Compiled from official CMS federal data
PENN MAR HEALTHCARE CENTER, EL MONTE, CA — Violations & Inspection Reports
Does PENN MAR HEALTHCARE CENTER have a federal violation or abuse history?
According to the public federal record on file with the Centers for Medicare & Medicaid Services (CMS), PENN MAR HEALTHCARE CENTER (CCN 05A360), in EL MONTE, CA, has federal inspection findings. CMS currently displays its federal abuse icon for this facility — a flag CMS assigns under its own published methodology for abuse-related citations (deficiency tag F600 and related).
In its current inspection cycle, CMS cited the facility for 16 deficiencies; the most severe is rated F — which CMS classifies as "potential for harm," a level below actual harm (risk, but no harm confirmed). The latest standard health inspection on file is dated 2025-11-21. Earlier-cycle citations appear in the dated timeline below as historical, not current. CMS has $4,893 in civil money penalties on file against the facility. The record also includes 8 abuse- or neglect-related citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series; most recent Nov 2025). This page restates the federal record and draws no conclusion of its own.
Abuse-, fall-, and care-related findings on the federal record
- 8 citations in CMS's "Freedom from Abuse, Neglect, and Exploitation" family (F600-series) — most recent Nov 2025.
- 5 citations for accident hazards or inadequate supervision (F689) — the deficiency family behind fall-related findings; most recent Dec 2024.
- 1 nutrition and hydration citation (F692) — the consumer terms are "malnutrition" and "dehydration"; most recent Dec 2023.
- 31 findings on file from complaint-triggered inspections.
Every figure above restates CMS’s own dated record; this page draws no conclusion of its own. Strict state filing deadlines can apply to nursing-home injury claims — a licensed attorney in your state can review this record.
FOR FAMILIES
What brings you to this record?
The Federal Record
CMS displays its federal abuse icon on this facility's official record.
Below is this facility's federal inspection record as on file with CMS.
Federal abuse icon on file
CMS displays this icon for facilities it has cited for resident abuse under its own published methodology — the government's own flag, restated here.
Scope & Severity — current cycle
CMS's own A–L scope/severity grid. Plotted cells mark this facility's most recent (current-cycle) citations.
Civil money penalties on file
$4,893
Have a lawyer review this record →
About this record: Federal nursing-home surveys are conducted on a recurring cycle by state survey agencies acting on CMS's behalf, and the figures on this page are compiled from CMS's published provider data, as on file with CMS; the federal record may understate what actually occurred, and inspection findings are point-in-time survey results, not a determination that any specific resident was harmed.
Deficiency timeline
Citations are listed by scope/severity (most severe first), not chronologically; each entry is labeled current-cycle or historical.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
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.
Ensure that residents are fully informed and understand their health status, care and treatments.
57 more citations on file — Abuse & neglect 7 · Accidents & supervision 4 · Medication & pharmacy 7 · Resident rights 3 · Other citations 34 (expand)
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
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.
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.
Have the Quality Assessment and Assurance group have the required members and meet at least quarterly
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Ensure each resident receives an accurate assessment.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Implement a program that monitors antibiotic use.
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.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Observe each nurse aide's job performance and give regular training.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Post nurse staffing information every day.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.
Employ staff that are licensed, certified, or registered in accordance with state laws.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
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.
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.
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Assure that each resident’s assessment is updated at least once every 3 months.
Observe each nurse aide's job performance and give regular training.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
Ensure resident rooms hold no more than 4 residents; for new construction after November 28, 2016, rooms hold no more than 2 residents.
Provide and implement an infection prevention and control program.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Have a plan that describes the process for conducting QAPI and QAA activities.
Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure medication error rates are not 5 percent or greater.
Ensure each resident’s drug regimen must be free from unnecessary drugs.
Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.
Overall CMS star rating
This facility: 2 · CMS state average: 3.2
Both figures as published by CMS.
You may be reading this record for the first time.
If something happened to someone you love at this facility, this federal record may be new to you today. The company that operates a nursing home, by contrast, is rarely seeing records like this for the first time — operators like these typically retain standing legal, risk, and insurance teams whose routine work includes records exactly like the one on this page. That is not a judgment of this facility; it is how the business is structured. Because strict time limits can apply, families often find it helps to have a qualified person review the record with them sooner rather than later.
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Federal record
PENN MAR HEALTHCARE CENTER — Federal Record
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SECTION 7 — CASE CONTEXT
Add what you saw at PENN MAR HEALTHCARE CENTER to this record
No call centers, no auctions. CareSentinel is an independent service that compiles the public CMS record and does not provide legal advice. The federal record is a point-in-time inspection record and may understate what actually occurred. CareSentinel is operated by Nodal Logics LLC.
Strict time limits can apply to taking legal action — consider consulting a qualified attorney promptly.
If you believe a resident is in immediate danger, call 911. Care concerns can also be reported at no cost to your state survey agency or the Long-Term Care Ombudsman program (ltcombudsman.org) — independent of any legal inquiry.
How to read this record
Making sense of a CMS inspection record
CMS scores every citation on a grid from A to L, combining how widespread a finding was with how serious it was. A–C is a deficiency CMS classifies as no harm; D–F as the potential for harm; G–I as actual harm that reached a resident; and J–L as immediate jeopardy, CMS’s most serious level. Later letters mark more serious findings.
Three questions to ask on a tour
- How is the home staffed on nights, weekends, and holidays?
- What happens when a resident’s condition changes suddenly?
- How, and how quickly, are families told about an incident?