Neffsville Nursing and Rehabilitation

Inspectors wroteBased on observation, record review, and staff interviews, it was determined the facility failed to ensure the environment was free from accident hazards and failed to provide adequate supervision and assistive devices to prevent accidents. Specifically, the facility utilized radiant space heaters in resident rooms and in a hallway of the rehabilitation unit following loss of heat, placing residents, including residents with cognitive impairment, at risk for serious injury or death. This failure constituted Immediate Jeopardy for the 22 residents on the Rehab unit.

Inspectors wroteBased on review of employee job descriptions, as well as observations, record review, and staff interviews, it was determined that the facility's administration, including the Nursing Home Administrator and Director of Nursing, failed to effectively utilize available resources to promote resident safety and maintain the highest practicable physical well-being of residents. Specifically, the facility failed to ensure the environment was free from accident hazards by permitting the use of radiant space heaters in resident rooms and hallways, including areas accessible to residents with cognitive impairment. This failure placed residents at risk for serious injury or death and resulted in an Immediate Jeopardy situation.

Inspectors wroteBased on observations, staff interview, and resdient interview it was determined the facility failed to maintain a clean, comfortable, and homelike environment in four of four resident bathrooms. (Apple, Rosemont, [NAME] and Rehab units)Findings Include:Observation of the Apple unit bathroom on October 17, 2025 at 11:15 a.m. revealed the floor of the shower was missing approximately 8 tiles and the corner of the wall separating the bathtub and the shower had broken and missing tiles. Observations of the Rosemont unit bathroom on October 17, 2025 at 11:20 a.m. revealed a soiled Band-Aid lying on the floor of the shower. The wall of the entrance to the shower was broken at the floor with missing tiles and the metal covering bent and sticking out. The wall next to the entrance to the bathroom was missing tiles and had broken tiles. [...]

Inspectors wroteBased on facility policy and procedure review, staff interview, clinical record review, and facility documentation review it was determine the facility failed to ensure that one of three residents reviewed was free from free from accidents and provided adequate supervision resulting in actual harm of a distal femur fracture of Resident 1.

Inspectors wroteBased on facility documentation, clinical records review and staff interview, it was determined that the facility failed to provide care and services in accordance with professional standards when the facility failed to notify the physician of recommendations following a specialist consultation for one out of 1 resident reviewed (Resident 2). Review of Resident 2's clinical records reveal medical diagnoses that include: [...]

Inspectors wroteBased on facility policy and procedure review, observations, and staff interview it was determined the facility failed to maintain a sanitary environment in the kitchen. Findings Include: Review of facility policy and procedure titled Cleaning and Sanitation of Food Service Area, last revised July 2023 revealed the food service staff will maintain the sanitation of the dining and food service areas through compliance with a written, comprehensive cleaning schedule. Observation of the dishwashing area on March 25, 2025 at 2:45 p.m. revealed a large brown colored substance covering the wall behind the dishwashing machine. Interview with Dietary Employee E3 on March 25, 2025 at 3:10 p.m. confirmed that the walls were dirty and that there had been a buildup of debris behind the dish washing machine. 28 Pa. Code: 201.18(b)(3) Management 28 Pa.

Inspectors wroteBased on a clinical records review and staff interview, it was determined that the facility failed to ensure that the wound care order was consistently followed for one of the three residents reviewed (Resident CL1).

Inspectors wroteBased on a review of the facility's policy, observations, clinical record reviews, and staff interviews, it was determined the facility failed to ensure Enhanced Barrier Precautions (EBP-infection control prevention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were in place for residents requiring enhanced barrier precautions for ten of ten residents reviewed (Residents 2, 21, 24, 28, 66, 70, 78, 123, 161, 170).

Inspectors wroteBased on facility policy, clinical record review, and staff interview, it was determined the facility failed to monitor weights and notify the physician of significant weight changes for six of 10 residents reviewed for nutrition (Residents 2, 6, 43, 161, 173, and 174).

Inspectors wroteBased on observations, and staff interviews, it was determined that the facility failed to properly store frozen food in the main kitchen, and properly serve meals on one of five units observed (Rehab unit).

Inspectors wroteBased on observation, review of clinical records, and staff interviews, it was determined that the facility failed to ensure assessments accurately reflected the resident's status for three of the 35 residents reviewed (Residents 2, 67, and 123).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure a baseline care plan for pressure ulcers was developed timely for one of seven residents reviewed (Resident 85).

Inspectors wroteBased upon clinical record review, it was determined the facility failed to develop comprehensive care plans for a foley catheter and a wound vac for two of eighteen residents reviewed (Resident 78 and Resident 123) .

Inspectors wroteBased on a review of the facility's policy, observation, clinical records review, and staff interview, it was determined that the facility failed to timely notify the physician of a change in condition and follow a medication order for two of 35 residents reviewed (Residents 67 and 345).

Inspectors wroteBased on review of facility's policy, clinical record review and staff interview it was determined the facility failed to assess, monitor and treat pressure ulcers for two of eight residents reviewed. (Residents 82 and 106) Findings Include: Review of the facility's policy titled Skin and Wound Management System, undated, revealed Residents identified with skin impairments will have appropriate interventions, treatment, and services implemented to promote healing and impede infection. Wound location, characteristics, and a physician's order for treatment are documented in the medical record. Review of Resident 82's weekly skin review dated August 21, 2023 revealed the resident had a wound on the right heel that was pending treatment. Further review of the clinical record revealed there was no other documentation of this wound or notification to the physician of this new wound. [...]

