Health inspection·February 15, 2024

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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 [DATE], 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. Page 1 of 5 395705 395705 02/15/2024 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. 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. 395705 Page 2 of 5 395705 02/15/2024 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0880 Provide and implement an infection prevention and control program. Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Some 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. 395705 Page 3 of 5 395705 02/15/2024 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0880 28 Pa. Code: 201.20(c) Staff Development. Level of Harm - Minimal harm or potential for actual harm 28 Pa. Code: 211.10(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services. Residents Affected - Some 395705 Page 4 of 5 395705 02/15/2024 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0919 Make sure that a working call system is available in each resident's bathroom and bathing area. Level of Harm - Minimal harm or potential for actual harm 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). Residents Affected - Few 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. 395705 Page 5 of 5