Madera Post Acute Center
Madera Post Acute Center in EL MONTE, CA — inspection on August 21, 2025.
Found 1 citation. 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.
Inspection Findings
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.