Pennsylvania Department of Health
HEMPFIELD MANOR
Building Inspection Results

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HEMPFIELD MANOR
Inspection Results For:

There are  39 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:Name: - Component: -- - Tag: 0000



Based on an Emergency Preparedness Survey completed on February 8, 2024, at Hempfield Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.




 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 085802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on February 8, 2024, it was determined that Hempfield Manor was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected wood frame building, without a basement, that is fully sprinklered.



 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure: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.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321

Based on observation and interview, it was determined the facility failed to maintain hazardous area enclosures in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on February 8, 2024, at 9:58 a.m., revealed the facility failed to maintain the required one-hour fire rating for hazardous area enclosures. The door to the laundry room (folding room side) was being held open with an unapproved hold-open device (rubber wedge).


Interview with the Facility Administrator and the Maintenance Supervisor on February 8, 2024, at 1:30 p.m., confirmed the listed hazardous are enclosure deficiency.


 Plan of Correction - To be completed: 04/01/2024

On 2/08/24, the rubber wedge door hold-open device was immediately removed from the laundry folding room to allow the self-closing door to work properly to achieve positive latching. All staff will be inserviced in the monthly department meetings in March 2024 by Maintenance Director or designee on the standards of safety regarding hazardous area enclosures and the prohibition on using rubber door wedges to prop open doors.
The Maintenance Director or Designee will audit via facility walkthroughs to ensure continual compliance with hazardous area enclosures. These audits will be completed weekly for four weeks, then monthly for three months, then quarterly, and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Cooking Facilities: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.
Cooking Facilities
Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless:
* residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2
* cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or
* cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4.
Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor.
18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0324

Based on observation, and interview, it was determined the facility failed to maintain the kitchen hood suppression system and equipment, in three instances, affecting one of seven smoke compartments.

Findings include:

1. Observation on February 8, 2024, at 10:05 a.m., revealed the fire suppression pull station in the kitchen was mounted at a height greater than the required 42 to 48 inches above the floor.

Interview with the Facility Administrator and the Maintenance Supervisor on February 8, 2024, at 1:30 p.m., confirmed the pull station was mounted higher than 48 inches.


2. Observation on February 8, 2023, revealed the following kitchen cooking equipment was not protected in accordance with NFPA 96, 12.1.2.3. and 12.1.2.3.1:

a) 10:11 a.m., revealed the wheeled gas-fired tilt-top skillet on the cooking line in the kitchen was not equipped with an approved method that would ensure that the appliance was returned to an approved design location under the kitchen hood extinguishing system after it had been moved for maintenance and cleaning;
b) 10:13 a.m., the gas-fired tilt-top skillet was not tethered in a way so it could not become detached from the gas line connection when moved for cleaning.

Interview with the Facility Administrator and the Maintenance Supervisor on February 8, 2024, at 1:30 p.m., confirmed the listed kitchen cooking equipment deficiencies.





 Plan of Correction - To be completed: 04/01/2024

The facility's kitchen hood fire suppression pull station will be lowered to meet the code requirements of 42"-48" above finish floor. This work will be completed by outside contractor, Summit, in March 2024.
On 2/08/24, the wheeled gas-fired tilt-top skillet was immediately placed in its approved designed location under the kitchen hood. The equipment location will be properly marked on the floor via visual markings. The tilt-top skillet was tethered by an outside contractor, Hobart, on 2/15/24 to eliminate the possibility of detaching from the gas supply line when moved for cleaning. All kitchen staff will be inserviced in March department meeting by Maintenance Director or Designee on the proper placement and location of the tilt skillet after cleaning.
The Maintenance Director or Designee will ensure proper placement of the tilt skillet via audit weekly for four weeks, then monthly for three months, then quarterly, and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Sprinkler System - Supervisory Signals:This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents.  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.
Sprinkler System - Supervisory Signals
Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired.
9.7.2.1, NFPA 72
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0352

Based on documentation review and interview, it was determined the facility failed to maintain the automatic sprinkler system in one instance, affecting the entire facility. Testing shall be in accordance with NFPA 72...14.4.5. Number 15 L (1).

Findings include:

1. Review of documentation on February 8, 2024, at 11:00 a.m., revealed the facility failed to perform the required semi-annual inspection of the valve supervisory switches/tamper switch (semi-annual) 14.4.5, initiating devices (1) of the automatic sprinkler system.

Interview with the Facility Administrator and the Maintenance Supervisor on February 8, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system testing deficiency.



