hospice care services.
F656: The facility failed to develop and implement a comprehensive care plan for one resident to meet medical, nursing, and psychosocial needs.
F661: The facility failed to complete a discharge summary for one resident following discharge from the facility.
F684: The facility failed to ensure a sanitary dressing change for one resident's skin tear, risking infection.
F812: The facility failed to ensure a two-inch air gap between ice machine drainage pipes and sewer drain to prevent backflow of contaminated water.
Report Facts
Resident census: 20
Residents selected for review: 15
Size of skin tear wound: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Nurse G | Licensed Nurse | Named in dressing change deficiency for skin tear care. |
| Licensed Nurse H | Licensed Nurse | Provided information about hospice care and discharge summary requirements. |
| Administrative Nurse D | Administrative Nurse | Provided statements regarding MDS completion, discharge summary, and dressing change expectations. |
| Maintenance Staff U | Provided information about ice machine drainage installation and potential backflow risk. |
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Oct 14, 2020
Visit Reason
An offsite revisit was conducted to verify correction of 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
Date: Sep 18, 2020
Visit Reason
An off-site revisit was conducted to verify correction of 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.
Inspection Report
Complaint Investigation
Census: 25
Deficiencies: 6
Date: Aug 20, 2020
Visit Reason
Health Resurvey and Complaint Investigation #153562 conducted to assess compliance with regulatory requirements.
Complaint Details
Complaint investigation #153562 triggered this resurvey.
Findings
The facility failed to complete significant change Minimum Data Set assessments, develop and implement comprehensive care plans including fall prevention, review and revise care plans after falls, provide appropriate wound care and assessments, thoroughly investigate falls and implement immediate interventions, and properly label and store injectable medications.
Deficiencies (6)
CFR 483.20(b)(2)(ii): Facility failed to complete a significant change Minimum Data Set for Resident R16 after changes in activities of daily living.
CFR 483.21(b)(1): Facility failed to develop and implement a comprehensive care plan for Resident R25 for fall prevention and failed to have baseline care plan available for staff guidance.
CFR 483.21(b)(2)(i)-(iii): Facility failed to review and revise care plans with interventions following falls for Residents R17, R16, and R25 to prevent further falls.
CFR 483.25: Facility failed to provide appropriate wound treatment, failed to report changes in skin condition, and failed to complete and document weekly wound assessments for Resident R8.
CFR 483.25(d)(1)(2): Facility failed to thoroughly investigate causes of falls and initiate appropriate immediate interventions for Residents R17, R16, and R25, and failed to follow fall interventions for Resident R25.
CFR 483.45(g)(h)(1)(2): Facility failed to provide appropriate labeling and storage of injectable medications for eight residents requiring insulin to ensure safe medication administration.
Report Facts
Resident census: 25
Residents requiring insulin: 9
Insulin syringes lacking open dates: 8
Resident falls: 13
Fall risk score: 15
Inspection Report
Abbreviated Survey
Census: 24
Deficiencies: 1
Date: Jun 30, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation and infection control.
Findings
The facility failed to ensure staff correctly doffed PPE according to CDC guidelines and did not thoroughly screen staff before reporting to work, allowing a staff member with a fever and shortness of breath to work. Multiple staff failed to complete required screening questions.
Deficiencies (1)
F880 Infection Prevention & Control: The facility failed to implement CDC recommended infection control practices, including improper removal of PPE outside resident rooms and inadequate staff screening for COVID-19 symptoms.
Report Facts
Total residents: 24
Temperature recorded: 100.4
Screening failures: 6
Inspection Report
Plan of Correction
Deficiencies: 2
Date: 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 deficient in proper placement of isolation bins and doffing of PPE within resident rooms, as well as incomplete wellness sheet completion and competency among staff.
Deficiencies (2)
F880-F: Facility staff were not properly educated on the location of isolation bins and doffing PPE within resident rooms. The facility will re-educate staff and monitor compliance three times a week for 30 days.
The facility shall re-educate staff on wellness sheet completion and competency. The Administrator or DON will monitor wellness checks five times per week and report findings to the Quality Assurance and Assessment Committee.
Inspection Report
Follow-Up
Deficiencies: 0
Date: May 14, 2019
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously identified deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
All previously reported deficiencies related to regulations 483.10(f), 483.10(g), 483.10(j), and 483.12(c) were corrected as of 04/18/2019. The revisit confirmed completion of corrective actions.
Inspection Report
Re-Inspection
Census: 27
Deficiencies: 4
Date: Mar 26, 2019
Visit Reason
The inspection was a health resurvey to assess compliance with regulatory requirements and to follow up on previous deficiencies.
Findings
The facility failed to facilitate regular Resident Council meetings and did not respond appropriately to resident grievances. Residents lacked private telephone access, and the facility failed to investigate and respond to grievances timely. Additionally, the facility failed to report two alleged incidents of staff-to-resident abuse to the state agency in a timely manner.
Deficiencies (4)
Resident Council meetings were not held regularly as requested, and the facility failed to respond to resident concerns or provide rationale for decisions.
The facility failed to provide residents reasonable access to telephones with privacy, affecting 5 residents without personal phones.
The facility failed to make prompt efforts to investigate, resolve, and provide decisions regarding grievances for 4 residents.
The facility failed to report two alleged incidents of staff-to-resident abuse to the state agency within required timeframes.
