Neffsville Nursing and Rehabilitation

In the surveyor’s words

From the most serious findings on record at Neffsville Nursing and Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, patternF689Feb 4, 2026

  Based on observation, record review, and staff interviews, it was determined the facility failed to ensure the environment was free from accident hazards and failed to provide adequate supervision and assistive devices to prevent accidents. Specifically, the facility utilized radiant space heaters in resident rooms and in a hallway of the rehabilitation unit following loss of heat, placing residents, including residents with cognitive impairment, at risk for serious injury or death. […]

• Immediate jeopardy, patternF600Jun 8, 2022

  Based on clinical record review, facility policy and facility documentation review, and staff interviews, it was determined that the facility failed to ensure that residents were free from neglect when they failed to provide treatment and care in accordance with professional standards of practice, facility policies, physician orders, and the comprehensive person-centered policy including life sustaining medications for 18 of 36 residents on the secure dementia unit (Rosemont). The failure resulted in 133 missed medication doses including insulin, antipsychotic, and heart medications. This placed the residents on the Rosemont unit in an Immediate Jeopardy situation. (Residents R1, R2, R3, R4, R6, R7, R8, R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, and R19). […]

• Immediate jeopardy, patternF725Jun 8, 2022

  Based on clinical record review, facility policy and facility documentation review, and staff interviews, it was determined that the facility failed to provide adequate and sufficient staff to ensure residents received treatment and care in accordance with professional standards of practice, facility policies, physician orders, and comprehensive person-centered policy including life sustaining medications for 18 residents on the secure dementia unit (Rosemont). The staffing failure resulted in 133 missed medication doses including insulin, antipsychotic, and heart medications but had the potential to adversely affect all 36 residents who require supervision. The failure to adequately staff the dementia unit placed the residents on the Rosemont unit in an Immediate Jeopardy situation. […]

• Actual harm, isolatedF689Sep 10, 2025

  Based on facility policy and procedure review, staff interview, clinical record review, and facility documentation review it was determine the facility failed to ensure that one of three residents reviewed was free from free from accidents and provided adequate supervision resulting in actual harm of a distal femur fracture of Resident 1. Findings include: Review of Resident 1's diagnosis list revealed a diagnosis of Obesity, history of falling, hip fracture, Muscle Weakness, CVA (Cerebral Vascular Accident- Stroke) and Dementia (group of conditions that cause a decline in cognitive function, including memory, thinking, reasoning, and problem-solving, severe enough to interfere with daily life). […]

• Actual harm, isolatedF686Apr 8, 2021

  Based on clinical record review and staff interview, it was determined that the facility failed to provide appropriate interventions following the administration of oxygen with the use of a nasal cannula, resulting in harm with the development a pressure ulcer for one of 6 residents reviewed (Resident R81). Findings include: Review of facility policy, Oxygen Administration, revised in January 2021, stated, securely anchor the tubing so that it does not rub or irritate the resident's nose, behind the resident's ears, etc. […]