Below average — CMS composite of the measures below.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Hempfield Manor during CMS and state inspections, most recent first.
The facility failed to ensure grievance forms could be filed anonymously at multiple posted grievance locations, including the front lobby and resident lounge areas. The posted grievance policy and the forms in the grievance boxes did not state that anonymous filing was allowed, and the NHA confirmed the policy did not provide residents information on the right to file a grievance anonymously.
Quarterly MDS assessments were not completed within the required timeframe for four residents. Review of clinical records showed that the ARD-to-completion window exceeded the 14-day limit in each case, and the RN Assessment Coordinator confirmed the facility did not ensure timely completion of the quarterly MDSs.
The facility failed to ensure MDS assessments accurately reflected resident status for 18 of 28 residents. For multiple residents, Section B showed the resident was understood or sometimes/usually understood, but the BIMS and Resident Mood Interview were not completed or were marked Not Assessed. In several cases, residents were documented as rarely understood and the required cognitive and mood interviews were still not completed, and the RNAC confirmed the deficiency during interview.
Failure to Maintain and Manage Oxygen Equipment: Four residents were observed receiving oxygen with equipment that was not maintained per policy or supported by current orders. Two residents had unlabeled tubing, one resident had tubing labeled outside the weekly replacement timeframe, and two residents were using oxygen without a current order for oxygen use. The NHA confirmed the facility failed to provide appropriate respiratory care and maintain oxygen equipment.
Insufficient Annual In-Service Education for Nurse Aides: The facility failed to provide the required 12 hours of annual in-service training for two nurse aides. One aide had about 2 hours of training in the review period, and another had 6.5 hours, despite the facility policy requiring annual training based on hire date. The NHA confirmed the deficiency during interview.
Insufficient nursing staffing led to delayed resident care and unmet needs. Residents reported waiting 30 minutes or longer, and sometimes more than an hour, for call light response, especially on the overnight shift. Grievances and interviews described missed or delayed assistance with toileting, wound care, hygiene, and getting out of bed, and one resident was found on the floor in the bathroom after waiting for help. Staff also acknowledged being short staffed and unable to keep up with resident needs.
Improper Storage of Medications and Medical Supplies: Surveyors found expired needles, syringes, swabs, and other supplies in a medication room, along with an insulin syringe without sterile wrapping and a saline enema with an expiration date. A resident’s medications were stored in pharmacy bottles and weekly dispense kits in a cabinet under the sink, and unlabeled pill planners with multiple meds were left on a shelf. The med refrigerator log also had multiple missing temperature entries, which the LPN and DON confirmed during interview.
Failure to Maintain Resident Dignity During Care: Multiple residents reported care that did not preserve dignity, including delayed assistance with toileting and cleanup, refusal to help a resident get into bed after bingo, and poor hygiene care such as feces on a resident’s feet and around a colostomy bag, soiled wound dressings, unchanged sheets, and unwashed hair. Residents with varying cognitive status and diagnoses including CHF, CVA, COPD, DM, anxiety, and depression described long call light wait times and extended delays after incontinence, and the NHA confirmed the facility failed to ensure care was provided in a manner that maintained resident dignity.
Failure to Obtain and Document Vision Services: A resident with Parkinsonism, Alzheimer's disease, and a seizure disorder needed new eyeglasses, but the record showed no assessment by a vision provider since admission and no care plan interventions related to corrective lenses. The resident was observed with prescription bifocals that had only one lens in the frame, while facility staff stated the glasses in the room were an old pair and that a new pair was being repaired, but no documentation of the repair or vision care was provided.
Missing Abuse, Neglect, and Exploitation Training for Staff: The facility failed to provide required education on dementia care and on abuse, neglect, exploitation, and reporting for five of ten staff members, including RNs, an LPN, an activity employee, and NAs. Review of training records showed no documentation of this annual inservice for the affected staff, and the NHA confirmed the lapse during interview.
The facility failed to provide infection control training for four of ten staff members, including an RN, an activity employee, and two NAs. Although the inservice education program listed prevention and control of infections/standard precautions as a topic, the training records for these employees did not show infection control training during the applicable annual periods. The NHA confirmed the lapse during interview.
The facility failed to complete required MDS assessments within the required time frame for four residents. An annual assessment and an admission assessment were completed late, and an RN assessment coordinator confirmed the missed time frames during interview.
The facility failed to provide effective communication training for four of ten direct care staff members, including an RN, an activity employee, and two NAs. Review of staff records showed the annual training files for these employees did not include this required topic, and the NHA confirmed the omission during interview.
The facility failed to provide resident rights training for five of ten staff members, including an RN, an LPN, activity staff, and two NAs. Although resident rights and confidentiality were listed as inservice topics, the reviewed training records for these employees did not show resident rights education, and the NHA confirmed the omission.
The facility failed to provide QAPI training for five of ten staff members, including an RN, an LPN, activity staff, and an NA. Review of staff training records showed no documented QAPI training for these employees, and the NHA confirmed the omission during interview.
Failure to provide compliance and ethics training was identified for an RN, an activity employee, and a nurse aide. Review of staff training records showed no compliance and ethics training for each of these employees during the reviewed periods, and the NHA confirmed the omission during interview.
Failure to provide behavioral health training for four of ten staff members was identified during review of facility documents and staff interview. Training records for an RN, an activity employee, and two NAs did not show behavioral health training, even though the facility’s inservice program included topics such as care of cognitively impaired residents and dementia training. The NHA confirmed the missing training.
A deficiency was cited for not ensuring a resident's right to dignity, self-determination, communication, and the exercise of their rights. The report does not specify the exact circumstances or individuals involved.
A resident with dementia and an identified risk for elopement was able to leave the facility unsupervised due to a malfunctioning front door alarm and lack of staff awareness of the resident's whereabouts. The resident was found outside by a hospice aide and safely returned, but staff were occupied with other duties and did not notice the resident's absence.
The facility failed to make grievance boxes accessible to residents in two nursing unit lounge areas, violating their grievance policy. The boxes were placed on a shelf out of reach for residents in wheelchairs, as confirmed by the Activity Director and Nursing Home Administrator. This deficiency breaches resident rights and management regulations.
Two residents with intact cognition and significant care needs reported being left in soiled conditions for extended periods due to staff scheduling and workload issues. One resident was left in a urine-soaked brief for two hours, while another sat in soiled conditions for four hours. The facility's failure to provide timely assistance compromised the residents' dignity and quality of life.