 Plan of Correction - To be completed: 04/01/2024

The facility contracts with a certified sprinkler contractor, Wm T. Spaeder, to maintain the entire sprinkler system including the testing requirements per NFPA 72. This contractor will provide the facility with the appropriate documentation regarding the semi-annual testing and inspection results for the valve supervisory switches/tamper switches. Maintenance staff will be in-serviced on the proper testing and documentation needed for the sprinklers systems in the March department meeting. The Maintenance Director or Designee will audit required documentation weekly for four weeks, then monthly for three months, then quarterly, and results will be reviewed at quarterly QAPI meetings
NFPA 101 STANDARD Sprinkler System - Maintenance and Testing: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.
Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0353

Based on observation and interview, it was determined the facility failed to maintain the automatic sprinkler system in two instances, affecting two of seven smoke compartments.

Findings include:

1. Observation on February 8, 2024, revealed the following automatic sprinkler system deficiencies:

a) 9:03 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the maintenance office/storage room;
b) 9:35 a.m., the facility failed to maintain storage below the 18-inch horizontal sprinkler plane in the business office storage closet.

Interview with the Facility Administrator and the Maintenance Supervisor on February 8, 2024, at 1:30 p.m., confirmed the listed automatic sprinkler system deficiencies.







 Plan of Correction - To be completed: 04/01/2024

On 2/08/24, all storage items were removed from the business office storage closet and the maintenance office/storage room to below the 18-inch horizontal sprinkler plane. All staff will be inserviced in March department meetings by Maintenance Director or Designee on proper storage locations and the restriction of storage heights to below the 18-inch horizontal sprinkler plane.
The Maintenance Director or Designee will audit via facility walkthroughs to ensure continual compliance with maintaining a clear 18-inch horizontal sprinkler plane. These audits will be completed weekly for four weeks, then monthly for three months, then quarterly, and results will be reviewed at quarterly QAPI meeting.

NFPA 101 STANDARD Portable Fire Extinguishers: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.
Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0355

Based on observation and interview, it was determined that the facility failed to maintain portable fire extinguishers in two instances, affecting two of seven smoke compartments.

Findings include:

1. Observation on February 8, 2023, revealed the following portable fire extinguisher deficiencies:

a) 9:07 a.m., there was an unsecured portable fire extinguisher behind the dryers in the laundry room;
b) 9:26 a.m., access to the portable fire extinguisher in physical therapy was blocked by an electric wheelchair.

Interview with the Facility Administrator and the Maintenance Supervisor on February 8, 2024, at 1:30 p.m., confirmed the listed portable fire extinguisher deficiencies.








 Plan of Correction - To be completed: 04/01/2024

The fire extinguisher located in the laundry room has been secured to the wall at proper heights with a clear access path. The electric wheelchair was immediately removed from in front of the fire extinguisher in the therapy department to achieve clear access. All staff will be inserviced in the monthly department meetings in March 2024 by Maintenance Director or designee on the standards of safety in regards to securing and having clear access to the portable fire extinguishers.
The Maintenance Director or Designee will audit via facility walkthroughs to ensure continual compliance with secured portable fire extinguishers and clear access to them. These audits will be completed weekly for four weeks, then monthly for three months, then quarterly, and results will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Subdivision of Building Spaces - Smoke Barrie: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.
Subdivision of Building Spaces - Smoke Barrier Doors
2012 EXISTING
Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors.
19.3.7.6, 19.3.7.8, 19.3.7.9
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0374

Based on observation and interview, it was determined the facility failed to maintain smoke barrier doors in one instance, affecting two of seven smoke compartments.
Findings include:
1. Observation on February 8, 2024, at 9:47 a.m., revealed the B wing smoke barrier doors equipped with latching hardware would not self-close and latch in their frame when tested.
Interview with the Facility Administrator and the Maintenance Supervisor on February 8, 2024, at 1:30 p.m., confirmed the listed smoke barrier doors deficiency.


 Plan of Correction - To be completed: 04/01/2024

On 2/08/24, maintenance staff immediately adjusted the B wing smoke barrier door to achieve positive latching. Maintenance staff will be inserviced in the monthly department meeting in March by Maintenance Director or designee on proper operation of fire and smoke doors.
The Maintenance Director or Designee will audit via facility walkthroughs to ensure continual compliance with all facility smoke barrier doors and their self-closing and latching function. These audits will be completed weekly for four weeks, then monthly for three months, then quarterly, and results will be reviewed at quarterly QAPI meetings.


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