Neffsville Nursing And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lancaster, Pennsylvania.
- Location
- 2829 Lititz Pike, Lancaster, Pennsylvania 17601
- CMS Provider Number
- 395205
- Inspections on file
- 24
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Neffsville Nursing And Rehabilitation during CMS and state inspections, most recent first.
Following a loss of heat in a rehab hallway, the facility placed multiple radiant space heaters in resident rooms and in a hallway accessible to residents, with surface temperatures measured between 123°F and 153°F. Heaters were positioned where residents, including those with moderate to severe cognitive impairment and varying levels of dependence for transfers and ambulation, could come into direct contact with hot surfaces and electrical components. A resident in a wheelchair was observed independently navigating around hallway heaters despite only caution cones being used as barriers. The facility had no policies guiding space heater use in resident care areas, and CNA interviews revealed inconsistent understanding of burn, fire, and electrical risks, leading surveyors to identify Immediate Jeopardy for residents on the rehab unit.
Facility administration, including the NHA and DON, failed to ensure a safe environment by allowing radiant space heaters to be used in resident rooms and hallways, including areas accessible to residents with cognitive impairment. Despite job descriptions requiring compliance with federal, state, and local regulations and maintenance of the highest degree of quality care, observations, record review, and staff interviews confirmed that these heaters were present in resident care areas. This failure to keep the environment free of accident hazards was cited under F689 and related state regulations and resulted in an Immediate Jeopardy situation.
Surveyors found that four resident bathrooms had broken or missing tiles, soiled items such as bandages and dirty wash rags on the floors, and damaged fixtures. A resident confirmed that these issues had persisted for some time and that bathrooms were sometimes left unclean during use. The Nursing Home Administrator acknowledged the need for repairs in each area.
A resident with a history of falls, impaired mobility, and CVA was left unattended in bed by a CNA during incontinence care, despite care plan requirements for two-person assistance. The resident slipped out of bed and sustained a distal femur fracture, resulting in hospitalization. Facility leadership confirmed that adequate supervision was not provided during the incident.
A resident with spina bifida and related conditions did not have specialist recommendations for a daily soap suds enema communicated to their primary care provider. Facility records lacked documentation of the consultation, no order was entered for the enema, and the physician was not informed, as confirmed by the DON.
Surveyors observed a large brown substance covering the wall behind the dishwashing machine, and a dietary employee confirmed a buildup of debris and dirty walls in the kitchen. This occurred despite facility policy requiring regular cleaning and sanitation of food service areas.
A resident with cerebrovascular disease and dementia had a worsening unstageable pressure ulcer. The facility failed to follow the physician's wound care orders, missing morning treatments on several occasions. The DON could not explain the missed treatments, leading to a deficiency in care practices.
The facility failed to implement Enhanced Barrier Precautions (EBP) for residents with wounds and indwelling medical devices, as required by their policy. Observations showed a lack of PPE and EBP signage in residents' rooms, and staff interviews revealed a lack of communication and understanding regarding PPE use. An employee reported not being informed about necessary PPE for wound care, and the Infection Preventionist incorrectly stated that no residents required EBP, indicating a systemic failure in infection control measures.
The facility failed to monitor and address significant weight changes in several residents, as required by their policy. Instances included delayed reweights, lack of timely interventions, and failure to notify physicians and dietitians of significant weight changes. These deficiencies were confirmed through interviews with the DON.
The facility failed to properly store frozen food in the main kitchen and serve meals on the Rehab unit. Observations revealed opened and unsealed frozen food items in the freezer. Additionally, meal trays with uncovered items like peaches, apple juice, and coleslaw were delivered to residents' rooms. Staff confirmed that food should have been covered.
The facility failed to ensure accurate resident assessments, as evidenced by errors in the MDS for three residents. One resident was incorrectly documented as having a urinary catheter, another as being on dialysis, and a third as using restraints. These inaccuracies were confirmed by staff and communicated to the DON.
A facility failed to develop a timely baseline care plan for a resident with an unstageable pressure ulcer. The resident was admitted with a right heel ulcer, but the care plan was not created until a week later. This delay was confirmed by the DON during an interview.
The facility failed to develop comprehensive care plans for two residents, one with a urinary catheter and another with a wound vac for an amputation stump. The absence of care plans was confirmed by facility staff, indicating deficiencies in addressing the residents' specific medical needs.