Report Facts
Resident census: 27
Residents sampled for review: 12
Residents without personal phone: 5
Residents with unresolved grievances: 4
Alleged abuse incidents not reported timely: 2
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Mar 26, 2019
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited during the inspection of Moran Manor on 03/26/2019.
Findings
The plan addresses multiple deficiencies related to Resident Counsel Meetings, availability of a telephone area for residents, management of resident concerns, and reporting suspicion of abuse, neglect, or exploitation. Corrective actions include staff re-education, establishment of meeting schedules, monitoring, and ongoing review by administration.
Deficiencies (4)
F565-E: There was no immediate correction available for the lack of Resident Counsel Meetings or follow-up from concerns. The Activity Director was re-educated to hold monthly meetings and communicate concerns to the Grievance Officer.
F576-E: There was no immediate correction available for the concern regarding an area for residents to use the telephone. The community repurposed a room as a Quiet Room and re-educated residents and staff on its use.
F585-E: There was no immediate correction available for managing concerns residents bring forward, especially during Resident Counsel. The Activity Director was re-educated to ensure concerns are documented and followed through per policy.
F609-D: There was no immediate correction available for reporting suspicion of abuse, neglect, or exploitation. Department Head Staff were re-educated on reporting policies and monitoring procedures were established.
Inspection Report
Re-Inspection
Deficiencies: 0
Date: Jun 28, 2018
Visit Reason
An offsite revisit survey was conducted to verify correction of all previous deficiencies cited on 2018-06-12.
Findings
All deficiencies cited in the previous survey have been corrected as of the compliance date 2018-06-22, and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Jun 12, 2018
Visit Reason
The inspection was conducted as a Health Resurvey and Complaint Investigation based on complaints #121638 and #109142.
Complaint Details
The visit was triggered by complaints #121638 and #109142. The complaint investigation found substantiated deficiencies related to care plan revisions and infection control.
Findings
The facility failed to timely review and revise care plans for residents at risk for falls and toileting needs, and failed to maintain an effective infection prevention and control program, specifically in cleaning a resident's room with a clostridium difficile infection.
Deficiencies (2)
Care Plan Timing and Revision: The facility failed to review and revise care plans for 2 residents, including interventions for falls and toileting needs.
Infection Prevention & Control: The facility failed to properly clean and disinfect a resident's room requiring contact isolation for clostridium difficile infection, including failure to change gloves and ensure surfaces remained wet for required contact time.
Report Facts
Resident census: 31
Residents reviewed: 15
BIMS score: 3
Fall assessment score: 19
Bleach solution ratio: 1
Bleach solution contact time: 10
Inspection Report
Deficiencies: 1
Date: Jun 12, 2018
Visit Reason
The inspection 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 deficiency to be a '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 effective 06/22/2018.
Deficiencies (1)
The facility had a 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm that is not immediate jeopardy.
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Jun 7, 2018
Visit Reason
This document is a Plan of Correction submitted by the facility in response to previously identified deficiencies, outlining corrective actions to address those deficiencies.
Findings
The plan addresses fall intervention care plans for residents and housekeeping procedures for cleaning rooms on isolation for C-diff. The facility describes education, review, and monitoring activities to ensure compliance.
Deficiencies (2)
F657 Resident #22 care plan reviewed and updated for fall interventions including gait belt, fall mat, and bed position. Resident #24 care plan updated to reflect ability and desire to verbalize toileting needs. Current residents' care plans reviewed to ensure appropriate fall and toileting plans. Nurses educated on care plan updates with ongoing review by DON/designee.
F880 Elder #78 room re-cleaned per policy on 6/7/18 by housekeeping supervisor. Housekeeping staff educated on cleaning rooms on isolation for C-diff with return demonstration. Supervisor to observe cleaning frequency with results reviewed at monthly QAPI meeting.
Report Facts
Complete Date: Jun 22, 2018
Inspection Report
Follow-Up
Deficiencies: 1
Date: Dec 1, 2016
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the deficiency identified under regulation 483.25 was corrected as of 12/01/2016. No other deficiencies or uncorrected issues are noted.
Deficiencies (1)
Regulation 483.25 deficiency was corrected by the revisit date of 12/01/2016.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: Dec 1, 2016
Visit Reason
This document is a plan of correction submitted in response to deficiencies identified in a complaint investigation at Moran Manor.
Complaint Details
This plan of correction is related to a complaint investigation at Moran Manor dated 11/21/2016.
Findings
The facility failed to provide necessary care and services to maintain residents' well-being, specifically regarding bathing and skin care. The plan outlines monitoring bathing completion, auditing documentation, re-educating staff on skin care, and ensuring timely treatment for skin impairments.
Deficiencies (1)
F-309: The facility did not ensure baths/showers were completed as per the plan of care and failed to provide timely treatment for residents' impaired skin. Staff will be re-educated and bathing and skin assessments will be monitored and audited.
Report Facts
Substantial date of compliance: Dec 1, 2016
Inspection Report
Complaint Investigation
Census: 33
Deficiencies: 1
Date: Nov 21, 2016
Visit Reason
The inspection was conducted as a complaint investigation (#107864) regarding the facility's failure to provide necessary care and services to residents with skin excoriation areas.
Complaint Details
The citation represents findings from complaint investigation #107864. The complaint was substantiated as the facility failed to provide necessary skin care treatments to residents #2 and #3, leading to worsening skin conditions and hospitalizations.
