Madera Rehab: 64 Falls in Two Months - CA
The facility's own tracking document showed 31 falls in January alone, followed by 11 more falls in the first 12 days of February. By March, the total had reached 64 incidents.
The administrator acknowledged the high fall rate during multiple interviews but consistently deflected responsibility. "There is a lot that goes on in this building," he told inspectors on March 5. "I am not a nurse, so I am not involved in that part, the clinical part of the meeting."
When pressed about the facility's Quality Assurance and Performance Improvement program, the administrator couldn't explain how data was used to reduce falls or what interventions had been implemented. The facility's performance improvement plan set a goal of reducing falls to 15 or fewer per month for three months. With 31 falls in January, inspectors asked if the quality program was effective.
"He could not answer if the QAPI was effective because he needed to review the month-to-month data," the inspection report stated.
The administrator was unable to provide documentation of committee minutes related to resident falls during a February 19 phone interview. He explained that each department head took their own minutes, but integrated records didn't exist. Falls were supposedly reviewed during daily clinical meetings, but he didn't attend those either.
The Director of Staff Development had conducted fall prevention training for staff on January 28 to address the high fall rate. She didn't test staff competency after the training.
Meanwhile, a resident requiring supplemental oxygen was breathing through equipment with a filter caked in dust and lint. Resident 8, admitted in January with congestive heart failure and fluid in the lungs, relied on an oxygen concentrator delivering 2-4 liters per minute through a nasal cannula.
During an inspection on March 6, the Assistant Director of Nursing examined the oxygen concentrator in Resident 8's room and found the filter covered with dust and lint. "Using a dirty oxygen concentrator was not acceptable," she told inspectors. A registered nurse added that Resident 8 wasn't getting the full benefit of supplemental oxygen and her respiratory condition could worsen.
The Director of Nursing confirmed that dirty oxygen concentrators could cause respiratory infections in residents. Licensed nurses were responsible for cleaning the equipment weekly and as needed, but this clearly wasn't happening.
Resident 8 had severe cognitive impairment, scoring just 5 out of 15 on a mental status assessment. She couldn't advocate for herself when breathing contaminated air through medical equipment that should have been maintaining her respiratory health.
The facility's own policies required nurses to ensure equipment was "in good operating order" and follow infection control procedures. The oxygen administration policy specifically stated that staff must check equipment "to be sure they are in good working order." Another policy mandated that devices be "maintained on schedule and according to manufacturer's instructions."
The oxygen concentrator manual warned that filters required more frequent inspection and cleaning in dusty environments, noting that "the air filter should be monitored closely in environments with abnormal amounts of dust and lint."
But policies meant nothing without oversight. The administrator's approach to quality improvement was to delegate everything clinical to nursing staff while taking no responsibility for ensuring systems worked. When asked about fall prevention strategies during his March interview, he simply stated that falls were the Director of Nursing's responsibility.
Federal regulations require nursing home administrators to ensure their facilities maintain effective quality assurance programs. The administrator at Madera couldn't explain what corrective actions had been taken, how interventions were monitored, or whether the quality program was reducing harm to residents.
The facility's quality committee was supposed to meet monthly to review data and make adjustments. But without integrated documentation or administrative oversight, the program existed mainly on paper.
Sixty-four falls in two months represents more than one fall per day at the 120-bed facility. Each fall carried the risk of fractures, head injuries, or other serious harm to vulnerable elderly residents. Yet the person ultimately responsible for resident safety claimed ignorance of how his facility was addressing the crisis.
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: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
MADERA REHABILITATION & NURSING CENTER in MADERA, CA was cited for violations during a health inspection on March 7, 2025.
The facility's own tracking document showed 31 falls in January alone, followed by 11 more falls in the first 12 days of February.
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.