The facility did not maintain a homelike environment in three of its four nursing units, as observed in the dusty debris on window air conditioning and heating units in several resident rooms. This was confirmed by the Nursing Home Administrator, indicating a failure to adhere to the facility's Environment Policy.
The facility failed to develop comprehensive care plans for two residents, one with dementia and another with PTSD, lacking specific goals and interventions for their conditions. The DON confirmed the oversight.
A facility failed to update a resident's care plan to reflect current medications and care needs. The resident, with diagnoses including dementia and bipolar disorder, was inaccurately documented as receiving Wellbutrin, which was not administered according to records. The DON confirmed the discrepancy.
A resident with dysphagia and orthostatic hypotension was administered medication by an RN while lying flat, contrary to best practices of elevating the head of the bed. This was confirmed by the Nursing Home Administrator and Director of Nursing, highlighting a failure to follow professional standards.
A facility failed to maintain proper communication with a dialysis center for a resident requiring dialysis. Despite the facility's policy mandating ongoing communication via a dialysis communication form, 11 out of 39 forms were incomplete. The resident, diagnosed with chronic renal disease and high blood pressure, was scheduled for dialysis three times a week. The Director of Nursing confirmed the communication lapses, highlighting a pattern of non-compliance with the facility's policy.
A resident was administered Tramadol for pain levels below the prescribed threshold without documented justification. The facility's failure to adhere to medication administration guidelines resulted in unnecessary medication use, as confirmed by the DON.
The facility failed to maintain complete and accurate medical records for two residents. One resident's psychoactive medication consent forms lacked a signing date, while another resident's wound VAC dressing changes were not documented as ordered. The DON confirmed these documentation lapses.
The facility did not meet the required staffing levels for nurse aides on both evening and night shifts. On one occasion, the facility failed to provide the mandated one NA per 11 residents during the evening shift, and on seven occasions, it did not provide one NA per 15 residents during the night shift. This was confirmed by the Nursing Home Administrator after reviewing staffing documents.
The facility did not meet the required LPN staffing levels during a night shift, providing only 17.70 hours instead of the required 22.40 hours for 112 residents. This deficiency was confirmed by the Nursing Home Administrator.
The facility did not meet the required minimum of 3.20 PPD hours of direct resident care on six days, with PPD hours ranging from 2.83 to 3.16. This was confirmed by the Nursing Home Administrator after reviewing nursing schedules and staff interviews.
The facility failed to meet required nurse aide staffing levels on several shifts over an eight-day period. On one daylight shift, the facility provided fewer hours than required for 112 residents. An evening shift also fell short of the required hours for the same number of residents. The night shift was notably understaffed on four occasions, with significant discrepancies between actual and required hours for resident care. The DON confirmed these deficiencies.
The facility did not meet the required LPN staffing levels during the night shift on two occasions. With a census of 106 residents, the facility was required to provide 21.20 hours of LPN coverage but only provided 15.50 and 19.40 hours on two nights. This was confirmed by the DON.
The facility did not meet the required 3.2 PPD hours of direct care on multiple days, providing only 2.90, 2.83, 3.11, 3.00, and 3.01 PPD hours on certain days. This was confirmed by the DON through a review of staffing documents and interviews.
The facility failed to investigate three allegations of abuse and neglect. A resident alleged an LPN refused treatment, which the LPN confirmed, despite signing off on previous treatments. Another resident alleged bullying and neglect by staff, and later reported feeling marginalized due to staff's refusal to engage in conversation. The facility did not investigate, identify alleged perpetrators, or report these incidents as required.
A resident's right to a dignified living experience was compromised when an LPN called her by a non-preferred name during a treatment discussion, despite the preferred name being listed in her medical record. This incident led to a grievance filed by the resident and was confirmed by the Nursing Home Administrator.
A resident with COPD and chronic respiratory failure experienced difficulty breathing due to an empty portable oxygen tank and was not connected to the room concentrator. The incident occurred during a busy shift change, and the staff were not informed of the resident's oxygen needs. The resident's call light remained unanswered for nearly an hour due to insufficient staffing and high call light volume. The facility's investigation confirmed the delay and the chaotic environment on the hall.
The facility failed to ensure proper monitoring and treatment of a resident's pressure ulcer, leading to the development and worsening of a Stage II pressure ulcer. Despite physician orders for daily dressing changes, multiple instances of missed documentation were noted, and the deficiency was confirmed by the Nursing Home Administrator and Director of Nursing.
Grievance Forms Not Available for Anonymous Filing
Penalty
Summary
The facility failed to ensure that grievance forms could be filed anonymously in four locations where grievance information was available, including the front lobby, resident lounges between units A/B and C/D, the grievance boxes in front of the activity department, and the resident lounges between units A/B and C/D. Review of the facility's Grievances policy, last reviewed 12/2/25, showed that a formal grievance had to be submitted in writing to the Grievance Officer and signed by the resident or the person filing the grievance on the resident's behalf. During observation, the grievance policy and procedure posted in the facility did not include wording stating that a grievance form could be filed anonymously, and the grievance forms available at the grievance box locations also did not include that wording. During interview, the Nursing Home Administrator confirmed that the facility's grievance policy and procedure did not provide information on residents' right to file a grievance anonymously.
Late Quarterly MDS Assessments
Penalty
Summary
Quarterly Minimum Data Set (MDS) assessments were not completed within the required time frame for four of 25 residents, including R5, R14, R43, and R60. The Resident Assessment Instrument User's Manual dated October 2024 stated that quarterly MDS assessments were to be completed no later than 14 days after the Assessment Reference Date (ARD), but the clinical record review showed that R5 had an ARD of 2/13/26 with an MDS completion date of 3/2/26, R14 had an ARD of 2/11/26 with an MDS completion date of 2/26/26, R43 had an ARD of 10/30/25 with an MDS completion date of 11/13/26, and R60 had an ARD of 9/26/25 with an MDS completion date of 10/1425. During interview, the Resident Nurse Assessment Coordinator confirmed that the facility failed to make certain that quarterly MDS assessments were completed in the required time frame for these four residents.