The facility failed to notify the physician of a significant weight change for a resident and did not administer prescribed Meropenem to another resident due to a nurse's oversight. The weight change was not rechecked as required, and the medication was available but not given. The physician was not informed of these issues promptly.
Improper Use of Radiant Space Heaters Creating Accident Hazards
Penalty
Summary
The deficiency involved the facility’s failure to maintain an environment free from accident hazards and to provide adequate supervision and assistive devices after a loss of heat in one rehabilitation hallway. On the evening of January 31, 2026, the facility responded to the heat loss by placing three radiant space heaters in resident rooms and two radiant space heaters in the affected hallway. During observations on February 3, 2026, surveyors found these radiant space heaters actively in use in resident rooms and in a hallway accessible to residents, positioned so that residents could come into direct contact with hot surfaces and electrical components. Temperature readings taken with the Maintenance Director on February 3, 2026, showed that the heaters in resident rooms reached surface temperatures ranging from 123°F to 153°F, and the heaters in the hallway measured between 136°F and 139°F. The Nursing Home Administrator acknowledged awareness of these temperatures and explained that heaters were placed in certain rooms based on residents’ transfer abilities and cognitive status. The Maintenance Director reported placing orange caution cones around the hallway heaters as a measure to prevent residents from walking into them. Despite this, observation in the hallway showed a resident in a wheelchair independently propelling using handrails and having to maneuver around both hallway heaters to continue ambulating. Review of Minimum Data Set (MDS) assessments revealed that one resident with a heater in the room was independent with transfers and ambulation and had moderate cognitive impairment, another was dependent for transfers and ambulation with moderate cognitive impairment, another was independent with transfers and ambulation with intact cognition, another was dependent for transfers and ambulation with severe cognitive impairment, and another was dependent for transfers and ambulation with a BIMS score indicating near-intact cognition. The Nursing Home Administrator reported that the facility had no policies or procedures providing guidance for the use of radiant space heaters in resident care areas. Interviews with CNAs showed inconsistent understanding of the risks associated with radiant space heaters, including burns, fire, and electrical hazards. These conditions led surveyors to identify an Immediate Jeopardy situation affecting residents on the rehabilitation unit. Immediate Jeopardy began when the facility lost heat in the rehabilitation unit and implemented the use of radiant space heaters in resident rooms and hallways, and continued until the facility removed all space heaters, implemented alternative heating measures, and demonstrated corrective actions were sufficient to remove the Immediate Jeopardy.
Removal Plan
- Remove space heaters from resident rooms and hallways.
- Maintain room temperatures at 71 degrees and above.
- Interview residents in affected rooms to ensure they are warm enough and offer extra blankets.
- Monitor residents.
- Contact vendor to provide PTAC units to provide heat in residents' rooms while awaiting repair of the heat source.
- Remove space heaters from the facility.
- Educate maintenance staff to ensure no space heaters are in use in resident rooms and hallways.
- Complete audits of resident room temperatures and hallway temperatures in the affected area until the heat source is repaired.
- Audit affected areas to ensure no space heaters are in use and report results to the QAPI committee for further action and recommendations.
Improper Use of Radiant Space Heaters Creating Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility administration, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), failing to effectively utilize available resources to promote resident safety and maintain residents’ highest practicable physical well-being. Review of the NHA’s job description, dated October 06, 2025, showed that the NHA is responsible for managing the facility in accordance with applicable federal, state, and local standards and for ensuring that the highest degree of quality care is provided to residents at all times. The DON’s position description, dated August 11, 2022, indicated responsibility for planning, organizing, developing, and directing the Nursing Service Department in accordance with current regulations and as directed by the Medical Director, to ensure that the highest degree of quality care is maintained. Survey findings under 42 CFR 483.25(d)(1)(2) (F689 – Free of Accident Hazards/Supervision/Devices) showed that the NHA and DON did not fulfill these essential job duties because they permitted the use of radiant space heaters in resident rooms and hallways, including areas accessible to residents with cognitive impairment. Observations, record review, and staff interviews confirmed that these heaters were in use in resident care areas. This failure to ensure an environment free from accident hazards placed residents at risk for serious injury or death and resulted in an Immediate Jeopardy situation, and was cited in conjunction with 28 Pa. Code 201.14(a), 201.18(e)(1), and 211.12(d)(1)(5).