Findings
The facility failed to provide timely and necessary treatment for two residents with extensive skin excoriation areas, despite documented risks and care plans. Licensed nursing staff did not identify or treat skin issues prior to residents' hospitalizations.
Deficiencies (1)
F 309: The facility failed to provide necessary care and services to maintain the highest practicable well-being for residents with skin excoriation areas. Two residents with documented risks and care plans did not receive timely skin treatment, resulting in worsening skin conditions and hospital transfers.
Report Facts
Resident census: 33
Sample size: 5
Residents with skin care deficiencies: 2
Braden score: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| licensed nurse D | Completed weekly skin assessment on 11/1/16 that failed to identify skin issues for resident #2. | |
| licensed nursing staff B | Reported resident #2 and #3 did not have skin treatments prior to hospital transfer and was unaware of skin problems. |
Inspection Report
Abbreviated Survey
Deficiencies: 1
Date: 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 and was found to be in substantial compliance based on credible allegation of compliance and evidence of correction.
Deficiencies (1)
The facility had a "D" level deficiency indicating no actual harm but potential for more than minimal harm that is not immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Caryl Gill | RN, BSN, Complaint Coordinator | Named in relation to the survey findings and correspondence. |
Inspection Report
Plan of Correction
Deficiencies: 12
Date: Oct 26, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies identified in a prior inspection, outlining corrective actions and compliance dates.
Findings
The facility identified multiple deficiencies related to housekeeping, maintenance, resident care plans, vital signs monitoring, medication administration, and staff education. The plan details re-education of staff, audits, repairs, and monitoring to ensure compliance.
Deficiencies (12)
F-253: The facility failed to maintain sanitary, orderly, and comfortable resident areas, requiring housekeeping and maintenance improvements and staff re-education.
F-278: The facility had a transcription error in the MDS for resident #39 regarding PASSR status, which was corrected and audits implemented.
F-279: The facility needed to develop, review, and revise residents' comprehensive care plans, ensuring nursing staff discontinued previous interventions appropriately.
F-309: The facility failed to ensure vital signs were properly monitored and recorded, requiring staff re-education and audits.
F-312: The facility did not consistently maintain residents' personal hygiene preferences through bathing, requiring interviews and audits.
F-315: The facility failed to provide appropriate treatment for residents incontinent of bladder, requiring re-education and audits of toileting programs.
F-323: The facility did not implement timely interventions following falls, requiring staff re-education and monitoring.
F-329: The facility failed to notify physicians of blood sugar values outside established parameters, requiring re-education and audits.
F-353: The facility did not ensure sufficient nursing staff to respond to call lights timely, requiring audits, staff re-education, and performance improvement plans.
F-425: The facility failed to ensure medications were available and administered as ordered, requiring re-education and audits.
F-428: The facility failed to ensure vital signs were monitored as ordered, requiring re-education and audits.
F-465: The facility failed to maintain sanitary and orderly maintenance services for staff areas, requiring repairs and monitoring.
Report Facts
Substantial date of compliance: Oct 26, 2016
Staff re-education date: Oct 6, 2016
Inspection Report
Follow-Up
Deficiencies: 0
Date: Oct 26, 2016
Visit Reason
This visit was conducted as a post-certification revisit to verify that previously cited deficiencies have been corrected.
Findings
All previously reported deficiencies listed on the CMS-2567 were corrected as of the revisit date.
Inspection Report
Follow-Up
Deficiencies: 1
Date: Oct 26, 2016
Visit Reason
This visit was conducted as a follow-up to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the previously identified deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 2016-10-26.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Sep 28, 2016
Visit Reason
A Health survey was conducted to determine if the facility complies with Federal participation requirements for nursing homes participating in Medicare and/or Medicaid.
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, resulting in a finding of substantial compliance.
Deficiencies (1)
The facility had an 'F' level deficiency that was widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Licensure Certification & Enforcement Manager | Signed the report and communicated the acceptance of the plan of correction. |
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 1
Date: Sep 28, 2016
Visit Reason
The inspection was conducted as a licensure resurvey and complaint investigation covering multiple complaint numbers.
Complaint Details
The inspection included findings from complaint investigations numbered 104762, 103931, 101763, 100263, 99368, 99371, 98982, and 98683.
Findings
The facility failed to retain 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.
Deficiencies (1)
28-39-158(a) Dietary services. The facility failed to retain the services of a full-time certified dietary manager to perform managerial duties and ensure a clean and sanitary dietary department for food storage, preparation, and service.
Report Facts
Resident census: 37
Inspection Report
Life Safety
Deficiencies: 0
Date: Aug 1, 2016
Visit Reason
A Life Safety Code survey was conducted 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 at an "F" level, indicating no harm with potential for more than minimal harm and no immediate jeopardy. The facility was required to submit an acceptable plan of correction within ten calendar days.
Inspection Report
Complaint Investigation
Census: 37
Deficiencies: 4
Date: Feb 11, 2016
Visit Reason
The inspection was conducted as a complaint investigation involving multiple complaint investigation numbers related to resident care and facility compliance.
Complaint Details
The inspection findings are based on complaint investigations #96544, #96560, #96654, #95537, and #95056.
Findings
The facility failed to review and revise the care plan for a resident with wandering behavior, failed to provide necessary care to prevent wandering into other residents' rooms, and failed to provide therapeutic diets as ordered by physicians. Additionally, the facility did not meet nutritional requirements for residents on modified diets.
