Health inspection·February 4, 2026

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Based 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.Findings include:During an interview conducted with the Nursing Home Administrator (NHA) on February 3, 2026, at approximately 8:20 a.m., the NHA reported one hallway in the rehabilitation unit lost heat on the evening of January 31, 2026. In response, the facility placed three radiant space heaters in resident rooms and two radiant space heaters in the rehabilitation unit hallway.Observations conducted February 3, 2026, at 8:24 a.m., during the survey revealed radiant space heaters actively in use in resident rooms and in a hallway accessible to residents. The heaters were positioned in locations where residents could come into direct contact with hot surfaces and electrical components.The Maintenance Director was contacted on February 3, 2026, at 8:25 a.m., and the surveyor accompanied the Maintenance Director while temperature readings of the space heaters were obtained.Temperature measurements of the space heaters located in resident rooms were as follows:Space Heater #2 located in Resident R1's and R2's room measured 138.5 FSpace Heater #3 located in Resident R3's room measured 153 FSpace Heater #4 located in Resident R4's and R5's room measured 123 FTemperature measurements of the space heaters located in the affected hallway were as follows:Space Heater #1 located at the entrance of the hallway measured 139 FSpace Heater #5 located at the end of the hallway measured 136 FInterview conducted with the Maintenance Director and the NHA on February 3, 2026, at approximately 8:42 a.m., NHA confirmed the facility was aware of the temperatures of the radiant space heaters located in resident rooms and the hallway. The NHA reported that space heaters were placed in the rooms of Residents R1, R2, R4, and R5 because those residents were dependent on staff for transfers. The NHA further indicated a space heater was placed in Resident R3's room because the resident had a BIMS score of 15, indicating intact cognition. The Maintenance Director reported placing orange caution cones around the space heaters located in the hallway to prevent residents from walking into them.Observations conducted in the affected hallway at approximately 8:58 a.m. revealed a resident in a wheelchair independently ambulating using handrails to pull themselves forward. The resident maneuvered around Space Heater #5 by moving to the opposite side of the hallway and continued down the hallway until reaching Space Heater #1, where the resident again had to maneuver around the heater to continue ambulation.Review of Resident R1's Minimum Data Set (MDS) revealed the resident was independent with chair-to-bed and bed-to-chair transfers and able to ambulate independently. The MDS further revealed a BIMS score of 12, indicating moderate cognitive impairment.Review of Resident R2's MDS assessment revealed the resident was dependent on staff for transfers and ambulation and had a BIMS score (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 3 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 02/04/2026 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)