Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
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.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Lancaster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Brethren Village | 0.1 mi | ★★★★★ | 3 | 0 |
| Rehabilitation Center At Brethren Village Llc | 0.1 mi | ★★★★★ | 0 | 0 |
| Landis Homes | 2 mi | ★★★★★ | 1 | 0 |
| Calvary Fellowship Homes Inc | 3 mi | — | 0 | 0 |
| Luther Acres Manor | 3.3 mi | ★★★★★ | 2 | 0 |
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