Deficiencies (4)
F280: The facility failed to review and revise the care plan for resident #2 to address wandering into other residents' rooms and provide staff interventions for redirection.
F309: The facility failed to provide necessary care and services to prevent resident #2 from wandering into other residents' rooms, despite documented behaviors and risks.
F363: The facility failed to provide the recommended dietary allowances, serving less meat than planned for residents on mechanical soft and ground meat diets.
F367: The facility failed to provide therapeutic diets as prescribed by physicians for multiple residents, lacking appropriate menus and substitutions for ordered diets.
Report Facts
Resident 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 ordered 1800 calorie ADA diet: 2
Residents ordered 2000 calorie ADA diet: 1
Residents ordered cardiac diets: 2
Residents ordered low concentrated sweets/consistent carbohydrate diets: 5
Elopement risk assessment score: 20.5
Meat serving weight: 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 and separated residents. | |
| 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. | |
| Dietary staff G | Reviewed dietary spread sheet and weighed pork servings. | |
| Dietary staff I | Served meals and used tongs and scoops without weighing portions. | |
| Consultant H | Advised facility to follow physician ordered diets and appropriate spread sheets. | |
| Licensed nursing staff E | Reported resident wandered until midnight and used other residents' bathrooms. | |
| Licensed nursing staff F | Documented resident behaviors and noted wandering as a behavior only if entering other rooms. | |
| Social service staff D | Reported resident liked to fold clothes and staff redirected resident with activities. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Feb 11, 2016
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation.
Complaint Details
This Plan of Correction is related to a complaint investigation identified as Moran Manor complaint 02112016.
Findings
The facility identified deficiencies related to individualized care plans for residents with wandering behavior, dietary management including serving utensil recommendations, and liberalized diet orders. The plan outlines corrective actions including staff reeducation, individualized care plans, and ongoing monitoring.
Deficiencies (4)
F-280: The facility failed to individualize monitoring and activities for residents with wandering behavior. The DON reeducated nursing staff and plans ongoing monitoring.
F-309: The facility did not adequately revise activity programs to reduce wandering into other residents' rooms. Staff reeducation and individualized behavior monitoring were planned.
F-363: The facility failed to ensure dietary staff followed recommended serving utensil guidelines. The dietary manager reeducated staff and will monitor compliance.
F-367: The facility did not properly review patient diet orders or educate staff on liberalized diets. The dietary manager will reeducate staff and monitor compliance.
Report Facts
Completion date: Mar 2, 2016
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jeanette Oberzan | Administrator | Submitted the Plan of Correction |
| Shirley Boltz | Contact for Plan of Correction assistance |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Sep 18, 2015
Visit Reason
This visit was a post-certification revisit to verify that previously cited deficiencies from an earlier survey were corrected.
Findings
All deficiencies previously reported on the CMS-2567 Statement of Deficiencies and Plan of Correction were corrected as of the revisit date.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: Sep 18, 2015
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report. It outlines corrective actions to address identified issues and ensure compliance with regulatory requirements.
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.
Deficiencies (9)
F-309: The facility will adequately monitor patients with peritoneal dialysis including daily blood pressure, weight, access site checks, and exchanges as ordered by the physician. Licensed nursing staff were reeducated on monitoring and documentation.
F-325: The facility will ensure nutrition strategies for elders are care planned and implemented, with audits and staff reeducation on meal preparation and service. Ongoing monitoring of meal service will be conducted.
F-329: The facility will educate nursing staff on a revised bowel management policy and monitor residents' bowel routines daily. Newly hired staff will be educated during orientation.
F-356: Nurse staffing information will be posted clearly and maintained for at least 18 months. Monitoring will be conducted daily and ongoing.
F-371: The facility will ensure all food is covered, labeled, dated, and stored properly. Dietary staff will be reeducated and ongoing inspections will be conducted.
F-431: Medication expiration dates will be monitored weekly by the DON/designee and pharmacy consultant. Licensed nursing staff will be reeducated on labeling and monitoring insulin pens.
F-441: Proper infection control practices will be ensured for glucose testing and dressing changes. Competency testing and staff reeducation will be conducted with ongoing monitoring.
F-463: The resident call system will be maintained as a functioning call light system with bi-monthly inspections and weekly checks by maintenance supervisor initially.
F-520: The facility will maintain a quality assessment and assurance committee that meets at least quarterly to identify and correct quality deficiencies. The committee includes key staff and consultants.
Report Facts
Completion date: Sep 18, 2015
Reeducation dates: Aug 27, 2015
Reeducation dates: Sep 2, 2015
Inspection Report
Enforcement
Deficiencies: 1
Date: Aug 25, 2015
Visit Reason
The visit was conducted to determine if the facility was 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 which was accepted, resulting in a finding of substantial compliance effective September 18, 2015.
Deficiencies (1)
The survey found 'F' level deficiencies that were widespread and constituted no actual harm but had potential for more than minimal harm without immediate jeopardy.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Irina Strakhova | Enforcement Coordinator | Named as the Enforcement Coordinator in the report. |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 9
Date: Aug 25, 2015
Visit Reason
Health Resurvey and Complaint Investigations #89971 and #90285 were conducted to investigate complaints and assess compliance with regulatory requirements.
Complaint Details
The inspection was triggered by complaint investigations #89971 and #90285.
