Inspection visit

Health inspectionDecember 21, 2023

NEFFSVILLE NURSING AND REHABILITATIONCMS #39520511 citations on this visit

11 citations recorded

Inspector’s narrative

What the inspector wrote

This survey cited 11 deficiencies. The full statement and the facility’s plan of correction follow, verbatim from the federal record.

F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Based 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). Findings include: Review of Resident 28's clinical record revealed a diagnosis of Type 1 Diabetes (insulin dependent). Review of Resident 28's November 2023 physician's orders revealed an order dated April 3, 2023, for Glucagon HCl Injection Solution Reconstituted 1 MG subcutaneously every 15 minutes as needed for as need it related to blood sugar bellow 70 and patient unresponsive turn on side, administer injection. Check BS every 15 minutes until BS reaches 70, offer a protein snack if PT responsive, call DR if nonresponsive. Review of the clinical record revealed a nursing note dated November 26, 2023, at 6:00 p.m. Resident 28 was found not responding and snoring heavily. Blood Sugar 42. IM Glucagon given. After 15 minutes, BS 62 but resident continues to not respond. Second dose of IM Glucagon given. After 15 minutes, BS 94, Resident w/ opened eyes but continues to sleep. Will continue to check BS & monitor level of consciousness. There is no further documentation that the physician was called until 8:00p.m. when staff gave a third dose of Glucagon due to BS of 43. Resident 28's blood sugar then was 84. When staff returned the residents blood sugar was 503. Resident remained lethargic with snoring respirations. On call provider called. Interview with the Nursing Home Administrator on December 21, 2023, at 11:00 a.m. revealed that there was no further documentation of the physician being called until 8:00 p.m. Review of facility policy Weight Assessment and Intervention, last revised March 2019, revealed: Any weight change of 5 pounds or more since the last weight assessment will be retaken for confirmation. If weight is verified, nursing will notify the Physician and Dietitian. Review of Resident 45's clinical record revealed diagnoses including liver cancer with metastasis to the lungs (cancer that has spread to the lungs) and malignant ascites (condition where fluid with cancer cells accumulates in the abdomen). Review of Resident 45's weights revealed on November 10, 2023, the resident was recorded as weighing 127 pounds (lbs.) On December 5, 2023, the resident was recorded as weighing 147.6 lbs., a 20.6 (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 15 Event ID: 395205 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0580 lb. weight gain in less than a month. Level of Harm - Minimal harm or potential for actual harm Review of Resident 45's progress notes revealed the dietitian was made aware of the resident's weight gain and requested a reweight. Residents Affected - Few Further review of Resident 45's weights revealed the resident was documented as weighing 147.6 lbs. on December 6, 2023, and December 10, 2023. Further review of Resident 45's progress notes failed to reveal evidence that the physician or provider were notified of Resident 45's weight gain. Review of Resident 45's Hospice notes revealed a nurse s note on December 12, 2023, which stated that the resident had increased dyspnea (difficulty breathing), moist nonproductive cough, wheezing, pain all over, and edema (swelling) up to the resident s hips and thighs. Further review of Resident 45's progress notes revealed a nurse s note on December 12, 2023, which stated: Hospice recommendation to begin Lasix [(water pill used to reduce fluid build up in body)] 40mg Po QD x 3 days [(by mouth daily for three days)] approved by [provider.] The delay in notifying the provider and addressing Resident 45's weight gain was discussed with the Nursing Home Administrator and Director of Nursing on December 21, 2023, at approximately 10:50 a.m. 28 Pa Code 211.12(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 2 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Based 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). Findings include: Review of facility policy, Abuse Policy, revised January 2020 revealed that all reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by the administrator and or designee. Interview with Resident 91 on December 19, 2023, at 9:03 a.m. revealed that she had reported $300 dollars missing approximately six months ago. Review of facility concern form completed June 9, 2023, revealed that Resident 91 had reported missing money and an investigation had been completed. Interview with the Nursing Home Administrator on December 21, 2023, at 12:30 p.m. confirmed that the allegation of misappropriation had not been reported to the appropriate state agency. 