Inspection Reports for
Moravian Manor
300 WEST LEMON STREET,, LITITZ, PA, 17543
Back to Facility Profile9 Reports
Inspection Report — Sep 24, 2024
Renewal
Date: 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.
Citations (4)
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
Residents Served: 29
Staffing Hours: 30
Waking Staff: 23
Deficiencies cited: 4
Inspection Report — Sep 6, 2023
Renewal
Date: 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.
Citations (16)
Failure to post the current Licensing Inspection Summary dated 8/1/22 in a conspicuous and public place; only an outdated LIS from 12/19/19 was posted.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
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 |
Notice — Sep 25, 2020
Date: Sep 25, 2020
Visit Reason
This document serves as a license renewal notice and certificate of compliance for Moravian Manor Assisted Living Home, confirming the facility's authorized capacity and informing about the upcoming annual inspection required by state regulations.
Findings
No inspection findings are reported in this document. It confirms issuance of a regular license following the renewal application and states that an onsite inspection will be conducted within the next twelve months.
Report Facts
Inspection Report — Oct 28, 2019
Renewal
Date: Oct 28, 2019
Visit Reason
The inspection was an unannounced renewal inspection of Moravian Manor to assess compliance with licensing requirements.
Findings
The submitted plan of correction was found to be fully implemented. Deficiencies included lack of training in fire safety and falls prevention, failure to provide quarterly financial transaction statements to residents, expired emergency water supplies, incomplete ADME documentation, and missing mobility needs in a medical evaluation.
Citations (5)
Staff Members A, B, and C did not receive training in fire safety conducted by a fire safety expert during 2018. Staff Members B and C also did not receive training in falls and accident prevention during 2018.
Residents #1 and #2 did not receive a quarterly account of financial transactions as required.
The supply of emergency water was expired and was replaced on 10/28/19. The dining services manager will check emergency water every 6 months to ensure it is not expired.
The medical evaluation for Resident #3 dated 10/16/19 did not include the resident's mobility needs.
The ADME documentation process was incomplete; the Director of Social Services will verify completion and ensure ADME is complete for all residents admitted to assisted living.
Report Facts
Residents served: 35
Total Daily Staff: 35
Waking Staff: 26
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Susan Brennan | PCHA, ALA | Signed multiple plans of correction |
Inspection Report — Sep 19, 2019
Renewal
Date: Sep 19, 2019
Visit Reason
The document is a renewal of the Assisted Living Home license for Moravian Manor, issued following receipt of the renewal application dated September 11, 2019. The Department advises that an onsite inspection will be conducted within the next twelve months as required by regulation.
Findings
No inspection findings are reported in this document. It serves as a certificate of compliance and license renewal notification for Moravian Manor.
Report Facts
Inspection Report — Apr 3, 2019
Renewal
Date: Apr 3, 2019
Visit Reason
The inspection was a full renewal inspection conducted on April 3, 2019, to assess compliance with 55 Pa.Code Ch. 2800 relating to Assisted Living Residences.
Findings
Violations of the Pennsylvania Assisted Living Residence regulations were found during the inspection. The facility was required to correct all citations specified in the violation report by the dates indicated and maintain continued compliance.
Report Facts
Number of Residents Served: 34
Number of Hospice Residents in past year: 1
Notice — Apr 2, 2019
Date: Apr 2, 2019
Visit Reason
The document serves as a notification of a revised license issued due to an error on the previously issued license and a renewal notice for the assisted living facility license.
Findings
The revised license removes the restriction of a Special Care Unit from the Certificate of Compliance. The renewal application was accepted and a regular license was issued.
Report Facts
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Robert E. Robinson | Director | Signed the revised license letter dated April 2, 2019. |
| Jacqueline L. Rowe | Director | Signed the renewal license letter dated September 20, 2018. |
Inspection Report — Sep 19, 2017
Original Licensing
Date: Sep 19, 2017
Visit Reason
The inspection was conducted as a licensing inspection for Moravian Manor, a new assisted living facility, to assess compliance with applicable regulations.
Findings
The facility was found to be in substantial compliance with regulations, but the licensing inspector was unable to complete a full inspection because the home was new and not yet serving four or more residents.
Inspection Report — September 14, 2021
Renewal
Date: September 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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