Pennsylvania Department of Health
NEFFSVILLE NURSING AND REHABILITATION
Building Inspection Results

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Severity Designations


Minimal Citation - No Harm	Minimal Harm	Actual Harm	Serious Harm

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

Initial comments:Name: - Component: -- - Tag: 0000
Based on an Emergency Preparedness Survey completed on December 11, 2025, at Neffsville Nursing and Rehabilitation, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.

Plan of Correction:

Initial comments:Name: MAIN BUILDING - Component: 01 - Tag: 0000
Facility ID #120302Component 01Main BuildingBased on a Medicare/Medicaid Recertification Survey completed on December 11, 2025, it was determined that Neffsville Nursing and Rehabilitation was not in compliance with the following requirements of the Life Safety Code for an existing health care occupancy. Compliance with the National Fire Protection Association's Life Safety Code is required by 42 CFR 483.90(a).This is a one-story, Type V (000), unprotected wood frame structure, with a basement, which is fully sprinklered.

Plan of Correction:

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:

Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.

Sprinkler System - Maintenance and Testing
Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available.
a) Date sprinkler system last checked _____________________
b) Who provided system test ____________________________
c) Water system supply source __________________________
Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system.
9.7.5, 9.7.7, 9.7.8, and NFPA 25

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0353 Based on observation and interview, it was determined the facility failed to maintain a supply of spare sprinkler heads, affecting the entire component. Findings include: 1. Observation on December 11, 2025, at 12:30 PM, revealed the facility did not have spare vertically oriented sidewall sprinkler heads, and did not have spare quick response sprinkler heads. These types of sprinkler heads were observed to be protecting various areas within the facility. Interview with the Maintenance Director on December 11, 2025, at 12:30 PM, confirmed the lack of a supply of spare sprinkler heads.

Plan of Correction - To be completed: 02/03/2026

Spare vertically oriented sidewall sprinkler heads and spare quick response sprinkler heads will be ordered

Audit to be completed to ensure the spare sprinkler heads are in stock

Maintenance director to be educated by NHA on ensuring sprinkler head spares are in stock

Maintenance Director/designee to audit sprinkler head spare stock bi-weekly x2, then quarterly thereafter with results to be reviewed at QAPI.

NFPA 101 STANDARD Portable Fire Extinguishers:

This is a less serious (but not lowest level) deficiency and is isolated to the fewest number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status.

Portable Fire Extinguishers
Portable fire extinguishers are selected, installed, inspected, and maintained in accordance with NFPA 10, Standard for Portable Fire Extinguishers.
18.3.5.12, 19.3.5.12, NFPA 10

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0355 Based on observation and interview, it was determined the facility failed to maintain unobstructed access to portable fire extinguishers, affecting one of 16 smoke compartments within the component. Findings include: 1. Observation on December 11, 2025, at 10:05 AM, revealed the portable fire extinguisher, located within the basement Maintenance Room, was obstructed by cardboard boxes. Interview with the Maintenance Director on December 11, 2025, at 10:05 AM, confirmed access to the extinguisher was obstructed.

Plan of Correction - To be completed: 02/03/2026

Carboard boxes obstructing the portable fire extinguisher were removed

Audit was completed to ensure portable fire extinguishers were not obstructed

Maintenance director will educate staff on ensuring portable fire extinguishers are free from obstruction

Maintenance Director/designee to audit portable fire extinguishers weekly x4 to ensure they are not obstructed, then monthly with results to be reviewed at QAPI.

NFPA 101 STANDARD Electrical Equipment - Power Cords and Extens:

Electrical Equipment - Power Cords and Extension Cords
Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4.
10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0920 Based on observation and interview, it was determined the facility failed to monitor the use of surge suppressors, affecting one of 16 smoke compartments within the component. Findings include: 1. Observation on December 11, 2025, at 10:10 AM, revealed a surge suppressor, supplying electrical power to a microwave and coffee machine, within the basement Maintenance Room. Interview with the Maintenance Director on December 11, 2025, at 10:10 AM, confirmed the high draw appliances were plugged into a surge suppressor.

Plan of Correction - To be completed: 02/03/2026

Surge suppressor supplying electrical power to a microwave and coffee machine within the basement maintenance room was removed

Audit was completed to ensure no surge suppressors supplying electrical power to microwaves and coffee machines

Maintenance staff members to be educated by maintenance director / designee on ensuring no surge suppressors supplying electrical power to microwaves and coffee machines

Maintenance Director/designee to audit microwaves and coffee machines to ensure no surge suppressors being used weekly x4 to ensure they are not obstructed, then monthly x2, and quarterly thereafter with results to be reviewed at QAPI.

NFPA 101 STANDARD Gas Equipment - Precautions for Handling Oxyg:

Gas Equipment - Precautions for Handling Oxygen Cylinders and Manifolds
Handling of oxygen cylinders and manifolds is based on CGA G-4, Oxygen. Oxygen cylinders, containers, and associated equipment are protected from contact with oil and grease, from contamination, protected from damage, and handled with care in accordance with precautions provided under 11.6.2.1 through 11.6.2.4 (NFPA 99)
11.6.2 (NFPA 99)

Observations:
Name: MAIN BUILDING - Component: 01 - Tag: 0929 Based on observation and interview, it was determined the facility failed to secure portable oxygen cylinders, affecting one of 16 smoke compartments within the component. Findings include: 1. Observation on December 11, 2025, at 11:00 AM, revealed three unsecured "E" size portable oxygen cylinders, within the Rehab Oxygen Room. Interview with the Maintenance Director on December 11, 2025, at 11:00 AM, confirmed the oxygen cylinders were not secured.

Plan of Correction - To be completed: 02/03/2026

The three unsecured E" size portable oxygen cylinders were secured

Audit was completed to ensure E" size portable oxygen cylinders are secured

Nursing staff to be educated by maintenance director/ designee on ensuring E" size portable oxygen cylinders are secured

Maintenance Director/designee to audit E" size portable oxygen cylinders to ensure they are secured weekly x4 then monthly thereafter with results to be reviewed at QAPI.

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