Findings
The facility was found deficient in multiple areas including failure to adequately monitor residents receiving dialysis, failure to prevent weight loss, failure to monitor bowel movements and administer medications appropriately, failure to post nurse staffing data in a prominent place, failure to maintain sanitary food storage and preparation conditions, failure to monitor medication expiration dates, failure to follow 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 attendance.
Deficiencies (9)
F309: The facility failed to adequately monitor vital signs, weights, and dialysis insertion site for a resident receiving dialysis and failed to timely assess a resident after a change in condition.
F325: The facility failed to implement interventions to prevent weight loss for a resident, including failure to provide ordered nutritional supplements.
F329: The facility failed to monitor bowel movements and administer laxatives per protocol for multiple residents with constipation.
F356: The facility failed to post nurse staffing data in a prominent place readily accessible to residents and visitors.
F371: The facility failed to store, prepare, and serve food under sanitary conditions, including unlabeled food items, food stored on the floor, and dirty kitchen equipment.
F431: The facility failed to adequately monitor expiration dates of medications, including undated insulin pens and expired stock medication.
F441: The facility failed to ensure proper infection control practices during blood glucose testing and wound care, risking cross contamination and infection.
F463: The facility failed to maintain a functioning call light system in multiple bathrooms and a resident room, affecting resident safety.
F520: The facility failed to maintain a quality assessment and assurance committee with physician attendance at meetings as required.
Report Facts
Resident census: 28
Residents reviewed for sample: 15
Residents reviewed for weight loss: 3
Residents reviewed for unnecessary medications: 5
Residents routinely requiring glucometer: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed nursing staff D | Licensed Nursing Staff | Named in findings related to dialysis monitoring, bowel movement monitoring, glucometer cleaning, and wound care technique. |
| Administrative nursing staff B | Administrative Nursing Staff | Named in findings related to dialysis monitoring, weight loss monitoring, bowel movement monitoring, glucometer training, and expired medication monitoring. |
| Direct care staff J | Direct Care Staff | Named in dialysis monitoring and resident feeding assistance. |
| Direct care staff I | Direct Care Staff | Named in dialysis monitoring and resident feeding assistance. |
| Licensed nursing staff N | Licensed Nursing Staff | Named in dialysis monitoring and resident death reporting. |
| Licensed nursing staff L | Direct Care Staff | Named in expired medication verification and resident feeding assistance. |
| Dietary staff F | Dietary Staff | Named in food storage and preparation findings. |
| Consultant staff K | Consultant Staff | Named in weight monitoring consultation. |
| Maintenance staff M | Maintenance Staff | Named in call light system maintenance. |
| Administrative staff A | Administrative Staff | Named in QAA committee findings. |
Inspection Report
Life Safety
Deficiencies: 1
Date: May 5, 2015
Visit Reason
A Life Safety Code survey was conducted by the State Fire Marshal's Office to determine 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 that is not immediate jeopardy. A plan of correction was required and enforcement remedies were recommended.
Deficiencies (1)
The facility was cited with an "F" level deficiency that was widespread, indicating noncompliance with Life Safety Code requirements with no harm but potential for more than minimal harm.
Report Facts
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. |
| Brenda McNorton | Director of Fire Prevention Division | Contact for Informal Dispute Resolution process. |
Inspection Report
Follow-Up
Deficiencies: 0
Date: Jun 27, 2014
Visit Reason
This post-certification revisit was conducted to verify that previously cited deficiencies from the CMS-2567 Statement of Deficiencies and Plan of Correction had been corrected.
Findings
All previously reported deficiencies identified by regulation numbers 483.15(h)(2), 483.25(a)(3), 483.25(h), 483.25(l), 483.25(m)(2), 483.35(i), 483.65, and 483.70(h) were corrected as of the revisit date.
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Jun 27, 2014
Visit Reason
This is a revisit inspection to verify correction of previously cited deficiencies at Moran Manor.
Findings
The report confirms that the previously reported deficiency under regulation 28-39-158(a) was corrected as of the revisit date.
Deficiencies (1)
Regulation 28-39-158(a) deficiency was corrected by the revisit date of 06/27/2014.
Inspection Report
Plan of Correction
Deficiencies: 9
Date: 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.
Findings
The plan addresses multiple deficiencies including maintenance issues, resident care concerns such as clothing and hygiene, accident prevention, bowel management, medication administration, dietary sanitation, infection control, and biohazard storage. The facility outlines corrective actions, staff re-education, and monitoring plans with target completion dates.
Deficiencies (9)
F253-E Maintenance staff to address slow draining bathroom sink and repair bulging baseboards. Monthly inspections and repairs will be conducted with oversight by the QAA committee.
F312-D Mandatory in-service for nursing staff on proper resident clothing and hygiene assistance, with monthly clothing inspections by Social Service or Designee.
F323-D Re-education on accident and incident policy; care plan reviewed for resident #27 with communication protocols for changes.
F329-D Review and re-education on bowel management program; daily audits and physician notification as needed.
F333-D Mandatory in-service on medication administration procedures; medication error for resident #2 corrected.
F371-F Dietary Manager to conduct mandatory in-service on cleaning and sanitation; implement cleaning schedules and inspections.
F441-E DON educated nurses on glucometer cleaning; infection tracking logs to be maintained and reviewed monthly.