Failure to Maintain Clean and Homelike Resident Bathrooms
Penalty
Summary
Surveyors observed that the facility failed to maintain a clean, comfortable, and homelike environment in four resident bathrooms across multiple units. Specifically, the Apple unit bathroom had a shower floor missing approximately eight tiles and a wall with broken and missing tiles. The Rosemont unit bathroom contained a soiled Band-Aid on the shower floor, a broken wall at the shower entrance with missing tiles and bent metal, and another wall with missing and broken tiles. In the [NAME] unit bathroom, a broken plastic light cover was found lying on the floor by the entrance door. The Rehab unit bathroom had a wall separating two showers with broken and missing tiles. Interviews with the Nursing Home Administrator confirmed the need for repairs in each area, and a resident reported that broken tiles had been present for some time, with instances of soiled bandages and dirty wash rags left on the bathroom floor during showers.
Failure to Provide Required Supervision During Incontinence Care Results in Resident Fracture
Penalty
Summary
A deficiency occurred when a resident with a history of obesity, falls, hip fracture, muscle weakness, CVA, and dementia was not provided with adequate supervision during incontinence care. The resident's care plan and cardex both indicated a need for extensive assistance from two staff members for bed mobility and repositioning. Despite this, a CNA provided care alone and left the resident in a lateral position on the bed while leaving the room to retrieve additional towels. During this time, the resident slipped out of bed and sustained a distal femur fracture, as confirmed by clinical records and staff interviews. Facility documentation and staff statements revealed that the CNA had lowered the bed and left the resident unattended, contrary to the care plan requirements. The resident was found on the floor, complaining of knee pain, and was subsequently admitted to the hospital with a femur fracture. The Nursing Home Administrator and Director of Nursing confirmed that appropriate staff supervision was not provided during the incident, resulting in actual harm to the resident.
Failure to Communicate Specialist Recommendations to Physician
Penalty
Summary
The facility failed to provide care and services in accordance with professional standards by not notifying the physician of recommendations following a specialist consultation for a resident with complex medical needs. The resident had diagnoses including spina bifida, hydrocephalus, neurogenic bladder, and neurogenic bowel. After a consultation with a spina bifida specialist, an after-visit summary was addressed to the Nursing Supervisor, which included a recommendation and order for a daily soap suds enema to begin on a specified date. Review of the resident's clinical record showed no progress note documenting the specialist consultation, no evidence that the primary care provider was informed of the new orders, and no entry of the enema order in the medication administration record. The physician's history and physical note did not reflect awareness of the consultation recommendations. During an interview, the DON confirmed that there was no documentation or communication with the primary care provider regarding the specialist's recommendations.
Unsanitary Conditions Observed in Kitchen Dishwashing Area
Penalty
Summary
The facility failed to maintain a sanitary environment in the kitchen, as required by its own policy and professional standards. During an observation of the dishwashing area, a large brown colored substance was noted covering the wall behind the dishwashing machine. A dietary employee confirmed that the walls were dirty and acknowledged a buildup of debris behind the dishwashing machine. The facility's policy, last revised in July 2023, requires food service staff to maintain sanitation in dining and food service areas through adherence to a comprehensive cleaning schedule. These findings indicate that the cleaning and sanitation procedures were not properly followed in the dishwashing area.
Failure to Follow Wound Care Orders for Resident
Penalty
Summary
The facility failed to consistently follow the physician's wound care treatment for a resident with a worsening unstageable pressure ulcer. The resident, who has a medical history of cerebrovascular disease and dementia, had a pressure ulcer on the right gluteus measuring 10.0 x 9.0 x 0.3 cm, with 40% slough and 50% eschar. A physician's order dated November 17, 2024, specified that the wound should be cleansed with normal saline solution, Santyl applied, and covered with bordered gauze twice daily and as needed. However, a review of the Treatment Administration Record for November 2024 revealed that the morning wound treatment was not provided on November 19, 20, and 22, 2024. An interview with the Director of Nursing on January 2, 2024, did not provide an explanation for the missed treatments. This failure to adhere to the prescribed wound care regimen contributed to the deficiency noted in the facility's care practices.