MDS assessments not accurately completed for multiple residents
Penalty
Summary
The facility failed to ensure that MDS assessments accurately reflected residents’ status for 18 of 28 residents. The RAI User’s Manual instructions cited in the report stated that a resident interview should be conducted for Section C: Cognitive Patterns and Section D: Mood when the resident is at least sometimes understood verbally, in writing, or by another method, and that Section O should reflect treatments, procedures, or programs received within the last 14 days or since admission/reentry. For multiple residents, Section B of the MDS indicated the resident was understood or sometimes/usually understood, yet the BIMS and Resident Mood Interview were not completed or were marked Not Assessed. This was documented for residents including R12, R20, R29, R48, R53, R56, R63, R74, R85, R95, R100, R102, and R119. In several cases, Section B indicated the resident was understood, while Sections C and D were left Not Assessed. For other residents, Section B indicated the resident was sometimes or usually understood, but Section C and Section D were not completed as required. For R4, R90, R101, and R114, Section C and Section D reflected that the resident was rarely understood, and the BIMS and Resident Mood Interview were not completed. For R103, Section C was documented as Not Assessed. During an interview on 3/19/26 at 2:27 p.m., the Resident Nurse Assessment Coordinator confirmed that the facility failed to ensure that MDS assessments accurately reflected the residents’ status for 18 of 28 residents.
Failure to Maintain and Manage Oxygen Equipment
Penalty
Summary
The facility failed to provide appropriate respiratory care and maintain oxygen equipment for four sampled residents who were observed using oxygen. Facility policy for oxygen by nasal cannula required cannula and tubing to be replaced weekly and labeled with the resident’s name and date. Resident R2, who had diagnoses including respiratory failure, hypertension, and anxiety disorder and was ordered 3 liters per minute of oxygen, was observed using oxygen with tubing labeled 2/14/26. Resident R46, who had diagnoses including cerebrovascular accident, diabetes mellitus, and bipolar disorder and was ordered 0-4 liters per minute of oxygen to maintain oxygen saturation above 90 percent with weekly tubing changes, was observed using oxygen with tubing that was not labeled. Resident R61, who had diagnoses including cerebrovascular accident, heart failure, and diabetes mellitus, was observed using oxygen even though no physician order for oxygen use was found in the current orders; the tubing was labeled 2/21/26. Resident R138, who had diagnoses including COPD, pneumonia, and diabetes mellitus, was also observed using oxygen despite no current physician order for oxygen use being present, although an order existed to change oxygen tubing weekly; the tubing was not labeled. During interview, the NHA confirmed that the facility failed to provide appropriate respiratory care and maintain oxygen equipment.
Insufficient Annual In-Service Education for Nurse Aides
Penalty
Summary
The facility failed to conduct at least 12 hours of in-service education within 12 months of the hire date anniversary for two of five nurse aides, Employees E6 and E7. The facility policy stated that nursing assistants are required to have 12 hours of training per year calculated from their date of hire. Review of staff records showed that E6 was hired on 1/9/24 and had approximately 2.00 hours of in-service education between 1/9/25 and 1/9/26, while E7 was hired on 1/10/23 and had 6.50 hours of in-service education between 1/10/25 and 1/10/26. During an interview, the Nursing Home Administrator confirmed that the facility failed to provide the required annual in-service education for these two nurse aides.
Insufficient Nursing Staffing and Delayed Resident Care
Penalty
Summary
Sufficient nursing staff were not provided each day to meet resident needs, and the facility failed to have nursing and related services available to help residents attain or maintain their highest practicable physical, mental, and psychosocial well-being. The deficiency was identified for 14 of 23 residents, including residents who reported long waits for call light response, often 30 minutes or longer and sometimes more than an hour. During a group interview, residents stated the lack of nurse aides was primarily on the evening shift and described delays when needing help to use the bathroom, receive pain medication, or after a fall. Resident council minutes also documented ongoing staffing concerns and requests for more help. Individual resident concerns and observations supported the staffing deficiency. One resident grievance stated the resident was not receiving adequate care on all shifts and wanted to get out of bed daily after breakfast, while another grievance reported a resident’s wound dressing was not changed again after a bowel movement, and the resident’s sheets had not been changed for a week, with crumbs on them and hair not washed. A resident was found on the floor in the bathroom with the bedside call light on, and the resident and roommate stated the resident often got up alone because staff took too long to respond. Other residents were observed with unbrushed hair, brown substance under fingernails, and one resident reported being incontinent while waiting for assistance to urinate. Staff interviews also confirmed the facility was short staffed and had difficulty keeping up with resident needs.
Improper Storage of Medications and Medical Supplies
Penalty
Summary
The facility failed to ensure that medical supplies and medications were properly stored and/or disposed of in one of two medication rooms on the A/B Nursing Unit. During an observation of the medication room, surveyors found multiple expired or improperly stored items, including 25-gauge needles, 22-gauge safety syringes, viral transport swabs, 5 milliliter syringes, feeding tube connector sets, a specimen collection set, and vacutainer collection winged needles. An insulin syringe was also observed without sterile wrapping, and a saline enema was present with an expiration date of 02/2026. The facility policy on medication storage stated that outdated, contaminated, or deteriorated items would be removed from stock. Surveyors also observed a bag of Resident R31's medications in community pharmacy bottles and weekly paper dispense kits stored in the cabinet below the medication room sink. In addition, personal daily pill planner sets containing multiple medications were found on a shelf in the medication room without a resident name or description of the medications. Review of the medication refrigerator temperature log showed multiple missing temperature entries across the documented period. During interviews, the LPN confirmed the expired medical supplies, the DON confirmed it was unknown who the medications in the personal pill dividers belonged to and acknowledged the missing refrigerator log dates, and the NHA confirmed the facility failed to ensure medical supplies and medications were properly stored and/or disposed of in the medication room.
Failure to Maintain Resident Dignity During Care
Penalty
Summary
The facility failed to ensure that care was provided in a manner that maintained resident dignity for five residents. The cited concern involved resident rights, including the right to a dignified existence, self-determination, and communication, and the facility policy stated that each resident must be treated with respect and dignity. Survey review also referenced the RAI User’s Manual and BIMS scoring guidance used to assess cognitive status. For one resident with heart failure, anxiety disorder, anemia, and a BIMS of 15, a grievance stated that after bingo the resident asked to go to bed, but staff sitting at the nurse’s station would not place the resident into bed. For another resident with a history of stroke, anxiety, depression, and a BIMS of 3, a grievance filed by the resident’s sister reported dried feces on the resident’s feet and around the colostomy bag. A third resident with COPD, diabetes, hypertension, and a BIMS of 9 had a grievance stating the resident had a bowel movement that soiled a wound dressing, was told the dressing had already been changed and could not be changed again, and the resident’s sheets had not been changed for a week, had crumbs on them, and the resident’s hair was not washed. Two additional residents reported long waits for toileting and cleanup. One resident with heart failure, diabetes, hypertension, and a BIMS of 15 said call light wait times were extended and that after soiling himself he had to wait 30 to 60 minutes for help getting cleaned up. Another resident with heart failure, diabetes, anxiety, and a BIMS of 12 reported staffing and call light wait-time concerns and said that on more than one occasion he soiled himself and waited more than an hour to be cleaned up. During interview, the Nursing Home Administrator confirmed the facility failed to make certain that care was provided in a manner that maintained resident dignity.
