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Complaint Investigation

Madera Rehabilitation & Nursing Center

January 9, 2025 · Madera, CA · 517 South A Street
Citations 1
CMS Rating 2/5
Beds 176
Provider ID 055147
Healthcare Facility
Madera Rehabilitation & Nursing Center
Madera, CA  ·  View full profile →
Inspection Summary

MADERA REHABILITATION & NURSING CENTER in MADERA, CA — inspection on January 9, 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.

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Inspection Findings

FF689
Minimal harm or outside and was found face down on his stomach. LVN 7 stated when Resident 2 was assessed, he had a Few affected

During an interview on 1/6/25 at 2:02 p.m. with LVN 3 and LVN 9, Resident 2 ' s electronic medical record (EMR) was reviewed. LVN 3 stated Resident 2 had fallen on 12/13/24 and 1/2/25. LVN 3 stated Resident 3 had fallen on 12/18/24. LVN 3 stated she was unable to locate a fall risk assessment before and after Resident 2 and Resident 3 ' s falls. LVN 9 stated the facility did not perform a formal fall risk assessment when a resident falls and located a Post Fall Review for Residents 2 and 3. LVN 9 stated the Post Fall Review was a summary of the fall but did not assess a resident ' s risk factors for falling or provide a fall risk score.

During a concurrent interview and record review on 1/9/25 at 11:05 a.m. with LVN 8, Resident 7 and 8 ' s progress notes and assessments were reviewed, LVN 8 stated Resident 7 had fallen on 10/22/24, 10/25/24, 11/13/24, 11/19/24 and 12/23/24. LVN 8 reviewed Resident 8 ' s progress notes and stated Resident 8 had fallen on 10/13/24, 12/20/24, 12/29/24, 1/1/25 and 1/8/25. LVN 8 stated the facility did not utilize fall risk assessments to determine the severity of a resident ' s fall risk. LVN 8 stated fall risk assessments were important to determine the level of a resident ' s fall risk, what factors contribute to the fall risk and to help determine what interventions would be effective.

During a review of Resident 2 ' s Admission Record (AR- a document containing resident medical and personal information), undated, the AR indicated, Resident 2 was admitted to the facility on [DATE] with diagnoses that included dementia (progressive state of decline in mental abilities), epilepsy (nerve cell activity in the brain is disturbed causing seizures [burst of sudden electrical activity]), muscle weakness, and difficulty in walking.

055147

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 055147 B.

Wing 01/09/2025

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

Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638

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 MADERA, 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 REHABILITATION & NURSING CENTER or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.


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