Above average — CMS composite of the measures below.
A standard survey is most likely before around July 2026
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 Madera Care Center during CMS and state inspections, most recent first.
The facility failed to report two separate alleged abuse incidents to the state agency as required by its own policies and regulations. In the first incident, an unknown intruder entered the building without staff knowledge, went into multiple residents’ rooms, attempted to lift a resident from bed, and approached another resident’s face as if to kiss her, causing fear and emotional distress among cognitively intact and cognitively impaired residents. An LVN confronted the intruder only after hearing a resident tell him to leave and later acknowledged she did not report the event to the Department because she believed it was not necessary without physical injury. In the second incident, one resident struck another in the face with a walker while being assisted for a therapy walk, causing a laceration above the eyebrow that required steri-strips. Documentation showed that the event was reported to the Ombudsman and local police, but not to the state Department. The DON and Administrator both stated they did not consider either event reportable to the Department based on their interpretation of physical harm, despite facility policies requiring immediate reporting of all alleged abuse, including resident-to-resident altercations and actions causing mental anguish.
A resident with multiple medical conditions, moderate cognitive impairment (BIMS 8), and a history of homelessness repeatedly stated a desire to leave and return to the river but was not reassessed for elopement risk or provided with documented safety interventions such as increased monitoring. On one afternoon, the resident was last seen during rounds, later could not be found by a CNA, and an extensive search of the building and surrounding area failed to locate the resident. Nursing documentation initially identified the event as an elopement, and police were contacted, but no staff witnessed the resident’s departure. After reviewing staff interviews and the physician’s H&P, the IDT determined the resident was A&Ox3 and reclassified the incident as an AMA discharge, and the Administrator and DON did not report the event to the State Survey Agency despite facility policy requiring reporting of elopements.
A persistent shortage of clean towels and washcloths during night shifts led staff to use toilet paper and cleaning spray for incontinent care, affecting over half of the residents who required pericare. Multiple staff and supply workers confirmed that linen closets were frequently empty or understocked at night, and that the issue was ongoing despite regular orders of new washcloths and staff meetings addressing linen disposal and hoarding.
A CNA failed to treat a resident with dignity and respect by refusing assistance, using her phone during care, and telling the resident to "shut up" when the resident requested help with her wheelchair footrest and shoes before dialysis. The resident, who required moderate assistance due to end stage renal disease and a femur fracture, experienced emotional distress as a result. Another resident witnessed the incident and confirmed the disrespectful behavior.
A resident undergoing dialysis was not placed on Enhanced Barrier Precautions (EBP) despite having an arteriovenous fistula, as required by facility policy. Staff did not wear gowns during post-dialysis assessments, and there were no EBP postings outside the resident's room. Interviews with facility staff confirmed the oversight, acknowledging that the resident met the criteria for EBP but was not included in the program.
A resident with hemiplegia and severe cognitive impairment fell during a transfer when a CNA attempted to move them alone, despite the care plan requiring two-person assistance. The resident's care plan and facility policies emphasized the need for adequate supervision and assistance to prevent such accidents.
A resident with acute and chronic respiratory failure was not provided with physician-ordered supplemental oxygen during a medical appointment outside the facility. The oversight occurred when an LVN failed to ensure the resident had her portable oxygen tank before leaving, resulting in the resident being without oxygen for approximately 7 hours. The resident returned without respiratory distress, but the family reported the issue.
A resident admitted with a stage 3 pressure ulcer had incomplete medical records due to a lack of documented wound assessments for nearly a month. Interviews with staff revealed that weekly assessments were required but not recorded, contrary to facility policy. This resulted in incomplete records, impacting the monitoring and treatment of the resident's condition.