Failure to Implement Enhanced Barrier Precautions for Residents
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for ten residents who required them due to the presence of wounds, indwelling medical devices, or other conditions. The facility's policy, dated August 2022, mandates the use of targeted gown and glove use during high-contact resident care activities, with communication via signage, Kardex, or assignment sheets, and PPE available in the resident's room. However, observations revealed a lack of PPE and EBP signage in the rooms of all ten residents reviewed, including those with cholecystostomy tubes, indwelling catheters, surgical wounds, and other medical devices. Interviews with staff, including Employee E4 and the Infection Preventionist, revealed a lack of communication and understanding regarding the use of PPE and EBP. Employee E4 reported not being informed about the necessary PPE for wound care and noted the absence of PPE in the room, leading to the use of only gloves. The Infection Preventionist, Employee E5, incorrectly stated that no residents on the Rehab unit required EBP, despite evidence to the contrary. These deficiencies were discussed with the Director of Nursing, highlighting a systemic failure in implementing and communicating infection control measures as per the facility's policy.
Failure to Monitor and Address Significant Weight Changes
Penalty
Summary
The facility failed to adequately monitor and address significant weight changes in six residents, as per their policy on Weight Assessment and Intervention. The policy requires that any weight change of 5 pounds or more be verified through a reweight, and if confirmed, the physician and dietitian should be notified. However, the facility did not adhere to this policy. For instance, Resident 2 experienced a weight loss from 217 pounds to 184 pounds over a month, but interventions were not implemented after the weight loss was confirmed. Similarly, Resident 6 lost 16 pounds in a week, but a reweight was delayed, and interventions were not put in place until two weeks later. Resident 43's significant weight loss was not addressed until 21 days after confirmation, and Resident 161's weight loss was neither reweighed nor reported to the physician or dietitian. Additionally, Resident 173 experienced a significant weight gain, but the physician was not notified, and no recommendations were made to prevent further weight gain. Resident 174 lost 7 pounds in ten days, but a reweight was not conducted despite the dietitian's request, and the physician was not informed. These failures to follow the facility's policy on monitoring and addressing significant weight changes were confirmed through interviews with the Director of Nursing. The report highlights deficiencies in the facility's processes for managing residents' nutritional health, as evidenced by the lack of timely reweights, notifications, and interventions.
Improper Food Storage and Meal Service on Rehab Unit
Penalty
Summary
The facility failed to properly store frozen food in the main kitchen and serve meals appropriately on the Rehab unit. During an observation of the walk-in freezer, it was found that several items, including cookie dough, potatoes, hamburger patties, carrots, and chopped chicken meat, were stored in opened and unsealed plastic bags. This was confirmed by the Assistant Food Service Director, Employee E3, who acknowledged that the frozen food should have been re-sealed after use. Additionally, meal service on the Rehab unit was observed to be inadequate. On two separate occasions, meal trays were delivered to residents with uncovered items such as peaches, apple juice, and coleslaw. The food cart was stationed at the end of the hallway, and staff delivered the trays to residents' rooms without covering the desserts and drinks. This practice was confirmed by Nursing Assistant, Employee E6, who stated that the food should have been covered before being served to residents.
Inaccurate Resident Assessments in MDS
Penalty
Summary
The facility failed to ensure accurate assessments of residents' health statuses, as evidenced by discrepancies in the Minimum Data Set (MDS) for three residents. Resident 2's MDS inaccurately indicated the presence of an indwelling urinary catheter, which was not supported by clinical records or confirmed by staff. Similarly, Resident 67's MDS incorrectly documented that the resident was on dialysis, a fact not corroborated by the clinical records or staff interviews. Additionally, Resident 123's MDS erroneously noted the use of restraints, which was not observed during a facility visit. These inaccuracies were confirmed through staff interviews, specifically with Licensed Employee E7, who acknowledged the errors in the MDS coding for all three residents. The discrepancies were communicated to the Director of Nursing, highlighting the facility's failure to maintain accurate clinical records and assessments as required by regulatory standards.
Delayed Baseline Care Plan for Pressure Ulcer
Penalty
Summary
The facility failed to ensure a timely development of a baseline care plan for a resident with an unstageable pressure ulcer. Upon admission, the resident was identified with a right heel unstageable pressure ulcer measuring 3.8 x 3.2 x 0.2 cm. However, the baseline care plan addressing this condition was not developed until a week after the resident's admission. This delay was confirmed during an interview with the Director of Nursing, who acknowledged that the care plan was not established promptly as required by the facility's protocols.
