Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around February 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Pennsburg Manor during CMS and state inspections, most recent first.
Surveyors observed unsanitary conditions in the dietary department, including stained ceiling tiles above a coffee maker, blackish/brown stains on the stove backsplash and burners, and a convection oven with burnt crumbs and grease buildup inside.
A resident who was not cognitively impaired and had no documented history of wandering was placed in a wandering security bracelet without evidence of risk or consent. The resident expressed feeling insulted by the bracelet, and there was no documentation of discussion or agreement regarding its use. The administrator later confirmed the bracelet should not have been applied.
A resident with frequent urinary incontinence and cognitive impairment was not assessed for urinary incontinence upon admission, and no individualized care plan or interventions were developed to address or restore bladder function, contrary to facility policy.
A resident at Pennsburg Manor, diagnosed with heart disease and major depressive disorder, experienced a change in their anti-depressant medication dosage from 50 mg to 75 mg. The facility failed to notify the resident's responsible party of this change, as confirmed by the DON. This deficiency was identified during a complaint survey, indicating non-compliance with federal and state notification requirements.
The facility failed to follow physician's orders for a resident with hypertension by administering midodrine four times when the resident's systolic blood pressure was greater than 90 mmHg, contrary to the specified parameters.
Unsanitary Conditions in Dietary Department
Penalty
Summary
The facility failed to maintain sanitary conditions in the dietary department as observed during an environmental tour. Specifically, five stained ceiling tiles were noted above a table with a large coffee maker. Additionally, the stove's backsplash and areas around the burners were stained with a blackish/brown substance. The bottom of the convection oven was found to be dirty with burnt crumbs, and the inside doors of the convection oven were covered with grease and burnt substances. These observations indicate that the facility did not store, prepare, distribute, and serve food in accordance with professional standards, as required by applicable regulations.
Failure to Respect Resident Dignity in Use of Wandering Security Bracelet
Penalty
Summary
The facility failed to provide care and services in a manner respectful of a resident's dignity, as required by regulation. A review of facility policy indicated that wandering security bracelets are to be used for residents at risk of elopement or unsafe wandering. Clinical record review for a resident admitted with pyogenic arthritis and spinal stenosis showed that the resident was not cognitively impaired, required supervision for ambulation and transfers, and did not exhibit wandering behavior. Elopement evaluations initially indicated no risk, and although a later evaluation noted the resident expressed a desire to go home and was labeled as wandering, there was no supporting evidence in the clinical record of actual wandering or elopement attempts. Observation revealed the resident wearing a wandering security bracelet, and during an interview, the resident expressed feeling insulted by the bracelet and stated they were only at the facility for antibiotics and physical therapy, wishing only to go outside when weather permitted. There was no documentation that the use of the bracelet was discussed with the resident or that the resident consented to its use. The facility administrator confirmed that the resident should not have had the wandering security bracelet.
Failure to Assess and Care Plan for Urinary Incontinence
Penalty
Summary
The facility failed to assess and provide appropriate treatment and services for urinary incontinence for one resident. According to the facility's Continence Management policy, residents are to be assessed for continence needs upon admission, and individualized interventions and care plans are to be developed based on these assessments. However, clinical record review showed that a resident admitted with diagnoses including encephalopathy and weakness, who was frequently incontinent of bowel and bladder, did not have a urinary incontinence assessment completed upon admission. The resident was documented as being incontinent of urine and using adult briefs, but there was no evidence of a completed assessment or a care plan with specific interventions to address or attempt to restore bladder continence. Additionally, the Minimum Data Set assessment indicated that the resident's urinary incontinence was to be addressed in the care plan, but no such plan was found in the records. Staff interviews confirmed that neither a urinary incontinence assessment nor care planned interventions had been completed or implemented for this resident, which was not in accordance with facility policy.
Failure to Notify Responsible Party of Medication Change
Penalty
Summary
Pennsburg Manor was found to be non-compliant with federal and state regulations regarding the notification of changes in a resident's condition. Specifically, the facility failed to notify the responsible party of a change in medication dosage for a resident diagnosed with heart disease and major depressive disorder. On December 20, 2024, a physician ordered an increase in the resident's anti-depressant medication, Zoloft, from 50 mg to 75 mg. However, there was no documentation to indicate that the resident's responsible party was informed of this change. During an interview on the same day, the Director of Nursing confirmed the absence of documented evidence that the responsible party had been notified about the medication dosage increase. This oversight was identified during an abbreviated survey conducted in response to a complaint, highlighting a failure in the facility's process to ensure proper communication with resident representatives regarding significant changes in treatment, as required by 42 CFR Part 483 and the 28 Pa. Code.
Plan Of Correction
Resident 1's RP was notified of the change in medication dose. The Director of Nursing will complete an audit of all charts for residents who have had an increase in antidepressant medication in the last 7 days ensuring notification compliance. The Director of Nursing or Designee will re-educate nurses on Notification of Changes to the resident RP and that documentation must be completed in PCC. The Director of Nursing or Designee will complete weekly random audits x 60 days ensuring compliance. The results of these audits will be presented at the QAPI meetings for review and/or recommendations. Preparation and submission of this plan of correction is required by state and federal law. This plan of correction does not constitute an admission for purposes of general liability, professional malpractice or any other court proceeding.
Failure to Follow Physician's Orders for Medication Administration
Penalty
Summary
The facility failed to ensure physician's orders were implemented for a resident with hypertension. The physician's order specified that the medication midodrine should not be administered if the resident's systolic blood pressure (SBP) was more than 90 mmHg. However, staff administered the medication four times in April 2024 when the resident's SBP was greater than 90 mmHg. This was confirmed by the Nursing Home Administrator during an interview.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Pennsburg
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Lifequest Nursing Center | 6.3 mi | — | 0 | 0 |
| Frederick Living - Cedarwood | 6.9 mi | — | 0 | 0 |
| Belle Terrace | 7.9 mi | — | 15 | 0 |
| Quakertown Center | 8.2 mi | — | 7 | 0 |
| Lutheran Community At Telford | 9.8 mi | — | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.