Failure to Report Intruder-Related Abuse Allegations and Resident-to-Resident Physical Abuse to State Agency
Penalty
Summary
The facility failed to report two separate episodes of alleged or suspected abuse to the state agency as required by regulation and facility policy. The first incident involved an unknown intruder who entered the building without staff knowledge and interacted with four residents in their rooms during evening hours. The intruder entered the room of two cognitively intact residents while they were in bed; one resident reported that the man, wearing a hoodie, spoke to her roommate and then asked her if she wanted to follow the word of God and follow him, and she stated that she and her roommate were scared and had experienced sleepless nights since the event. Another cognitively intact resident reported awakening to find the man inches from her face, leaning forward as if to kiss her, and described using her hands to stop him and feeling scared and needing to protect herself. A third cognitively intact resident reported seeing the intruder attempt to lift her moderately cognitively impaired roommate out of bed, describing him as acting as if he were on drugs and stating she was scared and did not know if he had a weapon. The fourth resident, with moderately impaired cognition, recalled the intruder entering her room and trying to lift her up, stating that he was rough with her and that she was scared and angry. Licensed Vocational Nurse (LVN) 1 described returning from break in the evening and noticing a man at the nurses’ station, assuming he was a visitor. While passing medications, she saw him enter a resident room and initially did not intervene. She later heard a resident telling the man to get out, went to the doorway, and confronted him. The intruder stated he was spreading happiness and love and claimed to be visiting a resident whose name was posted near the door. LVN 1 told him to leave after being informed by a resident that he had tried to lift her roommate out of bed, and the intruder exited through a hallway door. LVN 1 later learned from residents that one had been scared by his attempt to lift her and another reported he had bent over and tried to kiss her, causing emotional distress. LVN 1 stated she did not think the incident needed to be reported to the Department because no one was physically injured, despite the residents’ reports of fear and distress. The second unreported incident involved resident-to-resident physical abuse resulting in injury. One resident struck another across the face with a walker while being assisted out of bed for a therapy walk, causing approximately a one-inch laceration above the injured resident’s left eyebrow. Observation later showed a small bandage over the eyebrow, and the clinical record documented a physician’s order to monitor steri-strips on a skin tear to that area. Progress notes described the event as a resident-to-resident altercation in which the injured resident was the receiver and indicated that a suspected abuse report (SOC 341) was faxed to the Ombudsman and local police department, but did not list the state Department as a notified entity. The Director of Staff Development, who is responsible for educating staff on abuse reporting, stated that resident-to-resident abuse with injury should be reported to the Department and that she educates staff accordingly. The Director of Nursing confirmed that both the intruder incident and the resident-to-resident altercation were reported to the local police department but not to the state Department. She stated that after reviewing policy and regulations, facility leadership believed the events were not reportable because they did not, in their view, result in physical harm, defining physical harm as skin tears, fractures, or hematomas. The Administrator, identified as the facility’s Abuse Prevention Coordinator, similarly stated that there was no point in reporting the intruder event because no residents were physically harmed and characterized the resident-to-resident event as back and forth, concluding it did not need to be reported. The Administrator also acknowledged that an intruder physically lifting a resident out of bed could be physical abuse and that a resident being awakened by the intruder’s face close to hers and having to use her hands to keep him away was abuse, and stated that the facility did not conduct a 5-day abuse investigation after either incident. Facility policies on abuse, neglect, exploitation, and reporting require that all allegations of abuse or mistreatment be reported immediately to the Administrator and appropriate agencies, including the state survey agency, within prescribed timeframes, and define abuse to include actions causing physical harm, pain, or mental anguish, including certain resident-to-resident altercations and mental abuse such as harassment or sexual coercion.
