Cycle 1
Health 2025-01-31 · Fire 2025-01-31
0 health deficiencies
No concentrated health issue counts in this cycle.
6 fire-safety deficiencies
Top issue: Egress (2 deficiencies)
Warrington, PA
Neshaminy Manor Home
5-star overall rating with 5-star inspections with 6 fire-safety deficiencies in the latest cycle
1660 Easton Road, Warrington, PA
(215) 345-3810
Overall
5 / 5
CMS overall stars
Health inspections
5 / 5
Survey and complaint cycles
Staffing
4 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
360
Certified beds
Average residents
339
Average occupied residents
Ownership
Government
Publicly displayed owner type
Chain
No chain reported
Operator or chain grouping
Approved since
1967-01-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.48
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.72
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
2.04
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.24
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.19
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
2.95
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.31
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.03
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.57
CMS adjusted RN staffing hours
Adjusted total hours
3.83
CMS adjusted total nurse staffing hours
Case-mix index
1.16
Higher values indicate more complex resident acuity
RN turnover
21%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
15%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,406
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
44.45
Composite VBP score used to determine payment impact.
Payment multiplier
0.9976
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
5.31
Baseline 18.53% · Performance 18.97% · Measure score 5.31 · Achievement 5.31 · Improvement 0
Healthcare-associated infections
0
Baseline 7.20% · Performance 7.96% · Measure score 0 · Achievement 0 · Improvement 0
Total nurse turnover
10
Baseline 21.79% · Performance 21.86% · Measure score 10 · Achievement 10 · Improvement 0
Adjusted total nurse staffing
2.47
Baseline 3.38 hours · Performance 3.78 hours · Measure score 2.47 · Achievement 2.47 · Improvement 1.16
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.35% |
10.72%
0.4 pts better
|
No Different than the National Rate · Eligible stays 236 · Observed rate 9.32% · Lower 95% interval 7.56% |
| Discharge to community | 37.91% |
50.57%
12.7 pts worse
|
Worse than the National Rate · Eligible stays 118 · Observed rate 30.51% · Lower 95% interval 30.25% |
| Medicare spending per beneficiary | 0.99 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 100% |
95.27%
4.7 pts better
|
Numerator 167 · Denominator 167 |
| Falls with major injury | 0.6% |
0.77%
0.2 pts better
|
Numerator 1 · Denominator 167 |
| Discharge self-care score | 40% |
53.69%
13.7 pts worse
|
Numerator 50 · Denominator 125 |
| Discharge mobility score | 38.4% |
50.94%
12.5 pts worse
|
Numerator 48 · Denominator 125 |
| Pressure ulcers or injuries, new or worsened | 2.99% |
2.29%
0.7 pts worse
|
Numerator 5 · Denominator 167 · Adjusted rate 2.58% |
| Healthcare-associated infections requiring hospitalization | 7.96% |
7.12%
0.8 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 7.91% · Lower 95% interval 4.91% |
| Staff COVID-19 vaccination coverage | 0.55% |
8.2%
7.6 pts worse
|
Numerator 2 · Denominator 362 |
| Staff flu vaccination coverage | 39.55% |
42%
2.5 pts worse
|
Numerator 195 · Denominator 493 |
| Discharge function score | 41.6% |
56.45%
14.9 pts worse
|
Numerator 52 · Denominator 125 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 67 · Denominator 67 |
| Transfer of health information to patient | Not Available |
96.28%
|
Numerator Not Available · Denominator 7 · Too few residents or stays to report publicly. |
| Resident COVID-19 vaccinations up to date | 48.31% |
25.2%
23.1 pts better
|
Numerator 43 · Denominator 89 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.6 |
1.7
0.1 pts better
|
1.9
0.3 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.6 · Observed 1.1 · Expected 1.3 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.4 |
1.2
0.2 pts worse
|
1.8
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.4 · Observed 1.0 · Expected 1.2 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
86.9%
12.3 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 99.7% · Q3 98.8% · Q4 98.2% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 99.1% |
93.5%
5.6 pts better
|
95.5%
3.6 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 99.1% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 3.4% |
3.2%
0.2 pts worse
|
3.3%
0.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 4.3% · Q2 4.4% · Q3 2.7% · Q4 2.1% · 4Q avg 3.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 0.1% |
6.5%
6.4 pts better
|
11.4%
11.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.4% · Q3 0.0% · Q4 0.0% · 4Q avg 0.1% |
| Percentage of long-stay residents who lose too much weight | 3.2% |
6.5%
3.3 pts better
|
5.4%
2.2 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.8% · Q2 4.4% · Q3 3.8% · Q4 2.8% · 4Q avg 3.2% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.3% |
19.9%
0.4 pts worse
|
19.6%
0.7 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.8% · Q2 21.3% · Q3 18.9% · Q4 20.1% · 4Q avg 20.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 12.7% |
18.7%
6 pts better
|
16.7%
4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 12.0% · Q2 12.5% · Q3 12.4% · Q4 13.7% · 4Q avg 12.7% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.2%
0.2 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 14.8% |
19.6%
4.8 pts better
|
16.3%
1.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 17.5% · Q2 18.1% · Q3 12.5% · Q4 11.4% · 4Q avg 14.8% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 16.1% |
18.3%
