Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 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.
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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We read the 698 citations issued within 25 miles in the last 12 months — including the 9 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
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
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 | — | 9 | 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 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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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 August 2026) and official state health department websites.