Failure to Obtain and Document Vision Services
Penalty
Summary
The facility failed to obtain routine services from an eye care professional and failed to accurately document the need for vision care for Resident R12. The facility assessment stated that vision care would be provided for vision loss, cataracts, glaucoma, and macular degeneration. Resident R12 was admitted with diagnoses including Parkinsonism, Alzheimer's disease, and a seizure disorder. The MDS indicated that the resident did not use corrective lenses, and the most recent plan of care did not include goals or interventions related to corrective lenses. A physician order allowing the resident to be seen by an optometrist and ophthalmologist was discontinued when the resident was hospitalized and was not renewed after the resident returned to the facility. During interview, Resident R12 stated she needed new eyeglasses, and review of the clinical record did not reveal documentation that she had been assessed by a vision provider since admission. On a later interview, the resident again confirmed she needed new eyeglasses and showed her current glasses, which were observed to be prescription bifocals with only one lens in the frame. Facility administration stated the glasses in the room were the resident's old pair and that she had a new pair being repaired, but no documentation of the repair or any vision care provided was produced. The Nursing Home Administrator confirmed the facility failed to obtain routine services from an eye care professional and failed to accurately document the need for vision care for one of five residents.
Missing Abuse, Neglect, and Exploitation Training for Staff
Penalty
Summary
The facility failed to provide training on the prevention of abuse, neglect, and exploitation for five of ten staff members, including two RNs, one LPN, one activity employee, and two nurse aides. Review of the facility policy for inservice education showed that the program included topics such as Abuse, Neglect, and Misappropriation and Reporting Crimes Pursuant to the Elder Justice Act, but the training records for these employees did not show that they had received this required education during the reviewed training periods. Facility records showed that RN Employee E2, hired on 2/14/23, did not have abuse, neglect, and exploitation training documented for 2/14/25 through 2/14/26. LPN Employee E3, hired on 2/12/19, did not have the training documented for 2/12/25 through 2/12/26. Activity Employee E5, hired on 1/6/06, NA Employee E6, hired on 1/9/24, and NA Employee E7, hired on 1/10/23 also lacked documentation of this training for their reviewed annual periods. During an interview on 3/20/26, the Nursing Home Administrator confirmed the facility failed to provide the training for these five staff members.
Failure to Provide Infection Control Training
Penalty
Summary
The facility failed to provide infection control training for four of ten staff members, including an RN, an activity employee, and two nurse aides. The facility policy for inservice education listed Prevention and Control of Infections / Standard Precautions as a topic, but review of the training records for the identified employees showed no infection control training during the applicable annual training periods. The RN was hired on 2/14/23, the activity employee on 1/6/06, the first nurse aide on 1/9/24, and the second nurse aide on 1/10/23, and their records did not include infection control training. During interview, the Nursing Home Administrator confirmed that the facility failed to provide infection control training for four of ten staff members.
Late Completion of Required MDS Assessments
Penalty
Summary
The facility failed to ensure that comprehensive MDS assessments were completed within the required time frame for four of 22 residents. According to the RAI User's Manual, admission MDS assessments were to be completed no later than 14 days after admission, and annual MDS assessments were to be completed no later than the ARD. Resident R14 had an ARD of 8/11/25 and an MDS completion date of 8/26/25, Resident R25 had an ARD of 8/5/25 and an MDS completion due date of 8/20/25, Resident R27 had an admission date of 9/22/25 and an MDS completion due date of 10/8/25, and Resident R31 had an ARD of 8/5/25 and an MDS completion date of 8/20/25. During an interview on 3/19/26, the Resident Nurse Assessment Coordinator confirmed that the facility failed to make certain these MDS assessments were completed in the required time frame.
Missing Effective Communication Training for Direct Care Staff
Penalty
Summary
The facility failed to provide training on effective communication for four of ten direct care staff members, including RN Employee E2, Activity Employee E5, and Nurse Aides E6 and E7. Review of the facility policy for inservice education indicated that the inservice education program is planned and conducted for the development and improvement of skills and personnel. However, review of the staff lists and training records showed that each of these employees had training records for their respective annual periods that did not include training on effective communication. During an interview, the Nursing Home Administrator confirmed that the facility failed to provide this training for four of ten staff members.
Failure to Provide Resident Rights Training
Penalty
Summary
The facility failed to provide training on resident rights for five of ten staff members. Review of the facility's inservice education policy indicated that resident rights and confidentiality were included among the topics planned for staff education, but review of training records showed no resident rights training for RN E2, LPN E3, Activity staff E5, and NAs E6 and E7 during the reviewed annual periods. The facility staff list showed that these employees were hired on various dates between 2006 and 2024. During an interview, the Nursing Home Administrator confirmed that the facility failed to provide resident rights training for five of ten staff members. The report cited 28 Pa Code: 201.14(a), 28 Pa Code: 201.18(b)(1), and 28 Pa Code: 201.20(a)(c) in connection with the deficiency.
Failure to Provide QAPI Training to Staff
Penalty
Summary
The facility failed to provide training on its QAPI (Quality Assurance and Performance Improvement) Program for five of ten staff members reviewed. Review of the facility policy for Inservice Education dated 12/2/25 indicated that the inservice education program is planned and conducted for the development and improvement of skills and personnel. However, review of training records for RN E2, LPN E3, Activity staff E4, Activity staff E5, and NA E6 showed that each employee’s annual training record did not include QAPI Program training. The staff records reviewed showed that E2 was hired on 2/14/23, E3 on 2/12/19, E4 on 2/16/10, E5 on 1/6/06, and E6 on 1/9/24. Their training records for the applicable annual periods did not document QAPI training. During an interview on 3/20/26 at approximately 2:30 p.m., the Nursing Home Administrator confirmed that the facility failed to provide training on the QAPI Program for five of ten staff members.
