Pennsylvania Department of Health
HEMPFIELD MANOR
Patient Care Inspection Results

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HEMPFIELD MANOR
Inspection Results For:

There are  127 surveys for this facility. Please select a date to view the survey results.

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HEMPFIELD MANOR - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:
Based on a Medicare/Medicaid Recertification, State Licensure, Civil Rights Compliance, and an Abbreviated Survey in response to three complaints, on February 15, 2024, it was determined that Hempfield Manor 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 Regulation as they relate to the Health portion of the survey process.


 Plan of Correction:


483.80(a)(1)(2)(4)(e)(f) REQUIREMENT Infection Prevention & Control:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
§483.80 Infection Control
The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections.

§483.80(a) Infection prevention and control program.
The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements:

§483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards;

§483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to:
(i) A system of surveillance designed to identify possible communicable diseases or
infections before they can spread to other persons in the facility;
(ii) When and to whom possible incidents of communicable disease or infections should be reported;
(iii) Standard and transmission-based precautions to be followed to prevent spread of infections;
(iv)When and how isolation should be used for a resident; including but not limited to:
(A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and
(B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances.
(v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and
(vi)The hand hygiene procedures to be followed by staff involved in direct resident contact.

§483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility.

§483.80(e) Linens.
Personnel must handle, store, process, and transport linens so as to prevent the spread of infection.

§483.80(f) Annual review.
The facility will conduct an annual review of its IPCP and update their program, as necessary.
Observations:

Based on review of facility policies, review of Centers for Disease Control (CDC) guidelines for Legionella (bacterium that causes Legionnaires Disease found in pipes and heating systems) Control, the facility's infection control tracking logs for water management and staff interview, it was determined that the facility failed to implement a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility, failed to exercise proper infection control techniques and dispose of contaminated PPE (personal protective equipment) during a dressing change to prevent the potential of spread of infection for one of three residents (Resident R59).

Review of the facility "Legionella Policy-Environmental" reviewed 12/13/23, indicated that the facility will implement control measures to reduce the potential for the growth and spread of Legionella by quarterly testing of chlorine levels. The facility indicated that the "Weekly Water Temperature Inspection" logs are used to track the testing of the water temperatures and the chlorine levels. The log indicated quarterly chlorine levels will be a minimum residual level 0.5 mg/L (milligram per liter).

During an observation of the facility provided "Weekly Water Temperature/Inspection" forms dated October 2023 through February 2024, indicated in November "less than" and an unidentifiable word. The February 2024 column indicated a date of 2/2/24, with no documented chlorine level.

During an interview on 2/13/24, at 10:25 a.m., the Nursing Home Administrator and Maintenance Director confirmed that the facility failed to implement a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility.

During an interview on 2/14/23, at 9:25 a.m., Licensed Practical Nurse (LPN) Employee E1 indicated that Resident R59 was in enhanced precautions (staff to use PPE during dressing changes) as indicated by a sign above the bed.

During an observation on 2/14/24, at 9:25 a.m., of Resident R59's wound care revealed the following:

LPN Employee E1 removed scissors from her scrub pocket and cut off Resident R59's left foot dressing without first cleaning the scissors.

LPN Employee E1 removed soiled gloves multiple times and placed them in the garbage can below the sink utilized by both residents in the room.

LPN and the Nurse Aide (NA) Employee E4 removed their gowns, masks and gloves after treatment and placed them in the same garbage can and the bag was not removed prior to leaving the room.

During an interview on 2/14/24, at 10:25 a.m., LPN Employee E1 confirmed that the facility failed to exercise proper infection control techniques and dispose of contaminated PPE during a dressing change to prevent the potential of spread of infection for Resident R59.

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 201.18(b)(1)(e)(1) Management.

28 Pa. Code: 201.20(c) Staff Development.

28 Pa. Code: 211.10(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.



 Plan of Correction - To be completed: 03/25/2024

On 2/14/24, Environmental Services Supervisor retested the chlorine levels and recorded 1.0 mg/L in both areas tested (B hall and C hall), and the numeric level was recorded on the "Weekly Water Temperature form".
The Environmental Services Supervisor and Maintenance Staff will be educated by the corporate project Manager or designee in March 2024 on the appropriate procedure to test, record, and respond to chlorine levels per the facility's Water Management Program. A new chlorine tester will be purchased to ensure clearer numeric readings during facility chlorine testing.
The Environmental Services Supervisor or designee will audit chlorine levels in the facility through use of the new tester weekly for four weeks, monthly for three months, and then quarterly thereafter. Results of audits will be reviewed at Quarterly QAPI meetings.

