Pennsylvania Department of Health
 NESHAMINY MANOR HOME
Building Inspection Results

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NESHAMINY MANOR HOME
Inspection Results For:

There are  42 surveys for this facility. Please select a date to view the survey results.

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NESHAMINY MANOR HOME - 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 February 11, 2026, at Neshaminy Manor Home, it was determined there were no deficiencies identified with the requirements of 42 CFR 483.73.
 Plan of Correction:


Initial comments:Name: MAIN BUILDING 01 - Component: 01 - Tag: 0000
Facility ID# 140202Component 01Main Building Based on a Medicare/Medicaid Recertification Survey completed February 11, 2026, it was determined that Neshaminy Manor Home was not in compliance with the following requirements of the Life Safety Code for an existing Nursing 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 three-story, Type II (222), fire resistive building, that is fully sprinklered.
 Plan of Correction:


NFPA 101 STANDARD Hazardous Areas - Enclosure:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Hazardous Areas - Enclosure
Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door.
Describe the floor and zone locations of hazardous areas that are deficient in REMARKS.
19.3.2.1, 19.3.5.9

Area Automatic Sprinkler Separation N/A
a. Boiler and Fuel-Fired Heater Rooms
b. Laundries (larger than 100 square feet)
c. Repair, Maintenance, and Paint Shops
d. Soiled Linen Rooms (exceeding 64 gallons)
e. Trash Collection Rooms
(exceeding 64 gallons)
f. Combustible Storage Rooms/Spaces
(over 50 square feet)
g. Laboratories (if classified as Severe
Hazard - see K322)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0321 Based on observation and interview, it was determined the facility failed to maintain the fire resistive rating of hazardous area enclosures, affecting one of three levels. Findings include: 1. Observation on February 11, 2020, 2026, between 12:55 p.m., and 1:35 p.m., revealed detached self-closers at the following locations: a. 12:55 p.m., First Floor All Purpose Room, Storage Room B119. b. 1:35 p.m., First Floor Straight Hallway, Storage Room C147. Exit interview with the Assistant Administrator and the Maintenance Director on February 11, 2026, at 2:30 p.m., confirmed the detached self-closers.
 Plan of Correction - To be completed: 04/01/2026

The self-closure for the first floor all purpose room door, B119 was replaced with a new self-closure. The self-closer for the first-floor storage room door, C147 was replaced with a new self-closure.
Maintenance director or designee to conduct monthly inspection of the B119 and C147 doors to ensure the self-closure works properly.
The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.

NFPA 101 STANDARD Sprinkler System - Maintenance and Testing:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
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 01 - Component: 01 - Tag: 0353 Based on observation and interview, it was determined the facility failed to ensure automatic sprinkler system components were maintained affecting one of three levels. Findings include: 4. Observation on February 11, 2026, between 12:00 p.m., and 12:10 p.m., revealed sprinklers missing their escutcheon plates: a. 12:00 p.m., Kitchen Refrigerator #1. b. 12:10 p.m., Center Kitchen Ceiling above the Prep Area. Exit interview with the Assistant Administrator and the Maintenance Director on February 11, 2026, at 2:30 p.m., confirmed the missing escutcheons.
 Plan of Correction - To be completed: 04/01/2026

The escutcheon plates on the sprinkler were replaced on the Kitchen Refrigerator #1 and the center kitchen ceiling above the prep area.
Maintenance director or designee to conduct monthly inspection of the escutcheon plates on the sprinklers in the Kitchen Refrigerator #1 and the center kitchen ceiling above the prep area.
The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.