Failure to Provide Compliance and Ethics Training
Penalty
Summary
The facility failed to provide training on compliance and ethics for three of ten staff members: an RN, an activity employee, and a nurse aide. Review of the facility policy on inservice education indicated that the program is planned and conducted for the development and improvement of skills and personnel. However, review of the RN's training record for the period from 2/14/25 through 2/14/26 did not include compliance and ethics training, the activity employee's training record for the period from 1/6/25 through 1/6/26 did not include compliance and ethics training, and the nurse aide's training record for the period from 1/9/25 through 1/9/26 did not include compliance and ethics training. During interview, the Nursing Home Administrator confirmed that the facility failed to provide this training for the three staff members.
Failure to Provide Behavioral Health Training
Penalty
Summary
Behavioral health training was not provided for four of ten staff members, including an RN, an activity employee, and two nurse aides. Review of the facility policy and inservice education documentation showed that the facility’s inservice education program included topics such as care of cognitively impaired residents and dementia training, but the individual training records for the identified employees did not include behavioral health training. The RN was hired on 2/14/23, the activity employee on 1/6/06, one nurse aide on 1/9/24, and another nurse aide on 1/10/23, and their training records for the reviewed annual periods did not show behavioral health training. During interview, the Nursing Home Administrator confirmed that the facility failed to provide behavioral health training for these four staff members.
Failure to Honor Resident Rights
Penalty
Summary
A deficiency was identified regarding the failure to honor the resident's right to a dignified existence, self-determination, communication, and the exercise of their rights. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions that led to this deficiency, nor does it mention any particular events or residents involved.
Failure to Prevent Elopement Due to Inadequate Supervision and Faulty Door Alarm
Penalty
Summary
The facility failed to provide adequate supervision to prevent the elopement of a resident who was identified as being at risk for elopement. The resident, who had diagnoses including diabetes, high blood pressure, and dementia, was admitted with a care plan and physician's order for a secure care bracelet to monitor their location. Despite these interventions, the resident was able to exit the facility unsupervised and was found outside walking toward a main road by a hospice aide, who redirected the resident back inside. Staff statements indicated that the resident was last seen walking off the unit, and staff were occupied with other duties at the time. The resident was unable to recall how they exited the building or which door was used. Review of facility records and staff interviews revealed that the front door alarm system was not functioning appropriately at the time of the incident, with a significant delay in door closing. Other doors were functioning correctly, but the malfunction of the front door alarm contributed to the resident's ability to leave the facility undetected. The facility's policy required staff to be aware of the resident's location at all times, but this was not maintained, resulting in the resident being outside in cold weather without staff knowledge.
Inaccessible Grievance Boxes for Residents
Penalty
Summary
The facility failed to ensure that grievance boxes were accessible to residents in two nursing unit resident lounge areas, specifically the East and [NAME] Wings. The facility's grievance policy, reviewed on 1/6/25, mandates that all individuals be given the opportunity to present complaints through a formal grievance procedure. However, during an observation on 3/4/25, it was noted that the grievance boxes and forms were placed on a shelf out of reach for residents in wheelchairs. This inaccessibility was confirmed by the Activity Director and the Nursing Home Administrator during interviews conducted on 3/4/25 and 3/5/25, respectively. The deficiency is in violation of 28 PA Code: 201.18(e)(4) Management and 28 PA Code: 201.29(a)(b)(c) Resident rights.
Failure to Provide Prompt Assistance Compromises Resident Dignity
Penalty
Summary
The facility failed to provide prompt assistance to meet the care needs of two residents, R14 and R49, which compromised their dignity and quality of life. Resident R14, who has intact cognition with a BIMS score of 15, was left in a urine-soaked brief for two hours during a night shift, as reported by the resident. The staff member responsible allegedly told the resident that they must wait two hours because it was their schedule. This incident occurred despite the resident requiring substantial assistance for toileting hygiene and being frequently incontinent. Similarly, Resident R49, who also has intact cognition with a BIMS score of 15, reported having to sit in soiled conditions for four hours after moving their bowels because the staff was too busy. This resident has a medical history of diabetes, bilateral lower extremity amputation, and a stage II pressure ulcer in the sacral region, and requires substantial assistance for toileting hygiene. The Nursing Home Administrator and the Director of Nursing confirmed the facility's failure to provide an environment and care that promotes dignity for these residents.
Facility Fails to Maintain Homelike Environment Due to Dusty Air Units
Penalty
Summary
The facility failed to maintain a homelike environment in three of its four nursing units, specifically in the resident rooms on A, C, and D Wings. During an observation, it was noted that the window air conditioning and heating units in several rooms across these wings had accumulated dusty debris. This was confirmed by the Nursing Home Administrator during an interview, acknowledging the facility's failure to uphold a clean and comfortable environment as per their Environment Policy dated 1/6/25. The deficiency was identified under the Pennsylvania Code: 207.2 (a), which outlines the administrator's responsibility to ensure a safe and homelike environment for residents.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans that included person-centered care instructions for two residents. Resident R4, who was admitted with a diagnosis of dementia, did not have a care plan with goals and interventions addressing their dementia needs as of the current care plan dated 9/12/24. Similarly, Resident R86, who was admitted with a history of Post Traumatic Stress Disorder (PTSD), lacked a care plan with goals and interventions for PTSD as of the care plan dated 11/14/24. The Director of Nursing confirmed the facility's failure to ensure complete care plans for these residents' specific care needs.
Failure to Update Resident Care Plan
Penalty
Summary
The facility failed to update the care plan for Resident R4 to accurately reflect the current status and care needs. The facility's policy requires a comprehensive care plan to be developed, reviewed, and revised by a team of health professionals within 7 days of the comprehensive assessment. However, the care plan for Resident R4, last revised on 9/12/24, inaccurately indicated the resident was receiving Wellbutrin, an anti-depressant, which was not reflected in the medication administration records for February and March 2025. Resident R4, who has diagnoses of dementia, depression, anxiety, and bipolar disorder, was prescribed Risperdal, Depakote, Ativan, and Effexor as per the physician's order dated 3/4/25. The Director of Nursing confirmed the oversight during an interview on 3/4/25.
