Above average — CMS composite of the measures below.
The next survey window likely opens around January 2027
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Chowchilla Memorial Healthcare District during CMS and state inspections, most recent first.
The facility failed to complete required background and reference checks for five sampled employees, including LVNs and CNAs, and did not verify prior employment or LEIE status before hire. The DON said HR handled screening but she did not know why it was not done, while the ADM and CEO stated the facility had never checked backgrounds despite knowing the requirement was part of the Employment Policy and State and Federal rules.
Food items were found stored without proper dates or labels, including prepared toppings in a refrigerator and an opened bag of dry cereal in dry storage. The CDM and RD confirmed that all food items should be labeled and dated, and that items without visible dates or labels should be discarded because they were no longer considered safe or fresh.
A resident was moved to a different room without receiving advance written notice or a documented reason for the change. The resident said staff talked with her about the move but she was not asked to sign anything and remained unsure why she was moved. The DON acknowledged no written notice or supporting documentation was provided, and the facility had no written policy addressing advance written notice for room changes.
An expired inhaler for a resident was found in the med cart after its discard date, and the LVN stated it should have been removed and that there was no logbook to track cart checks. In a separate event, a wound treatment cart was observed unlocked and unattended, and the DON stated it should be locked at all times to prevent resident access to meds and sterile supplies.
Failure to Disinfect Shared Blood Pressure Cuff Between Residents: An LVN used the same blood pressure cuff on multiple residents without disinfecting it between uses and placed it back into the med cart after each use. The LVN stated the cuff should have been cleaned between residents, and the DON confirmed staff were expected to disinfect shared equipment between residents.
The facility failed to maintain cleanliness standards in the kitchen, as observed with a sink faucet covered in a black and brown substance. The Dietary Supervisor and a staff member admitted that the faucet, located near the dishwashing machine, was not cleaned daily as required. This oversight placed 27 residents at risk for foodborne illness due to potential cross-contamination, contrary to the facility's sanitation policy.
The facility failed to create and implement comprehensive care plans for two residents, leading to deficiencies in their care. One resident with COPD had no care plan addressing their condition, while another resident's care plan inaccurately included a diagnosis of kidney failure and fluid restriction without medical evidence. These oversights were acknowledged by staff, indicating a lapse in adherence to care planning procedures.
The facility failed to communicate pharmacy recommendations for two residents, leading to deficiencies in care. One resident's recommendation for blood tests was not communicated to the hospice provider, risking treatment against their wishes. Another resident's recommendation to rinse their mouth after using an inhaler was not implemented, increasing the risk of oral infection. Documentation and communication lapses were identified.
An LTC facility failed to implement effective infection prevention and control practices for several residents. An LVN did not perform hand hygiene when entering and exiting rooms, did not remove gloves after patient care, and did not bring the medication cart to each room while administering medications. These actions increased the risk of cross-contamination and infection spread among residents.
A resident was subjected to an unjustified fluid restriction without clinical justification or a person-centered care plan. The resident, admitted with a cerebral infarction and other conditions, had no evidence of kidney failure or fluid overload. Facility staff, including the LVN, RD, and DON, confirmed the lack of objective evidence for the restriction, which was carried over from a previous facility without verification. The care plan was not individualized, leading to potential harm such as dehydration.
A resident with severe cognitive impairment was allowed to smoke without a protective apron, leading to ashes falling on his clothing and wheelchair. Facility staff admitted to not following the smoking policy, which requires offering a non-combustible apron to prevent burns.
A resident on a fortified diet did not receive the prescribed Magic Cup dessert during lunch, which is crucial for those with involuntary weight loss. The resident, with severe cognitive impairment and multiple health issues, was observed without the necessary dietary supplement. The dietary staff, supervisor, and registered dietician confirmed the oversight, which did not adhere to the facility's diet order policies.
