Cycle 1
Health 2025-05-06 · Fire 2025-05-06
3 health deficiencies
Top issue: Nutrition and Dietary (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Pennsburg, PA
Pennsburg Manor
4-star overall rating with 4-star inspections with 3 recent health deficiencies
530 Macoby Street, Pennsburg, PA
(215) 679-8076
Overall
4 / 5
CMS overall stars
Health inspections
4 / 5
Survey and complaint cycles
Staffing
3 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
120
Certified beds
Average residents
107
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Genesis Healthcare
Operator or chain grouping
Approved since
1982-11-01
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
193 facilities
Chain averages 2 overall / 2 health / 3 staffing / 3 quality stars
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
0.96
Registered nurse staffing · state 0.78 · national 0.68
LPN hours / resident day
0.56
Licensed practical nurse staffing · state 0.91 · national 0.87
Aide hours / resident day
1.91
Nurse aide staffing · state 2.20 · national 2.35
Total nurse hours
3.43
All reported nurse hours · state 3.89 · national 3.89
Licensed hours
1.52
RN + LPN hours · state 1.69 · national 1.54
Weekend hours
3.17
Weekend nurse staffing · state 3.51 · national 3.43
Weekend RN hours
0.56
Weekend registered nurse coverage · state 0.55 · national 0.47
Physical therapist
0.09
Reported PT staffing · state 0.10 · national 0.07
Adjusted RN hours
0.89
CMS adjusted RN staffing hours
Adjusted total hours
3.18
CMS adjusted total nurse staffing hours
Case-mix index
1.48
Higher values indicate more complex resident acuity
RN turnover
28%
Annual RN turnover · state 43% · national 45%
Total nurse turnover
33%
Annual nurse turnover · state 47% · national 46%
SNF VBP
Value-based purchasing
Program rank
803
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
63.53
Composite VBP score used to determine payment impact.
Payment multiplier
1.0182
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
10
Baseline 16.43% · Performance 16.44% · Measure score 10 · Achievement 10 · Improvement 0
Healthcare-associated infections
6.23
Baseline 7.88% · Performance 5.97% · Measure score 6.23 · Achievement 6.23 · Improvement 6.11
Total nurse turnover
9.19
Baseline 27.17% · Performance 26.14% · Measure score 9.19 · Achievement 9.19 · Improvement 3.97
Adjusted total nurse staffing
0
Baseline 3.28 hours · Performance 3.14 hours · Measure score 0 · Achievement 0 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 10.46% |
10.72%
0.3 pts better
|
No Different than the National Rate · Eligible stays 297 · Observed rate 10.1% · Lower 95% interval 7.58% |
| Discharge to community | 48.91% |
50.57%
1.7 pts worse
|
No Different than the National Rate · Eligible stays 293 · Observed rate 44.03% · Lower 95% interval 42.44% |
| Medicare spending per beneficiary | 0.95 |
1.02
0.1 pts better
|
|
| Drug regimen review with follow-up | 90.33% |
95.27%
4.9 pts worse
|
Numerator 243 · Denominator 269 |
| Falls with major injury | 0% |
0.77%
0.8 pts better
|
Numerator 0 · Denominator 269 |
| Discharge self-care score | 30.81% |
53.69%
22.9 pts worse
|
Numerator 65 · Denominator 211 |
| Discharge mobility score | 27.96% |
50.94%
23 pts worse
|
Numerator 59 · Denominator 211 |
| Pressure ulcers or injuries, new or worsened | 1.86% |
2.29%
0.4 pts better
|
Numerator 5 · Denominator 269 · Adjusted rate 1.64% |
| Healthcare-associated infections requiring hospitalization | 5.97% |
7.12%
1.2 pts better
|
No Different than the National Rate · Eligible stays 230 · Observed rate 4.78% · Lower 95% interval 3.56% |
| Staff COVID-19 vaccination coverage | 65.83% |
8.2%
57.6 pts better
|
Numerator 79 · Denominator 120 |
| Staff flu vaccination coverage | 38.03% |
42%
4 pts worse
|
Numerator 81 · Denominator 213 |
| Discharge function score | 35.07% |
56.45%
21.4 pts worse
|
Numerator 74 · Denominator 211 |
| Transfer of health information to provider | 94.17% |
95.95%
1.8 pts worse
|
Numerator 113 · Denominator 120 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 107 · Denominator 107 |
| Resident COVID-19 vaccinations up to date | 7.69% |
25.2%
17.5 pts worse
|
Numerator 11 · Denominator 143 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 1.5 |
1.7
0.2 pts better
|
1.9
0.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.5 · Observed 1.4 · Expected 1.8 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 0.4 |
1.2
0.8 pts better
|
1.8
1.4 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.4 · Observed 0.3 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 85.4% |
86.9%
1.5 pts worse
|
93.4%
8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 85.4% · Q2 93.6% · Q3 83.1% · Q4 79.5% · 4Q avg 85.4% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 92.6% |
93.5%
0.9 pts worse
|
95.5%
2.9 pts worse
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 92.6% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 1.0% |
3.2%
2.2 pts better
|
3.3%
2.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.3% · Q4 2.6% · 4Q avg 1.0% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 17.2% |
6.5%
10.7 pts worse
|
11.4%
5.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 16.5% · Q2 18.9% · Q3 8.0% · Q4 25.3% · 4Q avg 17.2% |
| Percentage of long-stay residents who lose too much weight | 2.7% |
6.5%
3.8 pts better
|
5.4%
2.7 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.6% · Q2 3.3% · Q3 1.6% · Q4 1.5% · 4Q avg 2.7% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 20.8% |