Failure to Follow Medication Administration Standards
Penalty
Summary
The facility failed to adhere to professional standards of practice for one of the four residents observed, specifically Resident R57. The resident, who was admitted with diagnoses of dysphagia and orthostatic hypotension, was administered medication by RN Employee E2 while in a supine position. This action was contrary to the best practice of elevating the head of the bed at least 30-45 degrees when administering medication to a resident in bed, as confirmed by other nursing staff. The incident was confirmed during interviews with the Nursing Home Administrator and Director of Nursing, who acknowledged that RN Employee E2 did not follow professional standards. The active orders for Resident R57 included Midodrine HCl Oral Tablet 5 MG to be administered three times a day for hypotension, and the Medication Administration Record confirmed the lunchtime dose was given on the day of the observation.
Failure in Dialysis Communication for a Resident
Penalty
Summary
The facility staff failed to maintain ongoing communication with the hemodialysis center for a resident who required dialysis services. According to the facility's Dialysis Care Policy, there should be continuous communication and collaboration with the dialysis facility regarding the care and services provided. The policy specifies that qualified trained staff must use a written format, specifically a dialysis communication form, to facilitate this communication. However, a review of Resident R59's Dialysis Hand Off Communication Report forms revealed that out of 39 scheduled treatments, 11 forms were incomplete, with the section to be filled out by the dialysis center left blank on multiple occasions. Resident R59, who was readmitted to the facility with diagnoses including chronic renal disease and high blood pressure, was scheduled to receive dialysis three times a week. Despite this, the facility failed to ensure that the dialysis communication forms were completed and returned with the resident, as confirmed by the Director of Nursing. This lack of communication was observed on specific dates, indicating a pattern of non-compliance with the facility's policy, which could potentially impact the quality of care provided to the resident.
Unnecessary Medication Administration for Pain Management
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary medication use. A review of the clinical record and staff interviews revealed that a resident, who was admitted with diagnoses of pain in the left knee and right hip, was prescribed Tramadol HCI for pain management. The physician's order specified that Tramadol should be administered as needed for pain levels between 5 and 8 on the Numeric Pain Scale. However, the Medication Administration Record indicated that the resident received Tramadol eight times for pain levels below 5, without any documented explanation for this deviation from the prescribed order. The Director of Nursing confirmed these findings, acknowledging that the facility did not adhere to the medication administration guidelines, resulting in the unnecessary use of Tramadol for the resident. This deficiency was identified under the regulation 28 Pa. Code 211.12(d)(1)(3)(5) concerning nursing services.
Incomplete and Inaccurate Medical Records for Two Residents
Penalty
Summary
The facility failed to ensure that medical records for two residents were complete and accurately documented. For one resident with anxiety and bipolar disorder, the Acknowledgment of Psychoactive Medication Use forms were missing the date when signed by the resident. This was confirmed by the Director of Nursing (DON) during an interview, indicating a lapse in maintaining accurate documentation as per the facility's Documentation Policy. For another resident with diabetes and a diabetic wound, the treatment administration record did not document the wound VAC dressing changes as ordered on two specific dates. A registered nurse revealed that the dressing was not changed on one of the dates due to the resident's refusal, and the order to change the dressing schedule was not documented in the clinical record. The DON confirmed these findings, highlighting the facility's failure to maintain complete and accurate medical records for these residents.
Staffing Deficiency in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides on both the evening and night shifts over a specified period. Specifically, on one occasion, the facility did not provide the mandated one nurse aide per 11 residents during the evening shift, and on seven occasions, it did not provide one nurse aide per 15 residents during the night shift. This deficiency was identified through a review of staffing documents from January 9, 2025, to January 20, 2025, which showed discrepancies between the actual hours worked by nurse aides and the hours required based on the resident census. The Nursing Home Administrator confirmed these staffing shortfalls during an interview.
Plan Of Correction
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 credible allegation of compliance. All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Hempfield Manor will be protected from future staff ratios below the 1:11 nurse aide for evenings and 1:15 nurse aide for nights by a proactive preview by the DON/Designee of daily staff assignments and schedules to ensure adequate staff coverage. The nursing scheduler/designee will review projected staffing levels with the DON/designee daily for 3x weekly to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. Weekend and Shift Supervisors will be educated by DON/designee by 2/14/25 to immediately contact all off staff on the nursing list first to see about coverage and next contact DON/ADON for any day that ratios unexpectedly drop below the nurse aide ratio minimum for immediate resolution. Hempfield Manor will continue to aggressively advertise externally for recruitment of nursing/C.N.A. applicants to enhance current staffing levels. Hempfield Manor will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Hempfield Manor is an approved site for Fairview Manor's Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing class trainings throughout the year. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the ratio levels. All licensed nursing staff are asked to pick up at least one on-call shift per month to also cover calloffs that affect minimum ratios. Hempfield Manor has raised all wages for certified aides. Hempfield Manor also offers on call shifts/pay to current staff to cover extra shifts. Staffing ratios will be reviewed by a DON/nursing designee 3x's a week for a month, then weekly x3 weeks then monthly x2 months. Results will be reported on a monthly basis during monthly QAPI committee meeting and at Quarterly Quality Assurance/QAPI meeting.