A facility failed to follow its Hospice policy for a resident under hospice care by not communicating pharmacy recommendations for lab tests to the hospice provider and not implementing a hospice order to discontinue all lab tests. This lack of communication and coordination could have led to treatments against the resident's wishes, as confirmed by the DON and HDPCS.
A resident with a history of falls and moderate cognitive impairment experienced multiple falls due to inadequate supervision and insufficient interventions. Despite having alarms and visual checks, the resident continued to fall, particularly at night when supervision was lacking. The facility's DON acknowledged the falls as unavoidable, citing cost concerns for one-on-one supervision, but the lack of effective monitoring and intervention adjustments contributed to the resident's ongoing fall risk.
The facility failed to implement resident-centered care plans, leading to falls for two residents with severe cognitive impairment. One resident was left unsupervised in the shower room, and another was found ambulating unsupervised in the hallway, both resulting in injuries.
A resident with severe cognitive impairment fell after being left unsupervised in the shower room by a CNA. The facility failed to update the resident's care plan with new interventions following the fall, despite existing policies requiring such updates to prevent future incidents.
Failure to Complete Required Employee Background Checks
Penalty
Summary
The facility failed to conduct required background and reference checks for five of five sampled employees: LVN 2, LVN 3, CNA 1, CNA 2, and CNA 3. Review of each personnel file showed that the facility did not verify previous employment records or confirm that the applicants were not listed on the Office of Inspector General Exclusion Program (LEIE) before hire. The Director of Nurses stated that Human Resources completed the screening and hiring process, but she did not know why the background screening was not completed. During record review and interviews, the Administrator stated that the facility had never done background checks and that staff were often referred by other employees. He also stated he was aware that background checks were mandatory and would help protect residents from abusive employees. The Chief Executive Officer stated the facility had always been small, had never checked backgrounds, and was aware that background checks were a State and Federal requirement as well as part of the facility's Employment Policy.
Food Items Stored Undated and Unlabeled
Penalty
Summary
Food was stored, prepared, and served in an unsafe and unsanitary manner when a bowl of shredded cheese, a bowl of sour cream, and a bowl of sliced jalapenos were observed inside refrigerator 1 without dates or labels. During interview, the Certified Dietary Manager stated these items had been prepared on Monday for taco Tuesday lunch and confirmed they were undated and unlabeled. The CDM also stated that once food is opened, prepared, and stored in the refrigerator or freezer, it must be dated and labeled, and that food with no date or label should be discarded. An opened bag of dry cereal was also observed in the dry storage room without a date or label. The CDM stated the label and date had worn off and the product should be discarded because dating and labeling are important to determine freshness and ensure food safety. The Registered Dietician confirmed that all food items should be labeled and dated, that kitchen staff were responsible for properly labeling and dating food once it entered the kitchen, and that improper labeling and dating may compromise health risk and may cause someone to become sick.
Failure to Provide Written Notice Before Room Change
Penalty
Summary
The facility failed to provide written notice, including the reason for the change, before moving Resident 20 to a different room within the facility. During a concurrent observation and interview, Resident 20 stated she had been moved a few days after admission but did not receive written notice of the room change and was not asked to sign anything. She said staff spoke with her about the change, but she was still unsure why the move was made and stated staff wanted her down the hall to be alone. During interview and record review with the DON, the resident's EMR was reviewed and the DON acknowledged that no written notice or supporting documentation was provided to Resident 20 before the room change. The DON stated the facility did not have a specific written policy for room changes and reported that verbal notice was provided, notification was documented in progress notes, and residents were monitored for three days. The DON also acknowledged being unaware that written notice was required, and the facility was unable to provide documentation showing advance written notice or a written policy addressing the requirement.
