Hempfield Manor

In the surveyor’s words

From the most serious findings on record at Hempfield Manor, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jun 30, 2026

  Based 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]. […]

• Actual harm, isolatedF600May 18, 2023

  Based on review of facility policies, clinical records, incident reports, and staff interview, it was determined that the facility failed to provide services to create an environment free from neglect by transferring a resident improperly by failing to utilize a mechanical lift as per order, resulting in actual harm when the resident suffered a fall which caused a left knee fracture that required surgery for one of five residents (Resident R1). A review of the facility policy Abuse, Neglect, Exploitation & Misappropriation of Resident Property policy reviewed 12/6/23, defines neglect as the failure of the facility, its employees, or service providers to provide goods and services to a resident necessary to avoid physical harm, pain, mental anguish, or emotional distress. […]

• Actual harm, isolatedF689May 18, 2023

  Based on review of facility policies, clinical records, incident reports, and staff interview, it was determined that the facility failed to provide adequate supervision, implement effective fall interventions, and utilize a mechanical lift as per order to promote resident safety resulting in actual harm of a resident (Resident R1) which resulted in a left knee fracture that required surgery for one of five residents. Findings include: The facility does not have policies for use of mechanical lifts, transfers, or Activities of Daily Living. […]

• Actual harm, isolatedF600Apr 14, 2023

  Based on review of facility policy, clinical records, and staff interview, it was determined that the facility failed to protect a resident from neglect that resulted in actual harm for one of three residents reviewed (Resident R85), which resulted in actual harm of a knee fracture to Resident R85. This was identified as harm for past non-compliance for one resident (Resident R85). Findings include: Review of the United States Code of Federal Regulations (CFR), 42 CFR S483.12. […]

• No harm, potential for more than minimal, widespreadF849Apr 14, 2023

  Based on review of facility policy, hospice records, clinical record review and staff interviews, it was determined that the facility failed to maintain hospice records for three of three residents receiving hospice services (Resident R57 and R60, and R64) Findings include: Review of facility policy Hospice, last reviewed 12/6/22, stated that facility shall communicate and work with Hospice in the development and implementation of a coordinated plan of care between the nursing home and Hospice. This coordinated plan of care shall reflect the hospice philosophy. Be based on the assessment of the resident and the unique living situation in the nursing home and identify services, supplies, and equipment to be provided by the facility and those to be provided by the hospice care program. […]