Hempfield Manor
Inspection history, citations, penalties and survey trends for this long-term care facility in Greensburg, Pennsylvania.
- Location
- 1118 Woodward Drive, Greensburg, Pennsylvania 15601
- CMS Provider Number
- 395705
- Inspections on file
- 28
- Latest survey
- March 20, 2026
- Citations (last 12 mo.)
- 21
Citation history
Health deficiencies cited at Hempfield Manor during CMS and state inspections, most recent first.
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.
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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Surveyors identified that a fire-rated separation door between building levels did not meet NFPA 101 multiple occupancy requirements. Initially, the basement separation door had holes where panic hardware had been removed and only a turning knob remained, compromising the door’s fire-rated function. On revisit, although panic hardware had been installed, the door still failed to latch properly in the frame due to friction. Facility leadership and maintenance staff acknowledged these door deficiencies.
Surveyors found that the facility’s Emergency Preparedness Plan was not compliant with regulatory requirements because it lacked a documented community-based all-hazards risk assessment and the facility-based hazard vulnerability analysis had not been updated on an annual basis. During document review and an interview with the Maintenance Director, it was confirmed that the community-based HVA was missing from the plan and that the existing facility-based assessment had last been updated in 2024, leaving the plan without current, comprehensive all-hazards risk assessments.
Surveyors observed that stair towers used as exits were not properly maintained, as multiple stair landings were being used for storage. Chairs were found stored on landings in several stairwells on one floor, and the Maintenance Director confirmed that these items were being kept within the stair towers.
Surveyors found that the common area soiled linen room on the second floor, classified as a hazardous area in a sprinklered location, had a door that failed to positively latch when tested. This door is required to self-close and latch to maintain proper separation for hazardous areas. The issue was confirmed with the Maintenance Director during the survey.
Surveyors found that oxygen storage requirements were not maintained when a freestanding oxygen cylinder was observed unsecured in a third-floor room and the C-Hall oxygen storage room door failed to close and latch due to a coordinator malfunction. The Maintenance Director confirmed these oxygen storage deficiencies during the survey exit interview.
Surveyors found that the facility failed to review and update its emergency preparedness policies and procedures on an annual basis. During document review, the facility could not provide a community-based HVA, which is required to inform updates to the emergency preparedness plan, and the facility-based HVA had not been updated as required. In an interview, the Maintenance Director confirmed both the missing community-based HVA and the lack of an annual update to the facility-based HVA.
Surveyors found that the facility’s Emergency Preparedness Plan lacked required policies and procedures for tracking the location of on-duty staff and sheltered patients during and after an emergency. The plan also did not include a method to document the specific name and location of any receiving facility or other site if staff and patients were relocated. During the exit interview, the Maintenance Director confirmed that these tracking and documentation procedures were not present in the plan, affecting the entire facility.
Surveyors found that the facility failed to develop and maintain required arrangements with other facilities and providers to receive patients if operations were limited or ceased. Document review showed that transfer agreements were missing, and this absence of formal arrangements to ensure continuity of services was confirmed by the Maintenance Director during the exit interview.
Surveyors determined that the facility’s emergency preparedness communication plan did not include any method for sharing appropriate information from the emergency plan with residents and their families or representatives. During document review and staff interviews, it was confirmed that the written plan lacked a defined process for communicating emergency planning information to residents and their representatives, and this omission affected the entire facility.
Two residents receiving PRN anti‑anxiety medications were not protected from potential chemical restraints when PRN lorazepam/Ativan orders lacked required 14‑day stop dates and physician re‑evaluation. One resident with schizoaffective disorder, dementia, and anxiety had a PRN Ativan order without a stop date that was administered multiple times over several months. Another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease had a PRN lorazepam order without a stop date that was still being administered weeks later, with no documented physician reassessment. The DON confirmed that these PRN psychotropic orders should have included 14‑day limitations but did not.