Inspectors wroteBased on facility policy, observation, interview, and clinical record review, it was determined that the facility failed to ensure residents were free of accident hazards for three of 35 residents reviewed (Residents 12, 77, and 98) and failed to ensure residents had appropriate interventions in place to prevent falls for one of 35 residents reviewed (Resident 90).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to notify the provider of a resident change in condition in a timely manner for two of 35 residents reviewed (Residents 28 and 45).

Inspectors wroteBased on a review of facility policy, interviews with residents, review of facility documentation, and staff interview, it was determined that the facility failed to report an allegation of misappropriation of resident property to the appropriate State agency for one of 35 residents reviewed (Resident 91).

Inspectors wroteBased on a review of clinical records and staff interview, it was determined that the facility failed to develop a comprehensive care plan for one of 28 residents reviewed (Resident 73).

Inspectors wroteBased on interview and clinical record review, it was determined that the facility failed to ensure that residents were provided with consistent, adequate catheter care for one of five residents reviewed for catheters (Resident 79). Interview with Resident 79 on December 19, 2023, at approximately 12:50 p.m. revealed the resident had an indwelling foley catheter (a thin, flexible tube placed in the bladder through the urethra to drain urine). Resident 79 revealed staff were not routinely providing care to the catheter to prevent urinary tract infections (UTIs). Review of Resident 79's clinical record failed to review physician orders or nursing interventions on the care plan addressing the resident's catheter care. Interview with the Nursing Home Administrator on December 21, 2023, at approximately 12:35 p.m. [...]

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to provide pharmacy services for one of 40 residents reviewed. (Resident 82) Findings Include: Review of Resident 82's physician orders revealed an order for Oxycodone-acetaminophen (combination Narcotic pain reliever and Tylenol) oral tablet 7.5-325 give every six hours for pain dated August 21, 2023. Review of Resident 82's Medication Administration Record (MAR) for October 2023 revealed the resident did not receive all four doses on October 14, 2023, the midnight dose of October 15, 2023 or three doses on October 18, 2023 for a total of eight doses. Review of Resident 82's progress notes revealed a nursing entry dated October 14, 2023 at 4:44 a.m. revealed Resident ran out of his Percocet 7.5-325 mg po tab and missed last evening's 1800 (6 p.m.) dose and midnight 0000 dose. Supervisor notified. [...]

Inspectors wroteBased on clinical record review and staff interview it was determined the facility failed to monitor side effects for resident on antipsychotic medications for one of 5 residents reviewed. (Resident 6). Findings Include: Review of facility policy and procedure titled Antipsychotic Medication Use, revised on January 2016, revealed Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: General/anticholinergic: constipation, blurred vision, dry mouth, urinary retention, sedation Cardiovascular: orthostatic hypotension, arrythmias (abnormal heart beats) Metabolic: increase in total cholesterol/triglycerides, unstable or poorly controlled blood sugar, weight gain; or Neurologic: [...]

Inspectors wroteBased on a review of the facility's policy, clinical records pharmacy documentation review, and staff interviews, it was determined that the facility failed to ensure anti-seizure medication was administered as ordered by the physician for one of 35 residents reviewed (Resident 109).

Inspectors wroteBased on clinical record review and staff interview, it was determined that the facility failed to ensure that assessments accurately reflected the resident's status for three of 40 residents reviewed (Residents 56, 73, and 174).

Inspectors wroteBased on clinical record review and staff and resident interview it was determined the facility failed to obtain informed consent prior to laboratory studies for five of 40 residents reviewed (Residents 6, 79, 90, 100, and 107).

Inspectors wroteBased on review of facility documentation, observations and interview with staff, it was determined that the facility failed to maintain appropriate temperatures during dishwashing.

Inspectors wroteBased upon a review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that any irregularities were acted upon by a physician for three of five residents reviewed (Residents 65, 66, and 110).

Inspectors wroteBased upon interview and clinical record review, it was determined the facility failed to have resident participation in care plan meeting or develop a plan of care for one of 32 residents reviewed (Resident 2).

Inspectors wroteBased upon review of facility policy and procedure, interviews and clinical record review, it was determined the facility failed to have resident designate their own code status and failed to allow resident to participate in their own care treatment and discharge planning and failed to obtain appropriate signatures for POLST (Physician Orders for Life Sustaining Treatment) for one of 32 residents reviewed (Resident 2).

Inspectors wroteBased on clinical record reviews, resident and staff interviews, it was determined the facility failed to ensure physician orders were followed for three of 32 residents reviewed (Resident 12, 82, and 356) and failed to adequately and timely assess complete wound assessments for one of 32 residents reviewed (Resident 107).

Inspectors wroteBased on a review of the facility's policy, observation, clinical records review, and staff interviews, it was determined that the facility failed to follow the recommended treatment of the wound care doctor for one of the five residents reviewed (Resident 150).

Inspectors wroteBased on review of clinical record and staff interview, it was determined that the facility failed to appropriately monitor and assess a resident weight status for two of six residents reviewed (Resident 127, and 150).

Inspectors wroteBased on observation, and staff interviews, it was determined that the facility failed to ensure infection control and prevention were maintained during wound care treatment for one of two residents observed (Resident 150).