Hempfield Manor

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement that created an immediate jeopardy situation for one of 29 cognitively impaired residents (Resident R1). Findings Include: Review of the facility, Missing Resident Policy dated 12/2/25, indicated the facility will take all necessary steps to locate a resident that is missing. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of neurogenic bladder (bladder problems due to disease or injury of the nervous system involved in the control of urination), diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), and high blood pressure. [...]

Inspectors wroteBased on review of job descriptions, clinical records, and staff interviews, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed effectively manage the facility to protect residents from elopement. This failure resulted in a resident exiting the building unsupervised (Resident R1). This failure created an Immediate Jeopardy situation for one of 29 cognitively impaired residents (Resident R1).

Inspectors wroteBased on review of select facility documents, clinical record review as well as resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing to meet resident needs for seven of nine residents (Resident R1, R2, R3, R4, R5, R6, R7, R8, and R9).

Inspectors wroteBased on the review of facility policy and facility documents, observations and resident and staff interviews, it was determined that the facility failed to make certain grievance forms can be filed anonymously in four of four locations where grievance information is available. (front lobby, resident lounges between unit's A/B and C/D - grievance boxes with grievance forms are in front of the activity department and in resident lounges between unit's A/B and C/D).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that quarterly Minimum Data Set assessments were completed within the required time frame for four of 25 residents (Resident R5, R14. R43, and R60).

Inspectors wroteBased on a review of Resident Assessment Instrument (RAI) User's Manual, clinical records, and staff interviews, it was determined that the facility failed to ensure that MDS assessments accurately reflected the resident's status for 18 of 28 residents (Resident R4, R12, R20, R29, R48, R53, R56, R63, R74, R85, R90, R95, R100, R101, R102, R103, R114, R119).

Inspectors wroteBased on review of facility policy, clinical records, observations and staff interviews, it was determined that the facility failed to provide appropriate respiratory care and maintain oxygen equipment for four of eight sampled residents (Residents R2, R46, R61, and R138).

Inspectors wroteBased on resident and staff interviews, and facility documents (grievance and staffing) reviews, it was determined that the facility failed to have sufficient nursing staff to provide nursing and related services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for fourteen of twenty-three residents (Residents R1, R9, R12, R16, R23, R40, R44, R46, R64, R500, R501, R502, R503, and R505).

Inspectors wroteBased on a review of facility policy, observations, and staff interviews, it was determined that the facility failed to make sure that medical supplies and medications were properly stored and/or disposed of in one of two medication rooms (A/B Nursing Unit).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to conduct at least 12 hours of in-service education, within 12 months of their hire date anniversary, for nurse aides as required for two of five nurse aides (Employees E6 and E7). Findings Include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, Nursing Assistants are required to have 12 hours of training per year calculated from their date of hire. Review of Nurse Aide (NA) Employee E6's facility provided staff list indicated she was hired on 1/9/24. with approximately 2.00 hours in-service education between 1/9/25, through 1/9/26. Review of NA Employee E7's facility provided staff list indicated she was hired on 1/10/23 with 6.50 hours in-service education between1/10/25, through 1/10/26. During an interview on 3/20/26, at approximately 2:30 p.m. [...]

Inspectors wroteBased on review of facility policy, observation, and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for five of sixteen residents (Resident R9, R30, R74, R502, and R504).

Inspectors wroteBased on review of facility documents, resident and staff interviews, observation, and clinical record review, it was determined that the facility failed to obtain routine services from an eye care professional and failed to accurately document the need for vision care for one of five residents (Resident R12).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on the prevention of abuse, neglect, and exploitation for five of ten staff members (Employees E2, E3, E5, E6, and E7). Findings Include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Included in the list of topics was Abuse, Neglect, and Misappropriation and Reporting Crimes Pursuant to the Elder Justice Act. Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on the prevention of abuse, neglect, and exploitation. [...]

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on infection control for four of ten staff members (Employees E2, E5, E6, and E7).