Noncompliant Fire-Rated Separation Door Between Multiple Occupancies
Penalty
Summary
The facility failed to meet NFPA 101 multiple occupancy construction type requirements by not maintaining a compliant fire-rated separation door between building levels. During an observation in the basement, surveyors found that the building separation door had holes where the fire exit (panic) hardware had been removed, and the only remaining hardware was a turning knob, compromising the integrity of the fire-rated door. In a subsequent onsite revisit, surveyors observed that although panic hardware had been installed on the same fire-rated door, the door failed to latch properly in the frame due to friction. The administrator and maintenance staff confirmed the presence of the holes in the fire-rated door and later confirmed that the door continued to have a deficiency because it did not latch.
Plan Of Correction
The Facility submits this Plan of Correction under procedures established by the Department of Health in order to comply with the Department's directive to change conditions which the Department alleges is deficient under State and/or Federal Long Term Care Regulations. This Plan of Correction should not be construed as either a waiver of the facility's right to appeal or challenge the accuracy or severity of the alleged deficiencies or an admission of past or ongoing violation of State and Federal regulatory requirements. Please accept this plan of correction as the facility's written credible allegation of compliance such that all alleged deficiencies cited have been or will be corrected by the date or dates indicated. To remain in compliance with all federal and state regulations, the facility has taken or will take the actions set forth in the following plan of correction. 1. The correct fire rated hardware was ordered and will be installed on the basement building separation door. 2. Results will be shared with the Quality Assurance Performance Improvement Committee with corrections made as needed.
Failure to Maintain Current All-Hazards Emergency Preparedness Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to maintain an Emergency Preparedness Plan that was based on and included both a documented facility-based and community-based risk assessment utilizing an all-hazards approach. During document review, surveyors found that the Emergency Preparedness Plan did not contain a documented community-based risk assessment. The plan therefore lacked the required community-based hazard vulnerability analysis (HVA) component that should identify and address community-level emergency events. Surveyors also determined that the facility-based risk assessment within the Emergency Preparedness Plan had not been updated annually as required. The last update to the facility-based HVA was documented in 2024, indicating that it was not current at the time of review. During the exit interview, the Maintenance Director confirmed both the absence of the community-based HVA and that the facility-based HVA had not received the required annual update.
Plan Of Correction
4.1. The facility will update the facility assessment to include the All Hazards Assessment annually. 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-006. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Improper Storage of Chairs in Exit Stair Towers
Penalty
Summary
Surveyors found that stairways and smokeproof enclosures used as exits were not properly maintained as required by NFPA 101. On one of five levels, multiple stair tower landings were being used for storage. During observations on May 4, 2026, chairs were stored on the landings of stair #2 on the third floor C-wing at 11:30 a.m., stair #3 on the third floor B-wing at 11:40 a.m., and stair #4 on the third floor A-wing at 11:50 a.m. In an exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the presence of this storage within the stair towers.
Plan Of Correction
4.1. The chairs were permanently removed from the third floor C-wing, stair # 2, the third floor B-wing, stair # 3, and the third floor A-wing, stair # 4 on Tuesday, May 5th, 2026. 4.2. The maintenance staff will be in-serviced on importance of verifying that stairwells are cleared Stairways and smokeproof enclosures used 4.3. The maintenance staff will perform monthly audits to confirm that stairwells are cleared. Audits will be completed for 6 months. 4.4. The maintenance director will monitor to meet the compliance
Soiled Linen Room Door Failed to Latch in Hazardous Area
Penalty
Summary
Surveyors identified a deficiency related to NFPA 101 hazardous area enclosure requirements when observing the soiled linen room on the second floor. During the survey, the common area soiled linen room door was tested and found to fail to positively latch. This room qualifies as a hazardous area in a sprinklered location, and the door is required to self-close and latch to maintain proper separation. The deficiency was confirmed during an exit interview with the Maintenance Director, who acknowledged the door problem. No residents or specific patient conditions were mentioned in the report, and no additional contributing actions or events beyond the failed latching mechanism of the soiled linen room door were described.
