Every finding on record at Neshaminy Manor Home

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. 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.

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.

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 [DATE], with diagnoses that included PTSD, anxiety, and depression. The Minimum Data Set (MDS) assessment dated [DATE], 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 [DATE], with diagnoses that included chronic PTSD, depression, and insomnia. Review of the MDS assessment dated [DATE], 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.

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). On May 3, 2023, the resident weighed 110.9 lbs indicating a 7.6 percent weight gain. There was a lack of documented evidence to support the resident's responsible party was notified of the significant weight gain. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

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. On January 31, 2023, at 2:06 p.m., and again on February 2, 2023, at 10:15 a.m., a plastic cup with medications was observed on the resident's table. The resident stated at that time that the nurse left them there during the morning medication pass. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a PRN (as needed) psychoactive medication was limited to 14 days unless the physician documented in the clinical record the rationale for the PRN medication to be extended beyond 14 days for one of 35 sampled residents. (Resident 167) Findings include: Clinical record review revealed that Resident 167 had a diagnoses that included dementia and anxiety and had a physician's order for staff to administer a psychoactive medication ([MEDICATION(S)]) 0.5 milligrams every six hours as needed for anxiety dated December 13, 2021. The current order for [MEDICATION(S)] had been in place for longer than 14 days. There was no physician documentation of the rationale for the order to be extended beyond 14 days. In an interview on March 3, 2021, at 12:15 p.m., the Director of Nursing confirmed that the physician's order for the use of the psychoactive medication exceeded 14 days in duration, and that the physician did not provide a rationale for the continued use of the medication beyond 14 days. 28 Pa. Code 211.12(d)(5) Nursing services.

Based on observation, it was determined that the facility failed to provide a homelike setting during lunch on one of six units where meals were observed. (Unit A1) Findings include: Observation during lunch in the dining room on September 13, 2016, at 12:05 p.m., through 12:20 p.m., revealed that Residents R95 and R119 were fed by LPN1 and NA1, respectively. Both staff stood while feeding the residents their meal. On September 14, 2016, at 12:05 p.m., NA1 stood while feeding Resident R119's lunch and then at 12:45 p.m., NA1 stood while feeding Resident R95's lunch. On September 14, 2016, NA2 stood while feeding Residents R67 and R80 their lunch. 28 Pa. Code 201.29(j) Resident rights.

Based on observation and a review of previous staffing data postings, it was determined that the facility failed to post the actual number of nursing staff worked per shift. Findings include: During a tour of the facility conducted on September 13, 2016, at 9:30 a.m., the staffing information was posted at the receptionist desk. The posting did not include the number of staff members by category (registered nurses, licensed practical nurses, and nurse aides). During all days of the survey conducted from September 13 through 16, 2016, the nursing staffing posted did not include the number of staff members by category. Review of previous staffing data postings from January 11 through 17, 2016, June 1 through 7, 2016, and September 2 through 8, 2016, revealed the nursing staffing posted did not include the number of staff members by category.

Based on observations during the initial and daily environmental tours and staff interview, it was determined that the facility failed to ensure that the resident's environment was free of accident hazards on four of six nursing units. (Nursing Units C1, C2, A1, A2) In addition, the facility failed to ensure that potentially hazardous cleaning materials were stored safely on one of six nursing units (A0). Findings include: Observations during the initial and subsequent tours of the C1, C2, A1, and A2 nursing units conducted on August 4, 2015, August 5, 2015, and August 6, 2015, at various times, revealed four unsecured towel warmers with temperature readings of 159 degrees Fahrenheit and a recorded internal surface metal temperature of 143 degrees Fahrenheit. Residents residing on these units had assess to this potentially harmful device. In an interview on August 7, 2015, at 11:05 a.m., the Assistant Administrator stated that all towel warming devices would be moved to secured areas. On August 4, 2015, at 9:20 a.m., a cleaning product (Maxima) was observed in the A-Ground nursing unit shower room. The product label indicated that the cleaning product was potentially hazardous if ingested and could cause skin or eye irritation when exposed. The cleaner was stored in an unlocked cabinet. In an interview conducted that same day at 9:45 a.m., the A0 Unit Manager indicated that at least seven cognitively impaired mobile residents reside on the A0 nursing unit. 28 Pa. Code 201.18(b)(1) Management.

