Health inspection·March 7, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on 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). Findings included: Review of facility policy Resident Rights last reviewed 1/06/25, indicated the facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing required Minimum Data Set (MDS) assessments (mandated assessments of a resident's abilities and care needs), dated October 2023, indicated that a BIMS (Brief Interview of Mental Status) is a brief screener that aids in detecting cognitive impairment. Scores from a BIMS assessment suggests the following distributions: 13 - 15: cognitively intact 8 - 12: moderately impaired 0 - 7: severe impairment Review of the clinical record revealed Resident R14 was originally admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of adult failure to thrive (substantial decline in overall health and functional abilities) and venous insufficiency (veins have problems sending blood from the legs to the heart). Review of Section C: Cognitive Patterns, indicated, intact cognition with a BIMS Score of 15. Review of Section GG: 0170 Functional Abilities, indicated Resident R14 required substantial /maximal assistance for toileting hygiene. Review of Section H: 0300 Bladder and Bowel, indicated frequently incontinent. During an interview with Resident R14 on 3/3/25, at 12:54 p.m. the following was stated: last week Saturday night on the night shift around midnight I was left in a urine-soaked brief for 2 hours. The girl told me I must wait two hours because that's my schedule, I think she was fired, I haven't Page 1 of 10 395705 395705 03/07/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0550 seen her in a week. Level of Harm - Minimal harm or potential for actual harm Review of the clinical record revealed Resident R49 was originally admitted to the facility on [DATE]. Residents Affected - Few Review of the MDS dated [DATE], included diagnoses of diabetes, bilateral lower extremity amputation (surgical removal of both legs) and stage II pressure ulcer sacral region (shallow, crater like wound or blister containing fluid just below the base of the spine). Review of Section C: Cognitive Patterns, indicated, intact cognition with a BIMS Score of 15. Review of Section GG: 0170 Functional Abilities, indicated Resident R49 required substantial /maximal assistance for toileting hygiene. Review of Section H: 0300 Bladder and Bowel, indicated frequently incontinent. During an interview with Resident R49 on 3/3/25, at 1:14 p.m. the following was stated: The staff works very hard and is very nice, sometimes you have to wait to be changed. I moved my bowels and had to sit in s*** once for four hours because the staff was so busy. During an interview on 3/5/25, at approximately 2:45 p.m. the Nursing Home Administrator and the Director of Nursing confirmed the facility failed to provide an environment and care to promote dignity for each resident's quality of life for two of ten residents. 28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services 28 Pa. Code 201.29 (j) Resident Rights 395705 Page 2 of 10 395705 03/07/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. Based 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). Findings include: A review of the facility policy Environment Policy dated 1/6/25, indicated the facility will provide a safe, clean, comfortable, and homelike environment. During an observation of the facility on 3/7/25, at 1:00 p.m., the following was revealed: A Wing resident rooms 5W, 2W, 13W, and 14W (window) air condition/heating unit had dusty debris on the unit. C Wing resident rooms 33W, 43W, 45W, and 47W (window) air condition/heating unit had dusty debris on the unit. D Wing resident rooms 54W, 55W, 58W, and 59W (window) air condition/heating unit had dusty debris on the unit. During an interview on 3/7/25, at 1:30 p.m., the Nursing Home Administrator confirmed that the facility failed to maintain the facility in a homelike environment on three of four nursing units. Pa Code: 207.2 (a) Administrator's responsibility. 395705 Page 3 of 10 395705 03/07/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0585 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. Based 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). Findings include: A review of the facility policy Grievances reviewed 1/6/25, all persons will be provided with an opportunity to present these complaints through a formal grievance procedure. During an observation on 3/4/25, at 11:25 a.m. revealed the grievance box and forms were not accessible on the East and [NAME] nursing unit resident lounge areas. The grievance boxes had been placed on a shelf, out of the reach of residents in wheelchairs. During an interview on 3/4/25, at 11:40 a.m. The Activity Director Employee E1 confirmed the facility failed to make accessible grievance boxes to residents on two of two nursing units resident lounge areas (East and [NAME] Wings). During an interview on 3/5/25, at 2:45 p.m. The Nursing Home Administrator confirmed the facility failed to make accessible grievance boxes to residents on two of two nursing units resident lounge areas (East and [NAME] Wings). 