Plan Of Correction
K 03214.1. On the second floor, the common area soiled utility room door latch was repaired on May 4th, 2026. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0321; NFPA 101 Hazardous areas - enclosures. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0321 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0225. Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026
Failure to Maintain Required Oxygen Cylinder Storage and Secured Storage Room
Penalty
Summary
Surveyors identified deficiencies in the facility’s compliance with NFPA 101 and NFPA 99 requirements for gas equipment cylinder and container storage. During observation on the third floor, surveyors found a freestanding oxygen cylinder in room 5352 at 11:30 a.m. This cylinder was not described as being secured or stored in accordance with the specified oxygen storage requirements, which include proper enclosure and handling precautions for cylinders available for immediate use in patient care areas. Further observation at 11:40 a.m. revealed that the C-Hall oxygen storage room door failed to close and latch due to a malfunctioning door coordinator. This condition meant the designated oxygen storage room was not being properly secured as required. During the exit interview on the same day at 1:30 p.m., the Maintenance Director confirmed the oxygen storage deficiencies observed by the surveyors.
Plan Of Correction
Completion Date: 06/30/2026 Status: APPROVED Date: 06/09/2026 4.1. The empty freestanding oxygen cylinder on the 3rd floor rom 5352 was removed & placed into the proper oxygen storage room on May 4th, 2026. The corridor malfunction identified on the c hall oxygen storage door will be repaired to ensure proper closure. 4.2. The maintenance staff will be in-serviced to meet compliance requirements of K-0923; NFPA 101 Gas equipment - Cylinder & container storage. 4.3. The maintenance staff will perform monthly audits to meet compliance requirements of K-0923 to November 30th, 2026. 4.4. The maintenance director will monitor to meet the compliance requirements of K-0923.
Failure to Annually Update Emergency Preparedness Policies and Risk Assessments
Penalty
Summary
The deficiency involves the facility’s failure to ensure that its emergency preparedness policies and procedures were reviewed and updated at least annually, as required. Surveyors cited that the facility did not have an emergency preparedness plan community-based risk assessment available for review. This community-based Hazard Vulnerability Analysis (HVA) is one of the required components used to update the facility’s emergency preparedness policies and procedures each year. During document review, surveyors found that the facility could not provide the community-based HVA and also confirmed that the facility-based HVA had not been updated annually as required. In an exit interview, the Maintenance Director acknowledged the absence of the community-based HVA and the missing annual update to the facility-based HVA, confirming that the emergency preparedness policies and procedures were not properly updated based on the emergency plan and risk assessment.
Plan Of Correction
4.1. The facility will update the emergency preparedness to include the community based risk assessment 4.2. The Director of Maintenance or designee Services will monitor bi-annually to meet compliance with E-013.
Missing Emergency Tracking System for Staff and Patients
Penalty
Summary
Surveyors identified a deficiency related to the facility’s Emergency Preparedness Plan, specifically the absence of required policies and procedures for tracking on-duty staff and sheltered patients during an emergency. During document review, the surveyor examined the facility’s Emergency Preparedness Plan and found that it did not contain a system to track the location of on-duty staff and sheltered patients in the facility’s care during an emergency. The review further showed that the plan lacked provisions to document the specific name and location of any receiving facility or other location if on-duty staff and sheltered patients were relocated during an emergency. In an exit interview, the Maintenance Director confirmed that these policies and procedures were missing from the Emergency Preparedness Plan, affecting the entire facility.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to include a system to track the location of on-duty staff and sheltered patients in the facility's care during an emergency; the specific name and location of the receiving facility or other location of on-duty staff and sheltered patients are relocated during an emergency. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0018.