Based on clinical record review, observation, policy review and staff interview, it was determined that the facility failed to ensure that infection control practices were implemented to reduce the potential spread of infection for one of one sampled residents on transmission based precautions. (Resident R288) Findings include: Review of the facility's infection control policy entitled "Contact Precautions," dated August 12, 2014, revealed that residents being treated for [REDACTED]. diff) infection were to be placed on "contact precautions." Staff was to use barrier precautions for contact with resident and the resident's immediate environment, wear gloves when providing care and remove gloves and perform hand hygiene upon exiting the room to prevent the spread of infection. Clinical record revealed that Resident R288 was diagnosed on [DATE], with [DIAGNOSES REDACTED] infection. The resident was then treated with the antibiotic [MEDICATION NAME] for 14 days in July 2014. On August 8, 2014, the resident had another positive [DIAGNOSES REDACTED] laboratory test result and was again treated with the antibiotic [MEDICATION NAME]. At that time, the care plan was revised to include the use of "contact precautions." On September 11, 2014, a nurse documented that the resident had loose stools and that staff was to continue using "contact precautions." On September 16, 2014, at 10:23 a.m., a physical therapist was observed in Resident R288's room. The physical therapist had direct contact with the resident and the resident's environment when the resident was in bed. The physical therapist failed to wear a gown and utilize gloves when she had direct contact with the resident and the environment, and exited the room without washing her hands. On September 16, 2014, at 10:45 a.m., and on September 17, at 9:45 a.m., a housekeeper was observed in Resident R 288's room, and had direct contact with the resident's environment without wearing gloves. The housekeeper exited the room without washing his hands. In an interview on September 18, 2014, at 2:15 p.m., the infection control coordinator (RN1) stated that Resident R288 was on contact precautions and staff was to wear protective equipment and wash their hands prior to leaving the resident's room as required by facility policy. 28 Pa. Code 211.10(d) Resident care policies. 28 Pa. Code 211.12(d)(1) Nursing services.

Based on clinical record review, staff interview and observation, it was determined that the facility failed to ensure that a drug irregularity was identified by the consultant pharmacist for one of 30 residents sampled. (Resident R130) Findings include: Clinical record review revealed that Resident R130 had [DIAGNOSES REDACTED]. The resident received Dilantin (an anticonvulsant medication to control seizures) twice a day. The resident also received all nutrition by a tube feeding. According to the September 2014 Medication Administration Record, [REDACTED].m). The Dilantin was scheduled to be administered at 6:30 p.m., and at 6:00 a.m., with instructions that the tube feeding was to be held one hour before and one hour after medication administration. Observation on September 17, 2014, at 6:20 a.m., revealed that the tube feeding was completed. In an interview at 6:25 a.m., RN1 (medication nurse) stated that the tube feeding was completed at 6:00 a.m., and then the resident's Dilantin was administered. RN1 stated that this time frame was the normal routine. There was a lack of evidence that the tube feeding had been held for the hour time frame prior to the medication administration. There was no evidence that the consultant pharmacist had identified during the monthly review that the Dilantin and the tube feeding were scheduled to be administered during the same time which increased the risk for a drug interaction. 28 Pa. Code 211.12(d)(3) Nursing services.