483.13 - Resident Behavior and Facility Practices, 10-1-1998 edition Pa. Chapter 51: Code 51.3(g)(6) Notification 28 Pa. Code: 201.14(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(1) Management 28 Pa. Code: 201.29(d) Resident rights 28 Pa Code 211.10(a)(d) Resident Care Policies FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 3 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Ensure each resident receives an accurate assessment. Level of Harm - Potential for minimal harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Some Findings include: Review of Resident 56's quarterly MDS (Minimum Data Set - periodic assessment of resident needs) assessment of November 16, 2023, section H0100, bowel and bladder appliance, indicated that the resident had an indwelling catheter (tube that drains urine from the bladder into a bag outside the body). Further review of the clinical record revealed no indication that the resident had a catheter. Interview with licensed staff, E5, on December 20, 2023, at 1:00 p.m. confirmed that Resident 56 did not have a catheter and the MDS was coded incorrectly. Review of Resident 73's admission orders of September 12, 2023, included an order for hemodialysis (process to filter wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work) every Tuesday, Thursday, and Saturday. Review of progress notes revealed resident was out for dialysis on September 16, 2023. Review of Resident 73's admission MDS of September 18, 2023, section O - Special Treatment and Programs indicated that resident did not receive dialysis while a resident. Interview with licensed staff, E5, on December 21, 2023, at 11:55 a.m. confirmed that Resident 73's assessment was coded inaccurately. Review of Resident 174's discharge MDS assessment dated [DATE], revealed that the resident was discharged to home/community. Review of Resident 174's nursing progress notes dated October 9, 2023, revealed Physician was notified of the resident's increased confusion, and change in mental status, MD ordered to send resident to the hospital for evaluation. Interview with licensed employee E5 was conducted on December 21, 2023, at 12:45 p.m. Employee E5 reported that the resident was sent and admitted to the hospital and then went home. Employee E5 confirmed that Resident 174's MDS was coded inaccurately. 28 Pa. Code 211.5(f) Clinical records Previously cited 3/3/23 28 Pa. Code 211.12(c) Nursing services Previously cited 3/3/23 28 Pa. Code 211.12(d)(1)(5) Nursing services (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 4 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0641 Previously cited 3/2/23 Level of Harm - Potential for minimal harm Residents Affected - Some FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 5 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0656 Level of Harm - Minimal harm or potential for actual harm Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Based 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). Residents Affected - Few Findings include: Review of Resident 73's admission orders of September 12, 2023, included an order for hemodialysis (process to filter wastes, salts and fluid from the blood when the kidneys are no longer healthy enough to do this work) every Tuesday, Thursday, and Saturday. Further review of the clinical record revealed no care plan regarding dialysis. Interview with the Nursing Home Administrator on December 21, 2023, at 10:30 a.m. confirmed that there was no care plan in place to address the hemodialysis. 28 Pa. Code 211.5(f) Clinical records Previously cited 3/3/23 28 Pa. Code 211.11(a) Resident care plan 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12(d)(1)(5) Nursing services Previously cited 3/3/23 FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 6 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 Provide appropriate pressure ulcer care and prevent new ulcers from developing. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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) Residents Affected - Some 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. Review of Resident 82's progress notes revealed a skin and wound note by the wound CRNP, dated September 7, 2023 at 8:53 a.m. which documents two wounds to Resident 82's right foot. Right lateral (outside) mid foot pressure ulcer, 1.8cm (centimeters) x 4.4cm x 0.3 cm and a right heel pressure ulcer 1.6cm x 1.3cm x 0.2 cm. Further review of the clinical record revealed these areas were not documented and assessed or treated until found by the wound CRNP on September 7, 2023. Interview with the Director of Nursing on December 20, 2023 at 1:30 p.m. confirmed the documentation of Resident 82's wound on the weekly skin reviews were inaccurate and incomplete and there should have been documentation and treatment of a wound prior to being accessed by the wound CRNP on September 9, 2023. Clinical records review revealed Resident 106 was admitted to the facility on [DATE], with diagnosis of Respiratory Failure. Review of Resident 106's skin admission assessment revealed resident had a wound on the coccyx (tailbone). Clinical records review revealed that the coccyx wound identified upon admission on [DATE], was not assessed. Clinical records review failed to reveal that a wound treatment for Resident 106 ' s coccyx was initiated. Review of a wound consult assessment dated [DATE], revealed an unstageable wound (Obscured full-thickness skin and tissue loss) to sacrum/coccyx measuring 3.2 x 0.8 x 0.2 cm., with 100% slough (A non-viable yellow, tan, gray, green or brown tissue; usually moist, can be soft, stringy and mucinous in texture. Slough may be adherent to the base of the wound or present in clumps throughout the wound bed). Review of the physician order dated October 12, 2023, revealed a wound treatment order to cleanse the coccyx wound with normal saline, apply Medi honey (A dressing that aids and supports debridement and a moist wound healing environment in acute and chronic wounds and burns), apply border gauze (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 7 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0686 daily every evening shift. Level of Harm - Minimal harm or potential for actual harm Review of the October 2023, Treatment Administration Record (TAR) revealed that the wound treatment ordered on October 12, 2023, was not done until October 15, 2023, three days after the physician's order was made. Residents Affected - Some Interview with the Director of Nursing (DON) on December 21, 2023, at 11:00 a.m., was conducted. The DON confirmed that Resident 106 ' s identified coccyx/sacrum wound was not assessed upon admission on [DATE]. The DON reported that the wound treatment order made by the physician on October 12, 2023, was improperly transcribed to the Electronic Medical Records until corrected on October 15, 2023. The facility failed to ensure Resident 106's identified wound was assessed and treated timely. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.10(d) Resident Care Policies 28 Pa. Code 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 8 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based 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). Findings include: Review of facility policy, Medication Administration - General Guidelines, undated, revealed that the resident is always observed after administration to ensure that the dose was completely ingested. Additionally, residents are allowed to self-administer medications when specifically authorized by the attending physician and in accordance with procedures for self-administration of medications. Review of Resident 12's nursing progress note of May 14, 2023, revealed that When this nurse went in to give morning meds[medications] she found cup full of pills in garbage at residents bedside. When resident was asked when were they from she responded from last night. I reinforced with resident the need to take medications that Physician has prescribed to her. Review of Resident 12's psychiatry progress note of December 8, 2023, revealed Pt [patient] is agitated about how many pills she takes as she is looking at a cup of pills they brought her-says it used to be 10 pills and now its 20 (of note it looks more like 10 or less). Review of Resident 12's clinical record revealed no physician's order or assessment for self administration of medications. Observation on December 18, 2023, at 1:50 p.m. revealed licensed staff, E6, bring medication to Resident 77 and leave room. Resident 77 then observed sitting on the bed with pill cup containing three pills on seat of rolling walker. Resident 77 indicated that he/she had to take medicine before going to the facility store. Review of Resident 77's clinical record revealed no physician's order or assessment for self administration of medications. Observation on December 19, 2023, at 9:01 a.m during interview with Resident 98, revealed licensed staff, E7, placing pill cup containing multiple pills and Spiriva inhaler (relaxes muscles in the airways and increases air flow to the lungs) on the resident's overbed table. Interview with the resident revealed that staff do not usually leave medications. Resident then proceeded to use inhaler. Review of Resident 98's clinical record revealed no physician's order or assessment for self administration of medications, except for voltaren gel (topical medication for joint pain). Interview with the Nursing Home Administrator (NHA) on December 21, 2023, at 10:30 a.m. confirmed that the above residents do not have orders or assessments to self administer medications. The NHA also confirmed that medications should not be left at the bedside. Review of Resident 90's clinical record revealed a nursing progress note on November 29, 2023, which stated that the resident was found on the floor next to the bed at approximately 3:30 a.m. (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 9 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Further review of Resident 90's progress notes revealed an interdisciplinary team note on November 29, 2023, which stated: reviewed resident's fall from this AM at 0330. Resident tends to sleep close to the edge of the bed. [Social services] to reach out to [Hospice company] to request a full scoop mattress for resident's bed. Further review of Resident 90's progress notes revealed a nurse's note on December 14, 2023, which stated that the resident was found on the floor next to the bed and sustained a small skin tear to the left elbow. Observation of Resident 90 on December 19, 2023, at 10:30 a.m. revealed the resident was lying in bed on a regular mattress. Interview with the Nursing Home Administrator on December 20, 2023, at approximately 2:00 p.m. revealed the resident would be receiving a scoop mattress the following day. Interview with the Social Services Director, Employee E3, on December 21, 2023, at 10:20 a.m. revealed the employee did not contact Hospice regarding getting Resident 90 getting a scoop mattress until the day before on December 20, 2023. The above findings were discussed with the Nursing Home Administrator and Director of Nursing on December 21, 2023, at approximately 10:50 a.m. 28 Pa. Code 211.11(d) Resident care plan 28 Pa. Code 211.12 (c)(d)(1)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 10 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. Based 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. confirmed there was no documented evidence that Resident 79 was receiving catheter care. 28 Pa Code 211.12(d)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 11 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Level of Harm - Minimal harm or potential for actual harm Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Based 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) Residents Affected - Few 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. Medication dose is not available in facility's emergency kit but have Percocet 5-325 mg dose available. PRN Tylenol given this shift while waiting for Pharmacy to deliver med but med did not arrive upon routine delivery time. Interview with the Nursing Home Administrator and the Director of Nursing on December 21, 2023 at 11:15 a.m. confirmed Resident 82 did not receive medication as ordered by the physician due to unavailability from pharmacy. 