2.2 pts better
|
14.9%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.0% · Q2 16.9% · Q3 19.2% · Q4 12.2% · 4Q avg 16.1% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.4% |
0.9%
0.5 pts better
|
1.0%
0.6 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.6% · Q2 0.9% · Q3 0.3% · Q4 0.0% · 4Q avg 0.4% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 0.6% |
1.7%
1.1 pts better
|
1.7%
1.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.3% · Q2 0.3% · Q3 0.3% · Q4 0.6% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 31.7% |
26.4%
5.3 pts worse
|
19.8%
11.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 34.3% · Q2 30.5% · Q3 34.2% · Q4 27.7% · 4Q avg 31.7% |
| Percentage of long-stay residents with pressure ulcers | 4.8% |
5.3%
0.5 pts better
|
5.1%
0.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 5.5% · Q2 5.5% · Q3 4.4% · Q4 3.7% · 4Q avg 4.8% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 96.2% |
68.9%
27.3 pts better
|
81.7%
14.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 97.4% · Q2 97.1% · Q3 96.2% · Q4 94.3% · 4Q avg 96.2% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 7.8% |
9.8%
2 pts better
|
12.0%
4.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 7.8% · Observed 6.8% · Expected 9.6% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.1% |
1.5%
0.4 pts better
|
1.6%
0.5 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 2.9% · Q2 1.8% · Q3 0.0% · Q4 0.0% · 4Q avg 1.1% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 91.3% |
68.7%
22.6 pts better
|
79.7%
11.6 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 91.3% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 16.6% |
23.1%
6.5 pts better
|
23.9%
7.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 16.6% · Observed 13.5% · Expected 19.4% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-01-18 · Fire 2024-01-18
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-02-03 · Fire 2023-02-03
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
10 fire-safety deficiencies
Top issue: Smoke (5 deficiencies)
Fire safety
Fire-safety citations
E · Potential for more than minimal harm
2025-01-31
K211 · Egress Deficiencies
Fire Safety
Keep aisles, corridors, and exits free of obstruction in case of emergency.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-01-31
K222 · Egress Deficiencies
Fire Safety
Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-01-31
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-01-31
K521 · Services Deficiencies
Fire Safety
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-01-31
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2025-03-30
E · Potential for more than minimal harm
2025-01-31
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2025-03-30
E · Potential for more than minimal harm
2023-02-03
K131 · Construction Deficiencies
Fire Safety
Meet requirements for sections of health care facilities separated by fire resistive construction.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-02-03
K321 · Smoke Deficiencies
Fire Safety
Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-02-03
K353 · Smoke Deficiencies
Fire Safety
Inspect, test, and maintain automatic sprinkler systems.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-02-03
K363 · Smoke Deficiencies
Fire Safety
Install corridor and hallway doors that block smoke.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-02-03
K372 · Smoke Deficiencies
Fire Safety
Ensure smoke barriers are constructed to a 1 hour fire resistance rating.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-02-03
K920 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Ensure proper usage of power strips and extension cords.
Corrected 2023-04-17
E · Potential for more than minimal harm
2023-02-03
K923 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have proper medical gas storage and administration areas.
Corrected 2023-04-17
C · Minimal harm
2023-02-03
K291 · Egress Deficiencies
Fire Safety
Install emergency lighting that can last at least 1 1/2 hours.
Corrected 2023-04-17
C · Minimal harm
2023-02-03
K355 · Smoke Deficiencies
Fire Safety
Properly select, install, inspect, or maintain portable fire extinguishes.
Corrected 2023-04-17
C · Minimal harm
2023-02-03
K918 · Gas, Vacuum, and Electrical Systems Deficiencies
Fire Safety
Have generator or other power source capable of supplying service within 10 seconds.
Corrected 2023-04-17
Inspection history
Recent health citations
D · Potential for more than minimal harm
2023-06-07
F580 · Resident Rights Deficiencies
Health
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Corrected 2023-07-07
D · Potential for more than minimal harm
2023-02-03
F689 · Quality of Life and Care Deficiencies
Health
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected 2023-03-21
Penalties and ownership
What sits behind the stars
Ownership
Bailey, James
Corporate Director · Individual
Genesis Eldercare Network Services, Inc.
Operational/Managerial Control · Organization
Kozlowski, Evelyn
W-2 Managing Employee · Individual
Mcconnell, John
Operational/Managerial Control · Individual
Nearby options
Other facilities in reach
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Heritage Pointe Rehabilitation And Healthcare Ctr
Doylestown, PA
4-star overall rating with 4-star inspections with 4 recent health deficiencies
#2
Liberty Pointe Rehabilitation And Healthcare Ctr
Doylestown, PA
3-star overall rating with 3-star inspections with 3 recent health deficiencies with 5 fire-safety deficiencies in the latest cycle
#3
Harborview Rehabilitation Care Center at Doylestow
Doylestown, PA
1-star overall rating with 2-star inspections with $92,859 in total fines with 8 recent health deficiencies with 2 fire-safety deficiencies in the latest cycle
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