LPN Staffing Shortage on Night Shift
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of one licensed practical nurse (LPN) per 40 residents during the night shift on one occasion. Specifically, on January 11, 2025, the facility had a census of 112 residents but only provided 17.70 actual LPN hours instead of the required 22.40 hours. This staffing shortage was confirmed by the Nursing Home Administrator during an interview conducted on January 23, 2025.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Hempfield Manor will be protected from future staff ratios below the 1:40 night LPN by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by DON/Designee. The nursing scheduler/designee will review projected staffing levels with the DON/designee 3x weekly to ensure that any foreseeable staffing levels below LPN ratios are adequately covered. Weekend and Shift Supervisors will be educated by DON/designee by 2/14/25 to immediately contact all off staff on the nursing list first to see about coverage and next contact DON/ADON for any day that ratios unexpectedly drop below the LPN ratio minimum for immediate resolution. Hempfield Manor will continue to aggressively advertise externally for recruitment of nursing applicants to enhance current staffing levels. Hempfield Manor will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the minimum ratio levels. All licensed nursing staff are asked to pick up at least one on-call shift per month and be available for call offs that cause staffing levels to be below the minimum ratio levels. Hempfield Manor offers extra on call pay for on call availability. Hempfield Manor has raised all wages for licensed nursing staff. Staffing ratios will be reviewed by a DON/nursing designee 3x's a week for a month, then weekly x3 weeks then monthly x2 months. Results will be reported on a monthly basis during monthly QAPI committee meeting and at Quarterly Quality Assurance/QAPI meeting.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-required minimum of 3.20 hours of direct resident care per patient daily (PPD) on six out of twelve days reviewed. Specifically, on the dates of January 9, 10, 12, 16, 19, and 20, 2025, the facility provided less than the mandated hours, with PPD hours recorded as 3.16, 3.00, 2.83, 3.12, 2.96, and 3.01, respectively. This deficiency was identified through a review of nursing time schedules and staff interviews. The Nursing Home Administrator confirmed the shortfall in meeting the required PPD hours during an interview conducted on January 23, 2025.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Hempfield Manor will be protected from future staff ratios below 3.2 by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by DON/Designee. The nursing scheduler/designee will review projected staffing levels with the DON/designee daily for 3x weekly to ensure that any foreseeable staffing levels below 3.2 PPD are adequately covered. Weekend and Shift Supervisors will be educated by DON/designee by 2/14/25 to immediately contact all off staff on the nursing list first to see about coverage and next contact DON/ADON for any day that ratios unexpectedly drop below the 3.2 minimum for immediate resolution. Hempfield Manor will continue to aggressively advertise externally for recruitment of nursing/C.N.A. applicants to enhance current staffing levels. Hempfield Manor will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Hempfield Manor is an approved site for Fairview Manor's Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing class trainings throughout the year. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the PPD minimum levels. All licensed nursing staff are asked to pick up at least one on-call shift per month and be available for call offs that cause staffing levels to be below the minimum PPD levels. Hempfield Manor offers extra on call pay for on call availability. Hempfield Manor has raised all wages for certified aides and licensed nursing staff. Nurse Staffing PPD Hours will be reviewed by a DON/nursing designee 3x's a week for a month, then weekly x3 weeks then monthly x2 months. Results will be reported on a monthly basis during monthly QAPI committee meeting and at Quarterly Quality Assurance/QAPI meeting.
Staffing Deficiencies in Nurse Aide Coverage
Penalty
Summary
The facility failed to meet the required staffing levels for nurse aides (NAs) on multiple shifts over an eight-day period. Specifically, on December 4, 2024, the daylight shift did not have the required number of NAs, with only 81.30 hours provided instead of the required 84.00 hours for a census of 112 residents. On December 3, 2024, the evening shift was also understaffed, providing 74.20 hours instead of the required 76.36 hours for 112 residents. The night shift was particularly affected, with deficiencies noted on December 3, 4, 8, and 9, 2024. For instance, on December 3, 2024, only 51.20 hours were provided instead of the required 56.50 hours for 113 residents. Similar shortfalls occurred on the other noted dates, with the facility failing to meet the required staffing levels for the night shift. The Director of Nursing confirmed these staffing deficiencies during an interview on December 10, 2024.
Plan Of Correction
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 credible allegation of compliance. All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Hempfield Manor will be protected from future staff ratios below the 1:10 nurse aide for days, the 1:11 nurse aide for evenings and 1:15 nurse aide for nights by a proactive preview by the DON/Designee of daily staff assignments and schedules to ensure adequate staff coverage. The nursing scheduler/designee will review projected staffing levels with the DON/designee daily for 3x weekly to ensure that any foreseeable staffing levels below nurse aide ratios are adequately covered. Weekend and Shift Supervisors will be educated by DON/designee by 12/20/24 to immediately contact all off staff on the nursing list first to see about coverage and next contact DON/ADON for any day that ratios unexpectedly drop below the nurse aide ratio minimum for immediate resolution. Hempfield Manor will continue to aggressively advertise externally for recruitment of nursing/C.N.A. applicants to enhance current staffing levels. Hempfield Manor will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Hempfield Manor is an approved site for Fairview Manor's Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing class trainings throughout the year. Current class has 3 students and preparation underway for next class in January. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the ratio levels. All licensed nursing staff are asked to pick up at least one on-call shift per month to also cover call offs that affect minimum ratios. Hempfield Manor has raised all wages for certified aides. ALL trained staff is being asked to assist when CNA team is understaffed. Hempfield Manor also offers on call shifts/pay to current staff to cover extra shifts. Staffing ratios will be reviewed by a DON/nursing designee 3x's a week for a month, then weekly x3 weeks then monthly x2 months. Results will be reported on a monthly basis during monthly QAPI committee meeting and at Quarterly Quality Assurance/QAPI meeting.
LPN Staffing Shortage on Night Shift
Penalty
Summary
The facility failed to meet the required staffing levels for Licensed Practical Nurses (LPNs) during the night shift on two specific days. According to the review of nursing time schedules and facility census data from December 2, 2024, through December 9, 2024, the facility did not provide the minimum of one LPN per 40 residents on the nights of December 8 and December 9, 2024. On these nights, the facility had a census of 106 residents, requiring 21.20 hours of LPN coverage, but only provided 15.50 and 19.40 actual hours, respectively. This deficiency was confirmed by the Director of Nursing during an interview on December 10, 2024.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Residents of Hempfield Manor will be protected from future staff ratios below the 1:25 daylight LPN and 1:40 night LPN by a proactive preview of daily staff assignments and schedules to ensure adequate staff coverage by DON/Designee. The nursing scheduler/designee will review projected staffing levels with the DON/designee 3x weekly to ensure that any foreseeable staffing levels below LPN ratios are adequately covered. Weekend and Shift Supervisors will be educated by DON/designee by 12/20/2024 to immediately contact all off staff on the nursing list first to see about coverage and next contact DON/ADON for any day that ratios unexpectedly drop below the LPN ratio minimum for immediate resolution. Hempfield Manor will continue to aggressively advertise externally for recruitment of nursing applicants to enhance current staffing levels. Hempfield Manor will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the minimum ratio levels. All licensed nursing staff are asked to pick up at least one on-call shift per month and be available for call offs that cause staffing levels to be below the minimum ratio levels. Hempfield Manor offers extra on call pay for on call availability. Hempfield Manor has raised all wages for licensed nursing staff. On call is available for LPN staff to help cover call offs or unexpected reduction in staffing of LPN. Staffing ratios will be reviewed by a DON/nursing designee 3x's a week for a month, then weekly x3 weeks then monthly x2 months. Results will be reported on a monthly basis during monthly QAPI committee meeting and at Quarterly Quality Assurance/QAPI meeting.