Inspectors wroteBased on review of the Resident Assessment Instrument User's Manual, clinical records, and staff interview, it was determined that the facility failed to make certain that comprehensive Minimum Data Set (MDS - periodic assessment of care needs) assessments were completed in the required time frame for four of 22 residents (Resident R14, R25, R27, and R31).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on effective communication for four of ten direct care staff members (Employees E2, E5, E6, and E7).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on resident rights for five of ten staff members (Employees E2, E3, E5, E6, and E7).

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on QAPI (Quality Assurance and Performance Improvement) for five of ten staff members (Employees E2, E3, E4, E5, and E6). Findings Include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on the QAPI Program. Review of Licensed Practical Nurse Employee E3's facility provided staff list indicated she was hired on 2/12/19. [...]

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on compliance and ethics for three of ten staff members (Employees E2, E5, and E6). Findings Include: Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on on compliance and ethics. Review of the Activity Employee E5's facility provided staff list indicated she was hired on 1/6/06. Review of Activity Employee E5's training record for 1/6/25, through 1/6/26, did not include training on compliance and ethics. [...]

Inspectors wroteBased on review of facility documents and staff interview, it was determined that the facility failed to provide training on behavioral health for four of ten staff members (Employees E2, E5, E6, and E7). Review of the facility policy, Inservice Education dated 12/2/25, indicated, The inservice education program is planned and conducted for the development and improvement of skills and personnel. Included in the list of topics was Care of Cognitively Impaired Residents and Dementia Training. Review of Registered Nurse Employee E2's facility provided staff list indicated she was hired on 2/14/23. Review of RN Employee E2's training record for 2/14/25, through 2/14/26, did not include training on behavioral health. Review of the Activity Employee E5's facility provided staff list indicated she was hired on 1/6/06. [...]

Inspectors wroteBased on facility policy, document review, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for ten of twenty residents who require care (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10). Based on facility policy, document review, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for ten of twenty residents who require care (Residents R1, R2, R3, R4, R5, R6, R7, R8, R9, and R10).

Inspectors wroteBased on facility policy review, clinical and facility record review, facility submitted documents, and staff interviews, it was determined that the facility failed to provide adequate supervision to prevent elopement for one of nine residents (Resident R1). Review of the facility Missing Resident Policy dated 12/4/24, indicated the facility will complete all necessary steps to locate any resident that is missing from a community. Review of the clinical record revealed Resident R1 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 4/1/24, included diagnoses of diabetes (a metabolic disorder in which the body has high sugar levels for prolonged periods of time), high blood pressure, and dementia (a group of symptoms that affects memory, thinking and interferes with daily life). [...]

Inspectors wroteBased on review of facility policy, observations, and resident and staff interviews, it was determined that the facility failed to make accessible grievance boxes to residents on two of two nursing unit resident lounge areas (East and [NAME] Wings).

Inspectors wroteBased on review of facility policy, resident interviews, observation, and staff interviews, it was determined that the facility failed to provide prompt assistance to meet residents care needs for two of ten residents who require care (Residents R14 and R49).

Inspectors wroteBased on review of facility policy, observations and staff interviews it was determined that the facility failed to maintain a homelike environment throughout the facility (resident rooms) for three of four nursing units. (A, C, and D nursing units).

Inspectors wroteBased on a review of facility policy, clinical records, and staff interview, it was determined that the facility failed to develop care plans that included instructions to provide person centered care for two of five residents (Residents R4 and R86).

Inspectors wroteBased on review of facility policy, clinical records, and staff interview, it was determined the facility failed to update a care plan for one of five residents (Resident R4) to accurately reflect the current status of the resident and care needs.

