Health inspection·July 30, 2025

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 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). Findings included: Review of facility policy Resident Rights last reviewed 12/4/24, indicated in part The resident has a right to a dignified existence, self-determination, and communication with and access to person and services inside and outside the Manor. The Long-Term Care Facility Resident Assessment Instrument (RAI) User's Manual, which provides instructions and guidelines for completing the 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 intact8 - 12: moderately impaired0 - 7: severe impairmentReview of the clinical record revealed Resident R1 was admitted to the facility on [DATE].Review of the MDS dated [DATE], included diagnoses of cerebral infarction (stroke) and post-traumatic stress disorder (PTSD mental health condition caused by extremely stressful or terrifying event). Review of Section C: Cognitive Patterns, indicated, severe impairment with a BIMS Score of 3. Review of Section GG: 0130 Functional Abilities, indicated Resident R1 required substantial/maximal assistance with toileting hygiene (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). Review of facility records revealed Resident R1 on 5/2/25, filed a grievance related to the wait time for the call light response. Resident R1's grievance reads in part he waited a very long time; no one would come to help me to the bathroom. Review of the clinical record revealed Resident R2 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], dementia (loss of thinking, remembering and reasoning skills) and pressure ulcer (damage to the skin and/or underlying tissue due to pressure on the skin). Review of Section C: Cognitive Patterns, indicated, severe impairment BIMS Score could not be assessed, resident is rarely/never understood. Review of Section GG: 0130 Functional Abilities, indicated Resident R2 is dependent with toileting hygiene (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity). Review of facility records revealed Resident R2 on 5/2/25, sister filed a grievance related to care. Resident R2's grievance reads in part, family came in to visit, was in bed with clothing on upper body, no brief or clothes on. The bed was completely soiled, resident laying in feces apparently no one attended to him in a while. Review of the clinical record revealed Resident R3 was admitted to the Page 1 of 3 395705 395705 07/30/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cerebral infarction (stroke) and dysphagia (difficulty swallowing) and chronic pain syndrome. Review of Section C: Cognitive Patterns, indicated severe impairment with a BIMS Score could not be assessed, resident is rarely/never understood. Review of Section GG: 0130 Functional Abilities, indicated Resident R3 is dependent with hygiene including dressing (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity). Review of facility records revealed Resident R3 on 5/6/25, daughter filed a grievance related to care. Resident R3's grievance reads in part, mom is still in her bed clothes, why is she not dressed. Review of the clinical record revealed Resident R4 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cerebral infarction (stroke) and dysphagia (difficulty swallowing) and chronic pain syndrome. Review of Section C: Cognitive Patterns, indicated severe impairment with a BIMS Score of 6. Review of Section GG: 0130 Functional Abilities, indicated Resident R4 is dependent with hygiene including dressing. Review of Section GG: 0170 Mobility, indicated Resident is dependent with chair and bed transfers (helper does all the effort. Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity). Review of facility records revealed Resident R4 on 5/6/25, Power of Attorney (POA) filed a grievance related to care. Resident R4's grievance reads in part, POA was upset because she had requested that Resident R4 be up and out of bed right after breakfast and Resident R4 was still in bed at 12:30 p.m . Review of the clinical record revealed Resident R5 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cellulitis of lower limb (bacterial infection of the skin), diabetes with a foot wound, and atherosclerosis of coronary artery bypass graph (hardening of arteries). Review of Section C: Cognitive Patterns, indicated, cognitively intact with a BIMS Score of 15. Review of Section GG: 0130 Functional Abilities, indicated Resident R5 required partial/moderate assistance with toileting hygiene (helper does less than half the effort. Helper lifts or holds or supports trunk or limbs but provides less than half the effort). Review of facility records revealed Resident R5 on 6/24/25, has a grievance that reads in part, resident is constantly wet and her behind in very red and hurts. She is worried about infection. Review of the clinical record revealed Resident R6 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of parkinson's disease (brain disorder that affects movement), anorexia (eating disorder), and muscle weakness. Review of Section C: Cognitive Patterns, indicated, cognitively