Inspection·September 15, 2023

F 0578 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. 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. Resident was belly breathing. Review of Resident 20's POLST (Pennsylvania Orders for Life Sustaining Treatment) signed by the resident and dated March 16, 2018 revealed the resident was a DO Not Resuscitate and wanted comfort measure only including not to send to the hospital for life sustaining treatment only if comfort needs cannot be met. Review of Resident 20's care plan revealed a care plan initiated on January 28, 2020 for receiving only comfort measures and not to be hospitalized . Interview with the Nursing Home Administrator and the Director of Nursing on September 14, 2023 at 1:00 p.m. confirmed Resident 20 was sent to the hospital on June 26, 2023 against the wishes of her POLST. Review of Resident 49's clinical record revealed Resident 49's Living Will indicating Resident 49 was not interested in life sustaining measures in the event of illness. Further review of Resident 49's clinical record revealed a physician's order for Full Code status. Further review of Resident 49's clinical record revealed resident had a Full Code status. Review of Resident 49's Quarterly Minimum Data Set (periodic assessment of resident needs) dated July 20, 2023, revealed a Brief Interview for Mental Status score of 15 indicating Resident 49 was cognitively intact. Further review of Resident 49's clinical record revealed a Physician's Order for Life Sustaining Treatment (POLST) dated February 21, 2020, indicating a Do Not Resuscitate (DNR) status and further (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 9 Event ID: 395325 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395325 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/15/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Moravian Manor 300 West Lemon Street Lititz, PA 17543 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)