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Nursing HomeMedicaid Investigative

Penn Mar Healthcare Center

Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.

3938 Cogswell Road, El Monte, CA 9173245 bedsLicensed & Active
2/5
Medicare
Inspection
Quality
Staffing
Google rating
2.2/5

based on 13 Google reviews

5
4
3
2
1

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8/ 10
critical Risk

Quality Concerns Identified

Medicare inspection and quality data reveal areas that families should carefully evaluate before choosing this facility.

  • Abuse citation on record
  • Low overall rating (2/5 stars)
  • Low staffing rating (1/5 stars)
  • Above-median deficiencies (21 vs median 13.0)
  • High staff turnover (54%)
  • High RN turnover (100%)

Below average in CA · Critically understaffed (RN) · Significantly below average staffing · $4,893 in fines · Abuse citation

Source: Medicare data

What this means for your family

This facility has serious allegations of physical abuse and the use of locked rooms for isolation that must be investigated. While some family members report positive outcomes for their loved ones, the recurring reports of staff aggression and poor hygiene are significant red flags.

Google Reviews

Google Reviews

13 reviews on Google
Families should exercise extreme caution, as several reviews describe severe allegations of physical abuse, improper use of isolation rooms, and neglectful care. While some visitors have noted good food quality and organized staff, there are recurring reports of a prison-like environment and unprofessional nursing behavior.

Quality Themes

Tap a score for details
Food4.0Staff1.0Clean1.0Activities0.0MedsN/AMemoryN/AComms2.0ValueN/A

Strengths

  • Organized staff members
  • Good quality food appearance
  • Positive interactions with some staff

Concerns

  • Use of isolation/locked rooms as punishment (mentioned by 3 reviewers)
  • Unprofessional or rude nursing staff (mentioned by 2 reviewers)
  • Poor facility hygiene and odors

Rating Trends

Tap a year to see what changed

2342.3'13(3)1.51.0'16(3)1.04.0'21(1)5.05.0'23(1)1.0'26(1)

Distribution · 14 analyzed

5
3
4
1
3
0
2
1
1
9

How They Respond to Reviews

0%response rate

Questions for Your Tour

  • 1How do you ensure the facility remains clean and fresh-smelling for the residents every day?
  • 2What specific steps are being taken to improve communication between the nursing staff and family members?
  • 3Could you tell me more about the daily activities and social events available to keep residents engaged?
  • 4How do you handle medical emergencies or changes in a resident's condition during the night?
  • 5What is your approach to managing resident behavior and ensuring everyone feels respected and comfortable in their environment?
  • 6I've heard great things about the appearance of the food here; how do you work with residents to ensure they enjoy their dining experience?

Personalized based on this facility's data


Key Review Excerpts

I went for a visit once, and discovered they use isolation techniques and put people in locked rooms, and called the LTCO about it. I have enough to say though, my family member is doing extremely well in this facility, and the interaction with staff has been very good.

Family member of a resident · 2021★★★★

This place is the hell itself!they treat people very badly I was there one of the nurses whose name was Alfonso pushed me to the wall because I asked for my prayer book!

Former patient · 2016☆☆☆☆

The first few months when I would come to visit the facility smelled so badly of urine and feces, (even in the eating area) that it was nauseating

Family member of a resident · 2017☆☆☆☆
Source: 13 Google reviews

Staffing

Staffing Hours

per resident/day · Medicare 2026
RN Hours
0.08hrs
10%
Registered nurses for medical care
Total Nursing
3.29hrs
80%
All nurses + aides combined
Staff Turnover
56%
Lower is better (< 30% = good)
RN Turnover
100%
Lower is better (< 30% = good)

Both RN and total nursing hours are below national benchmarks. This can mean less clinical attention per resident, so ask about their staffing plan.

