Madera Rehab: 42 Falls in Six Weeks, DON Unprepared - CA
The facility had logged 31 falls in January alone. Eleven more occurred in the first twelve days of February. When inspectors sat down with the Director of Nursing on February 12 and asked what the interdisciplinary team had identified as the root cause of the January 30 fall, she couldn't say. "I think she was going to fall anyways, even with those interventions in place," she told them. She acknowledged she knew falls were a widespread problem at the facility. She said she hadn't had time to familiarize herself with the facility's policies and procedures yet.
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See the Derila PillowForty-two falls. Six weeks. And the person responsible for preventing them hadn't read the playbook.
The Director of Staff Development knew the numbers too. She told inspectors she'd held a fall prevention in-service for staff on January 28 to address the high rate. She did not test whether any of the staff retained what she'd taught them.
The administrator knew even less. During an interview on February 12, he told inspectors he was aware there were issues with the number of falls but described them as a clinical matter, the Director of Nursing's responsibility. He said he didn't attend the interdisciplinary fall review meetings. He said he was unaware of the details of the January 30 fall with injury.
When inspectors returned to speak with him again on March 5, his position hadn't shifted. "There is a lot that goes on in this building," he said. He described the Director of Nursing as being in charge of resident falls and the interdisciplinary team. "I am not a nurse, so I am not involved in that part, the clinical part of the meeting."
His own job description, reviewed by inspectors, said otherwise. The facility's undated administrator job description listed his primary purpose as directing the day-to-day functions of the facility and assuming administrative authority, responsibility, and accountability for all of its activities and programs. It specifically required him to review accident and incident reports and to establish an effective accident prevention program.
He had done neither.
The facility's own safety policy, dated January 2024, stated that resident safety and supervision to prevent accidents were facility-wide priorities, that safety risks would be identified on an ongoing basis, and that when hazards were found, staff would review events to identify root causes. When risks like falls couldn't be eliminated entirely, the policy required staff to develop strategies to reduce the chance of injury.
What the record showed instead was a facility where falls were climbing, the nursing director was still getting oriented, the staff development director ran a training session she never verified anyone absorbed, and the administrator had decided the whole problem belonged to someone else.
Inspectors noted the deficiency affected many residents.
The resident who fell on January 30 and was injured is identified in the inspection report only as Resident 1. The interdisciplinary team that reviewed her fall included the assistant director of nursing, the unit manager, and an activities staff member. A note in the record was signed by the Director of Nursing on February 12. No one could say what the team had concluded.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Madera Rehabilitation & Nursing Center from 2025-03-07 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: November 13, 2026 · Our methodology
MADERA REHABILITATION & NURSING CENTER in MADERA, CA was cited for violations during a health inspection on March 7, 2025.
The facility had logged 31 falls in January alone.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.