Inspectors wroteBased on review of facility job description, resident record review, and staff interviews, it was determined that the facility failed to follow professional standards of practice for one of four residents observed (Resident R57). Review of the facility Registered Nurse (RN) job description, revised 2/07, indicated the RN must function within the scope of practice according to the State Board of Nursing. Administers medication and treatments as prescribed by the physician. Assumes responsibility for his/her own professional competence. Review of the clinical record indicated that Resident R57 was admitted to the facility on [DATE]. Review of the Minimum Data Set (MDS - periodic assessment of resident care needs) dated 1/10/25, included diagnoses of dysphagia (difficulty swallowing) and orthostatic hypotension (decrease in blood pressure after rising from laying or sitting). [...]

Inspectors wroteBased on review of facility policy and clinical records, and staff interview, it was determined that facility staff failed to maintain ongoing communication with the hemodialysis (a machine filters wastes, salts and fluid from your blood when your kidneys are no longer healthy enough to do this work adequately) center for one of two residents reviewed (Resident R59).

Inspectors wroteBased on clinical record review and staff interview, it was determined the facility failed to ensure resident was free from unnecessary medication for one of twenty-four residents reviewed (Resident 39).

Inspectors wroteBased on review of facility policies and clinical records and staff interview, it was determined that the facility failed to make certain that medical records on each resident are complete and accurately documented for two of four residents (Residents R4 and R168) A review of the facility policy Documentation Policy dated 1/6/25, indicated the facility will provide an account of the resident's care and treatment and information will be appropriate. The resident's medical record shall be complete, accurate, and timely. A review of the clinical record on 3/7/25, indicated that Resident R4 was admitted to the facility on [DATE]. Diagnoses included anxiety and bipolar disorder (a mental condition marked by alternating periods of elation and depression). [...]

Inspectors wroteBased on a review of facility policies, documents and staff interviews it was determined that the facility failed to conduct a through investigation three of three allegations of possible abuse and neglect. (5/20/24, 6/11/24, and 6/26/24)

Inspectors wroteBased on a review of facility policy, resident medical records, facility provided documents, staff statements and staff interviews, it was determined that the facility failed to provide a dignified living experience for one of three residents (Resident R4).

Inspectors wroteBased on review of select facility documents, clinical record review as well as resident and staff interviews, it was determined that the facility failed to ensure sufficient staffing to meet resident need for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policy, clinical records, and staff interviews, it was determined that the facility failed to make certain that residents were monitored, assessed, and received the necessary services to prevent pressure ulcers from developing or worsening for one of three residents (Resident R1).

Inspectors wroteBased on review of facility policies, review of Centers for Disease Control (CDC) guidelines for Legionella (bacterium that causes Legionnaires Disease found in pipes and heating systems) Control, the facility's infection control tracking logs for water management and staff interview, it was determined that the facility failed to implement a comprehensive program for water management to monitor the potential development and spread of Legionella within the facility, failed to exercise proper infection control techniques and dispose of contaminated PPE (personal protective equipment) during a dressing change to prevent the potential of spread of infection for one of three residents (Resident R59). [...]

Inspectors wroteBased on facility policy, observation and staff interview, it was determined that the facility failed to ensure that care was provided in a manner which maintained resident dignity for one of three residents (Residents R59).

Inspectors wroteBased on facility policy, clinical record, facility provided documents and staff interview it was determined that the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the residents' choices for one of two residents (Resident R21). Review of the facility policy Physician Services, last reviewed on 12/13/23, indicated that all medications and treatments administered to the resident must be ordered by the physician. Review of the clinical record indicated that Resident R21 was admitted to the facility on [DATE], with diagnoses which included Type 2 Diabetes Mellitus, Parkinsons (a disorder of the nervous system that affects movement), anxiety, and cognitive disorder. [...]

Inspectors wroteBased on observations and staff interview it was determined that the facility failed to maintain an environment free of potential accident hazards when the salon was unsecured containing hazardous items in two unsecured cabinets (Beauty Salon).

Inspectors wroteBased on a review of facility policy, observations and staff interviews, it was determined that the facility failed to provide a functional resident call bell system for the beauty salon (Beauty Salon).