Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
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 Neshaminy Manor Home during CMS and state inspections, most recent first.
Call Bell Not Kept Within Reach: A resident with vision impairment, cervical spine fusion, and RA was observed with her call bell on the floor behind her and later wrapped around the side rail and out of reach. The resident, who was dependent on staff for ADLs and at risk for falls, stated she did not know where her call bell was and that she wanted it within reach.
A resident with HTN had an order for amlodipine once daily, with instructions to hold the dose if pulse was below 60 bpm. MAR review showed the med was given multiple times over several months without documented pulse checks before administration, and the ADON confirmed the missing documentation.
Failure to Assess PTSD and Provide Trauma-Informed Care: The facility failed to ask two residents with PTSD if they wanted a trauma-related assessment and did not document assessment of symptoms or triggers. One resident had PTSD, anxiety, and depression, and the other had chronic PTSD, depression, insomnia, nightmares, tearfulness, and a veteran history, but neither care plan included interventions to address trauma history or minimize re-traumatization.
The facility did not meet the required LPN to resident ratios on one day, failing to provide one LPN per 25 residents during the day shift and one LPN per 40 residents during the night shift. This was identified through a review of nursing schedules.
The facility did not meet the required 3.2 hours of direct nursing care per resident in a 24-hour period, as evidenced by a review of nursing schedules. On one occasion, the care provided was only 3.08 hours per resident, which is below the regulatory requirement.
The facility failed to maintain clear emergency exit egress paths, as snow and ice obstructed exits in two of three levels. Specific obstructions were noted at the AO courtyard emergency exit and the D1 patio. These findings were confirmed during an interview with the Administrator and Maintenance Director.
The facility failed to maintain proper functioning of exit egress doors, specifically at the AO Courtyard, where the egress exterior gate lock was not equipped with a delayed egress SLA and failed to open. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility failed to maintain smoke barrier walls, as an unsealed penetration was found above the double doors from the loading dock into the laundry department. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director. The unsealed penetration compromises the smoke barrier's integrity, which is essential for maintaining a 1/2-hour fire resistance rating.
The facility failed to maintain its HVAC system on one level, as observed with portable air conditioner units vented above drop ceilings into interstitial spaces, creating plenums in the AO-Staff Break Room and Admin Department. These findings were confirmed during an exit interview with the Administrator and Maintenance Director.
The facility was found to be in violation of NFPA standards due to the improper use of a power strip in the D1-ADON office, which was used to power heat draw equipment, a refrigerator, and a microwave. This was confirmed during an exit interview with the Administrator and Maintenance Director.
The facility was found to have deficiencies in oxygen storage, including an improperly latched oxygen cabinet in the AO level clean utility room and failure to separate empty from full portable oxygen cylinders in the D1 level storage room. These issues were confirmed during an exit interview with the Administrator and Maintenance Director.
Call Bell Not Kept Within Reach
Penalty
Summary
The facility failed to ensure a call bell was accessible for one resident who had diagnoses including blindness in the right eye, fusion of the cervical spine, and rheumatoid arthritis. The resident’s MDS indicated she was able to communicate her needs and was dependent on staff for assistance with activities of daily living. Her care plan identified her as at risk for falls and having vision impairment, with an intervention that the call bell should be kept within reach. During observation, the resident was seen in a wheelchair beside her bed with the call bell on the floor behind her, and on another occasion she was observed in her wheelchair at the foot of the bed with the call bell wrapped around the side rail and out of reach. On both occasions, the resident stated she did not know where her call bell was, that it could not be reached, and that she would like to have it.
Failure to Follow Physician Order for Blood Pressure Medication
Penalty
Summary
The facility failed to ensure a physician's order was implemented for Resident 129, who had diagnoses including hypertension. The physician ordered amlodipine besylate once daily and specified that the medication was not to be given if the resident's pulse was less than 60 beats per minute. Review of the resident's MAR for December 2025, January 2026, and February 2026 showed the medication was administered 31 times in December, 24 times in January, and 2 times in February without documented evidence that the resident's heart rate was assessed before administration as ordered. During an interview, the Assistant DON confirmed there was no documented evidence that the resident's pulse was taken prior to medication administration per the physician's order.