Failure to Develop Comprehensive Care Plans for Residents
Penalty
Summary
The facility failed to develop comprehensive care plans for two residents, leading to deficiencies in their care. Resident 78, who has a history of prostate cancer and an enlarged prostate, was found to have a urinary catheter in place. However, upon review of the clinical records, there was no evidence of a care plan addressing the management and care of the urinary catheter. This lack of documentation was confirmed by the Nursing Home Administrator during an interview. Similarly, Resident 123, who had a physician's order for a wound vac to be applied to the right above-the-knee amputation stump, did not have a comprehensive care plan for this treatment. An observation confirmed the presence of the wound vac machine, but the clinical records did not reflect a care plan for its use. The Director of Nursing confirmed that a care plan was not developed until after the surveyor's inquiry, indicating a delay in addressing the resident's wound care needs.
Failure to Notify Physician and Administer Medication
Penalty
Summary
The facility failed to timely notify the physician of a change in condition and follow a medication order for two residents. Resident 67 experienced a significant weight gain of 18.5 pounds over a month, which was not rechecked within 48 hours as per the facility's policy. The physician was not notified of this significant weight change until eight days later, despite the dietitian's request for a reweight to confirm the change. Additionally, Resident 67 was observed with a swollen left arm, but the change in condition was not addressed until several days after the weight gain was identified. Resident 345 had a physician order for Meropenem, an antibiotic, to be administered intravenously every 12 hours. However, the medication was not administered on multiple occasions due to the agency nurse's failure to locate the medication, which was available in the facility. The physician was not notified of the missed doses until two days later. The Director of Nursing confirmed that the medication was available and that the physician should have been notified of the missed doses in a timely manner.
Latest citations in Pennsylvania
A resident with dementia, psychotic disturbance, mood disturbance, and anxiety, residing on a locked unit with a wander guard, was able to leave the secured area by closely following a housekeeper through coded double doors and out a side door without being noticed. Staff did not check for residents before and after exiting the unit, and the resident left the premises, traveled into the community, and purchased food and a drink before being located by local police and returned without injury. The facility’s elopement policy required monitoring for missing residents and initiation of emergency procedures, but these measures were only implemented after the resident was discovered missing and an elopement alarm was activated.
Surveyors observed that dietary staff did not follow the facility’s personal hygiene policy requiring hair restraints, as two dietary employees worked over uncovered food on the tray line with uncovered mustaches. In the same food preparation area, equipment including a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored and used beneath window frames with peeling paint, and a nearby window blind had dried food debris along its length. Another window frame above a storage rack of meal trays also had peeling paint, demonstrating unsanitary food storage and preparation conditions.
Surveyors determined that the facility failed to provide required written notices of transfers and discharges to multiple residents and/or their representatives, and did not notify the State LTC Ombudsman when residents were transferred to the hospital after changes in condition or left against medical advice. Record reviews showed repeated absence of documentation that residents or responsible parties received written information about the transfers, and that the Ombudsman was informed. The Administrator confirmed that these notifications were not sent.
The facility failed to address repeated grievances regarding slow responses to resident call bells. The grievance policy required acknowledgment and active resolution of both written and verbal complaints, yet multiple residents reported that call bells often went unanswered for more than 30 minutes. Resident council minutes over several consecutive months documented ongoing complaints about delayed call bell response, and grievance records showed multiple similar complaints over an extended period. The DON and the administrator acknowledged a pattern of complaints about slow call bell responses and confirmed that the facility had not responded to these grievances.
Surveyors found that the facility did not ensure a safe, clean, and comfortable environment on two nursing units, noting a shattered clear plastic fire extinguisher cover in a hallway between resident rooms, holes in bathroom walls, a dented and misshaped room entrance doorframe near the floor, a hole in the wall between resident beds, and dented, crumbling wallboard near a bathroom entrance. These conditions were cited under state regulations for licensee responsibility and management.
A deficiency was identified when a resident’s MDS assessment did not accurately reflect the resident’s need for corrective lenses. The resident had a history of diabetes mellitus and falls and was care planned for impaired vision with a requirement for glasses. Despite this, the MDS indicated that no corrective lenses were needed during the look-back period, while direct observation showed the resident wearing glasses, and the Administrator later confirmed the inaccuracy of the MDS documentation.