Failure to Supervise, Reassess Elopement Risk, and Report an Unwitnessed Elopement
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and to reassess and manage elopement risk for a resident who repeatedly expressed a desire to leave and return to the river. The resident was admitted with multiple medical diagnoses, including a wedge compression fracture of the lumbar spine, obstructive and reflux uropathy, heart disease, acute kidney failure, urinary retention, urinary tract infection, and a history of homelessness. A Minimum Data Set assessment dated 1/17/26 documented a BIMS score of 8, indicating moderate cognitive impairment. An elopement risk assessment completed on 1/12/26 indicated the resident was not considered at risk for elopement, and there was no documentation that this assessment was revisited despite the resident’s ongoing verbalizations about wanting to leave the facility. On 2/8/26, nursing documentation showed that the resident was last seen at approximately 2:15 p.m. during initial rounds and was reported missing by a CNA at about 3:15 p.m. Staff then searched the entire building, perimeter, outside areas, and surrounding buildings but were unable to locate the resident. The nurse notified the DON and Administrator at 3:40 p.m. and contacted the police at 3:48 p.m. The police later arrived to complete a report regarding the resident’s elopement. Interviews with the DSD and DON confirmed that nursing documentation initially identified the event as an elopement and that no staff member witnessed the resident leaving the facility. The DSD also confirmed there was no documentation of interventions or safety precautions, such as frequent checks or a specific care plan, implemented after the resident verbally expressed a desire to leave. The facility did not report the elopement to the State Survey Agency as required by its own policies. The Administrator, DSD, and DON acknowledged that the resident left the premises without staff awareness or supervision and that the resident had a BIMS score of 8 and a history of homelessness. After the resident’s departure, the IDT reviewed staff interviews and the physician’s H&P, determined the resident was A&Ox3, and reclassified the incident as an AMA discharge rather than an elopement. The Administrator confirmed that, based on this post-incident determination, the facility did not notify the State Survey Agency, despite the facility’s elopement policy requiring appropriate reporting to the State Survey Agency when a resident leaves without authorization and/or necessary supervision. At the time of the Administrator’s interview, the resident had still not been located.
Linen Shortage During Night Shifts Impacts Incontinent Care
Penalty
Summary
The facility failed to ensure a consistent supply of clean linen, specifically towels and washcloths, for incontinent residents during night shifts. Observations and interviews revealed that linen closets in all three hallways were frequently understocked or empty of essential items, particularly during the night. Staff reported having to use non-linen items such as toilet paper and cleaning spray to provide incontinent care when washcloths and towels were unavailable. This shortage was confirmed by multiple staff members across different shifts, with some stating that the problem was ongoing and typical for night shifts. Laundry and central supply staff indicated that new washcloths were regularly ordered, but many were being thrown away or went missing, leading to persistent shortages. Housekeeping staff also reported finding dirty washcloths in resident trash cans, which they reported to supervisors. Documentation from a recent staff meeting showed that the issues of linen hoarding and improper disposal were discussed, but the problem persisted, as evidenced by the lack of linen during subsequent observations and staff interviews. The deficiency affected a significant portion of the facility's population, with over half of the 64 residents being incontinent and requiring regular pericare. Staff consistently reported that the lack of proper linen made it difficult to provide adequate care, especially during the night when linen supplies were depleted at the start or during the shift. Both the Administrator and DON acknowledged that the available linen was insufficient to meet resident needs throughout the evening and night shifts.
Failure to Treat Resident with Dignity and Respect
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) failed to treat a resident with dignity and respect during an early morning interaction. The resident, who was alert, oriented, and Spanish-speaking only, requested assistance from the CNA to locate the footrest for her wheelchair and to help with her shoes in preparation for dialysis. The CNA refused to assist with the shoes, was observed using her phone, and responded to the resident's requests by telling her to "shut up." This exchange caused the resident to experience mental and emotional distress, including anger and frustration. The resident had a history of right femur fracture and end stage renal disease, requiring dialysis and moderate assistance with transfers, dressing, and personal hygiene. The incident was corroborated by another resident in the room, who witnessed the CNA instructing the resident to "wait and shut up" when she asked for the footrest. The witness also reported that the CNA was not providing appropriate assistance to another roommate who was incontinent and unable to change herself, further indicating a lack of respect and responsiveness to residents' needs. Interviews with facility staff, including the Director of Staff Development, Director of Nursing, and Administrator, confirmed that the CNA's behavior was not in accordance with facility policy, which requires all staff to treat residents with kindness, respect, and dignity. The CNA denied the allegation but acknowledged that such behavior would be unacceptable. The facility's investigation substantiated the resident's claim, supported by a witness, and determined that the CNA's actions failed to honor the resident's rights to a dignified existence and respectful communication.
