Deficiencies per Year
16
12
8
4
0
Unclassified
Census Over Time
Census
Capacity
Inspection Report
Renewal
Census: 29
Capacity: 40
Deficiencies: 4
Sep 24, 2024
Visit Reason
The inspection was conducted as a renewal inspection of the Moravian Manor facility to review compliance with licensing requirements.
Findings
The inspection found several deficiencies including incomplete direct care staff training, incomplete fire drill records, medication labeling discrepancies, and medication storage and documentation issues. Plans of correction were accepted and fully implemented by the follow-up date.
Deficiencies (4)
| Description |
|---|
| Staff C had not completed the Department-approved direct care training course and passed the competency test. |
| Fire drill records did not specify the amount of time required for evacuation of residents including seconds for multiple dates. |
| Resident 1's prescription medication label dosage instructions did not match the prescribed dosage. |
| Resident 1's glucometer reading was not documented on the electronic medication administration record (eMAR). |
Report Facts
License Capacity: 40
Residents Served: 29
Staffing Hours: 30
Waking Staff: 23
Deficiencies cited: 4
Inspection Report
Renewal
Census: 26
Capacity: 40
Deficiencies: 16
Sep 6, 2023
Visit Reason
The inspection was conducted as a renewal review of the Moravian Manor assisted living facility on 09/06/2023, 09/07/2023, and 09/08/2023 to determine compliance with licensing requirements and verify the implementation of the submitted plan of correction.
Findings
The inspection identified multiple deficiencies including failure to post the current Licensing Inspection Summary, missing medical evaluations prior to admission, lack of involvement of the assisted living portion in quality management plans, direct care staff lacking required qualifications and training, absence of staff trained in first aid and CPR during certain shifts, incomplete documentation of staff training, missing items in the first aid kit, missed fire drills and incomplete fire drill records, incomplete medical evaluations and assessments, medication storage and usage issues, and failure to conduct quarterly reviews of resident support plans. All deficiencies had plans of correction accepted and were implemented by 11/27/2023.
Deficiencies (16)
| Description |
|---|
| Failure to post the current Licensing Inspection Summary dated 8/1/22 in a conspicuous and public place; only an outdated LIS from 12/19/19 was posted. |
| No documentation of a medical evaluation prior to 10/30/19 for Resident #1. |
| Assisted living portion of the community not involved in quality management plan reviews or meetings. |
| Direct care staff persons A and B lacked a high school diploma, GED, or active registry status on the Pennsylvania nurse aide registry. |
| No staff trained in first aid and certified in obstructed airway techniques and CPR were present during specified shifts in August 2023. |
| Direct care staff persons A and B provided unsupervised assisted living services without completing the required Department-approved direct care training and competency test. |
| Monthly staff training documentation ceased in April 2023; incomplete records of training completion including infection control and emergency preparedness. |
| First aid kit in nurse's station missing tweezers. |
| Unannounced fire drills were not held during January, July, and August 2023. |
| Fire drill records for 5/9/23 and 6/15/23 lacked time to evacuate, number of residents evacuated, number of staff participating, and exit routes used. |
| Medical evaluations for Residents #2 and #3 lacked indication of tuberculin skin test results or chest X-ray as required. |
| Resident #1’s most recent medical evaluation was outdated; previous evaluation also outdated. |
| Resident #2’s prescribed medication was not available in the residence on a specified date. |
| Used tube of medication found in first aid kit belonged to a discharged resident. |
| Resident #1 and Resident #3 had outdated assessments; previous assessments also outdated. |
| Resident #1, #2, and #3’s support plans were not reviewed quarterly as required; no reviews completed in 2022 for Resident #1. |
Report Facts
Residents served: 26
License capacity: 40
Total daily staff: 26
Waking staff: 20
Dates of inspection: 3
Fire drills missed: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Denise Geib | Administrator | Educated staff on posting Licensing Inspection Summary and other violations |
| Anderson | Clinical Coordinator | Responsible for maintaining ADME tracking tool, training plans, and assessments |
Inspection Report
Renewal
Capacity: 40
Deficiencies: 0
Sep 14, 2021
Visit Reason
The document is a renewal license issued in response to the facility's renewal application submitted on September 7, 2021, for Moravian Manor Assisted Living Home, pursuant to Title 55, PA Code, Chapter 2800.
Findings
A regular license is being issued based on the renewal application. The Department advises that an onsite annual inspection will be conducted within the next twelve months to ensure compliance with applicable regulations.
Report Facts
Certificate number: 333090
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Jamie L. Buchenauer | Deputy Secretary | Signed the renewal license letter |
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