28 PA Code: 201.18(e)(4) Management. 28 PA Code: 201.29(a)(b)(c) Resident rights. 395705 Page 4 of 10 395705 03/07/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Findings include: Review of facility's policy Comprehensive Care Plan dated 12/4/24, indicated the facility will develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. Review of the clinical record revealed that Resident R4 was admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - periodic assessment of resident care needs) dated 12/18/24, indicated diagnoses of dementia. Review of Resident R4's current care plan dated 9/12/24, failed to reveal a care plan with goals and interventions for dementia. Review of the clinical record revealed that Resident R86 was admitted to the facility on [DATE]. Review of a Psychology Initial Assessment dated 11/21/24, indicated Resident R86 had a history of Post Traumatic Stress Disorder (PTSD). Review of Resident R86's MDS (Minimum Data Set, periodic assessment of resident care needs) dated 1/30/25, indicated diagnoses of PTSD. Review of Resident R86's care plan dated 11/14/24, failed to reveal a care plan with goals and interventions for PTSD. During an interview on 3/7/25, at 1:05 p.m. the Director of Nursing confirmed that the facility failed to ensure that a comprehensive resident care plan was complete for resident care needs for Residents R4 and R86. 28 Pa. Code 211.12(d)(5) Nursing Services. 395705 Page 5 of 10 395705 03/07/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0657 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings include: Review of the facility policy Comprehensive Care Plans dated 1/6/25 indicated the facility will develop a comprehensive care plan for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial wellbeing. Review of the admission record indicated Resident R4 admitted to the facility on [DATE]. Review of Resident R4's Minimum Data Set (MDS - a periodic assessment of care needs) dated 12/18/24, indicated the diagnoses of dementia, depression, anxiety, and bipolar disorder (a mental condition marked by alternating periods of elation and depression), the resident is alert and oriented and able to make needs known. Review of Resident R4's physician order dated 3/4/25, indicated to give Risperdal (antipsychotic), Depakote (treats depression), Ativan (anti-anxiety medication), and Effexor (an anti-depressant) daily. Review of Resident R4's current care plan revised on 9/12/24, indicated the resident was receiving Wellbutrin (anti-depressant). Review of Resident R4's medication administration record (MAR) dated February and March 2025 did not indicated that the resident was receiving Wellbutrin. Interview on 3/4/25, at 3:00 p.m. the Director of Nursing (DON)confirmed the facility failed to update a care plan for Resident R4 to accurately reflect the current status of the resident and care needs. 28 Pa. Code: 211.11(a)(b)(c)(d) Resident care plan. 28 Pa. Code: 211.12(d)(1)(5) Nursing services. 395705 Page 6 of 10 395705 03/07/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0658 Ensure services provided by the nursing facility meet professional standards of quality. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Few 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). During an observation on 3/3/25 at approximately 11:29 a.m. RN Employee E2 administered medication to Resident R57 while Resident 57 was in the supine position (lying flat on their back) in bed. During an interview on 3/3/25 at approximately 11:30 a.m. with RN Employee E2, confirmed, she administered Midodrine HCl Oral Tablet 5 MG, to Resident R57 while Resident R57 was in the supine position. Review of Resident R57's 3/3/25 active orders indicate Midodrine HCl Oral Tablet 5 MG by mouth three times a day for hypotension. The Medication Administration Record (MAR) on 3/3/25 revealed RN Employee E2 documented Midodrine HCl Oral Tablet 5 MG lunch time dose was given. During an interview on 3/5/25 at 2:40 p.m. the Nursing Home Administrator and Director of Nursing confirmed that RN Employee E2 failed to follow professional standards of practice for one of four residents observed. During interviews on 3/6/25 at approximately 1:00 p.m. with RN Employee E3, Licensed Practical Nurse (LPN) Employee E4, and RN Employee E5, confirmed best practice is to elevate the head of the bed at least 30-45 degrees when administering medication to a resident in bed. 28 PA. Code: 201.14(a) Responsibility of licensee. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395705 Page 7 of 10 395705 03/07/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0698 Provide safe, appropriate dialysis care/services for a resident who requires such services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Few Findings include: A review of the facility policy Dialysis Care Policy reviewed 1/6/25, indicated residents ordered dialysis will have ongoing communication and collaboration with the dialysis facility regarding dialysis care and services. Qualified trained staff will communicate via written format with a dialysis communication form. A review of the clinical record indicated Resident R59 was re-admitted to the facility on [DATE], with diagnoses that included chronic renal disease (ESRD - the kidneys permanently fail to work) and high blood pressure. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 12/27/24, indicated the diagnoses remain current. A review of a physician's order summary dated 1/3/25, indicated Resident R59 was to receive dialysis three days a week on Monday, Wednesday, and Friday. A review of the nurse progress notes indicated Resident R59 receives dialysis three times a week. A review of Resident R59's Dialysis Hand Off Communication Report forms from 12/1/24 through 3/3/25, revealed 11 communication forms out of 39 scheduled treatments were observed. The section to be completed by dialysis and returned with the resident were left blank on 12/6/24, 12/9/24, 12/16/24, 12/23/24, 1/3/25, 1/10/25, 1/27/25, 1/31/25, 2/3/25, 2/5/25 and 2/19/25. During an interview on 3/7/25, at 9:53 a.m. the Director of Nursing confirmed the above findings and the facility failed to ensure the dialysis communication form was completed between the facility and dialysis center for Resident R59. 28 Pa. Code: 211.12(d)(1)(3)(5) Nursing services. 395705 Page 8 of 10 395705 03/07/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0757 Ensure each resident’s drug regimen must be free from unnecessary drugs. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Few Findings include: A review of the facility policy Medication Administration General Guidelines reviewed 1/6/25, indicated medications are administered according to written orders of the attending physician. When PRN (as needed) medications are administered, documentation of complaints or symptoms for which medication was given is to be provided. A review of the clinical record indicated Resident R39 was admitted to the facility on [DATE], diagnoses included pain in left knee and pain in right hip. A review of the Minimum Data Set (MDS - periodic assessment of care needs) dated 2/4/25, indicated the diagnoses remain current. Review of Resident 39's physician order dated December 6, 2024, revealed an order for Tramadol HCI (A medication used to treat severe pain) 50 mg Give one tablet by mouth every 6 hours as needed for pain 5-8 (Numeric Pain Scale: 0-no pain; 1-3-mild pain; 4-6-moderate pain; 7-10-severe pain). Review of Resident 39's February 2025, Medication Administration Record (MAR) revealed that from September 1, 2025, until September 28, 2025, the Tramadol medication was administered to Resident 39 a total of 8 times with a pain level rating of less than 5. Review of Resident 39's clinical record failed to reveal an explanation as to why the resident was administered with as needed Tramadol for a pain level rating of less than 5. During an interview on 3/7/25, at 11:20 am the Director of Nursing confirmed the above findings, and the facility failed to ensure Resident 39 was free from unnecessary use of as needed Tramadol. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services. 395705 Page 9 of 10 395705 03/07/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). A review of the MDS (minimum data set - resident assessment and care screening) dated 12/18/24, indicated the diagnoses remained current and the resident can make needs known. A review of physician orders dated 3/4/25, indicated Resident R4 received psychoactive medications daily for treatment. A review of Resident R4's Acknowledgment of Psychoactive Medication Use forms signed by the resident for consent, did not include a date when signed by the resident. During an interview on 3/7/25, at 12:00 p.m. the Director of Nursing (DON) confirmed the consent forms for Resident R4 were not dated when signed by the resident. A review of the clinical record on 3/7/25, indicated that Resident R168 was admitted to the facility on [DATE]. Diagnoses included diabetes and a diabetic wound to the left lower extremity. A review of a physician order dated 2/25/25 indicated a wound VAC (treatment to remove pressure over a wound) dressing change on Tuesday, Thursday, and Saturday. A review of the treatment administration record dated February and March 2025 did not include documentation that the dressing was changed as ordered on 2/27/25 and 3/1/25. During an interview on 3/7/25, at 3:15 p.m. Registered Nurse Employee E8 revealed the dressing was not changed on 2/27/25 because the resident refused, and the dressing was changed the next day. Further review revealed the order was to be changed to Monday, Wednesday, and Friday and this was not documented in the clinical record. During an interview on 3/7/25, at 3:30 p.m. the DON confirmed the above findings, and the facility failed to make certain that medical records on each resident are complete and accurately documented for Residents R4 and R168. 28 Pa. Code: 211.5(f)(g)(h) Clinical records. 395705 Page 10 of 10