Pennsylvania Department of Health
HEMPFIELD MANOR
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

There are 44 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


HEMPFIELD MANOR - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:Name: - Component: -- - Tag: 0000

Based on an Emergency Preparedness Survey completed on March 10, 2026, at Hempfield Manor, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000

Facility ID# 085802
Component 01
Main Building

Based on a Medicare/Medicaid Recertification Survey completed on March 10, 2026, it was determined that Hempfield Manor was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).

This is a one-story, Type V (111), protected wood frame building, without a basement, that is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Corridor - Doors:

This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.

Corridor - Doors
Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material.
Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies.

19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485
Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0363

Based on observation and interview, it was determined the facility failed to maintain corridor doors in one instance, affecting one of seven smoke compartments.

Findings include:

1. Observation on March 10, 2026, at 9:05 a.m., revealed the door to Room 42 failed to latch when tested.

Interview with the Facility Administrator and Maintenance Director on March 10, 2026, at 11:00 a.m., confirmed the corridor door failed to latch at the time of the survey.

Plan of Correction - To be completed: 04/14/2026

On 3/10/26, the resident room 42 door was repaired and tested for latching to ensure proper working order.

Maintenance Director educated on facility door checks and proper latching by Nursing Home administrator.

The Maintenance Director or Designee will audit via facility walkthroughs to ensure doors are operating properly.

These audits will be completed weekly for four weeks, then monthly for three months, then quarterly. Results of Audits will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Fire Drills:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Fire Drills
Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms.
19.7.1.4 through 19.7.1.7

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0712

Based on documentation review and interview, it was determined the facility failed to perform one of 12 required fire drills, affecting the entire facility.

Findings include:

1. Review of documentation on March 10, 2026, at 8:30 a.m., revealed the facility lacked documentation for one of the twelve required fire drills. The facility lacked documentation for a fire drill for third shift in the second quarter.

Interview with the Facility Administrator and Maintenance Director on March 10, 2026 at 8:30 a.m., confirmed the facility lacked documentation for one of 12 fire drills.

Plan of Correction - To be completed: 04/14/2026

On 3/10/26, the documentation provided to Surveyor revealed a fire drill was not completed for third shift in the second quarter of the required drills.

Maintenance Director educated on fire drill frequency and alternating shifts each quarter over 12 months by Nursing Home administrator.

The Maintenance Director or Designee will provide a yearly schedule of fire drills including each shift per quarter.

Fire drills will be audited by Maintenance Director monthly for three months, then quarterly. Results of Audits will be reviewed at quarterly QAPI meetings.

NFPA 101 STANDARD Electrical Systems - Essential Electric Syste:

This is a less serious (but not lowest level) deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Electrical Systems - Essential Electric System Alarm Annunciator
A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator.
6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0916

Based on observation and interview, it was determined the facility failed to maintain the remote alarm annunciator for the emergency generator, affecting the entire facility.

Findings include:

1. Observation on March 10, 2026, at 10:00 a.m., revealed the remote annunciator had three blinking fault lights.

Interview with the Facility Administrator and Maintenance Director on March 10, 2026, at 11:00 a.m., confirmed the emergency generator remote annunciator was communicating faults in the emergency electrical system or was not functioning properly.

Plan of Correction - To be completed: 04/14/2026

On March 10, 2026, the remote alarm annunciator for the emergency generator was displaying three blinking fault lights. The codes were identified due to the high level of fuel in the fuel tank. Generator was run to reduce fuel level. The blinking lights were no longer present.

Maintenance Director was educated by Nursing home administrator on the blinking codes on the annunciator panel.

Maintenance Director will perform audits weekly x 4 weeks, and monthly x 3 months to ensure panel is operating and functional.

Audits will be reviewed during QAPI Quarterly.

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