A Millcreek Township long-term care facility was cited twice by the Pennsylvania Department of Health after a patient suffered a broken hip, a torn wrist ligament and went into shock when a nursing assistant improperly tried to lift them out of bed.

The resident was hospitalized for 10 days.

Greenfield Healthcare and Rehabilitation, 1521 W. 54th St., was cited for failing to keep the patient free from abuse and neglect, and keeping them free of accident hazards.

"I was lifted up and fell out of the lift," the resident told a state health inspector. "I hit the floor hard and got a terrible gash to the back of my head."

The incident occurred Sept. 29 but the citations were issued following a Jan. 27 inspection, the results of which the state health department published on its website in early March.

It is the latest in a series of incidents at Greenfield that have resulted in state health department citations. It received 19 citations in January, and six more in November and December.

No fines or licensure status changes for the facility have been issued, according to the state health department website.

Citations reported in the past year include:

Repeatedly not having enough nurses or nursing assistants working.

Not emptying a resident's bedside commode for more than 13 hours, despite that it was filled and its lid had fallen onto the floor.

Residents lying in bed, soaked in their own urine, despite pressing a call bell for more than an hour.

Not strongly enforcing the facility's nonsmoking policy for a patient on supplemental oxygen.

Residents not given pain medications in a timely manner.

Patient care staff working while wearing ear buds or talking on their cell phone.

Greenfield officials did not return repeated calls seeking comment on the citations.

The facility was cited in connection with the patient's fall because only one nursing assistant using a mechanical lift was attempting to transfer them from a bed to a wheelchair. State health codes require two people to assist when a resident can't help themselves.

The employee involved received a disciplinary action and the staff was "re-educated" on the proper use of a Hoyer lift with two assistants, according to the inspection report.

Greenfield officials did not explain in the report why only one staff member was attempting to lift the resident, but many of the 19 citations issued in January deal with a lack of staffing at the facility.

Many, but not all, long-term care facilities in Erie County and across Pennsylvania are struggling to meet updated staffing levels for nurses and nursing assistants.

Since July 2024, facilities have been required to provide at least 3.2 hours of direct, daily care to each resident. The staffing minimums for nursing assistants are now one for every 10 residents during the day, one for every 11 in the evening, and one for every 15 overnight.

The minimums for licensed practical nurses are one per 25 residents during the day, one per 30 in the evening and one per 40 overnight. Also, there needs to be at least one registered nurse for every 250 residents.

If you have a parent or spouse who will be moving into a long-term care facility, the Pennsylvania Department of Aging's long-term care ombudsman offered several tips for selecting a facility:

Look at publicly available information such as health inspection reports and reviews.

Talk with people in your community about their experiences with a facility.

If at all possible, make sure you make a site visit and see the place for yourself.

To contact your local ombudsman, call (814) 459-4581 ext. 593 or email them at ombudsman@gecac.org.

Contact David Bruce at dbruce@timesnews.com or by calling 814-870-1736.

(This story was updated to add new information.)

This article originally appeared on Erie Times-News: PA Health Dept. cites Millcreek nursing home after patient fall