Quality Measures

Quality Measures

Resident outcomes compared with national, state, and local averages · 15 measures

Medicare Rating
5/ 5
Better Than Avg

11

measures

Worse Than Avg

2

measures

Mixed Results

2

measures

Long-Stay Residents
🚿

Residents whose bladder or bowel control got worse

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
19.4%
CA
10.7%
Los angeles
9.7%
🚶

Residents whose walking got worse

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
15.3%
CA
10.5%
Los angeles
9.5%
🛏️

Residents needing more daily help over time

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
14.4%
CA
10.4%
Los angeles
12.5%
💉

Residents vaccinated for the flu

↑ Higher is better
This Facility83.9%
Worse than Avg
Here
83.9%
US
95.5%
CA
98.2%
Los angeles
97.8%
😔

Residents with depression symptoms

↓ Lower is better
This Facility0.0%
Better than Avg
Here
0.0%
US
12.1%
CA
7.0%
Los angeles
8.7%

Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.

💊

Residents on anti-anxiety or sleep medication

↓ Lower is better
This Facility16.9%
Mixed vs Avgs
Here
16.9%
US
19.5%
CA
13.7%
Los angeles
10.8%
Short-Stay Residents (Rehab / Post-Acute)
💉

Short-stay residents vaccinated for the flu

↑ Higher is better
This Facility34.8%
Worse than Avg
Here
34.8%
US
79.7%
CA
93.2%
Los angeles
92.5%
💉

Short-stay residents vaccinated for pneumonia

↑ Higher is better
This Facility98.9%
Better than Avg
Here
98.9%
US
81.8%
CA
94.2%
Los angeles
94.5%
Source: Medicare quality measures

US average from Medicare published data

Inspection History

Medicare Inspection History

3-year lookback · Medicare 2026

19deficiencies
1penalties
Above state avg (15.4)
31 complaint-triggered
$4,893 in fines

Penn Mar Healthcare Center shows a concerning pattern of recurring violations, with families filing 34 complaints that triggered federal investigations. The facility repeatedly struggles with resident protection from abuse and neglect, nursing staff competency and supervision, and medication management safety. While all violations show correction dates, the persistent recurrence of similar issues—particularly involving resident safety and staffing problems—suggests ongoing systemic challenges that families should carefully evaluate during visits.

Dec 4, 2025Complaint
1
0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Nov 21, 2025Routine
20
0727Potential for harm · WidespreadCorrected

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

0521Potential for harm · WidespreadCorrected

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

0918Potential for harm · WidespreadCorrected

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

0552Potential for harm · PatternCorrected

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

0578Potential for harm · PatternCorrected

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

0656Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

0726Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

0812Potential for harm · PatternCorrected

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

0842Potential for harm · PatternCorrected

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

0868Potential for harm · PatternCorrected

Administration Deficiencies

Have the Quality Assessment and Assurance group have the required members and meet at least quarterly

0353Potential for harm · PatternCorrected

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

0605Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

0641Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

0756Potential for harm · IsolatedCorrected

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

0355Potential for harm · IsolatedCorrected

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

0761Potential for harm · IsolatedCorrected

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

0004Minimal · WidespreadCorrected

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

0881Minimal · PatternCorrected

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

0887Minimal · PatternCorrected

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

0911Minimal · PatternCorrected

Environmental Deficiencies

Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.

Jul 9, 2025Complaint
1
0600Potential for harm · IsolatedCorrected

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

May 14, 2025Complaint
3
0730Potential for harm · PatternCorrected

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

0732Minimal · PatternCorrected

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

May 7, 2025Complaint
1
0656Potential for harm · IsolatedCorrected

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Apr 15, 2025Complaint
1
0684Potential for harm · IsolatedCorrected

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Federal Penalties

Fine

Jan 8, 2024

$4,893

Ownership & Operations

Who Operates This Facility

Owner / Operator

Penn Mar Healthcare Center

Organization Type

for profit

Ownership & Management

Owners

Undisclosed

Ownership Data Not Available · Organization

Source: Medicare provider data

Contact

Get in Touch

Contact this facility directly and verify the details that matter most to your family.

References & Resources

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Safer Alternatives Nearby

Based on current clinical data, we identified 6 nearby facilities within 10 miles that may offer a stronger care environment. We encourage families to compare options carefully.

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