NFPA 101 STANDARD Utilities - Gas and Electric:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Utilities - Gas and Electric
Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life.
18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0511 Based on observation and interview, it was determined the facility failed to comply with NFPA 70, National Electric Code, for electrical wiring and equipment, affecting two of three levels. Findings include: 1. Observations on February 11, 2026, between 11:40 a.m. and 1:00 p.m., revealed storage within three feet of the electrical panels in following locations. Per NFPA70 110.26(A)(1), a 3 ft. depth clearance is required in front of electrical equipment with a nominal voltage to ground of 0 to 150 volts. a. 11:40 a.m. Ground Level Maintenance TV Room. b. 1:00 p.m., First Floor All Purpose Room, Storage Room B119. Exit interview with the Assistant Administrator and the Maintenance Director on February 11, 2026, at 2:30 p.m., confirmed the storage within three feet of electrical panels.
 Plan of Correction - To be completed: 04/01/2026

Items were removed from the ground level maintenance tv room and the all-purpose room storage room to ensure a 3ft depth clearance in front of electrical equipment. Facility will add tape around the electrical panels to ensure nothing is stored within 3ft of the electrical panels.
Maintenance director or designee to conduct monthly inspection of the maintenance tv room and all-purpose storage room to ensure nothing is stored within 3ft of the electrical panels.

NFPA 101 STANDARD HVAC:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
HVAC
Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications.
18.5.2.1, 19.5.2.1, 9.2




Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0521 Based on document review, observation and interview, it was determined the facility failed to maintain and inspect Heating, Ventilating and Air Conditioning (HVAC) equipment at required intervals, affecting two of three levels. Findings include: 1. Document review on February 11, 2026, at 9:00 a.m., revealed the July 2021 fire damper inspection report listed 5 dampers as deficient. Evidence of corrective action was unavailable at time of survey. Exit interview with the Assistant Administrator and the Maintenance Director on February 11, 2026, at 2:30 p.m., confirmed the missing documentation. 2. Observation on February 11, 2026, at 12:30 p.m., revealed a fire/smoke damper missing its protective flange that prevents a rated wall penetration, above ceiling tile at double doors near room A021. Exit interview with the Assistant Administrator and the Maintenance Director on February 11, 2026, at 2:30 p.m., confirmed the deficient damper.
 Plan of Correction - To be completed: 04/01/2026

Facility received Damper documentation from LSS. A flange was added to the fire smoke damper near room A021. Approved fire caulk was used to seal around the flange.
Maintenance director or designee will conduct monthly inspection to ensure facility has all the paperwork needed for the fire dampers. Maintenance director or designee will conduct monthly inspection of the fire damper near room A021 to ensure the flange is installed and there is no penetration.
The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.

NFPA 101 STANDARD Electrical Systems - Other:This is a less serious (but not lowest level) deficiency and affects more than a limited 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. This deficiency was not found to be throughout this facility.
Electrical Systems - Other
List in the REMARKS section any NFPA 99 Chapter 6 Electrical Systems requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.
Chapter 6 (NFPA 99)
Observations:
Name: MAIN BUILDING 01 - Component: 01 - Tag: 0911 Based on observation and interview, it was determined facility failed to maintain protection of electrical wiring, affecting two of three levels. Findings include: 1. Observations on February 11, 2026, between 11:50 a.m. and 1:05 p.m., revealed the following electrical deficiencies: a. 11:50 a.m., junction box missing its cover plate, Ground Level Laundry behind Dryer 3. b. 11:55 a.m., duplex outlet box pulled out of the wall, Ground Level Laundry near Lint Hopper. c. 1:05 p.m., large junction box missing its cover plate, First Floor double smoke doors, above ceiling and near room D109. Exit interview with the Assistant Administrator and the Maintenance Director on February 11, 2026, at 2:30 p.m., confirmed the electrical deficiencies. Refer to NFPA 70, National Electric Code, and NFPA 99, 6.3.2.1.
 Plan of Correction - To be completed: 04/01/2026

A cover plate was added to the junction box behind dryer #3 and the junction box near D109. The duplex outlet box near the lint hopper was repaired.
Maintenance Director or designee to conduct monthly inspection of the junction box behind dryer #3 and D109 to ensure they have a cover plate. Maintenance director or designee to conduct monthly inspection of the duplex outlet box near the lint hopper to ensure it is installed correctly.
The Maintenance Director or designee will report monthly findings to Quality Assurance for a 90-day period.





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