A resident with chronic kidney disease and DM was documented on the MDS as alert and frequently incontinent of urine, and the CAA indicated that urinary incontinence should be addressed in the care plan. Review of the resident’s current care plan showed no interventions related to urinary incontinence, and the DON confirmed there was no documented evidence that this identified care area was included in the plan.
A resident with chronic kidney disease, polyneuropathies, and muscle weakness, who had no cognitive impairment and required substantial staff assistance for showers and total assistance for transfers, was scheduled to receive showers twice weekly on the evening shift. Over a 30-day period, there was no documentation that showers were provided, offered, or refused, and the resident reported not having had a shower since admission. The DON confirmed the absence of documentation that shower care was offered or provided, resulting in a deficiency related to nursing services and ADL care.
Surveyors found that staff did not follow multiple physician orders for three residents. A resident with diabetes received ordered insulin even when blood glucose readings were below the ordered hold parameter. Another resident with cerebral palsy, DM, and heart failure had repeated significant overnight weight gains without evidence that the physician was notified as ordered. A third resident with anemia and CKD had ordered CBC and CMP lab tests that were not documented as completed. The DON confirmed there was no documentation that these physician orders were carried out.
Staff failed to follow facility policy and physician orders requiring documentation of non-pharmacological interventions (NPI’s) before administering PRN oxycodone for two residents. One resident with osteoarthritis, hip pain, and diabetes had orders for NPI documentation each shift and PRN oxycodone for moderate to severe pain, yet received the narcotic multiple times in a month without any recorded attempt of NPI’s beforehand. Another resident with a history of stroke, diabetes, hemiplegia, and hemiparesis also had orders to document NPI’s prior to PRN pain medication, but similarly received PRN oxycodone several times without documentation that NPI’s were tried first, resulting in noncompliance with state pharmacy and nursing service regulations.
Failure to Prevent Elopement From Secured Unit
Penalty
Summary
The deficiency involves a resident with unspecified dementia without behavioral disturbance, psychotic disturbance, mood disturbance, and anxiety who was admitted to the facility in November 2025 and resided on a locked, secured unit requiring a code to exit. The facility had a written "Wandering and Elopements" policy that directed staff, when a resident was missing, to initiate the elopement/missing resident emergency procedure, determine if the resident was on an authorized leave, search the building and premises if not authorized to leave, and notify administration, the resident’s representative, the attending physician, and law enforcement if the resident was not located. On the date of the incident, the resident closely followed a housekeeper through double doors on the ground floor into a back hallway and then out a side door, leaving the secured unit without authorization. The housekeeper was unaware that the resident had followed through the door, and staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit. An elopement alarm was later activated after the resident was found to be unaccounted for on the secured unit, and the facility’s established protocols were then initiated, including notification of local law enforcement. The resident was subsequently located off premises by local police, sitting in a relaxed manner, conversing appropriately with officers, holding a beverage, and with no visible injuries, and he denied pain or discomfort. Facility documentation showed that the resident had been able to travel far enough to purchase food and a drink at a restaurant, as evidenced by a receipt from a nearby McDonald’s. A progress note recorded that the resident had been noted not on the unit, an immediate search was conducted, administration and proper authorities were notified, and the resident was returned safely, with a skin check completed and the resident later observed in his room eating dinner. In an interview, the resident stated that it was taking too long to get out of the building, that he waited for an opportunity and took it, and that he wanted to leave and go back to his place. In a separate interview, the Nursing Home Administrator confirmed that staff failed to ensure the resident’s safety by not checking for residents before and after exiting the unit, leading to the elopement from the secured environment.
Unsanitary Food Storage and Staff Hygiene Practices in Dietary Department
Penalty
Summary
The facility failed to store and handle food in a sanitary manner in the dietary department in accordance with its own policy and professional standards. The facility’s “Personal Hygiene” policy dated February 2, 2026, required all staff to wear hair restraints to effectively keep hair from contacting exposed food. During observation of the lunch meal service tray line on April 15, 2026, from 11:30 a.m. to 12:03 p.m., two dietary employees were observed working directly over uncovered food on the tray line with uncovered mustaches. In the same area, the window frame above the shelf where a large mixer with an uncovered bowl, a Robot-coupe mixer, and a blender were stored had peeling paint, while the Robot-coupe mixer and blender were actively being used to prepare resident food. Additionally, the blind in this window frame had dried food debris along its length, and another window frame above a storage rack of resident meal trays also had peeling paint. These conditions were cited under 42 CFR 483.60(i) Food Safety Requirements and 28 Pa. Code 201.14(a) Responsibility of licensee, and had been previously cited on March 26, 2025. No specific residents, medical histories, or clinical conditions were described in the report; the deficiency focused on environmental and staff hygiene practices in the dietary department during food preparation and tray line service.
