Moravian Manor

In the surveyor’s words

From the most serious findings on record at Moravian Manor, in the surveyor’s own words.

• Actual harm, isolatedF689Aug 20, 2026

  Based on review of clinical record, facility documentation, and staff interview, it was determined the facility failed to ensure that residents received adequate accident prevention measures by failing to obtain hot beverage temperatures prior to serving resulting in actual harm of a burn caused by hot liquid served for one of four sampled residents (Resident 4). This failure resulted in an Immediate Jeopardy situation. The incident has been identified as past non-compliance.Findings include:Review of Resident 4's diagnosis list revealed diagnoses including vascular dementia (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability). […]

• No harm, potential for more than minimal, patternF689Apr 9, 2025

  Based on review of the National Fire Protection Agency's (NFPA) 96, observation and interview with staff, it was determined the facility failed to provide an environment free of accident hazards for one of two dining areas. (2nd floor dining room). Findings include: Review of NFPA 96: Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations states that open flames are not permitted in health care settings. Observation in the second floor dining room on April 9, 2025 at 11:15 a.m. revealed four hotel pans containing food being warmed by 8 sterno burners (fuel made from denatured and jellied alcohol). Interview with Dietary Employees E3 and E4 on April 9, 2025 at 11:35 a.m. […]

• No harm, potential for more than minimal, isolatedF550Aug 28, 2025

  Number of residents sampled: Number of residents cited: Based on observations and interview with staff, it was determined that the facility failed to treat each resident with respect and dignity during meal service in one of two dining rooms (Herrnhut).Findings include:Observation on August 26, 2025, at 11:47 a.m. revealed Employee E4 wearing disposable gloves while feeding Resident 9.Observations on August 27, 2025, at 11:54 a.m. revealed Employee E4 wearing disposable gloves while feeding Resident 19 and Employee E5 wearing disposable gloves while feeding Resident 14.Observations on August 28, 2025, at 11:54 a.m. revealed Employee E6 wearing disposable gloves while feeding Resident 14. Employee E6 was also standing while feeding Resident 14. […]

• No harm, potential for more than minimal, isolatedF610Jul 31, 2024

  Based on a review of the facility's policy, clinical records, and staff interview, it was determined that the facility failed to thoroughly investigate an injury of unknown origin for one of the 18 residents reviewed (Resident 53). Findings include: Review of the facility's policy titled Abuse Investigation, with a review date of May 17, 2023, revealed that all reports of resident abuse, neglect, and injuries of unknown origin are promptly investigated by facility management. The investigation includes interviewing staff members (on all shifts) who had contact with the resident during the alleged incident. […]

• No harm, potential for more than minimal, isolatedF578Sep 15, 2023

  Based upon review of clinical records, it was determined the facility failed to ensure resident's code status coincided with resident's wishes and failed to ensure those wishes were identified in resident's medical record for two of 24 residents reviewed (Residents 20 and 49). Findings include: Review of Resident 20's Progress Notes revealed a nursing entry dated June 28, 2023 stating Resident was sent to the hospital on June 26, 2023 at 10:30 p.m. due to a decline in the residents status, residents eyes where rolling in back of head and was very hard to get a response out of, resident heart rate was high as well as blood pressure and the residents hands where blue and arms clenched tight against chest. […]