F465-E Remove outside biohazard storage shed and replace with new building; monthly inspections to ensure safety.
S0600-F Facility to employ qualified Dietary Manager within 12 months; ongoing training and sanitation oversight planned.
Report Facts
Completion dates: Jun 13, 2014
Completion dates: Jun 27, 2014
Completion date: Jul 15, 2015
Completion date: Mar 30, 2015
Inspection Report
Re-Inspection
Census: 30
Deficiencies: 8
Date: May 28, 2014
Visit Reason
This is a health resurvey inspection to verify correction of previous deficiencies and assess compliance with regulatory requirements.
Findings
The facility was found deficient in housekeeping and maintenance services, assistance with activities of daily living, fall prevention and supervision, medication monitoring and administration, food sanitation, infection control, and maintenance of a safe environment.
Deficiencies (8)
483.15(h)(2) Housekeeping and maintenance services were inadequate to maintain a safe and sanitary environment, including slow draining sinks, stained carpets with urine odors, damaged baseboards, and closet doors off rollers.
483.25(a)(3) The facility failed to provide necessary assistance with grooming and personal hygiene for a cognitively impaired resident, including inappropriate clothing and unclean face.
483.25(h) The facility failed to ensure adequate supervision and assistive devices to prevent repeated falls for a resident with a history of multiple falls and high fall risk.
483.25(l) The facility failed to monitor bowel movements and administer physician-ordered Milk of Magnesia for a resident, resulting in prolonged periods without bowel movements.
483.25(m)(2) The facility failed to monitor and administer Lamotrigine 100 mg twice daily as ordered, resulting in administration of 24 doses of 200 mg in error.
483.35(i) The facility kitchen failed to maintain sanitary conditions, including grime buildup on floors, walls, ice machine, fan, can opener, and damaged knife handles.
483.65 Infection control program failed to adequately sanitize the common use glucometer and lacked consistent tracking and trending of infections and antibiotic usage.
483.70(h) The facility failed to maintain a safe and sanitary environment in the biohazard storage shed and kitchen, including structural damage and grime buildup on floors and walls.
Report Facts
Resident census: 30
Medication error doses: 24
Fall risk score: 17
Bowel movement absence days: 5
Bowel movement absence days: 4
Lamotrigine blood level: 1.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff J | Licensed Nursing Staff | Administered Lamotrigine and performed blood glucose testing |
| Staff B | Licensed Administrative Staff | Confirmed medication error and infection control procedures |
| Staff P | Dietary Staff | Reported kitchen sanitation issues and cleaning schedules |
| Staff E | Direct Care Staff | Assisted resident with hygiene and toileting |
| Staff F | Direct Care Staff | Assisted resident with hygiene and dressing |
| Staff D | Direct Care Staff | Provided information on bowel movement documentation and fall prevention |
| Staff K | Direct Care Staff | Provided information on resident dressing and toileting |
| Staff A | Administrative Staff | Acknowledged resident clothing issues and infection control procedures |
| Staff C | Administrative Nurse | Described fall protocols and interventions |
Inspection Report
Follow-Up
Deficiencies: 4
Date: Oct 30, 2013
Visit Reason
This is a post-certification revisit to verify that previously cited deficiencies have been corrected as documented on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The report confirms that all previously identified deficiencies have been corrected as of 09/18/2013. No uncorrected deficiencies remain at the time of this revisit.
Deficiencies (4)
Regulation 483.25 F0309 deficiency was corrected on 09/18/2013.
Regulation 483.25(d) F0315 deficiency was corrected on 09/18/2013.
Regulation 483.25(i) F0325 deficiency was corrected on 09/18/2013.
Regulation 483.30(a) F0353 deficiency was corrected on 09/18/2013.
Report Facts
Deficiencies corrected: 4
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 4
Date: Aug 19, 2013
Visit Reason
Complaint investigation #67332 regarding failure to provide adequate care and services to residents, including assessment and treatment delays, toileting plans, nutrition, and staffing.
Complaint Details
Complaint investigation #67332 focused on failure to provide adequate care and services including timely assessment and treatment, toileting, nutrition, and staffing.
Findings
The facility failed to timely assess and notify the physician regarding a resident's gastrointestinal bleeding requiring blood transfusion, failed to provide adequate toileting plans for multiple residents, failed to implement nutrition strategies for a resident with weight loss, and failed to provide sufficient nursing staff to meet resident care needs.
Deficiencies (4)
F309: The facility failed to adequately assess and ensure timely physician notification regarding a resident's drop in hemoglobin and black stool, resulting in delayed blood transfusion treatment.
F315: The facility failed to develop and implement individualized toileting plans for four residents to maintain continence and prevent urinary tract infections.
F325: The facility failed to provide nutrition strategies as care planned for one resident, resulting in continued weight loss and inadequate meal assistance.
F353: The facility failed to provide sufficient nursing staff to ensure resident well-being and provision of care, as evidenced by staff and resident interviews.
Report Facts
Resident census: 34
Weight loss percentage: 6.19
Resident weight: 106
Hemoglobin lab value: 7.7
Red blood cell count: 2.38
Licensed nursing staff count: 2
Residents requiring one person assist: 5
Residents requiring two person assist: 21
Inspection Report
Follow-Up
Deficiencies: 1
Date: May 10, 2013
Visit Reason
This visit was a post-certification revisit to verify correction of previously cited deficiencies.