Failure to Provide Required Written Transfer Notices and Ombudsman Notification
Penalty
Summary
Surveyors found that the facility failed to provide required written notifications of transfers and discharges to residents and/or their representatives, and failed to notify the Office of the State Long-Term Care Ombudsman for six residents who were transferred out of the facility. Clinical record review showed that one resident was transferred to the hospital after a change in condition on December 26, 2025, without documented evidence that the resident or responsible party received written information regarding the transfer or that a copy of the transfer notice was sent to the Ombudsman. Another resident was transferred to the hospital after a change in condition on January 9, 2026, with no documented evidence that the Ombudsman was notified of the transfer. Additional record reviews revealed that three more residents were transferred to the hospital after changes in condition on March 30, 2026, and March 12, 2026, without documentation that the residents and/or their responsible parties or legal representatives were provided written information regarding the transfers, or that the Ombudsman was notified. One resident left the facility against medical advice on February 3, 2026, and there was no documented evidence that the Ombudsman was notified of this transfer. In an interview on April 17, 2026, the Administrator confirmed that notifications of transfers were not sent to the residents and/or their representatives and that written notices of the transfers and discharge were not sent to the Office of the State Long-Term Care Ombudsman.
Failure to Address Repeated Grievances About Slow Call Bell Response
Penalty
Summary
The facility failed to address ongoing grievances related to slow response times to resident call bells, as required by its grievance policy. The policy, last reviewed on February 24, 2026, stated that grievances could be either formal written complaints or verbal complaints to staff, and that the facility was to acknowledge and actively work toward resolution of such complaints. During a confidential resident group interview on April 14, 2026, all four participating residents reported that call bells were answered slowly, often taking more than 30 minutes. Review of resident council minutes from September 8, 2025, through December 11, 2025, showed repeated complaints about slow call bell responses at each monthly meeting, with no evidence that any resident council minutes were recorded in 2026. Additionally, review of resident grievances from October 31, 2025, through March 23, 2026, revealed multiple complaints about slow call bell responses on several dates in late 2025 and early 2026. In an interview on April 17, 2026, the DON and Nursing Home Administrator confirmed there was a pattern of complaints about slow call bell responses and that the facility had failed to respond to those grievances. These findings demonstrate that the facility did not honor residents’ rights to have grievances acknowledged and addressed, despite repeated verbal and written complaints documented through resident council minutes and the grievance process.
Damaged Walls, Doorframes, and Fire Extinguisher Cover Compromise Safe, Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment on two of five nursing units, specifically the [NAME] and [NAME] units. During observations conducted over two days, surveyors noted that the clear plastic fire extinguisher cover in the hallway between rooms 135 and 137 was shattered. In one resident bathroom, there were holes on the left and right walls, and the doorframe at the entrance to another resident room was dented and misshaped near the floor. Additionally, there was a hole in the wall between the beds in another resident room, and the wallboard at the bottom of the wall to the right of the entrance to a bathroom in yet another room was dented and crumbling. These environmental deficiencies were directly observed in resident care areas and common hallways and were cited under 28 Pa. Code 201.14(a) regarding the responsibility of the licensee and 28 Pa. Code 201.18(e)(2.1) regarding management responsibilities.
Inaccurate MDS Documentation of Resident’s Need for Corrective Lenses
Penalty
Summary
A deficiency occurred when the facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected a resident’s current status. Clinical record review showed that Resident 139 had diagnoses including diabetes mellitus and a history of falls, and the resident required glasses to correct impaired vision. The resident’s care plan documented a problem with impaired vision and indicated that glasses were required beginning March 8, 2022. However, the MDS assessment dated [DATE] documented in Section B (Hearing, Speech, and Vision) that the resident did not require corrective lenses during the previous seven days. On observation on April 14, 2026, at 11:00 a.m., Resident 139 was noted to be wearing glasses. In an interview on April 17, 2026, at 1:00 p.m., the Administrator confirmed that the MDS assessment for this resident was inaccurate, as it did not reflect the resident’s actual need for and use of corrective lenses during the assessment look-back period.
