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Complaint Investigation

Madera Post Acute Center

Inspection Date: August 21, 2025
Total Violations 1
Facility ID 055141
Location EL MONTE, CA
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Inspection Findings

F-Tag F0684

Quality of Life and Care Deficiencies
Harm Level: Potential for More Than Minimal Harm

F 0684 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

LVN 2 administered Tresiba 55 units to Resident 1.During a telephone interview on 8/20/2025 at 3:37 PM with LVN 2, LVN 2 stated on 8/9/2025 at 5:40 AM, LVN 2 administered Tresiba 55 units to Resident 1.During

a concurrent interview and record review on 8/21/2025 at 12:25 PM with the DON, Resident 1's MAR dated 8/1/2025-8/31/2025 was reviewed. The MAR indicated the 8/9/2025 6:30 AM dose for Tresiba 55-unit[s] subcutaneous injection was not administered. The DON stated LVN 2 should have documented the 6:30 AM dose of Tresiba administered by LVN 2 on 8/9/2025 in Resident 1's MAR.During a review of the facility's undated Policy and Procedure (P&P) titled, Medication Administration, the P&P indicated, medications will be administered as prescribed by the physician. The P&P's administration process indicated that the person administering the medication is to initial the resident's medication sheet in the provided space under the appropriate date and time for that particular dose administered. The P&P's administration process indicated, documentation on the medication sheet is done immediately following administration.

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📋 Inspection Summary

Madera Post Acute Center in EL MONTE, CA inspection on recent inspection.

Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.

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

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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