Based on clinical record review, review of incident reports, staff interview and observation, it was determined that the facility failed to ensure that adequate supervision was provided to prevent injuries from falls for two of 12 residents sampled identified at risk for falls. (Residents R97, R337) Findings include: Clinical record review revealed that Resident R97 had [DIAGNOSES REDACTED]. The resident was admitted to the facility on [DATE], and had a history of [REDACTED]. Review of the resident's fall history and incident reports revealed that on December 9, 2011, at 3:00 p.m., staff responded to a sounding bed alarm to find the resident on the floor. Staff documentation noted that the resident stated she had gotten up to go to the bathroom. Staff did document that the resident had a history of [REDACTED]. Also documented was that the resident had been observed attempting to stand and self transfer without staff assistance. The resident sustained [REDACTED]. The resident's fall risk assessments from January 2, 2012, through November 1, 2012, identified the resident at high risk for falls. Review of the care plan dated March 27, 2012, and most recently reviewed on September 25, 2012, also identified the resident's risk potential for falls. Care plan interventions to prevent injuries from falls included the use of bed alarm, clip chair alarm, alarming floor mats, and non skid floor mats in the bathroom and bedside. Another documented intervention directed that "staff to stay with resident when she is on the toilet, no un-supervised toileting." Review of the nurse aide assignment sheet also direct that staff was to supervise all toileting. On November 1, 2012, a nurse documented that at 2:30 p.m., Resident R97 had fallen in the bathroom. Review of the facility's "Fall Investigation Tool" report revealed that the resident had gotten off the toilet by herself and was holding onto the door knob when staff opened the door from the other side and the resident let go and fell to floor. Review of the witness statements revealed that the staff had assisted the resident to the toilet and after completing hygiene care the staff left the bathroom to empty the trash. When the staff returned the resident was already off the toilet and holding onto the doorknob as previously noted. The resident had been left unsupervised in the bathroom. During the initial tour, on November 26, 2012, at 9:25 a.m., the unit manager had stated that the staff had left the resident unattended in the bathroom. At 10:00 p.m., the resident complained of right hip and rib pain with movement and breathing. The resident was transferred to the hospital for evaluation and a nurse documented upon return that the resident had three rib fractures. The resident continued to complain of pain with movement, laughing and coughing. The resident required increased medication to manage her pain related to the rib fractures. In addition to a routine pain management program of Tylenol twice a day she received Tylenol with codeine as needed. She received 14 doses of this medication from November 3, 2012, through November 25, 2012. As a result of the fall on November 1, 2012, staff applied an alarm to the bathroom door so as to alert staff when the resident attempted to enter the bathroom. On November 27, 2012, at 12:09 p.m., Resident R97 was observed by the surveyor in her wheelchair in the bathroom doorway. The door was open and no alarm had sounded or was sounding at the time. There was no staff with the resident or in the immediate vicinity. At 12:14 p.m., accompanied by the unit manager the resident was observed seated on the toilet. The unit manager confirmed that staff had not activated the door alarm prior to the resident entering the bathroom unassisted. Clinical record review revealed that Resident R337 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) assessment dated [DATE], identified that the resident was severely cognitively impaired and exhibited wandering behaviors on a daily basis. Nurses' notes identified that the resident exhibited anxiety and wandering behaviors that intruded on the privacy and activity of other residents that required administration of as needed antianxiety medication. For example, on October 18, 2012, at 4:53 p.m., a nurse documented that the resident required antianxiety medication due to "pacing on the hallway, disruptive to others, grabbing other residents by the arms and taking them along." On October 19, 2012, at 7:15 p.m., a nurse documented that the resident "displayed wandering behavior that put the resident at significant risk of getting into a potentially dangerous place" and that the "behavior significantly intrudes on the privacy and activities of others." The nurse documented that the resident displayed "agitation interfering with the care of others, pulling at others as they are walking around the unit, telling them they are wrong and need to be disciplined." The resident received antianxiety medication at that time. On October 22, 2012, at 7:42, staff again documented that the resident's "wandering behavior intrudes on the privacy or activity of others." The care plan in effect from September 21, 2012, identified goals and staff interventions for the resident to wander safely throughout the unit and to be free from injuries from falls. One intervention was for staff to provide "close supervision, attempt to keep in supervised areas." Nurses' notes and incident report review also identified that on September 20, 2012, at 7:20 a.m., the resident was found to have an acute fracture of the left distal radius. The facility's investigation stated "after extensive investigation, no definitive cause was found." In an interview on November 29, 2012, at 10:30 a.m., the Director of Nursing stated that after the incident the staff was to check the floor for the resident's whereabouts every 15 minutes. On October 25, 2012, at 3:17 p.m., a nurse documented that Resident R337 was standing and talking with the nurse and another resident (Resident R307). Resident R307 was holding a wheelchair arm cover and without warning lashed out and forcefully struck Resident R337 in the right upper arm with the cover. Resident R337 was very angry and attempted to hit Resident R307 but the nurse was able to separate them. Review of the incident report revealed that Resident R307 was having difficulty sleeping, having abrupt mood swings and impulsive actions. Staff documented that the psychiatrist would evaluate Resident R307's behavior and determine if psychiatric hospitalization was needed. Resident R307's care plan was updated for behavioral issues including aggressive wandering and for staff to monitor. There was no evidence to support that a plan for additional supervision was provided for these two residents to keep them from wandering into each others personal space to prevent additional altercations. On October 27, 2012, a nurse documented that at 2:30 p.m., a housekeeper was approaching the entrance to the nursing unit and observed Resident R337 with her hands on the hips of a resident (R307). Resident R307 was heard stating "get away from me and leave me alone." Resident R337 was then forcefully pushed by Resident R307 and fell to the floor. As a result of the fall, Resident R337 was transferred to the hospital and diagnosed with [REDACTED]. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 10/21/11