Failure to Include Urinary Incontinence in Comprehensive Care Plan
Penalty
Summary
The facility failed to develop a comprehensive care plan that addressed an identified care area for one resident. Clinical record review showed that this resident had chronic kidney disease and diabetes mellitus, and a Minimum Data Set completed on February 20, 2026, documented that the resident was alert and frequently incontinent of urine. The Care Area Assessment summary dated the same day specified that the resident’s urinary incontinence was to be addressed in the care plan. However, review of the current care plan revealed no evidence that interventions for urinary incontinence were included. In an interview on April 17, 2026, at 10:25 a.m., the Director of Nursing confirmed that there was no documented evidence that this identified care area was addressed in the resident’s care plan.
Failure to Provide Scheduled Showers and Document ADL Care
Penalty
Summary
The facility failed to provide and document assistance with activities of daily living, specifically showering, for one resident who was dependent on staff for this care. The resident was admitted on March 12, 2026, with diagnoses including chronic kidney disease, polyneuropathies, and muscle weakness. A Minimum Data Set assessment dated March 19, 2026, showed the resident had no cognitive impairment, required substantial staff assistance for showers, and was totally dependent on staff for transfers. Facility documentation indicated the resident was scheduled to receive showers on Wednesdays and Saturdays during the evening shift. However, the resident reported on April 14, 2026, that they had not had a shower since admission, and review of the clinical record showed no evidence that a shower had been provided, offered, or refused during the previous 30 days. The DON confirmed on April 16, 2026, that there was no documented evidence that showers were offered or provided to this resident. This deficiency was cited under 28 Pa. Code 211.12(d)(1)(5) related to nursing services.
Failure to Follow Physician Orders for Insulin, Weight Monitoring, and Lab Tests
Penalty
Summary
The deficiency involves the facility’s failure to implement and follow physicians’ orders for three residents. For one resident with diabetes mellitus, a physician ordered Novolog insulin to be administered in the morning prior to breakfast, with instructions to hold the insulin if the resident’s blood sugar was less than 80 mg/dL. Review of the April 2026 MAR showed that staff administered the insulin on three occasions when the resident’s blood sugar was below 80 mg/dL, contrary to the physician’s order. Another resident with cerebral palsy, diabetes mellitus, and heart failure had a physician’s order to be weighed every night shift and to notify the physician if the resident gained more than 2 lbs in 24 hours or 5 lbs in one week. Clinical records showed multiple instances of significant weight gains over 24-hour periods, including gains of 4.7 lbs, 3.4 lbs, 6 lbs, 2.3 lbs, 5.8 lbs, 4 lbs, 2.4 lbs, and 3.3 lbs, without documented evidence that the physician was notified as ordered. A third resident with anemia and chronic kidney disease had a physician’s order for two blood tests (CBC and CMP), but the clinical record contained no documentation that these lab tests were obtained. The DON confirmed there was no documented evidence that care and services were provided in accordance with these physicians’ orders.
Failure to Document Non-Pharmacological Interventions Before PRN Narcotic Administration
Penalty
Summary
Facility staff failed to follow the facility’s pain management policy and specific physician orders requiring documentation of non-pharmacological interventions (NPI’s) and their effectiveness prior to administering as-needed narcotic pain medication for two residents. The policy, last reviewed February 24, 2026, required staff to document NPI’s and their effectiveness for patients receiving pain interventions. For a resident with left knee osteoarthritis, right hip pain, and diabetes, a physician ordered on March 17, 2026, that NPI’s be documented every shift, and on April 6, 2026, ordered oxycodone every four hours as needed for moderate to severe pain. Review of the MAR showed that this resident received as-needed oxycodone 23 times in April 2026 without documented evidence that NPI’s were attempted prior to administration. Another resident with diagnoses including cerebral infarction (stroke), diabetes, hemiplegia, and hemiparesis had a physician order dated February 7, 2026, directing staff to document NPI’s used before administering as-needed pain medication, and an order dated April 3, 2026, for oxycodone every four hours as needed for moderate to severe pain. MAR review revealed this resident received as-needed oxycodone nine times in April 2026 without documented evidence that NPI’s were attempted prior to administration, in violation of 28 Pa. Code 211.9(a)(1) Pharmacy services and 28 Pa. Code 211.12(d)(1)(5) Nursing services.
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