Findings
The report confirms that the previously identified deficiency under regulation 483.20(l)(3) was corrected as of the revisit date.
Deficiencies (1)
Regulation 483.20(l)(3) deficiency was corrected by the revisit date of 2013-05-10.
Inspection Report
Plan of Correction
Deficiencies: 1
Date: May 10, 2013
Visit Reason
This document is a plan of correction submitted in response to a complaint investigation at Moran Manor.
Findings
The plan addresses deficiencies related to discharge planning, requiring a pre-discharge care plan involving an interdisciplinary team and confirmation of services prior to discharge.
Deficiencies (1)
F284-D: The facility must continue discharge planning upon admission and hold a pre-discharge care plan with an interdisciplinary team including nursing, social services, therapy, resident, and/or caregiver. The director of nursing or administrator must review and confirm discharge services at least 24 hours prior to discharge and ensure the resident and family understand discharge instructions.
Inspection Report
Complaint Investigation
Census: 34
Deficiencies: 1
Date: May 2, 2013
Visit Reason
The inspection was conducted as a complaint investigation related to complaint #65030 concerning discharge planning and post-discharge care.
Complaint Details
The complaint investigation involved complaint #65030. The facility was found to have failed in discharge planning and post-discharge coordination for one resident discharged home in April 2013.
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 to ensure continuity of care after discharge.
Deficiencies (1)
483.20(l)(3) Anticipate discharge: The facility failed to develop a post-discharge plan of care to ensure services and equipment were in place for a resident discharged home.
Report Facts
Resident census: 34
Residents selected for discharge: 3
Inspection Report
Re-Inspection
Deficiencies: 1
Date: Apr 20, 2013
Visit Reason
This is a revisit inspection to verify that previously reported deficiencies have been corrected.
Findings
The report confirms that the deficiency identified as Reg. # 28-39-158(a) with ID Prefix S0600 was corrected as of 04/20/2013.
Deficiencies (1)
Regulation 28-39-158(a) deficiency previously cited was corrected on 04/20/2013.
Inspection Report
Follow-Up
Deficiencies: 3
Date: Apr 20, 2013
Visit Reason
This is a post-certification revisit to verify that previously reported deficiencies have been corrected as indicated on the CMS-2567 Statement of Deficiencies and Plan of Correction.
Findings
The revisit confirmed that the deficiencies identified under regulations 483.10(c)(7), 483.25(c), and 483.35(i) were corrected as of the revisit date.
Deficiencies (3)
Regulation 483.10(c)(7) deficiency was corrected by 04/20/2013.
Regulation 483.25(c) deficiency was corrected by 04/20/2013.
Regulation 483.35(i) deficiency was corrected by 04/20/2013.
Inspection Report
Plan of Correction
Deficiencies: 4
Date: Apr 1, 2013
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited in a prior inspection report.
Findings
The plan addresses deficiencies related to the surety bond for residents' personal funds, staff education on skin care policies, and employment and training of a qualified dietary manager including proper food storage and handling.
Deficiencies (4)
F161-B: The facility must ensure the surety bond covers the total balance of residents' personal funds and monitor compliance quarterly.
F314-D: The facility must educate staff on skin care policies including repositioning, off-loading, dressing changes, monitoring, nutrition, and hydration.
F371-F: The facility must employ a qualified dietary manager within 12 months and educate dietary staff on proper storage and service of food to prevent foodborne illness.
S600-F: The facility must employ a qualified dietary manager within 12 months and educate dietary staff on proper storage and service of food to prevent foodborne illness.
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 |
Inspection Report
Census: 35
Deficiencies: 3
Date: Mar 25, 2013
Visit Reason
The inspection was conducted to assess compliance with dietary services regulations, including staffing and food safety practices.
Findings
The facility failed to employ a full-time certified dietary manager to oversee dietary services. Observations revealed food safety concerns including serving non-pasteurized soft fried eggs and failure to use hairnets by staff serving food in the memory care unit.
Deficiencies (3)
28-39-158(a) Dietary services. The facility failed to employ a full-time qualified dietary manager to oversee dietary services. The dietary staff was not certified as a dietary manager at the time of inspection.
The facility served soft runny eggs with noncongealed yolks that were not pasteurized, contrary to facility policy requiring pasteurized eggs for undercooked and fried eggs.
Staff serving food in the memory care unit did not wear hairnets, risking possible contamination of food, contrary to facility policy requiring hair restraints in all food preparation and serving areas.
Report Facts
Resident census: 35
Residents served soft runny eggs: 8
Residents served buffet style without hairnets: 10
Inspection Report
Plan of Correction
Deficiencies: 2
Date: Dec 15, 2012
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies cited in a complaint investigation at Moran Manor.
Complaint Details
This Plan of Correction is related to a complaint investigation at Moran Manor.
Findings
The facility was found deficient in maintaining freedom from abuse and involuntary seclusion, and in investigating and reporting allegations of abuse. The plan outlines staff education, documentation improvements, and ongoing monitoring to ensure compliance.
Deficiencies (2)
F223-D: Facility shall remain free from abuse/involuntary seclusion. Staff will be educated on abuse and proper notification, and charge nurses will document inappropriate sexual touching incidents. Compliance will be monitored monthly.
F225-D: Facility shall investigate and report allegations of abuse. Staff will be educated on reporting procedures, and notifications will be made to appropriate officials within 5 working days. Compliance will be monitored monthly.
