Neshaminy Manor Home

In the surveyor’s words

From the most serious findings on record at Neshaminy Manor Home, in the surveyor’s own words.

• No harm, potential for more than minimal, isolatedF558Feb 6, 2026

  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 [DATE], 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. […]

• No harm, potential for more than minimal, isolatedF684Feb 6, 2026

  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. […]

• No harm, potential for more than minimal, isolatedF699Feb 6, 2026

  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… […]

• No harm, potential for more than minimal, isolatedF580Jun 7, 2023

  Based on clinical record review, it was determined that the facility failed to notify a resident's responsible party of a significant change in treatment and condition for one of seven sampled residents. (Resident 1) Findings include: Clinical record review revealed that Resident 1 was admitted to the facility with diagnoses that included hypertension and hypertensive urgency. On May 1, 2023, the physician ordered hydralazine 10 milligrams (mg) every eight hours for hypertension. On May 26, 2023, the physician increased Resident 1's morning dose of hydralazine to 25 mg. There was no documented evidence that the resident's responsible party was notified of the change. Further review of Resident 1's clinical record revealed that on April 5, 2023, she weighed 103 pounds (lbs). […]

• No harm, potential for more than minimal, isolatedF689Feb 3, 2023

  Based on clinical record review, resident interview, and review of facility policy, it was determined that the facility failed to safely administer medications for one of 35 sampled residents. (Resident 94) Findings include: Review of the facility policy entitled, Administration of Medications, last reviewed December 2022, revealed that medications administered by the nurse are not left at the bedside or in the resident's possession even for a brief period of time. Clinical record review revealed that Resident 94 had diagnoses that included anxiety, depression, and bipolar disorder. According to the Minimum Data Set assessment, dated November 5, 2022, the resident had some memory problems and required assistance from staff for mobility and activities of daily living. […]