28 Pa. Code 211.9(j) Pharmacy services. 28 Pa. Code 211.12(d)(1)(5) Nursing services. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 12 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. Based 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: akathisia (uneasiness), dystonia (muscle contraction), extrapyramidal effects (involuntary movements), akinesia (inability to move); or traditive dyskinesia, (muscle movements cause by medications), stroke, or TIA. Review of Resident 6 care plan revealed a care plan with a focus on Hazel uses psychotropic medications r/t (related to) depression, anxiety and mood disorder d/t (due to) know physiological condition with mixed features with an intervention of Monitor/record/report to MD prn side effects and adverse reactions of psychoactive medications: unsteady gait, tardive dyskinesia, EPS (shuffling gait, rigid muscles, shaking), frequent falls, refusal to eat, difficulty swallowing, dry mouth, depression, suicidal ideations, social isolation, blurred vision, diarrhea, fatigue, insomnia, loss of appetite, weight loss, muscle cramps nausea, vomiting, behavior symptoms not usual to the person initiated on November 2, 2022. Review of Resident 6 clinical record revealed there was no documented evidence the facility was monitoring for potential side effects related to the administration of antipsychotic medications. Interview with the Nursing Home Administrator and Director of Nursing on December 21, 2023 at 11:15 a.m. confirmed the facility failed to monitor Resident 6 for side effects related to antipsychotics per facility policy. 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 13 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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). Residents Affected - Few Findings include: Rview of the facility's policy titled Medication Administration-General Guideline; undated revealed medications are administered by written orders of the attending physician. Clinical records review revealed Resident 109 was admitted to the facility on [DATE], with a diagnosis of Cerebral Infarction (A condition caused by a lack of blood flow to part of your brain), Traumatic Brain Injury (TBI- An injury that affects how the brain works), and Epilepsy (A disorder in which nerve cell activity in the brain is disturbed, causing seizures). Nursing progress notes revealed resident arrived in the facility on September 14, 2023, around 10:00 a.m., and orders were verified with the Nurse Practitioner (NP), Employee E4 at 11:00 a.m. Review of the physician's order dated September 14, 2023, revealed the following anti-seizure medication orders: Lacosamide oral solution 10mg/ml give 20mg via peg tube two time a day, Phenobarbital elixir 20mg/5ml give 15ml via peg tube two times a day, Valproate Sodium Solution 250mg/5ml give 5 ml via peg tube every 8 hours, and Oxcarbazepine 600mg via peg tube every 3 times a day. Review of the September 2023, Medication Administration Record (MAR) revealed that on September 14, 2023, Resident 109 was not administered Valproate medication at 4:00 p.m., Oxcarbazepine was not administered at 2:00 p.m. and 9:00 p.m., Lacosamide and Phenobarbital was not administered at 9:00 p.m. Clinical records review failed to reveal that the physician was notified on September 14, 2023, that the above anti-seizure medication was not administered to Resident 109. Interview with the NP on December 21, 2023, at 9:00 a.m., confirmed that she /he was notified that Resident 109's missed the scheduled September 14, 2023, anti-seizure medications on the morning of September 15, 2023. The NP reported that nursing staff informed her/him that the medications were not administered on September 14, 2023, because the medications were not available (awaiting pharmacy delivery). Review of the pharmacy documentation, Inventory in Hand revealed that Valproate, Lacosamide, Oxcarbazepine, and Phenobarbital medications were all available in the facility's emergency medication supply. Interview with the Nursing Home Administrator, and Director of Nursing on December 21, 2023, at 10:00 a.m., confirmed that the above medications were available in the facility on September 14, 2023, but were not administered. The NHA confirmed that the physician was not notified of the missed anti-seizure medication of Resident 109 on September 14, 2023, until the next day. The facility failed to ensure Resident 109 was free from a significant medication error by not (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 14 of 15 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 395205 B. Wing A. Building (X3) DATE SURVEY COMPLETED 12/21/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Neffsville Nursing and Rehabilitation 2829 Lititz Pike Lancaster, PA 17601 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0760 following the physician's order for anti-seizure medications. Level of Harm - Minimal harm or potential for actual harm 28 Pa Code 211.5 (f) Clinical records 28 Pa code 211.10 (c) Resident care policies Residents Affected - Few 28 Pa. 211.12(c)(d)(1)(3)(5) Nursing services FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 15 of 15