Failure to Assess PTSD and Provide Trauma-Informed Care
Penalty
Summary
The facility failed to assess residents with a diagnosis of PTSD and failed to develop and implement individualized, person-centered care plans to provide trauma informed care for two sampled residents. Facility policy required the social worker, at admission, to ask the resident or responsible party about any history of traumatic experience and, if indicated, offer a trauma-related assessment to identify the level of trauma and support care that recognizes trauma symptoms and avoids re-traumatization. Resident 16 was admitted with diagnoses including PTSD, anxiety, and depression, and the MDS showed the resident was cognitively intact with PTSD. There was no documentation that the resident was asked whether he wanted a trauma-related assessment, no documentation that symptoms or triggers related to PTSD were assessed, and no specific interventions were identified to minimize triggers or re-traumatization. Resident 44 was admitted with chronic PTSD, depression, and insomnia, and the MDS showed the resident was cognitively intact with PTSD. Facility records also noted nightmares, tearfulness, depression, and a history of PTSD, including that the resident was a veteran, but the care plan did not include measures to address trauma history or identify triggers, and there was no documentation of a trauma-related assessment or interventions to minimize triggers or re-traumatization. The Director of Social Work confirmed that both residents were not asked if they wanted to participate in a trauma-related assessment.
LPN Staffing Ratio Deficiency
Penalty
Summary
The facility failed to meet the required licensed practical nurse (LPN) to resident ratios on one of the 21 days reviewed. Specifically, on October 6, 2024, the facility did not have the mandated number of LPNs during both the day and night shifts. During the day shift, from 7:00 a.m. to 3:00 p.m., the facility did not maintain the minimum ratio of one LPN per 25 residents. Additionally, during the night shift, from 11:00 p.m. to 7:00 a.m., the facility failed to meet the required ratio of one LPN per 40 residents. This deficiency was identified through a review of nursing schedules covering the periods from October 1 to 7, 2024, January 1 to 7, 2025, and January 24 to 30, 2025.
Plan Of Correction
Director of Nursing will in-service Staffing Coordinator, ADON's, Nursing Supervisors and Unit Managers regarding minimum staffing to resident ratios on all shifts. Director of Nursing, Administrator, Associate Administrator, Staffing Coordinators, and ADON's will continue to review staffing daily to ensure facility meets staffing ratios. DON will report any shift that does not meet the minimum LPN requirements to the Administrator. Director of Nursing/Designee will continue to actively pursue applicants for nursing positions to assure staffing to resident ratios are met every shift. Staffing to resident ratios will be reviewed at QAPI meetings.
Deficiency in Minimum Nursing Care Hours
Penalty
Summary
The facility failed to meet the regulatory requirement of providing a minimum of 3.2 hours of direct nursing care per resident in a 24-hour period. This deficiency was identified during a review of nursing schedules over three separate weeks. Specifically, on Sunday, October 6, 2024, the facility provided only 3.08 hours of care per resident, falling short of the mandated minimum care hours.
Plan Of Correction
Director of Nursing will in-service Staffing Coordinator, ADON's, Nursing Supervisors and Unit Managers regarding minimum of 3.2 hours of direct resident care for each resident. Director of Nursing, Administrator, Associate Administrator, Staffing Coordinators, and ADON's will continue to review staffing daily to ensure facility meets staffing ratios. DON will report anytime the minimum of 3.2 hours of direct care for the entire facility to the Administrator. Director of Nursing/Designee will continue to actively pursue applicants for nursing positions to assure staffing to resident ratios are met every shift. Staffing to resident ratios will be reviewed at QAPI meetings.
Obstructed Emergency Exit Egress Paths
Penalty
Summary
The facility failed to maintain the means of egress free of impediments, as observed during a survey. On January 30, 2025, at 11:20 a.m., it was noted that emergency exit egress paths to the public way were obstructed by snow and ice. This issue affected two of the three levels of the facility. Specific locations of the obstructions included the AO courtyard emergency exit at 10:10 a.m. and the D1 patio at 11:10 a.m. The obstructions were confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:45 p.m.
Plan Of Correction
The snow and ice were removed from the emergency exit egress paths for the A0 courtyard emergency exit and the D1 patio. Maintenance director or designee to conduct inspection of the emergency exit egress paths for the A0 courtyard and D1 patio to ensure they are not obstructed by snow and ice after winter storms. The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.
Failure to Maintain Egress Door Functionality
Penalty
Summary
The facility failed to maintain proper functioning of exit egress doors on one of its three levels, specifically at the AO Courtyard. During an observation conducted on January 30, 2025, at 10:10 a.m., it was noted that the egress exterior gate lock was not equipped with a delayed egress special locking arrangement (SLA) and failed to open as required. This deficiency was identified through direct observation and was confirmed during an exit interview with the Administrator and Maintenance Director later that day. The deficiency indicates a failure to comply with the National Fire Protection Association (NFPA) 101 Life Safety Code requirements for egress doors, which mandate that doors in a required means of egress should not be equipped with a latch or lock that requires a tool or key from the egress side unless specific conditions are met. The lack of a delayed egress SLA on the exterior gate lock compromised the safety and security protocols intended to ensure rapid evacuation in case of an emergency.