LPN Employee E1 and Nurse Aide Employee E4 were immediately educated on proper infection control techniques and disposal of contaminated PPE.
The Director of Nursing or designee will provide education to nursing staff members on Feb 28,2024 on proper infection control techniques and disposal of contaminated PPE. In addition, Infection Preventionist or designee will provide all direct care staff education on infection control in regards to PPE donning, doffing, and disposal during March 2024 inservices.
Audits will be performed by Infection Preventionist or designee via conducting rounds throughout the facility on infection control techniques and disposal of PPE weekly for one month, then monthly for three months.
Findings of the audits will be forwarded to the Quality Assessment Process Improvement Committee for review and recommendations.




483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights: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.
§483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

§483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

§483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

§483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

§483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

§483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of three residents (Residents R59).

Findings include:

Review of facility policy "Resident Rights" dated 12/13/23, indicated the Resident has a right to a dignified existence. The facility must treat each Resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life.

Review of the clinical record indicated that Resident R59 was admitted to the facility on 12/20/23, with diagnoses that included malnutrition, falls, heart disease and peripheral vascular disease. A review of the Minimum Data Set (MDS-a periodic assessment of resident care needs) dated 12/27/23, indicated the diagnoses remained current.

Review of the facility provided pressure ulcer list indicated Resident R59 developed pressure ulcers of his right and left heels on 2/7/24.

During an observation of wound care on 2/14/24, from 9:25 a.m. through 10:17 a.m., Licensed Practical Nurse (LPN) Employee E1 wrote on the dressing after it was placed on Resident R59's bilateral feet.

During an interview on 2/14/24, at 10:17 a.m., LPN Employee E1 confirmed the facility failed to maintain Resident R59's dignity when writing on the dressings after placement on the resident.

28 Pa. Code: 201.29(j) Resident rights.


 Plan of Correction - To be completed: 03/25/2024

This plan of correction has been prepared and executed because the law requires it. This plan does not constitute an admission that any of the citations are either legally or factually correct. This plan of correction is not meant to establish any standard of care, contract, obligation, or position. Hempfield Manor reserves the right to raise all possible contestations and defenses in any civil, criminal, claim, action or proceeding. Please accept this plan of correction as Hempfield Manor's credible allegation of compliance.
LPN Employee E1 who performed the dressing change was immediately provided with education on dignity regarding writing on the dressing after already being placed on the resident involved.
All nursing staff were educated by ADON on wound care on 2-19-2024 and ADON will complete wound care competencies on all nursing staff by 3/18/24 with emphasis placed on resident rights and dignity issues during wound care dressing changes. All staff will be educated by NHA or designee on dignity issues and resident rights during March 2024 inservices.
All newly hired RN/LPN's will have wound care competencies completed by the Infection Preventionist/designee prior to providing direct care to ensure that residents dignity is maintained. The Infection Preventionist/Designee will complete audits on wound care/dignity twice a week for four weeks, then weekly for one month, then monthly for 3 months.
All newly hired staff will continue to be educated by a facility designee on resident rights/dignity as part of their on-boarding process. The DON/representative will complete audits on resident rights/dignity twice a week for four weeks, then weekly for one month, then monthly for 3 months.
The results of audits will be reviewed through the Quality Assessment Process Improvement Committee.

483.25 REQUIREMENT Quality of Care: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.
§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.
Observations:
Based on facility policy, clinical record, facility provided documents and staff interview it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the residents' choices for one of two residents (Resident R21).

Review of the facility policy "Physician Services," last reviewed on 12/13/23, indicated that all medications and treatments administered to the resident must be ordered by the physician.

Review of the clinical record indicated that Resident R21 was admitted to the facility on 12/1/23, with diagnoses which included Type 2 Diabetes Mellitus, Parkinsons (a disorder of the nervous system that affects movement), anxiety, and cognitive disorder.

Review of the Physician Orders Audit Report indicated that on 12/2/23, Resident R21 was ordered the Freestyle Libre 2 Sensor for glucose monitoring (device that requires no finger sticks). Resident R21's family member (FM1) requested due to Resident R21's inability to tolerate fingersticks.

During a phone interview on 2/15/24, at 11:53 a.m., FM1 indicated that she asked for the Freestyle Libre system for Resident R21 due to crying in pain every time a fingerstick was done for glucose monitoring. The system was purchased and the facility utilized it instead of fingersticks. The physician wrote the order per FM1's request on 12/2/23.

Review of Resident R21's Medication Administration Record (MAR) dated February 2024, indicated that from February 1, 2024 through February 14, 2024, Resident R21's Freestyle Libre was not provided as per the physician order of 12/2/23.

During an interview on 12/15/24, at 1:17 p.m., the Nursing Home Administrator and Director of Nursing confirmed that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the residents' choices.