Expired inhaler left in medication cart and wound cart left unlocked
Penalty
Summary
Medication storage was not maintained in accordance with facility policy when an inhaler for one resident was found in the medication cart after its labeled discard date. During observation, the inhaler was seen opened and still present in the cart with an orange label showing it had been opened on 12/31/25 and was to be discarded on 2/10/26. The LVN stated the inhaler had expired and should have been removed and disposed of, and also stated there was no logbook or other method to track whether medication cart checks for outdated items had been completed. Record review showed the inhaler had been discontinued on 1/13/26. The wound treatment cart was also observed unlocked and unattended in the hallway outside Nurse Station One. The LVN stated the cart should have been locked so residents could not access medications or sterile wound supplies, and the DON stated the wound cart should be locked at all times to prevent residents from getting into it and injuring themselves. Facility policy stated medication rooms, cabinets, and medication supplies should remain locked when not in use or attended by authorized persons, and outdated, contaminated, discontinued, or deteriorated medications should be immediately removed from stock and disposed of according to procedure.
Failure to Disinfect Shared Blood Pressure Cuff Between Residents
Penalty
Summary
The facility failed to follow infection control and prevention standards of practice when an LVN did not disinfect a shared blood pressure cuff between residents. During an observation on 2/18/26 at 8:19 a.m. in Resident 7's room, LVN 1 took Resident 7's blood pressure with a blood pressure cuff and then placed the cuff into the medication cart without properly cleaning or disinfecting it after use. The same cuff was then used on Resident 9 in the activities room at 8:40 a.m., on Resident 27 in the room at 8:47 a.m., and on Resident 28 in the hallway near the medical records office at 9:20 a.m., each time without disinfecting the cuff between residents and each time placing it back into the medication cart without proper cleaning or disinfection. During an interview on 2/18/26 at 2:57 p.m., LVN 1 stated she should have properly cleaned the blood pressure cuff in between residents and that shared equipment should be disinfected to prevent cross contamination. During an interview on 2/19/26 at 10:27 a.m., the DON stated the expectation was for nursing staff to disinfect equipment shared between residents and that this was important to prevent the spread of infections. The facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment, stated reusable resident care equipment, including blood pressure cuffs, will be cleaned and disinfected between residents, and CDC guidance reviewed by surveyors stated reusable medical equipment such as blood pressure cuffs should be cleaned and reprocessed prior to use on other patients or when soiled.
Failure to Maintain Cleanliness of Kitchen Sink Faucet
Penalty
Summary
The facility failed to maintain professional standards for food service safety by not ensuring the cleanliness of the kitchen sink faucet. During an observation and interview with the Dietary Supervisor (DS), it was noted that the sink faucet near the dishwashing machine was covered with a black and brown substance. The DS acknowledged that the base of the sink faucet was not clean and confirmed that it should be cleaned daily. This oversight was further corroborated by an interview with a staff member who admitted that the sink faucet was supposed to be cleaned daily but was not. The facility's policy and procedure document titled 'Sanitation in Preparation and Serving' emphasized the importance of cleaning and sanitizing all equipment before use to prevent food poisoning. However, the failure to adhere to this policy placed the 27 residents who received meals from the kitchen at risk for foodborne illness due to potential cross-contamination. The DS confirmed that the lack of cleanliness in the food preparation area could lead to illness among residents.
Deficiencies in Care Planning for Two Residents
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans for two residents, leading to deficiencies in their care. For Resident 12, who was admitted with a diagnosis of Chronic Obstructive Pulmonary Disease (COPD) among other conditions, there was no care plan created to address the COPD diagnosis. Despite the resident's need for routine and as-needed medication to manage breathing difficulties, the absence of a care plan meant that nursing staff lacked guidance on appropriate interventions. This oversight was acknowledged by both the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON), who confirmed that the facility's policy and procedure for care planning were not followed. Resident 78's care plan inaccurately included a diagnosis of kidney failure and a related fluid restriction, despite no medical evidence supporting such a condition. The resident's medical records and lab results did not indicate any kidney issues, and interviews with the Registered Dietician (RD) and the DON confirmed the absence of a kidney diagnosis. The care plan was created by the Director of Staff Development (DSD) without verifying the resident's actual medical needs, leading to an inaccurate and non-individualized care plan. This misstep was recognized by the DSD, who admitted to assuming the need for a fluid restriction without proper assessment. The facility's failure to adhere to its care planning policy resulted in a lack of appropriate, individualized care for both residents. The care plans were not based on comprehensive assessments, which are essential for ensuring that residents receive care tailored to their specific medical conditions and needs. The deficiencies in care planning were acknowledged by multiple staff members, including the LVN, RD, and DON, highlighting a significant lapse in the facility's adherence to its own procedures and standards of practice.