Failure to Implement Enhanced Barrier Precautions for Dialysis Resident
Penalty
Summary
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident undergoing dialysis, identified as Resident #7. The facility's policy required EBPs for residents with indwelling medical devices, such as an arteriovenous fistula, to prevent the transmission of multi-drug-resistant organisms. Despite this requirement, Resident #7, who had a fistula and was receiving hemodialysis, was not placed on EBP. Observations and interviews revealed that staff did not wear gowns when checking the resident's dialysis access site, and there were no EBP postings outside the resident's room. Interviews with facility staff, including a Licensed Vocational Nurse, the Unit Manager, the Infection Preventionist, the Director of Nursing, and the Executive Director, confirmed that Resident #7 met the criteria for EBP but was not included in the program. The Infection Preventionist acknowledged the oversight, and the Director of Nursing stated that the facility's expectation was for the Infection Preventionist to recognize and implement EBP immediately when required. The Executive Director also confirmed that the resident should have been on EBP to ensure safety protocols were followed.
Inadequate Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and assistance for a resident who required a two-person assist for transfers. On the day of the incident, a Certified Nursing Assistant (CNA) transferred the resident from a wheelchair to a bed without the required assistance from another staff member. This action resulted in the resident falling from the bed onto the floor, which could have led to potential injury. The resident involved had a medical history of hemiplegia and hemiparesis affecting the left side, as well as contractures in the left knee, ankle, and upper arm. The resident was assessed as having severe cognitive impairment and was dependent on others for toileting hygiene and transfers. The resident's care plan clearly indicated the need for two staff members to assist with transfers to ensure safety. Interviews with staff, including the CNA involved, confirmed that the resident required two-person assistance for transfers. The CNA admitted to transferring the resident alone, believing it was safe, despite the care plan's instructions. The facility's policies emphasized the importance of individualized, resident-centered safety measures, including adequate supervision and assistance to prevent accidents, which were not followed in this case.
Failure to Provide Supplemental Oxygen During Medical Appointment
Penalty
Summary
The facility failed to provide a resident with physician-ordered supplemental oxygen during a medical appointment outside the facility. The resident, who was dependent on supplemental oxygen due to acute and chronic respiratory failure with hypercapnia, went approximately 7 hours without oxygen. The deficiency occurred when the resident left the facility for a medical appointment without the portable oxygen tank, as ordered by her physician. The incident was attributed to the oversight of LVN 1, who was responsible for the resident's care on the day of the appointment. LVN 1 did not ensure that the resident had her oxygen tank before leaving, despite the physician's order for continuous oxygen administration. The resident returned to the facility without experiencing respiratory distress, but her family notified the staff of the oversight. The facility's investigation confirmed that LVN 1 forgot to send the resident with the oxygen tank.
Incomplete Documentation of Pressure Ulcer Assessment
Penalty
Summary
The facility failed to maintain complete and accurate medical records for a resident who was admitted with a stage 3 pressure ulcer to the sacral region. The deficiency was identified when it was found that the resident's pressure ulcer assessment was not documented until nearly a month after admission. This lack of documentation was contrary to the facility's policy and procedure titled 'Charting and Documentation' and 'Prevention of Pressure Injuries'. Interviews with the Registered Nurse (RN), Physician Assistant (PA), Director of Nursing (DON), and Administrator (ADM) revealed that wound assessments, including measurements, were required to be documented weekly to monitor the condition and progress of the wound. The RN, who was the designated wound nurse on weekends, admitted to providing wound care and assessments but was unable to locate the records for the period from admission until the first documented assessment. The PA and DON emphasized the importance of weekly assessments and complete medical records to ensure proper care and monitoring of the wound. The facility's policies required that all services provided to residents, including wound care, be documented in the medical record to reflect the quality of care. The failure to document the wound assessments as per the facility's policy resulted in incomplete medical records, which could impact the monitoring and treatment of the resident's condition. The deficiency highlights a lapse in adhering to established procedures for documenting resident care, particularly in the context of pressure ulcer management.
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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 Madera
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Madera Rehabilitation & Nursing Center | 1.7 mi | ★★★★★ | 12 | 0 |
| Chowchilla Memorial Healthcare District | 15.6 mi | ★★★★★ | 8 | 0 |
| Palms Care Center | 15.7 mi | ★★★★★ | 0 | 0 |
| Foundation Skilled Nursing | 17.9 mi | ★★★★★ | 37 | 0 |
| North Point Healthcare & Wellness Centre Lp | 18.8 mi | ★★★★★ | 0 | 0 |
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