Pennsylvania Department of Health
MORAVIAN HALL SQUARE HEALTH AND WELLNESS CENTER
Patient Care Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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MORAVIAN HALL SQUARE HEALTH AND WELLNESS CENTER - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, and a Civil Rights Compliance survey, completed March 12, 2026, it was determined that Moravian Hall Square Wellness Center was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.\~

Plan of Correction:

483.60(g) REQUIREMENT Assistive Devices - Eating Equipment/Utensils:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

§483.60(g) Assistive devices
The facility must provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks.

Observations:
Based on clinical record review, observation, and staff interview, it was determined that the facility failed to ensure that adaptive equipment was provided to one of two sampled residents who required adaptive equipment with meals. (Resident 42)

Findings include:

Clinical record review revealed that Resident 42 had diagnoses that included fracture of the third and fourth metacarpal bones (in the hand), chronic pain syndrome, and osteoarthritis. Review of the care plan revealed that the resident was at risk for nutrition problems with an intervention for adaptive equipment while eating. The intervention was for staff to provide built-up left angled utensils, a divided plate, and a cup with a lid and straw for all meals. A physician's order dated February 3, 2026, directed staff to provide built-up left angled utensils, a divided plate, and a cup with a lid and straw for all meals. On March 11, 2026, from 8:15 a.m. through 8:25 a.m., Resident 42 was observed in her room with her meal and without built-up left angled utensils or a divided plate. On March 11, 2026, from 12:10 p.m. through 12:35 p.m., Resident 42 was observed in the dining room with her meal and without built-up left angled utensils, a divided plate, or a cup with a lid and straw.

In an interview on March 12, 2026, at 11:45 a.m., the Director of Physical Therapy confirmed that the resident should have received the built-up left angled utensils, divided plate, and a cup with lid and straw at all meals.

28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Plan of Correction - To be completed: 03/17/2026

1- Team was educated immediately. The Dietary supervisor and the Team Lead were counseled.
2- Inservice provided to all Healthcare Dining staff about following diet orders and the importance provided by Dietitian.
3- Daily standup meeting with lunch and dinner with Dining Supervisor and Lead to review residents on adaptive utensils, plates, bowls, etc.
4 Meal Audits by Dietitian, Assistant General Manager or Nutritional Care Manager. Weekly for 4 weeks followed by monthly for 3 months. If any deficiencies noted audits will revert to weekly for an additional 3 months.

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