Failure to Communicate Pharmacy Recommendations
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality for two residents. For Resident 10, the facility did not communicate a pharmacy recommendation to the hospice provider. The recommendation involved obtaining several blood tests, including Serum B-12, Creatinine Level, Liver Function, and BMP, which were necessary to monitor the resident's therapy. The Director of Nursing (DON) and the Director of Staff Development (DSD) confirmed that there was no record of this communication, which could have led to the resident receiving treatment or procedures against his wishes. For Resident 22, the facility did not implement a pharmacy recommendation related to the use of a Budesonide-Formoterol Fumarate Dihydrate inhaler. The recommendation was to rinse the mouth with water and spit back into a cup after using the inhaler to prevent oral thrush. The DON and the Infection Preventionist (IP) confirmed that there was no documentation of this recommendation being noted or acted upon, which could have increased the risk of the resident developing an oral infection. The facility's policies and procedures, including those related to charting and documentation, were reviewed and indicated that all services provided to residents should be documented in their medical records. This documentation is essential for facilitating communication between the interdisciplinary team regarding the resident's condition and response to care. However, in both cases, the lack of documentation and communication led to deficiencies in the care provided to the residents.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure effective infection prevention and control practices were implemented for nine of 14 sampled residents. The Licensed Vocational Nurse (LVN) did not perform hand hygiene when entering and exiting the rooms of these residents. This included not washing hands after administering medications or performing patient care tasks such as checking blood pressure and blood sugar levels. The lack of hand hygiene was observed across multiple interactions with residents, despite the facility's policy requiring hand hygiene to prevent the spread of infections and cross-contamination. Additionally, the LVN did not remove gloves after providing patient care for several residents and exited the rooms while still wearing them. The LVN walked down the hallway back to the medication cart with gloves on, which posed a risk of cross-contamination. The facility's policy and professional guidelines clearly state that gloves should be removed before leaving a resident's room to prevent the spread of infections. Furthermore, the LVN did not bring the medication cart to each resident's room while administering medications and patient care. Instead, the LVN prepared medications at the nursing station and walked to the residents' rooms without the cart, which was often several feet away. This practice increased the risk of cross-contamination as the LVN had to walk back and forth between the medication cart and the residents' rooms, potentially spreading germs and compromising the health and safety of the residents.
Unjustified Fluid Restriction for Resident
Penalty
Summary
The facility failed to manage and monitor the quality of care for a resident when it unjustly implemented a fluid restriction without clinical justification, comprehensive assessment, or a person-centered care plan. The resident, who was cognitively intact, was admitted with a diagnosis of cerebral infarction, history of endocarditis, acute embolism, thrombosis, and hypotension. Despite these conditions, there was no evidence of kidney failure or fluid overload that would warrant a fluid restriction. The resident's care plan inaccurately indicated a potential fluid volume overload related to kidney failure, which was not supported by any medical diagnosis or evidence in the resident's medical record. Interviews with facility staff, including the LVN, RD, DON, and DSD, revealed that there was no objective evidence or clinical reason for the fluid restriction. The care plan was not individualized and was based on assumptions rather than a comprehensive assessment of the resident's needs. The facility's policy and procedure for care planning were not followed, as the care plan was not based on a diagnosis or resident assessment. The fluid restriction order was carried over from a previous facility without verification of its necessity. This oversight had the potential to cause harm to the resident, including dehydration and electrolyte imbalance, due to the inappropriate medical treatment and lack of freedom in fluid intake.
