Pennsburg Manor

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812May 6, 2025

  Based on observation, it was determined that the facility failed to maintain sanitary conditions in the dietary department. Findings include: An environmental tour of the food service department on May 4, 2025, at 9:06 a.m., revealed the following: There were five stained ceiling tiles above a table that contained a large coffee maker. There were areas on the back splash of the stove and around the burners that were stained with a blackish/brown substance. The bottom of the convection oven was dirty with burnt crumbs. The doors on the inside of the convection oven were covered with grease and burnt substances. 28 Pa.Code 201.14(a) Responsibility of licensee. 28 Pa. Code 201.18(b)(3) Management.

• No harm, potential for more than minimal, isolatedF656Jul 8, 2026

  Based on clinical record review and staff interview, it was determined that the facility failed to implement care plan interventions for one of nine sampled residents. (Resident 3) Findings include:Clinical record review revealed that Resident 3 had diagnoses that included malignant neoplasm of the right lung, arterial fibrillation and chronic pain. Resident 3 had current physician orders for staff to administer an anti-coagulant, (Eliquis), a pain medication, (Gabapentin), and to apply a pain relief gel, (Voltaren), every day. The medications and the gel was scheduled to be administered and applied at 9:00 a.m. A review of the care plan revealed that the resident was at risk for complications related to the use of anti-coagulant therapy. […]

• No harm, potential for more than minimal, isolatedF684Jul 8, 2026

  Based on review of facility policy, clinical record review and staff interview, it was determined that the facility failed to ensure that physician's orders were implemented in relation to administration of medications in a timely manner for three of nine sampled residents. (Residents 1, 2 and 3) Findings include;Review of the facility policy entitled, Medication Administration, reviewed February 2026, revealed that medications were to be given in accordance with physician orders. Medications were to be administered within 60 minutes of the scheduled time except before or after meals orders. In addition, staff was to observe the client for medication actions/reactions and record in nursing notes as appropriate. […]

• No harm, potential for more than minimal, isolatedF690Mar 26, 2026

  Based on facility policy review, clinical record review, and staff interview, it was determined that the facility failed to provide treatment and services to restore continence to the extent possible for one of four sampled residents with urinary incontinence. (Resident 87) Findings include: Review of the facility policy entitled, Continence Management, last revised July 15, 2025, revealed that residents were to be assessed for continence management. Residents who were incontinent of bladder were to receive appropriate treatment for prevention of incontinence associated dermatitis and to restore bladder continence to the extent possible. […]

• No harm, potential for more than minimal, isolatedF880Mar 26, 2026

  Based on facility policy review, clinical record review, observation, and staff interview, it was determined that the facility failed to implement Enhanced Barrier Precautions (EBPs) and the use of personal protective equipment (PPE) to prevent the spread of infection for two of 21 sampled residents. (Residents 2 and 11)Findings include: Review of the facility policy entitled, Enhanced Barrier Precautions, last reviewed November 14, 2025, revealed that, in addition to standard precautions, Enhanced Barrier Precautions (EBPs) would be used (when Contact precautions do not otherwise apply) for novel or targeted Multi-Drug-Resistant-Organisms (MDROs). […]