Penn Mar Healthcare Center
Below-average Medicare ratings — review the inspection history and ask the administrator about recent corrections before visiting.
based on 13 Google reviews
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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
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 detailsStrengths
- 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
Distribution · 14 analyzed
How They Respond to Reviews
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.”
“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!”
“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”
Staffing
Staffing Hours
per resident/day · Medicare 2026Both 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
11
measures
2
measures
2
measures
Residents whose bladder or bowel control got worse
Residents whose walking got worse
Residents needing more daily help over time
Residents vaccinated for the flu
Residents with depression symptoms
Highly dependent on how each facility screens and codes depressive symptoms, so it varies widely between facilities.
Residents on anti-anxiety or sleep medication
Short-stay residents vaccinated for the flu
Short-stay residents vaccinated for pneumonia
US average from Medicare published data
Inspection History
Medicare Inspection History
3-year lookback · Medicare 2026
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, 2025Complaint1
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, 2025Routine20
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.
Services Deficiencies
Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.
Gas, Vacuum, and Electrical Systems Deficiencies
Have generator or other power source capable of supplying service within 10 seconds.
Resident Rights Deficiencies
Ensure that residents are fully informed and understand their health status, care and treatments.
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.
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.
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.
Nutrition and Dietary Deficiencies
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
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.
Administration Deficiencies
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Smoke Deficiencies
Inspect, test, and maintain automatic sprinkler systems.
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.
Resident Assessment and Care Planning Deficiencies
Ensure each resident receives an accurate assessment.
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.
Smoke Deficiencies
Properly select, install, inspect, or maintain portable fire extinguishes.
Miscellaneous Deficiencies
To conduct inspection, testing and maintenance of fire doors by qualified individuals.
Emergency Preparedness Deficiencies
Develop and maintain an Emergency Preparedness Program (EP).
Infection Control Deficiencies
Implement a program that monitors antibiotic use.
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.
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, 2025Complaint1
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, 2025Complaint3
Nursing and Physician Services Deficiencies
Observe each nurse aide's job performance and give regular training.
Quality of Life and Care Deficiencies
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Nursing and Physician Services Deficiencies
Post nurse staffing information every day.
May 7, 2025Complaint1
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, 2025Complaint1
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
Penn Mar Healthcare Center
for profit
Ownership & Management
Owners
Undisclosed
Ownership Data Not Available · Organization
Contact
Get in Touch
Contact this facility directly and verify the details that matter most to your family.
References & Resources
Medicare Care Compare
Official Medicare quality ratings, inspections & staffing data
Google Maps
Photos, directions & neighborhood info
Google Reviews
13 reviews from families & visitors
Official Website
Visit hcai.ca.gov
Medicare data downloads
Original nursing home datasets
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