Resident Smoking Safety Deficiency
Penalty
Summary
The facility failed to ensure the safety of a resident, identified as Resident 10, who was observed smoking without adequate protective measures. Resident 10, who has a diagnosis of dementia, cerebrovascular accident, and senile degeneration of the brain, was found to have a severely impaired cognitive status with a BIMS score of 5 out of 15. Despite these impairments, Resident 10 was allowed to smoke in the designated smoking area without wearing a smoking apron, resulting in ashes falling on his shirt and into his wheelchair, posing a risk of burns. Interviews with facility staff, including LVN 1, LVN 2, and the Director of Nursing, revealed that the facility's smoking policy, which requires residents to be offered a non-combustible apron prior to smoking, was not followed. Activities Personnel 1, who was present with Resident 10 during the smoking incident, admitted to not having received training on the facility's smoking procedures and forgetting to provide the smoking apron. This oversight was acknowledged as a safety issue by the staff, as the resident's cognitive impairments and lack of safety awareness increased the risk of injury from the hot ashes.
Failure to Provide Correct Fortified Diet to Resident
Penalty
Summary
The facility failed to provide the correct diet for one of the sampled residents during lunch tray assembly. Resident 2, who was on a fortified diet to increase calories and protein intake, did not receive the prescribed Magic Cup frozen dessert, which is essential for those experiencing involuntary weight loss. This oversight occurred on February 18, 2025, when the dietary staff did not follow the diet order, potentially impacting the resident's nutritional requirements necessary for sustaining or gaining weight. Resident 2's medical history includes hospice care, dementia, hypertension, muscle weakness, repeated falls, and atrial fibrillation. The resident's Minimum Data Set indicated severe cognitive impairment. During observations and interviews, it was confirmed that the lunch tray was missing the Magic Cup, which was acknowledged by the dietary staff, supervisor, and registered dietician. The facility's policies and procedures require adherence to diet orders, which was not followed in this instance, leading to the deficiency.
Failure to Communicate Hospice Orders and Recommendations
Penalty
Summary
The facility failed to adhere to its Hospice policy and procedures for a resident who was under hospice care. The pharmacy had recommended several laboratory tests, including Serum B-12, Creatinine Level, Liver Function, and BMP, due to the resident's medication potentially depleting vitamin B-12 and causing lactic acidosis. However, this recommendation was not communicated to the hospice provider, as confirmed by both the Director of Nursing (DON) and the Hospice Director of Patient Care Services (HDPCS). The lack of communication meant that the hospice provider was unaware of the need for these tests, which could have impacted the resident's care. Additionally, there was a failure to implement a hospice order to discontinue all laboratory tests for the resident. The hospice order was issued, but the facility staff did not have any record or proof of receiving this order, as stated by the DON and the Director of Staff Development (DSD). This oversight could have led to the resident receiving treatments or procedures against their wishes, as the facility did not follow the hospice's directive to stop routine labs. The facility's Hospice Program Policy and Procedure, which outlines the responsibilities of coordinating care between the facility and hospice staff, was not followed. The policy requires the facility to ensure that hospice staff are oriented on the facility's procedures, including record-keeping requirements. However, the designated person to coordinate care was not identified, and there was no documentation to support that the necessary communication and coordination occurred, leading to the deficiencies noted in the report.