intact with a BIMS Score of 15. Review of Section GG: 0130 Functional Abilities, indicated Resident R6 is dependent with toileting hygiene (helper does all the effort). Resident does none of the effort to complete the activity. Or the assistance of two or more helpers is required for the resident to complete the activity). Review of facility records revealed Resident R6 on 7/23/25, and spouse had a grievance that reads in part, the call light not answered for long periods, resident is having accidents because she can't wait. She should not go by herself, but the light is frequently not answered in a timely manner. Review of the clinical record revealed Resident R7 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cellulitis of lower limb (bacterial infection of the skin), uterine cancer (cancer of the female reproductive system), and muscle weakness. Review of Section C: Cognitive Patterns, this portion not completed at this time. Review of Section GG: 0130 Functional Abilities, this portion not completed at this time. Review of facility records revealed Resident R7 on 7/27/25, daughter had a grievance that reads in part, mother called me last night crying was put on a bed pan for more than an hour without being shown where her call bell was placed, she was yelling for someone to come in and help 395705 Page 2 of 3 395705 07/30/2025 Hempfield Manor 1118 Woodward Drive Greensburg, PA 15601

F 0550 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some her. Review of the clinical record revealed Resident R8 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of acute respiratory failure with hypoxia (not enough oxygen in your blood) amaurosis fugax (temporary loss of vision due to disruption of blood flow to the eye) and obesity. Review of Section C: Cognitive Patterns, indicated moderate impairment with a BIMS Score of 9. Review of Section GG: 0130 Functional Abilities, indicated Resident R8 is dependent with toileting hygiene (helper does all the effort). Review of Section GG: 0170 Mobility, indicated Resident R8 required substantial/maximal assistance with toilet transfers (helper does more than half the effort. Helper lifts or holds trunk or limbs and provides more than half the effort). During an interview with Resident R8 on 7/30/25, at 10:00 a.m. the following was stated: Often you wait a while for someone when you call for help to go to the bathroom. I have waited an hour on a few occasions recently. Review of the clinical record revealed Resident R9 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of parkinson's disease (brain disorder that affects movement), muscle weakness and pressure ulcer (damage to the skin and/or underlying tissue due to pressure on the skin). Review of Section C: Cognitive Patterns, cognitively intact with a BIMS Score of 15. Review of Section GG: 0130 Functional Abilities, indicated Resident R9 is dependent with toileting hygiene (helper does all the effort). Review of Section GG: 0170 Mobility, indicated Resident R9 required partial/moderate assistance with toileting hygiene (helper does less than half the effort. Helper lifts or holds or supports trunk or limbs but provides less than half the effort). During an interview with Resident R9 on 7/30/25, at 10:15 a.m. the following was stated: there is about a half an hour wait when you push the call button, sometimes it hard to wait that long. Review of the clinical record revealed Resident R10 was admitted to the facility on [DATE]. Review of the MDS dated [DATE], included diagnoses of cardiomyopathy (difficulty for the heart to pump blood), sleep apnea and left bundle branch block (disruption to normal electrical impulses that control the heart). Review of Section C: Cognitive Patterns, moderately impaired with a BIMS Score of 10. Review of Section GG: 0130 Functional Abilities, indicated Resident R10 is dependent with toileting hygiene (helper does all the effort). Review of Section GG: 0170 Mobility, indicated Resident R10 required partial/moderate assistance with toileting hygiene (helper does less than half the effort. Helper lifts or holds or supports trunk or limbs but provides less than half the effort). During an interview with Resident R10 on 7/30/25, at 10:30 a.m. the following was stated: you have to wait anywhere between a half hour to an hour when you ask for help, I can't do things for myself, like go to the bathroom on my own, you have to rely on others. During an interview with Employee E2 RN on 7/30/25 at 9:00 a.m. the following was stated: Residents aren't getting the care they should be due to the staffing. Resident care and outcomes are impacted. During an interview with Employee E4 LPN on 7/30/25 at 9:30 a.m. the following was stated: Residents' care is impacted due to the amount of staffing. During an interview on 7/30/25, at approximately 3:40 p.m. the Nursing Home Administrator confirmed the facility failed to provide an environment and care to promote dignity for each resident's quality of life for ten of twenty residents. 28 Pa. Code 211.12 (a)(c)(d)(4)(5) Nursing Services 28 Pa. Code 201.29 (j) Resident Rights 395705 Page 3 of 3