Health inspection·September 10, 2025

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm Residents Affected - Few Based 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. Findings include: Review of Resident 1's diagnosis list revealed a diagnosis of Obesity, history of falling, hip fracture, Muscle Weakness, CVA (Cerebral Vascular Accident- Stroke) and Dementia (group of conditions that cause a decline in cognitive function, including memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life). Review of Resident 1's Minimum Data Set (MDS-periodic assessment of resident needs) dated May 5, 2025, revealed the resident was cognitively intact. Review of Resident 1's Care Plan revealed a care plan for ADL (Activities of Daily Livingbasic self-care tasks that individuals perform on a regular basis to maintain their health and independence) self-care performance deficit r/t (related/to) impaired mobility and CVA revealed an intervention initiated on October 22, 2024 indicating the resident requires extensive assistance of 2 staff participation to reposition in bed. Review of Resident 1's Care Cardex for bed mobility revealed the resident required extensive assistance of 2 staff participation to reposition and turn in bed. Resident 1's cardex was located in the room on the door of the closet. Review of Resident 1's Progress Notes revealed an Incident Note date September 1, 2025, at 7:47 a.m. indicating CNA (Certified Nursing Assistant) notified this nurse that the resident was on the floor around 0450 (4:50 a.m.). the resident was noted sitting on the floor besides (his/her) bed with (his/her) back towards the wheelchair. CNA provided care to the resident and left (him/her) in a lateral (side laying) position to look for a drop sheet 10 minutes before. The resident complained of pain in (his/her) right knee. The resident said: I slipped out of bed and hit my knee, and I can't reposition it.the resident was transferred to (his/her) bed with three assistants by mechanical lift. Further review of Resident 1's progress notes revealed an entry dated September 2, 2025 at 9:35 a.m. indicating IDT (Interdisciplinary Team group of diverse professionals with different areas of expertise who collaborate to achieve a common goal, often to provide coordinated, holistic care for complex needs, particularly in healthcare) reviewed residents fall from bed on 9/1/25. Resident reported (he/she) had moved (his/her) leg too far off of the bed when (his/her) was lying on (his/her) side and the slid out of bed onto the floor. Resident c/o (complained of) pain in right knee and had limited mobility, noted to be externally rotated (indicative of a fracture of the femur) Resident admitted to the hospital with distal femur fracture (knee). Review of facility documentation into the investigation of the cause of the fall revealed a statement from Nursing Assistant Employee E3, dated September 1, 2025. I went into the residents room about 0435 to clean and wash and dress resident. After washing and dressing (him/her), (he/she) began to have a bowel movement. Resident was on (his/her) side in the middle facing the window and I asked if (he/she) was ok while I went to grab more towels. I lowered the bed and went to grab the linen off the cart in the hallway I could hear (him/her) yelling help. I went into the resident's room, and (he/she) was on the floor in the sitting position. I asked (him/her) what happened, and (he/she) stated (his/her) leg went too far over (the edge of the mattress) and (he/she) slipped out of bed. Interview with the Nursing Home Administrator and the Director of Nursing on September 10, 2025, at 2:00 p.m. confirmed Resident 1 was not provided appropriate staff supervision during care while Employee E3 left the bedside to get more towels while providing incontinence care which resulted in actual harm to Resident 1 who was admitted to the hospital for a fractured femur. 28 Pa. Code 201.14(a) Responsibility of licensee 28 Pa. Code 201.18(b)(1)(3)(e)(1) Management 28 Pa. Code 211.10(d) Resident care (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 2 of 3 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 09/10/2025 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 policies 28 Pa. Code 211.12(c)(d)(1)(5) Nursing services Level of Harm - Actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 395205 If continuation sheet Page 3 of 3