Based on clinical record review and staff interview, it was determined that the facility failed to develop resident care plans that addressed each resident's care needs that were identified on the comprehensive assessment for seven of 30 sampled residents. (Residents R24, R121, R158, R175, R226, R242, CR3) Findings include: Clinical record review revealed that Resident R24 was admitted to the facility on [DATE]. The annual Minimum Data Set (MDS) assessment of August 5, 2011, identified that the resident had cognitive impairment. Staff documented on the Care Area Assessment (CAA) summary that the resident's [MEDICAL CONDITION] was to be addressed on the comprehensive care plan. Review of the care plan revealed that staff had failed to address the resident's [MEDICAL CONDITION]. Clinical record review revealed that Resident R121 had a significant change MDS assessment completed on December 5, 2010. Staff documented on the CAA summary, that the resident's visual function, communication and use of [MEDICAL CONDITION] drugs were care areas that were to be addressed on the comprehensive care plan. Review of the care plan revealed that staff had failed to address these areas. Clinical record review revealed that Resident R158 had a MDS assessment completed on September 1, 2011. Staff documented on the CAA summary, that the resident's visual function, mood state, dental care and use of [MEDICAL CONDITION] drugs were care areas that were to be addressed on the comprehensive care plan. Review of the care plan revealed that staff had failed to address these areas. Clinical record review revealed that Resident R175 had an initial MDS assessment completed on September 21, 2011. Staff documented on the CAA summary that the resident's visual function and urinary incontinence were care areas that were to be addressed on the comprehensive care plan. Review of the care plan revealed that staff had failed to address these areas. Clinical record review revealed that Resident R226 had an initial MDS assessment on July 18, 2011, that identified that the resident was occasionally incontinent of bladder and required extensive staff assistance to use the toilet. Staff documented on the CAA summary of July 27, 2011, that the resident's urinary incontinence was to be addressed on the comprehensive care plan. Review of the care plan revealed that staff had failed to address the urinary incontinence. In an interview on October 21, 2011, at 10:10 a.m., RN1 stated that Resident R226's care plan failed to address urinary incontinence. Clinical record review revealed that Resident R242 had an initial MDS assessment completed on September 7, 2011. Staff documented on the CAA summary associated with that assessment that the resident's visual function was to be addressed on the comprehensive care plan. Review of the care plan revealed that staff had failed to address this area. In an interview on October 21, 2011, at 11:30 a.m., RN2 stated that the care plans for Residents R121, R158, R175, R242 did not fully address the residents' needs based on the MDS assessment. Clinical record review revealed that Resident CR3 had an initial MDS assessment completed on August 18, 2011. Staff documented on the CAA summary that the resident's risk for pressure sore development and [MEDICAL CONDITION] drug use were areas that were to be addressed on the care plan. Review of the care plan revealed that staff had failed to address these areas. In an interview on October 21, 2011, at 10:50 a.m., RN3 confirmed that the resident's care plan failed to address these areas.

Based on clinical record review and staff interview, it was determined that the facility failed to ensure that a recommendation from a vision consultation was acted upon timely for one of 30 sampled residents. (Resident R206) Findings include: Clinical record review revealed that Resident R206 had a [DIAGNOSES REDACTED]. On March 24, 2011, and September 23, 2010, the eye physician recommended "continue to monitor sed rate." A sed rate (sedimentation rate) is a blood test that helps to indicate inflammation by measuring red blood cells. There was a lack of evidence to support that the laboratory test was completed. In an interview on October 20, 2011, at 11:10 a.m., the Director of Nursing stated that the laboratory test had not been completed. 28 Pa. Code 211.12(d)(5) Nursing services. Previously cited 9/24/10