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Citations

11 citations recorded^*CMS

What do CMS severity letters mean?

Serious (G-L). Actual harm to a resident, or immediate jeopardy. Codes G through I indicate actual harm; J through L indicate immediate jeopardy to resident health or safety.

General (A-F). No actual harm found, or harm that is minimal. The facility must still submit a Plan of Correction. Most CMS citations land here.

Each letter combines severity with scope: how many residents the deficiency affected.

0580GeneralS&S Dpotential for harm
F580 - Notification of Changes
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
0552GeneralS&S Epotential for harm
F552 - Planning and Implementing Care
Ensure that residents are fully informed and understand their health status, care and treatments.
0609GeneralS&S Dpotential for harm
F609 - The facility must develop and implement written policies and procedures that:
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
0641GeneralS&S Bno actual harm
F641 - Accuracy of Assessments
Ensure each resident receives an accurate assessment.
0656GeneralS&S Dpotential for harm
F656 - Comprehensive Care Plans
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
0686GeneralS&S Epotential for harm
F686 - Skin Integrity
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
0689GeneralS&S Epotential for harm
F689 - Accidents
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
0690GeneralS&S Dpotential for harm
F690 - Incontinence
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
0755GeneralS&S Dpotential for harm
F755 - Pharmacy Services
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
0758GeneralS&S Dpotential for harm
F758 - Medication Errors
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
0760GeneralS&S Dpotential for harm
F760 - Residents are free of any significant medication errors
Ensure that residents are free from significant medication errors.

FAQ · About this visit

Common questions about this visit

What happened during the December 21, 2023 survey of NEFFSVILLE NURSING AND REHABILITATION?

This was a inspection survey of NEFFSVILLE NURSING AND REHABILITATION on December 21, 2023. The surveyor cited 11 deficiencies, recorded on the federal Form 2567 statement of deficiencies.

Were any deficiencies cited at NEFFSVILLE NURSING AND REHABILITATION on December 21, 2023?

Yes, 11 deficiencies were cited, each with a CMS Scope and Severity grade. The first was: "Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) tha..."

What type of survey was this?

This was a inspection survey conducted by state surveyors under federal Centers for Medicare & Medicaid Services (CMS) oversight. Findings are published on CMS Care Compare.

SourceView on CMS Care Compare

Next steps

Concerned about a resident’s care?Find your local ombudsman through the Eldercare Locatoror file a complaint with your state survey agency.

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Data from CMS Care Compare public records. Dataset last refreshed June 15, 2026. If you believe any information is inaccurate, report it here.

Health inspection·December 21, 2023