Penn Mar Healthcare Center

In the surveyor’s words

From the most serious findings on record at Penn Mar Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF600Jun 4, 2024

  Based on interview and record review, the facility failed to protect residents' rights to be free from emotional abuse (non-physical behaviors that were meant to control, isolate, or frighten) and physical abuse (any intentional act causing injury or trauma to another person) for three of seven sampled residents (Residents 3, 4 and 7) when: a. Resident 3 punched Resident 4 in the face on 5/29/2024 in the patio.Resident 4 punched Resident 3 in the mouth on 5/29/2024 in the patio. This deficient practice resulted in Resident 3 and Resident 4 being subjected to emotional and physical abuse. Resident 4 became upset and punched Resident 3 on the mouth. […]

• No harm, potential for more than minimal, widespreadF727Nov 21, 2025

  Based on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, seven days a week from 11/1/2025 through 11/19/2025 for six out of 19 days. This deficient practice had the potential to affect the quality of nursing care provided to the residents.Findings: During a concurrent interview and record review on 11/19/2025 at 2:28 pm with the Director of Staff Development (DSD), the Nurse Staffing Sign-in Sheet for the month of November 2025 was reviewed. The Nurse Staffing Sign-in Sheet dated 11/1/2025 through 11/19/2025 did not indicate an RN was on duty for 6 days. The DSD stated the facility had no full time RN who worked eight hours per day, seven days a week since August 2025. […]

• No harm, potential for more than minimal, patternF552Nov 21, 2025

  Based on interview and record review the facility failed to obtain written informed consent for two of five sampled residents (Residents 6 and 9) by failing to:a. Obtain a written informed consent for the use of Lithium Carbonate (mood stabilizing medication to treat bipolar disorder [mental disorder characterized by periods of depression and of elevated mood]) for Resident 9.b. Ensure Resident 6 had written informed consents for the use of Clozapine (medication used to treat schizophrenia [mental disorder characterized by abnormal social behavior and failure to understand what is real]) and Fluvoxamine Maleate (medication used to treat depression [persistent feelings of sadness and worthlessness and a lack of desire to engage in formerly pleasurable activities]) before use. […]

• No harm, potential for more than minimal, patternF578Nov 21, 2025

  Based on interview and record review, the facility failed to ensure a copy of the Advance Directive (AD- a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them) was not incomplete nor missing the conservator's signature, and readily available in the residents' medical chart for three of five sampled residents (Residents 5, 8 and 21) in accordance with the facility's Policy and Procedure (P&P) titled Advance Directives. These failures had the potential for the facility staff not knowing Residents 5, 8 and 21's specific wishes to follow and provide medical treatment and services against the will of the residents. Findings: a. […]

• No harm, potential for more than minimal, patternF656Nov 21, 2025

  Based on interview and record review the facility failed to develop and implement an individualized/person- centered care plan (CP) for two of two sampled residents (Residents 9 and 31) in accordance with facility's Policy and Procedure (P&P) titled Care Planning. These deficient practices had the potential for Residents 9 and 31 to not receive necessary treatment and specific care services. Findings: a. During a review of Resident 9's admission Record (AR), the AR indicated Resident 9 was admitted to the facility on [DATE] with diagnoses that included anxiety (emotion characterized by an unpleasant state of inner turmoil) and schizophrenia (a mental illness characterized by disturbances in thought). […]