Health inspection·July 31, 2024

F 0610 Respond appropriately to all alleged violations. Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Few 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. Review of Resident 53's diagnosis list includes Alzheimer's Disease (irreversible, progressive degenerative disease of the brain, resulting in loss of reality contact and functioning ability), and Vascular Dementia with behavioral disturbances. Review of Resident 53's clinical record including the nursing progress notes dated June 20, 2024, at 10:17 p.m., revealed that during the weekly skin assessment, a 20.0 x 9.0 cm (centimeter). yellow bruise area was observed on the resident's right upper arm. The same note also revealed that the resident was combative and resistant to care as observed by the writer on the night the bruise was observed, the physician and the responsible party were notified. Interview with the Director of Nursing on July 31, 2024, at 11:30 a.m., revealed an investigation for an injury of unknown origin is to inlcude statements from staff that had contact with the resident 24 hours before discovering the bruise. Review of the facility's documentation/investigation revealed the facility did not perform a thorough investigation as evidenced by missing statements from several of the staff that cared for Resident 53, 24 hours before discovering the bruise on Resident 53's right upper arm. Interview with the Director of Nursing on July 31, 2024, confirmed the facility did not obtain statements from several staff that cared for the resident within the 24 hours prior to discovering the bruise. The facility failed to ensure Resident 53's bruise of unknown origin was thoroughly investigated. 28 Pa. Code 201.14(a) Responsibility of Licensee Previously cited 9/15/23 Page 1 of 2 395325 395325 07/31/2024 Moravian Manor 300 West Lemon Street Lititz, PA 17543

F 0610 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management Level of Harm - Minimal harm or potential for actual harm Previously cited 9/15/23 28 Pa. Code 201.29(a)(d) Resident Rights Residents Affected - Few Previously cited 9/15/23 28 Pa. Code 211.5(f) Clinical Records Previously cited 9/15/23 395325 Page 2 of 2