Inadequate Supervision Leads to Repeated Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent falls for a resident identified as a high fall risk. This resident, who had a history of falls and was assessed as moderately cognitively impaired, experienced five falls over a period of approximately two months. Despite having interventions such as bed and chair alarms, frequent visual checks, and fall mats, the resident continued to fall, indicating that the measures in place were insufficient to prevent these incidents. Interviews with staff revealed that while the resident was supervised during the day, particularly when out of his room, there was a lack of consistent supervision at night. The resident was known to be impulsive and would often get out of bed without assistance, increasing his risk of falls. The facility's Director of Nursing acknowledged that the resident's falls were considered unavoidable, and the cost of providing one-on-one supervision was deemed too expensive. The resident's care plan included various interventions aimed at reducing fall risk, but these were not effectively implemented or monitored, particularly during nighttime hours. The facility's policy on fall prevention emphasized the need for staff to assist and supervise residents at risk of falls, yet the resident continued to fall, resulting in a fracture. The interdisciplinary team had determined that the falls were unavoidable, but the lack of adequate supervision and the failure to adjust interventions contributed to the ongoing risk of falls for the resident.
Failure to Implement Resident-Centered Care Plans Resulting in Falls
Penalty
Summary
The facility failed to implement a resident-centered comprehensive care plan for two residents, resulting in falls. Resident 1, who had severe cognitive impairment and was at risk for falls, was left unsupervised in the shower room by a CNA who went to get skin protectant cream. This led to Resident 1 falling and being found on the floor by the CNA upon her return. The care plan for Resident 1 indicated that the resident should be frequently observed and placed in a supervised area when out of bed, which was not followed by the staff involved. Resident 2, also with severe cognitive impairment and a history of muscle weakness and difficulty walking, was found ambulating unsupervised in the hallway by an activity assistant. Resident 2 lost balance and fell, resulting in a head laceration and other injuries. The care plan for Resident 2 required assistance with ambulation and transfers, including verbal cues for safety, which was not adhered to by the staff. The physical therapy notes also indicated that Resident 2 needed supervision and verbal cues for all functional mobility due to safety concerns. Both incidents highlight the failure of the facility staff to follow the care plans designed to ensure the safety of the residents. The care plans were not implemented as required, leading to falls and injuries for both residents. The facility's policy and procedure on care planning emphasized the importance of integrating assessment findings and developing reasonable and measurable goals for residents, which were not met in these cases.
Failure to Update Care Plan After Resident Fall
Penalty
Summary
The facility failed to revise and implement a person-centered comprehensive care plan for a resident who fell on a specified date. The resident, who had a severe cognitive impairment as indicated by a BIMS score of 7, was found lying on her left side next to a shower hose in the center shower room. Approximately two minutes prior, the resident had been assisted to the toilet in the shower room by a CNA, who then left the resident unsupervised to get skin protectant cream. Upon returning, the CNA found the resident on the floor. The care plan, dated several months prior, indicated the resident was at risk for falls due to generalized muscle weakness and required frequent observation and supervision when out of bed. However, the care plan was not updated with new interventions following the fall incident on the specified date, as confirmed by an LVN during a review of the resident's care plan and progress notes. The LVN acknowledged that care plan interventions should have been updated after the fall but were not. During an interview, the CNA admitted to leaving the resident unsupervised in the shower room, which led to the fall. The facility's policy on falls and fall risk management, reviewed with the Administrator, stated that staff should identify and implement interventions to prevent falls and minimize complications based on previous evaluations and current data. The policy also emphasized the importance of updating the care plan with input from the interdisciplinary team and the attending physician to reduce specific fall risk factors. The Administrator confirmed that care plan interventions should be updated and revised following falls to ensure resident safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Chowchilla
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Palms Care Center | 0 mi | ★★★★★ | 0 | 0 |
| Madera Care Center | 15.6 mi | ★★★★★ | 2 | 0 |
| Merced Behavioral Center | 16.1 mi | ★★★★★ | 0 | 0 |
| Madera Rehabilitation & Nursing Center | 16.4 mi | ★★★★★ | 12 | 0 |
| Anberry Post Acute | 16.9 mi | ★★★★★ | 0 | 0 |
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