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Complaint Investigation

Madera Post Acute Center

February 5, 2025 · El Monte, CA · 11900 Ramona Boulevard
Citations 2
CMS Rating 1/5
Beds 148
Provider ID 055141
Healthcare Facility
Madera Post Acute Center
El Monte, CA  ·  View full profile →
Inspection Summary

Madera Post Acute Center in EL MONTE, CA — inspection on February 5, 2025.

Found 2 citations. Severity: Standard violations.

Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.

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Inspection Findings

FF580
Minimal harm or monitor/document location, size, and treatment of skin injury and report abnormalities, failure to heal, s/sx of Few During a concurrent observation and interview on 2/5/2025 at 12:55 pm with LVN 3, Resident 8's left toes affected

During a review of Resident 8's Minimum Data Set (MDS- a resident assessment tool) dated 11/5/2024, the MDS indicated Resident 8 had intact cognition (ability to think, remember, and reason).

The MDS indicated Resident 8 required partial/moderate assistance (helper does less than half the effort and lifts or holds trunk or limbs but provides less than half the effort) with showering/bathing self and putting on/taking off footwear.

The MDS indicated Resident 8 required supervision or touching assistance (helper provides verbal cues and/or touching/steadying and/or contact guard assistance as resident completes the activity and may be provided throughout the activity or intermittently) with lying to sitting on side of bed, chair/bed-to-chair transfers, and walking 10 feet.

The MDS indicated Resident 8 used a wheelchair.

The MDS indicated Resident 8 had one venous ulcer (an open sore on the leg caused by poor blood circulation in the veins) and arterial ulcer (an ulcer due to inadequate blood supply to the affected area) present.

During a review of Resident 8's untitled care plan (CP) initiated on 12/18/2025, and revised on 1/30/2025, the CP indicated Resident 8 had left lower leg scattered venous ulcer.

The CP interventions included for staff to administer treatment as ordered, monitor/document/report to MD as needed for signs and symptoms (s/sx) of infection: green drainage, foul odor, redness, and swelling, and document progress in wound healing on an ongoing basis and notify MD 2 as indicated.

055141

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055141 B.

Wing 02/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ramona Nursing and Rehabilitation Center 11900 Ramona Boulevard El Monte, CA 91732

During a review of Resident 8's untitled care plan (CP) initiated on 12/18/2025, and revised on 1/30/2025, the CP indicated Resident 8 had left lower leg scattered venous ulcer.

The CP interventions included for staff to administer treatment as ordered, monitor/document/report to MD as needed for signs and symptoms (s/sx) of infection: green drainage, foul odor, redness, and swelling, and document progress in wound healing on an ongoing basis and notify MD 2 as indicated.

During a review of Resident 8's untitled CP initiated on 1/14/2025, the CP indicated Resident 8 had left leg/actual impairment to skin integrity related to scattered skin irritation.

The CP interventions included to monitor/document location, size, and treatment of skin injury and report abnormalities, failure to heal, s/sx of infection, maceration etc. to MD.

During a concurrent observation and interview on 2/5/2025 at 12:55 pm with LVN 3, Resident 8's left toes were observed. LVN 3 stated LVN 3 had been monitoring Resident 8's edema to the feet since 12/2024. LVN 3 stated Resident 8's left second, and third toes were black and purple. LVN 3 stated the left great toe was swollen with purple discoloration on the inner side that was partially opened. LVN 3 stated Resident 8's left foot had plus 4 pitting edema (severe swelling that leaves a deep indentation in the skin that takes more than 30 seconds to go away).

055141

Form Approved OMB

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.

Building 055141 B.

Wing 02/05/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Ramona Nursing and Rehabilitation Center 11900 Ramona Boulevard El Monte, CA 91732

Frequently Asked Questions

What is an F-tag violation?
F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
Were these violations corrected?
Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
How often do nursing home inspections happen?
CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
What should families do about these violations?
Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in EL MONTE, CA, (5) Report new concerns to state authorities.
Where can I see the full inspection report?
Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Madera Post Acute Center or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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