Lack of Emergency Transfer Arrangements With Other Facilities
Penalty
Summary
The deficiency involves the facility’s failure to develop and maintain arrangements with other facilities and providers to receive patients if the facility experiences limitations or cessation of operations. During document review, surveyors determined that the facility did not have the required transfer agreements or documented arrangements in place as mandated under the emergency preparedness regulations, which require policies and procedures to ensure continuity of services to patients. On the date of the survey, at a specified time in the morning, the surveyor’s review of facility documentation showed that these arrangements were missing. In an exit interview later that day, the Maintenance Director confirmed that the transfer agreements were not in place, corroborating the surveyor’s findings that the facility lacked the necessary arrangements to ensure continuity of services in an emergency situation.
Plan Of Correction
4.1. The facility will update the emergency preparedness plan to provide arrangements with other facilities and other providers to receive patients in the event of limitations or cessation of operations to maintain the continuity of services to facility patients. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0025. Completion Date: 07/07/2026 Status: APPROVED Date: 06/09/2026
Failure to Include Resident/Family Communication Method in Emergency Plan
Penalty
Summary
Surveyors found that the facility failed to maintain and update an emergency preparedness communication plan that included a method for sharing information from the emergency plan with residents and their families or representatives. During document review and interview on May 4, 2026, at 8:30 a.m., the surveyor determined that the written emergency communications plan lacked any described process or method for communicating appropriate portions of the emergency plan to residents and their families or representatives, affecting the entire facility. In an exit interview with the Maintenance Director on the same day at 1:30 p.m., the Maintenance Director confirmed that the emergency communications plan did not include such a method for sharing information from the emergency plan with residents and their families or representatives. No specific residents, medical histories, or clinical conditions were identified in the report, and the deficiency pertained to the facility-wide emergency preparedness communication plan documentation and content.
Plan Of Correction
4.1. The facility will update the emergency communications plan to include a method of sharing information from the emergency plan with the residents and their families or representatives, affecting the entire facility. 4.2. The Director of Maintenance or designee will monitor bi-annually to meet compliance with E-0035.
Failure to Limit and Re‑Evaluate PRN Psychotropic Medications
Penalty
Summary
The deficiency involves the facility’s failure to ensure that residents were free from potential chemical restraints by not complying with federal requirements for PRN psychotropic medications. For one resident with schizoaffective disorder bipolar type, dementia, and anxiety disorder, the MDS showed cognitive impairment and the care plan identified mood problems, yelling out, and anxiety/restlessness. A physician ordered PRN Ativan for anxiety with no stop date specified. The MAR showed the PRN Ativan was administered multiple times over several months, including in January, March, and April 2026, without a 14‑day limitation or documented stop date. The DON stated that the PRN order was supposed to have a 14‑day stop date, confirming that the order did not meet regulatory requirements. For another resident with metabolic encephalopathy, heart failure, and peripheral vascular disease, a physician ordered PRN lorazepam every four hours for anxiety, again without a specified stop date. The MAR documented administration of lorazepam nearly a month after the order was written, with no evidence that the physician had re‑evaluated the continued use of the PRN anti‑anxiety medication beyond 14 days. The DON confirmed that no stop date had been added to this order. These omissions resulted in PRN psychotropic medications being available and used beyond 14 days without required time limitations or documented physician re‑evaluation, constituting a failure to ensure residents were free from potential chemical restraints and unnecessary drugs.
Plan Of Correction
Pharmacist will send out a re-education to all the providers regarding PRN psychotropics and end dates by May 4, 2026. Resident records for all residents receiving psychotropics were checked on April 30, 2026- no other orders were missing stop dates. New psychotropic orders added to Point Click Care dashboard on May 1, 2026- listing shows new orders and stop dates. Interdisciplinary team will review dashboard during clinical meeting for stop dates- any missing stop dates will be added. Charge nurses will audit order listing report for new psychotropic orders- 5 residents will be audited x 4 weeks, then 2 residents per week for 4 weeks, then random residents monthly. Audits will be added to quality indicators and reviewed at QAPI.
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