28 Pa. Code: 201.14(a) Responsibility of licensee.

28 Pa. Code: 201.18(b)(1)(e)(1) Management.

28 Pa. Code: 201.29(j) Resident rights.

28 Pa. Code: 211.10(c)(d) Resident care policies.

28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services.


 Plan of Correction - To be completed: 03/25/2024

The Director of Nursing immediately placed an order for the Freestyle Libre2 Sensor on R21 on 2/15/24.
All current resident charts were reviewed on 2/16/24 to ensure that any other residents using the Freestyle Libre2 Sensor had current orders and sensors were being provided per resident's choice and standards of practice. All new admissions will be screened by DON or designee for the use of the Glucose monitoring devices to ensure that the facility has the appropriate orders.
The Director of Nursing or designee will provide educational instruction to nursing staff members on Feb 28th, 2024 on physicians orders for glucose monitoring devices. Audits will be performed by DON or designee on physician orders for glucose monitoring devices weekly for one month, then monthly for three months and Findings of the audits will be forwarded to the Quality Assessment Process Improvement Committee for review and recommendations

483.25(d)(1)(2) REQUIREMENT Free of Accident Hazards/Supervision/Devices: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.
§483.25(d) Accidents.
The facility must ensure that -
§483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and

§483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.
Observations:
Based on observations and staff interview it was determined that the facility failed to maintain an environment free of potential accident hazards when the salon was unsecured containing hazardous items in two unsecured cabinets (Beauty Salon).

Findings include:

During an observation on 2/13/24, at 10:50 a.m., the main hallway between the two nursing unit halls, the beauty salon door was unsecured with a hoyer lift placed inside and one upper cabinet with a bottle of eye wash, a bottle of Tylenol with tablets inside, and the lower cabinet had a bottle of "sledge hammer" all purpose cleaner.

During an interview on 2/13/24, at 10:53 a.m., the Nursing Home Administrator (NHA) stated that the salon door should have been locked. The NHA confirmed that the cabinets should have been secured and that the facility failed to maintain the environment free from potential hazards.


28 Pa. Code 201.14(a) Responsibility of licensee.

28 Pa. Code: 201.18 (e)(1) Management.

28 Pa. Code 207.2(a) Administrator's responsibility.
28 Pa. Code: 211.10(d) Resident care policies.





 Plan of Correction - To be completed: 03/25/2024

All items were cleared out of the unlocked and unsecured beauty salon cabinets and the door to the beauty salon was locked immediately on 2/13/24.
The Environmental Supervisor or designee will educate all staff in March 2024 inservices regarding the beauty salon remaining locked when not in use, and also that no items are to be left in unsecured cabinets.
The Environmental Supervisor or designee will ensure the beauty salon will remain secure via visual audit checks weekly for four weeks, monthly for three months, and quarterly thereafter. Results of audits will be reviewed at quarterly QAPI meetings.

483.90(g)(1)(2) REQUIREMENT Resident Call System: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.
§483.90(g) Resident Call System
The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from-

§483.90(g)(1) Each resident's bedside; and
§483.90(g)(2) Toilet and bathing facilities.
Observations:
Based on a review of facility policy, observations and staff interviews, it was determined that the facility failed to provide a functional resident call bell system for the beauty salon (Beauty Salon).

Findings include:

Review of the facility provided checklists of Environmental Services monthly review indicated that the nurses call system of all call lights and bulbs are functioning is identified.

During an observation on 2/13/24, at 10:50 a.m., of the hair salon, the emergency call bell alarm was triggered however, the light above the door and the alert sound were not in functioning order.

During an interview on 2/13/24, at 10:50 a.m., Nurse Aide Employee E2 indicated that the light above the door should illuminate and a sound should be present to alert staff of the need for assistance.

During an interview on 2/13/24, at 10:53 a.m., the Nursing Home Administrator and Maintenance Director Employee E3 confirmed that the facility failed to provide a functional call bell system for the hair salon to alert staff if assistance is needed.


28 Pa. Code: 205.28 (c) (1) Nurse's station.

28 Pa. Code: 205.67 (j) (k) Electric requirements for existing and new construction.


 Plan of Correction - To be completed: 03/25/2024

On 2/13/24, the call light in the beauty salon was immediately repaired and batteries replaced to ensure full functioning of the call bell.
The Environmental Services Supervisor or designee will educate all staff in March 2024 inservices regarding call bell functioning, alternate call bell equipment location and how to report any malfunction timely to maintenance department. The NHA or designee will educate the Environmental Services Supervisor and maintenance staff on the Vigil Call Bell system in regards to maintaining checks on call bell functioning and repair. The Environmental Services Supervisor or designee will audit common area call light functioning plus random room call lights weekly for four weeks, monthly for three month, and quarterly thereafter. Results of audit will be reviewed at Quarterly QAPI meetings.


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