Report Facts
Plan of Correction completion date: Dec 15, 2012
Inspection Report
Follow-Up
Deficiencies: 0
Date: Dec 15, 2012
Visit Reason
This visit was a post-certification revisit to verify that previously reported deficiencies had been corrected.
Findings
The report confirms that the deficiencies previously cited under regulations 483.13(b), 483.13(c)(1)(i), and 483.13(c)(1)(ii)-(iii), (c)(2)-(4) were corrected as of the revisit date.
Inspection Report
Complaint Investigation
Census: 31
Deficiencies: 2
Date: Nov 16, 2012
Visit Reason
Complaint investigation #61653 regarding allegations of sexual abuse by one resident toward two cognitively impaired residents.
Complaint Details
The complaint investigation was triggered by allegations that resident #1 sexually abused residents #2 and #3, both cognitively impaired. The facility failed to document incidents in the victims' medical records and did not notify the state agency promptly. Police and the residents' durable power of attorney were eventually notified after multiple incidents.
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.
Deficiencies (2)
483.13(b), 483.13(c)(1)(i) - The facility failed to protect two cognitively impaired residents from sexual abuse by another resident.
483.13(c)(1)(ii)-(iii), (c)(2)-(4) - The facility failed to thoroughly investigate and report allegations of sexual abuse to the state agency as required.
Report Facts
Resident census: 31
Residents selected for review: 6
BIMS score: 3
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 by resident #1. | |
| Direct care staff B | Witnessed resident #1 touching other residents inappropriately. | |
| Direct care staff C | Observed and intervened when resident #1 touched another resident. | |
| Administrative nursing staff D | Reported awareness of resident #1's inappropriate behavior and physician's medication order. |
Inspection Report
Plan of Correction
Deficiencies: 4
Date: N001003 POC 6OFT11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a complaint investigation.
Complaint Details
This Plan of Correction is in response to deficiencies cited during a complaint investigation identified as Moran Manor 081913 Complaint.
Findings
The facility identified multiple deficiencies related to resident care including inadequate assessment and notification of changes in condition, individualized toileting plans, nutrition care planning, and sufficient nursing staff to meet resident needs. The Plan of Correction outlines steps to address these issues through staff education, monitoring, and care plan updates.
Deficiencies (4)
F309-G: The facility failed to provide necessary care and services to maintain residents' physical, mental, and psychosocial well-being, including timely notification to physicians of changes in condition.
F315-E: The facility failed to develop and implement individualized toileting plans based on residents' voiding histories to maintain bladder function and reduce urinary tract infection risk.
F325-D: The facility failed to ensure nutrition strategies were care planned and implemented to reduce risk of significant weight loss or gain among residents.
F353-E: The facility failed to provide sufficient nursing staff to meet the needs of residents, including respecting resident preferences and timely response to call lights.
Report Facts
Dates for compliance and education: Sep 18, 2013
Dates of staff education and audits: Aug 29, 2013
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Ashley Vogel | Administrator | Submitted the Plan of Correction to KDADS. |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N001003 POC EQUX11
Visit Reason
This document is a Plan of Correction submitted in response to deficiencies identified in a prior inspection at Moran Manor.
Findings
No specific findings or deficiencies are detailed in this document. It serves solely as a Plan of Correction record with no deficiencies listed.
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N001003 POC OQ6E11
Visit Reason
This document is a Plan of Correction related to a prior inspection event identified by Event ID OQ6E11.
Findings
No deficiency records or findings are included in this Plan of Correction document.
Inspection Report
Plan of Correction
Deficiencies: 7
Date: N001003 POC ZRMD11
Visit Reason
This document is a Plan of Correction submitted by the facility in response to deficiencies cited during a prior inspection.
Findings
The plan addresses multiple deficiencies related to significant change MDS completion, care plan revisions, wound care, fall interventions, and medication storage. The facility outlines corrective actions, staff training, monitoring, and dates of substantial compliance.
Deficiencies (7)
F0000: The facility does not admit to the accuracy of any specific fining or allegations but submits this plan as a written allegation of substantial compliance with Federal Medicare and Medicaid requirements.
F637-D: The MDS Coordinator completed a significant change MDS for resident R(16) on August 24, 2020, and staff were re-educated on criteria and timing for significant change MDS.
F656-D: Resident R(25)'s comprehensive care plan was revised on August 24, 2020, and staff were re-educated on care plan policies.
F657-D: Residents R(17) and R(16) had their comprehensive care plans revised on August 25, 2020, with staff training planned on care plans and fall-related revisions.
F684-D: Wound care for resident R(8) was corrected by rinsing off soap and notifying the doctor on August 19, 2020, with staff training planned on wound care and skin assessment.
F689-D: Residents R(17) and R(16) care plans were revised on August 25, 2020, with training on communicating fall interventions planned.
F761-E: Undated insulin pens were removed and replaced on August 17, 2020, with staff training on medication storage and insulin storage planned.
Report Facts
Substantial compliance dates: Multiple substantial compliance dates ranging from August 24, 2020 to September 10, 2020
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Jennifer Adams | Administrator | Submitted the Plan of Correction |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: N001003 POC
Visit Reason
This document is a Plan of Correction related to a prior inspection or regulatory event for the facility identified as State ID N001003.
Findings
No records or details of deficiencies or corrective actions are provided in this Plan of Correction document.
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