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

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

NEFFSVILLE NURSING AND REHABILITATION
Inspection Results For:

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

Initial comments:

Based on a follow-up survey completed on May 21, 2025, it was determined that Neffsville Nursing and Rehabilitation failed to correct the deficiencies identified during the abbreviated complaint survey of September 17, 2024, and the subsequent revisit surveys of November 13, 2024 and February 18, 2025, and continues to be out of compliance with the following requirements of the Commonwealth of Pennsylvania Long Term Care Licensure Regulations for the Health portion of the survey process.

Plan of Correction:

� 211.12(f.1)(3) LICENSURE Nursing services. :

(3) Effective July 1, 2024, a minimum of 1 nurse aide per 10 residents during the day, 1 nurse aide per 11 residents during the evening, and 1 nurse aide per 15 residents overnight.

Observations:

Based on a review of facility staffing data, it was determined that the facility failed to ensure a minimum of one nurse aide per 10 residents on the day shift for four days, a minimum of one nurse aide per 11 residents on the evening shift for two days and a minimum of one nurse aide per 15 residents on the night shift for two days for the period from May 10 through May 19, 2025.

Findings include:

Review of facility staffing data from May 10 through May 19, 2025, revealed the following dates and shifts that did not meet the requirements of one nurse aide per 10 residents on the day shift, one nurse aide per 11 residents on the evening shift and one nurse aide per 15 residents on the night shift.

Day shift
5/10/2025
5/11/2025
5/17/2025
5/19/2025

Evening shift
5/11/2025
5/18/2025

Night shift
5/10/2025
5/18/2025

The aforementioned data was conveyed to the Director of Nursing in a telephone interview on May 21, 2025.

Plan of Correction - To be completed: 07/02/2025

1. The minimum number of CNA staff members will meet the ratio requirement of 1:10 on days, 1:11 on evenings, and 1:15 on night shift.
2. The facility will maintain CNA ratios by offering incentives, recruitment, utilizing agency and holing daily meetings to ensure ratios are being met.
3. Education to nursing scheduler and DON/ADON regarding CNA ratios and meeting state requirements.
4. Review daily and weekly schedules (NHA, DON, Scheduler) to ensure CNA staffing ratios are being met. This will be done daily x 3 weeks and weekly thereafter. Results will be brought to facility QAPI meeting for review.

� 211.12(i)(2) LICENSURE Nursing services.:

(2) Effective July 1, 2024, 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 3.2 hours of direct resident care for each resident.

Observations:

Based on a review of facility staffing data, it was determined that the facility failed to meet the required Per Patient Day (PPD) of 3.20 for six days during the period from May 10 through May 19, 2025.

Findings include:

A review of facility staffing data from May 10 through May 19, 2025, revealed that on the following days the facility had a PPD below the required 3.20.

5/10/2025 - 3.04
5/11/2025 - 2.67
5/16/2025 - 3.13
5/17/2025 - 3.05
5/18/2025 - 2.86
5/19/2025 - 3.03

The aforementioned data was conveyed to the Director of Nursing in a telephone interview on May 21, 2025.

Plan of Correction - To be completed: 07/02/2025

1. The minimum PPD will reach the daily requirement of 3.2 hours direct care per 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 met.
3. Education to DON/ADON and scheduler on PPD to meet min state requirements.
4. Audit daily and weekly schedules (NHA,DON,Scheduler) to ensure PPD is being met. This will be completed daily x 3 weeks and weekly thereafter. Results to be brought to QAPI meeting for review.

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