Failure to Meet Minimum Direct Care Hours
Penalty
Summary
The facility failed to meet the state-mandated requirement of providing a minimum of 3.2 hours of direct resident care per patient daily (PPD) on five out of eight days reviewed. Specifically, on the dates of December 3, 4, 7, 8, and 9, 2024, the facility provided 2.90, 2.83, 3.11, 3.00, and 3.01 PPD hours of care, respectively. This deficiency was identified through a review of nursing time schedules and staff interviews. The Director of Nursing confirmed the shortfall in meeting the required PPD hours during an interview conducted on December 10, 2024.
Plan Of Correction
All residents received appropriate care and services to meet their needs on the identified days and there was no direct correlation to an individual resident. Hempfield Manor will continue to aggressively advertise externally for recruitment of nursing/C.N.A. applicants to enhance current staffing levels. Hempfield Manor will also review potential admissions and reconsider admissions if the facility is unable to meet minimum staffing levels. Hempfield Manor is an approved site for Fairview Manor's Pennsylvania Nurse Aide Training and Competency Evaluation Program and has ongoing class trainings throughout the year. Administrative RNs are assigned to an on-call schedule and are available to cover shifts when foreseeable staffing levels are below the PPD minimum levels. All licensed nursing staff are asked to pick up at least one on-call shift per month and be available for call offs that cause staffing levels to be below the minimum PPD levels. Hempfield Manor offers extra on call pay for on call availability. Bonus for staff bringing in new employees is in place. Hempfield Manor has raised all wages for certified aides and licensed nursing staff. Nurse Staffing PPD Hours will be reviewed by a DON/nursing designee 3x's a week for a month, then weekly x3 weeks then monthly x2 months. Results will be reported on a monthly basis during monthly QAPI committee meeting and at Quarterly Quality Assurance/QAPI meeting.
Failure to Investigate Allegations of Abuse and Neglect
Penalty
Summary
The facility failed to conduct thorough investigations into three allegations of possible abuse and neglect. The first incident involved a resident who alleged that an LPN refused to provide treatment, which the LPN confirmed, citing unawareness of a physician's order, despite having signed off on the treatment on previous days. The second incident involved a resident alleging bullying and refusal of care by a staff member. The third incident involved the same resident alleging that staff refused to engage in conversation, making her feel marginalized. The Nursing Home Administrator confirmed that the facility did not complete thorough investigations, identify alleged perpetrators, or report these incidents to regulatory agencies as required by policy.
Failure to Honor Resident's Preferred Name
Penalty
Summary
The facility failed to provide a dignified living experience for Resident R4 by not honoring her preferred name, as outlined in the facility's Resident Rights policy. On 5/18/24, Resident R4 filed a grievance after LPN Employee E1 called her by a non-preferred name during a discussion about her treatment. LPN Employee E1 confirmed in a handwritten statement that she used the non-preferred name, which was listed in the computer, despite the resident's preferred name being clearly indicated in her computerized medical record. This incident was confirmed by the Nursing Home Administrator during an interview on 7/15/24, acknowledging the failure to respect the resident's preferred name, thus creating a non-dignified living experience.
Insufficient Staffing Leads to Resident Oxygen Deprivation
Penalty
Summary
The facility failed to ensure sufficient staffing to meet the needs of Resident R1, who was admitted with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure requiring oxygen therapy. On the evening of 4/3/24, Resident R1 experienced difficulty breathing and was found without oxygen. The portable oxygen tank was empty, and the resident was not connected to the room concentrator. The incident occurred during a busy shift change, and the staff were not informed of the room change or the resident's oxygen needs. The resident's oxygen saturation levels dropped to 70% before being connected to the concentrator, which brought the levels back up to 92-96%. However, there was a significant delay in responding to the resident's call light, which remained unanswered for nearly an hour due to the high volume of call lights and insufficient staffing on the hall that night. Interviews with staff members revealed that the hall was extremely hectic, and there were only two nurse aides available to handle the high acuity of residents. The staff admitted to being overwhelmed and unable to respond to call lights in a timely manner. The nurse aides and the med nurse were not informed of the resident's transfer to the hall or her oxygen requirements, leading to a delay in addressing the resident's critical needs. The lack of communication and coordination among the staff further exacerbated the situation, resulting in the resident being without oxygen for an extended period. The facility's investigation confirmed the room change and the staff's statements about the busy shift and the delay in responding to call lights. The call bell log showed that Resident R1's call light was on for 47 minutes before being turned off. The Nursing Home Administrator acknowledged the facility's failure to ensure sufficient staffing to meet the resident's needs, as evidenced by the staff's inability to promptly address the resident's oxygen issue and the overall chaotic environment on the hall that night.
Failure to Prevent and Treat Pressure Ulcers
Penalty
Summary
The facility failed to ensure that Resident R1 was properly monitored, assessed, and received the necessary services to prevent the development or worsening of pressure ulcers. Resident R1, who was admitted with no unhealed pressure ulcers, was later found to have a Stage II pressure ulcer on the buttocks. Despite the presence of a physician's order to apply Medihoney and cover with border gauze daily, the Treatment Administration Record (TAR) showed multiple instances where the dressing changes were not documented as completed. Specifically, there were missing entries for dressing changes on 2/12/24, 2/17/24, 2/18/24, and 2/19/24. The deficiency was confirmed during an interview with the Nursing Home Administrator and Director of Nursing, who acknowledged that the facility did not ensure proper monitoring and assessment of Resident R1's skin condition. The resident's pressure ulcer worsened over time, as indicated by the measurements recorded on 2/14/24 and 2/21/24, showing an increase in size and deterioration of the wound. This failure to adhere to the facility's Pressure Ulcer Policy and ensure timely and consistent wound care contributed to the development and worsening of the pressure ulcer for Resident R1.
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Illustrative
What surveyors actually found near you
We read the 811 citations issued within 25 miles in the last 12 months — including the 11 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greensburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Westmoreland Manor | 1.2 mi | ★★★★★ | 9 | 0 |
| Rehab & Nursing Ctr Greater Pittsburgh | 2.2 mi | ★★★★★ | 11 | 0 |
| Saint Anne Home | 2.6 mi | ★★★★★ | 2 | 0 |
| Redstone Highlands Health Care | 2.9 mi | ★★★★★ | 15 | 1 |
| Oak Hill Rehabilitation & Healthcare Center | 4.4 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.