Plan Of Correction
A delayed egress was installed in the exterior gate lock of the A0 Courtyard to ensure the gate will open after 15 seconds. The Maintenance Director or designee will conduct quarterly inspections on the exterior gates to ensure they will open after 15 seconds. The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.
Unsealed Penetration in Smoke Barrier
Penalty
Summary
The facility failed to maintain smoke barrier walls, which is a requirement for ensuring fire safety. During an observation on January 30, 2025, at 9:50 a.m., an unsealed penetration was found above the double doors leading from the loading dock into the laundry department. This deficiency was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:45 p.m. The unsealed penetration compromises the smoke barrier's integrity, which is essential for maintaining a 1/2-hour fire resistance rating as per NFPA 101 standards.
Plan Of Correction
Maintenance to seal penetration above double doors from loading dock into laundry department with an approved UL listed fire stop barrier system. Maintenance director or designee to conduct monthly inspections of penetrations. The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.
HVAC System Maintenance Deficiency
Penalty
Summary
The facility failed to maintain the heating, ventilation, and air conditioning (HVAC) system on one of its three levels. During an observation on January 30, 2025, it was noted that a portable air conditioner unit was vented above the drop ceiling into the interstitial space or attic, creating a plenum, inside the AO-Staff Break Room at 10:15 a.m. Additionally, at 11:15 a.m., several portable air conditioner units were observed in various office and conference locations within the Admin Department, also vented above the drop ceiling into the interstitial space or attic, creating a plenum. These findings were confirmed during an exit interview with the Administrator and Maintenance Director on the same day.
Plan Of Correction
Portable air conditioning in the A0 staff room and the various locations in the administration department were removed or re-vented into the return system to ensure a plenum was not created. Maintenance director or designee will conduct monthly inspections of the portable air conditioning units to ensure they are not vented into the interstitial space or attic thus creating a plenum. The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.
Improper Use of Power Strips in Facility Office
Penalty
Summary
The facility failed to comply with the National Fire Protection Association (NFPA) standards regarding the use of electrical devices, specifically power strips, in a non-compliant manner. During an observation on January 30, 2025, at 11:00 a.m., it was noted that a power strip was being used in the D1-ADON office to power heat draw equipment, a refrigerator, and a microwave. This usage was deemed improper and unauthorized according to the NFPA guidelines, which specify that power strips in patient care vicinities should only be used for patient-care-related electrical equipment and must meet specific UL standards. The improper use of the power strip was confirmed during an exit interview with the Administrator and Maintenance Director on the same day at 12:45 p.m.
Plan Of Correction
The power strip in the D1 ADON office was removed. A new outlet was installed. The maintenance department will conduct quarterly electrical inspections in the D1 ADON office, checking for any power strips. The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.
Oxygen Storage Deficiencies in Facility
Penalty
Summary
The facility failed to maintain proper oxygen storage requirements, as observed during a survey on January 30, 2025. At 10:20 a.m., it was noted that the oxygen cabinet in the AO level clean utility room did not latch properly, which is a violation of the storage requirements for gas equipment. This deficiency indicates that the facility did not ensure that the storage locations were secure, as required by the guidelines for handling and storing oxygen cylinders. Additionally, at 11:15 a.m., in the D1 level oxygen storage room, empty portable oxygen cylinders were not separated from full portable oxygen cylinders. This failure to segregate empty cylinders from full ones is a breach of the established protocols for oxygen storage, which require that empty cylinders be clearly marked and stored separately to avoid confusion. These deficiencies were confirmed during an exit interview with the Administrator and Maintenance Director.
Plan Of Correction
The latch to the oxygen cabinet in the A0 clean utility room was replaced to ensure it would latch. The empty portable oxygen cylinders were separated from the full portable oxygen cylinders in the D1 oxygen storage room. D1 staff will be in-serviced on keeping full and empty oxygen cylinders separate. Maintenance will conduct quarterly inspections on the A0 clean utility room oxygen cabinet to ensure it latches properly. Maintenance will conduct monthly inspections on the D1 oxygen storage room to ensure the full and empty oxygen cylinders are separated. The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.
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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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| Heritage Pointe Rehabilitation And Healthcare Ctr | 2.5 mi | ★★★★★ | 5 | 0 |
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| Harborview Rehabilitation Care Center At Doylestow | 3.5 mi | ★★★★★ | 8 | 1 |
| Wesley Enhanced Living - Doylestown | 3.7 mi | ★★★★★ | 13 | 0 |
| Masonic Village At Warminster | 3.7 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.