19.9%
0.9 pts worse
|
19.6%
1.2 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 20.0% · Q2 20.0% · Q3 18.2% · Q4 25.0% · 4Q avg 20.8% |
| Percentage of long-stay residents who received an antipsychotic medication | 24.5% |
18.7%
5.8 pts worse
|
16.7%
7.8 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 24.1% · Q2 20.8% · Q3 26.0% · Q4 26.9% · 4Q avg 24.5% · 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 | 40.7% |
19.6%
21.1 pts worse
|
16.3%
24.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 49.2% · Q2 42.4% · Q3 28.6% · Q4 40.7% · 4Q avg 40.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 28.3% |
18.3%
10 pts worse
|
14.9%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 15.6% · Q2 34.4% · Q3 30.0% · Q4 33.9% · 4Q avg 28.3% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 0.0% |
0.9%
0.9 pts better
|
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% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.7% |
1.7%
About the same
|
1.7%
About the same
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 2.7% · Q3 1.4% · Q4 2.6% · 4Q avg 1.7% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 35.9% |
26.4%
9.5 pts worse
|
19.8%
16.1 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 38.0% · Q2 34.9% · Q3 43.1% · Q4 27.9% · 4Q avg 35.9% |
| Percentage of long-stay residents with pressure ulcers | 4.6% |
5.3%
0.7 pts better
|
5.1%
0.5 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 3.1% · Q2 5.1% · Q3 4.8% · Q4 5.4% · 4Q avg 4.6% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 45.0% |
68.9%
23.9 pts worse
|
81.7%
36.7 pts worse
|
Short Stay · 2024Q4-2025Q3 · Q1 30.8% · Q2 28.2% · Q3 47.6% · Q4 75.2% · 4Q avg 45.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 5.4% |
9.8%
4.4 pts better
|
12.0%
6.6 pts better
|
Short Stay · 20240701-20250630 · Adjusted 5.4% · Observed 4.8% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 1.2% |
1.5%
0.3 pts better
|
1.6%
0.4 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 3.5% · Q2 1.3% · Q3 0.0% · Q4 0.0% · 4Q avg 1.2% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 34.0% |
68.7%
34.7 pts worse
|
79.7%
45.7 pts worse
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 34.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 17.6% |
23.1%
5.5 pts better
|
23.9%
6.3 pts better
|
Short Stay · 20240701-20250630 · Adjusted 17.6% · Observed 17.6% · Expected 23.9% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2024-04-19 · Fire 2024-04-19
2 health deficiencies
Top issue: Quality of Life and Care (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2023-05-25 · Fire 2023-05-25
2 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
F · Potential for more than minimal harm
2025-05-06
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-06
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-05-06
F690 · Quality of Life and Care Deficiencies
Health
Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.
Corrected 2025-06-10
D · Potential for more than minimal harm
2025-01-13
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 2025-02-11
D · Potential for more than minimal harm
2024-04-19
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2024-06-02
D · Potential for more than minimal harm
2023-10-16
F684 · Quality of Life and Care Deficiencies
Health
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected 2023-11-14
D · Potential for more than minimal harm
2023-03-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2023-04-19
Penalties and ownership
What sits behind the stars
Ownership
Genesis Operations Iv LLC
5% Or Greater Direct Ownership Interest · Organization
Berg, Michael
Corporate Officer · Individual
Fc-Gen Operations Investment LLC
5% Or Greater Indirect Ownership Interest · Organization
Fishman, Steven
5% Or Greater Indirect Ownership Interest · Individual
Gen Operations I LLC
5% Or Greater Indirect Ownership Interest · Organization
Gen Operations Ii LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare Inc
5% Or Greater Indirect Ownership Interest · Organization
Genesis Healthcare LLC
5% Or Greater Indirect Ownership Interest · Organization
Genesis Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Ghc Holdings LLC
5% Or Greater Indirect Ownership Interest · Organization
Hccf Management Group Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Mcbrearty Hindson, Ashley
Operational/Managerial Control · Individual
Omar, Stacy
Operational/Managerial Control · Individual
Sun Healthcare Group Inc
5% Or Greater Indirect Ownership Interest · Organization
Sundance Rehabilitation Holdco Inc
5% Or Greater Indirect Ownership Interest · Organization
Welltower Op LLC
5% Or Greater Indirect Ownership Interest · Organization
Whitman, Arnold
5% Or Greater Indirect Ownership Interest · Individual
Zac Properties Xi LLC
5% Or Greater Indirect Ownership Interest · Organization
Nearby options
Other facilities in reach
#1
Lifequest Nursing Center
Quakertown, PA
4-star overall rating with 4-star inspections with 4 recent health deficiencies with 6 fire-safety deficiencies in the latest cycle
#2
Frederick Living - Cedarwood
Frederick, PA
5-star overall rating with 5-star inspections with 1 fire-safety deficiencies in the latest cycle
#3
Belle Terrace
Quakertown, PA
3-star overall rating with 3-star inspections with 8 recent health deficiencies with 9 fire-safety deficiencies in the latest cycle
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