Pennsylvania Department of Health
NESHAMINY MANOR HOME
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

NESHAMINY MANOR HOME
Inspection Results For:

There are 99 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.


NESHAMINY MANOR HOME - Inspection Results	Scope of Citation Number of Residents Affected By Deficient Practice

Initial comments:
Based on a Medicare/Medicaid Recertification survey, State Licensure survey, Civil Rights Compliance survey and an Abbreviated survey in response to two complaints, completed February 6, 2026, it was determined that Neshaminy Manor Home , 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.\~

Plan of Correction:

483.10(e)(3) REQUIREMENT Reasonable Accommodations Needs/Preferences:

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.

§483.10(e)(3) The right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents.

Observations:
Based on clinical record review and resident interview, it was determined that the facility failed to ensure a call bell was accessible for one of 36 sampled residents. (Resident 129)

Findings include:

Clinical record review revealed that Resident 129 had diagnoses that included blindness in the right eye, fusion of the spine in the cervical region, and rheumatoid arthritis. The Minimum Data Set assessment dated November 21, 2025, indicated that the resident was able to communicate her needs and was dependent on staff for assistance with activities of daily living. The care plan indicated the resident was at risk for falls and had vision impairment. Interventions included that the call bell should be kept within reach.

On February 3, 2026, at 12:58 p.m., Resident 129 was observed in a wheelchair bedside her bed and her call bell was on the floor behind her. On February 5, 2026, at 11:46 a.m., the resident was observed in her wheelchair at the foot of the bed and the call bell was observed behind her wrapped around the side rail and out of reach. Both times, the resident stated she did not know where her call bell was, that her call bell could not be reached, and that she would like to have it.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 03/24/2026

1-Resident – R129 was immediately assessed 2/6/2026 and the call bell was placed in reach and functioning, she was aware of location of call bell, and able to access the call bell.
2-An audit was conducted on all current residents to instruct on the call bell that is in place and functioning, location of call bell, and the ability for resident to access the call bell.
3-All Departments will be re-educated that call bell is in place and functioning, location of call bell, and the ability for resident to access the call bell. New Employee orientation updated to include call bell orientation.
4-DON/ Designee will conduct random daily checks x four weeks, then weekly x four weeks, then monthly times three months and results presented to the Quality Improvement (QI) Committee for further recommendations.

483.25 REQUIREMENT Quality of Care:

§ 483.25 Quality of care
Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Observations:
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to ensure physician's orders were implemented for one of 36 sampled residents. (Resident 129)

Findings include:

Review of the policy entitled, "Administration of Medication," last reviewed January 8, 2026, revealed staff were to obtain vital signs if necessary, and document physician indicated medication administration information on the Medication Administration Record (MAR).
Clinical record review revealed that Resident 129 had diagnoses that included hypertension (high blood pressure). On October 25, 2024, the physician ordered staff to administer a blood pressure medicine (amlodipine besylate) one time a day. Staff were not to administer the medication if the resident's pulse (the number of times a heart beats in one minute) was less than 60 beats per minute. Resident 129's MAR for December 2025, and January and February 2026, revealed that staff administered the medication 31 times in December, 24 times in January, and two times in February with no documented evidence that the heart rate was assessed prior to medication administration per physician's order.

In an interview on February 6, 2026, at 9:35 a.m., Assistant Director of Nursing 1 confirmed there was no documented evidence that Resident 129's pulse was taken prior to medication administration per physician's order as identified.

28 Pa. Code 211.10(d) Resident care policies.

28 Pa. Code 211.12(d)(1)(5) Nursing services.

Plan of Correction - To be completed: 03/24/2026

1. Resident – R129 was immediately assessed by MD. The MD discontinued the monitoring of the pulse.
2. An audit was conducted on 2/12/2026 on all current residents Medication Record to ensure medications as administered according to parameters.
3. Licensed Nursing staff will be re-educated on ensuring medications are administered according to parameters.
4. DON/ Designee Weekly ongoing monitoring will continue, and results presented to the Quality Improvement (QI) Committee for further recommendations.

483.25(m) REQUIREMENT Trauma Informed Care:

§483.25(m) Trauma-informed care
The facility must ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.

Observations:
Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to assess residents with a diagnosis of post-traumatic stress disorder (PTSD) and develop and implement an individualized person-centered care plan to render trauma informed care for two of 36 sampled residents. (Residents 16 and 44)

Findings include:

Review of the facility policy entitled, "Trauma Informed Care," last reviewed July 10, 2025, revealed that the social worker was to ask the resident or resident's responsible party (RP), at the time of admission, if there was any history of a traumatic experience and, if so, the social worker was to ask the resident or resident's RP if they would like to participate in a trauma related assessment to determine the level of trauma caused to ensure the care staff provided involved understanding, recognizing and responding to the effects of all types of trauma, and recognize the widespread impact and signs and symptoms of trauma in the resident and avoid re-traumatization.

Clinical record review revealed that Resident 16 was admitted to the facility on February 10, 2025, with diagnoses that included PTSD, anxiety, and depression. The Minimum Data Set (MDS) assessment dated November 12, 2025, revealed that the resident was cognitively intact and had a diagnosis of PTSD. There was no documentation to support that the resident was asked if he wanted to participate in a trauma-related assessment to assess for symptoms or triggers related to the diagnosis of PTSD. There was no documentation to support that symptoms or triggers were assessed related to the diagnosis of PTSD. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization.

Clinical record review revealed that Resident 44 was admitted to the facility on June 15, 2017, with diagnoses that included chronic PTSD, depression, and insomnia. Review of the MDS assessment dated December 30, 2025, revealed that the resident was cognitively intact and had a diagnosis of PTSD. Review of facility documentation revealed that on March 30, 2020, a Psychiatry Nurse Practitioner's note indicated the resident was lonely and depressed, had been struggling with vivid nightmares that were scary, and had become tearful. On December 14, 2021, a physician noted the resident had PTSD. On April 19, 2023, a Psychiatry Nurse Practitioner's note indicated the resident was a veteran with a history of PTSD. Resident 44's care plan did not include any measure to address the resident's history of trauma or identify triggers. There was no documentation to support that symptoms or triggers were assessed related to the diagnosis of PTSD. There were no specific interventions to meet the resident's needs for minimizing triggers and/or re-traumatization on the care plan.

In an interview on February 5, 2026, at 2:00 p.m., the Director of Social Work confirmed that Resident 16 and Resident 44 were not asked if they wanted to participate in a trauma related assessment.

28 Pa. Code 211.12(d)(3)(5) Nursing services.

Plan of Correction - To be completed: 03/24/2026

1. Residents R16 and R44 were immediately reviewed for Trauma Informed Care, and care plan was developed and implemented to develop individualized person- centered care.
2. All residents will be assessed to determine who are trauma survivors and if identified will received culturally competent, trauma informed care in accordance with practice and accounting for resident's experiences and preferences.
3. Staff responsible for assessing for Trauma informed Care will be in-serviced for identifying trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident.
4.Director of Social work/ Designee will conduct audits weekly, and the results presented to the Quality Improvement (QI) Committee for further recommendations.

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