Pennsylvania Department of Health
NEFFSVILLE NURSING AND REHABILITATION
Patient Care Inspection Results

Note: If you need to change the font size, click the "View" menu at the top of the page, place the mouse over the "Text Size" menu item, and select the desired font size.

Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NEFFSVILLE NURSING AND REHABILITATION
Inspection Results For:

There are 272 surveys for this facility. Please select a date to view the survey results.

Surveys don't appear on this website until at least 41 days have elapsed since the exit date of the survey.


NEFFSVILLE NURSING AND REHABILITATION - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on an Abbreviated Survey in response to two complaints completed on May 23, 2024, it was determined that Neffsville Nursing and Rehabilitation was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 PA Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations as they relate to the Health portion of the survey process.

Plan of Correction:

� 211.12(f.1)(2) LICENSURE Nursing services. :

(2) Effective July 1, 2023, a minimum of 1 nurse aide per 12 residents during the day, 1 nurse aide per 12 residents during the evening, and 1 nurse aide per 20 residents overnight.

Observations:

Based upon review of staffing records, it was determined the facility failed tofailed to provide a minimum of one nurse aide per 12 residents during the day and evening shifts, and one nurse aide per 20 residents during the night shift on 9 of 21 days (April 7, April 8, April 11, April 12, April 13, April 14, April 16, April 17, and April 19, 2024).

Findings include:

The facility failed to meet the ratio requirement for Nurse Aides on the following dates and shifts:

April 7, 2024 - 11-7 shift
April 8, 2024 - 7-3 shift
April 11, 2024 - 11-7 shift
April 12, 2023 - 3-11 shift
April 13, 2024 - 7-3 and 11-7 shifts
April 14, 2024 - 7-3 and 3-11 shifts
April 16 2024 - 7-3 shift
April 17, 2024 - 3-11 shift
April 19, 2024 - 3-11 shift

Interview conducted with the Director of Nursing on June 4, 2024 when the above information was provided.

Plan of Correction - To be completed: 06/30/2024

1. The minimum number of CNA staff members will meet the ratio requirement of 1:12 on day and evening shift and 1:20 on night shift.

2.The facility will maintain CNA ratios by offering incentives, recruitment, utilizing agency and holding daily staffing meetings to ensure ratios are being met.

3. Education to nursing management, DON, and NHA on CNA ratios meeting state guidelines.

4.Audit daily and weekly schedules (NHA and DON) to ensure CNA staffing ratios are being met. This will be completed daily x 4, weekly x 2 and monthly x1. Results will be reviewed in facility QAPI meeting.

� 211.12(f.1)(4) LICENSURE Nursing services. :

(4) Effective July 1, 2023, a minimum of 1 LPN per 25 residents during the day, 1 LPN per 30 residents during the evening, and 1 LPN per 40 residents overnight.

Observations:

Based upon review of staffing records, it was determined the facility failed to meet the ratio requirement for LPNs of 1 LPN to 25 residents on three of 21 days reviewed (April 7, April 13, and April 14, 2024).

Findings include:

The facility failed to meet the ratio requirement for LPNs on the following dates and shifts:

April 7, 2024 - 7-3 shift
April 13, 2024 - 7-3 shift
April 14, 2024 - 7-3 shift

Interview conducted with the Director of Nursing on June 4, 2024 when the above information was provided.

Plan of Correction - To be completed: 06/30/2024

1. The minimum number of LPN staff members will meet the ratio requirement of 1:25 on day shift, 1:30 on evening shift and 1:40 on night shift.

2.The facility will maintain LPN ratios by offering incentives, recruitment, utilizing agency and holding daily staffing meetings to ensure ratios are being met.

3. Education to nursing management, DON, and NHA on LPN ratios meeting state guidelines.

4.Audit daily and weekly schedules (NHA and DON) to ensure LPN staffing ratios are being met. This will be completed daily x 4, weekly x 2 and monthly x1. Results will be reviewed in facility QAPI meeting.

� 211.12(i)(1) LICENSURE Nursing services.:

(1) Effective July 1, 2023, the total number of hours of general nursing care provided in each 24-hour period shall, when totaled for the entire facility, be a minimum of 2.87 hours of direct resident care for each resident.

Observations:

Based upon review of staffing records, it was determined the facility failed to meet the State minimum requirement of 2.87 PPD for multiple days reviewed.

Findings include:

Review of staffing records revealed the facility failed to meet the State minimum requirement of 2.87 PPD for the following dates:

April 12, 2024 - 2.82 PPD
April 13, 2024 - 2.81 PPD
April 14, 2024 - 2.66 PPD
April 15, 2024 - 2.73 PPD

Interview conducted with the Director of Nursing on June 4, 2024 when the above information was provided.

Plan of Correction - To be completed: 06/30/2024

1. The minimum PPD will meet the requirement of 2.87 hours of direct care for each resident.

2.The facility will maintain daily PPD requirements by offering incentives, recruitment, utilizing agency and holding daily staffing meetings to ensure PPD requirements are being met.

3. Education to nursing management, DON, and NHA on PPD meeting state guidelines.

4.Audit daily and weekly schedules (NHA and DON) to ensure PPD is being met. This will be completed daily x 4, weekly x 2 and monthly x1. Results will be reviewed in facility QAPI meeting.

Back to County Map

Home : Press Releases : Administration
Health Planning and Assessment : Office of the Secretary
Health Promotion and Disease Prevention : Quality Assurance

Copyright � 2001 Commonwealth of Pennsylvania. All Rights Reserved.
Commonwealth of PA Privacy Statement