Madera Rehabilitation & Nursing Center
MADERA REHABILITATION & NURSING CENTER in MADERA, CA — inspection on March 7, 2025.
Found 12 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.
Inspection Findings
environmentally fitting for the resident.
The DON declined to say if Resident 2 ' s flaccid (limp) left
Status, dated 2/2021, the P&P indicated, .
Our facility promptly notifies the resident, his or her attending physician, and the resident representative of changes in the resident ' s medical/mental condition and/or status . a nurse will notify the resident ' s representative when . the resident is involved in any accident or incident that results in an injury . there is a significant change in the resident ' s physical, mental, or psychosocial status . there is a need to change the resident ' s room assignment . it is necessary to transfer the resident to a hospital .
The nurse will record in the resident ' s medical record information relative to changes .
055147 03/07/2025
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated 10/24 was reviewed.
The P&P indicated, .
Residents are provided with a safe, clean, comfortable and homelike environment .
During a review of the facility's policy and procedure (P&P) titled, Quality of Life - Homelike Environment, dated 10/24 was reviewed.
The P&P indicated, .
Residents are provided with a safe, clean, comfortable and homelike environment .
During a review of the facility's document titled, Maintenance Manager, undated was reviewed.
The document indicated, .
Essential Duties and Responsibilities .
Performing regular inspections of resident rooms for order safety and proper performance of equipment .
Maintaining maintenance logs weekly, monthly, and quarterly as required .
055147 03/07/2025
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
neglect . or injury of unknown source is suspected, the suspicion must be reported immediately to the
The state licensing/certification agency responsible for surveying/licensing the facility . 6.
Upon
administrator is responsible for determining what actions (if any) are needed for the protection of residents .
055147 03/07/2025
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
she was new to the facility and was not very familiar with Resident 2. Resident 2 ' s AR was
being a risk factor for Resident 2 ' s falls.
The DON stated Resident 1 ' s left sided paralysis could
055147 03/07/2025
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
During a review of the facility's document titled, USER MANUAL [brand name] ' , dated 2018, the document indicated, . unit and mattress are intended to help reduce the incident of pressure ulcers while optimizing patient comfort .
Pressure Adjust Knob adjustable by patient ' s weight .
Turn the Pressure Adjust Knob to set a comfortable pressure level by using the weight scale as a guide .
055147 03/07/2025
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
During an interview on 3/5/25 at 10:28 a.m. with the Physical Therapy Assistant (PTA), the PTA stated she worked with Resident 2 daily.
The PTA stated Resident 2 fell twice on 2/20/25.
The PTA stated she saw Resident 2 after his first fall on 2/20/25 and he told her he sat at the edge of the bed and started to fall asleep, falling forward.
The PTA stated Resident 2 was impulsive and was frequently leaning forward, sitting at the edge of the bed unsupervised when she picked him up for therapy.
The PTA stated the resident needed supervision to sit at the edge of the bed safely.
During a review of Resident 2 ' s Post-Fall Review, dated 2/15/25 at 4:40 p.m., the note indicated, .
IDT met to review the incident happened on 2/15/2025 .
Root cause: Falling asleep while sitting up.
Recommendations: 1.
Pain assessment .
Neuro check .
Monitor for delayed trauma .
Modification of bed mobility program .
When [Resident 2] is wanting to sit on the side of the bed, staff to encourage activities . signed by the DON on 2/17/25.
During a review of Re[TRUNCATED]
055147 03/07/2025
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
During a telephone interview on 2/18/25 at 4:52 p.m. with Registered Nurse 2, RN 2 stated she was the nurse on duty when Resident 1 fell on 1/30/25. RN 2 stated Resident 1 was found by staff on the floor in the bathroom after an unwitnessed fall. RN 2 stated she did not attend a fall prevention in-service.
During a review of the facility ' s job description titled Floor Nurse, undated, the job description indicated, . purpose of your job position is to provide each resident with routine daily nursing care in accordance with current federal, state, and local standards .
Monitoring residents that are at risk for falls .
Abiding with all facility policies and procedures .
Attending annual facility in-service training programs .
The facility was unable to provide a policy and procedure for staff competencies.
055147 03/07/2025
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
During an interview on 2/12/25 at 4:01 p.m. with the Director of Staff Development (DSD), the DSD stated she was aware the facility had a high number of resident falls.
The DSD stated she held a fall prevention in-service for the staff on 1/28/25 to address the high fall rate.
The DSD stated she did not test the staff ' s competency after the in-service.
During a concurrent interview and record review on 2/12/25 at 4:17 p.m. with the ADM, the facility ' s document titled Incidents By Incident Type, dated 1/1/25 to 2/12/25 was reviewed.
The document indicated there were 31 falls in 1/2025 and 11 falls between 2/1/25-2/12/25.
The ADM stated he was aware there were issues with the number of resident falls.
The ADM stated the falls were a clinical issue and would fall under the DON ' s responsibility.
The ADM was unaware of the details regarding Resident 1 ' s fall with injury on 1/30/25.
The ADM stated he did not attend the fall IDT meetings because it was the clinical staff ' s responsibility.
During an interview on 3/5/25 at 2:37 p.m. with the ADM, the ADM stated resident falls were discussed between clinical staff in the IDT.
The ADM stated, There is a lot that goes on in this building.
The ADM stated the Director of Nursing was in charge of resident falls and the IDT.
The ADM stated, I am not a nurse, so I am not involved in that part, [the] clinical part of the meeting.
During a review of the facility ' s job description titled Administrator, undated, the job description indicated, . primary purpose of your job position is to direct the day-to-day functions of the facility .
Ensure that all employees, residents, visitors and the general public follow established policies and procedures .
Assume the administrative authority, responsibility and accountability of directing the activities and programs of the facility .
Make routine inspections of the facility to assure that established policies and procedures are being implemented and followed .
Review accident/incident reports and establish an effective accident prevention program .
During a review of the facility ' s P&P titled Safety and Supervision of Residents, dated 1/2024, the P&P indicated, .
Our facility strives to make the environment as free from accident hazards as possible.
Resident safety and supervision and assistance to prevent accidents are facility-wide priorities .
Safety risks and environmental hazards are identified on an ongoing basis .
When accident hazards are identified, the facility staff shall review the events in an attempt to identify the root-cause and possible associated hazards .
When safety risks can not be completely eliminated, such as the risk for falls and related injuries, the facility staff shall develop strategies to mitigate the risk for injuries .
Resident supervision is a core component of the approach to safety.
The type and frequency of resident supervision is determined by the individual resident ' s assessed needs .
055147 03/07/2025
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
During a review of Resident 14's AR, dated 3/13/24, the AR indicated, Resident 14 was admitted from
(a decline in memory or other thinking skills severe enough to reduce a person's ability to perform everyday activities), Type 2 Diabetes Mellitus, Major Depressive Disorder (a mood disorder that causes a persistent feeling of sadness and loss of interest), Hypertension, and Anxiety Disorder (a mental health illness characterized by a sudden feeling of panic and fear, restlessness, and uneasiness).
During a review of Resident 14's OSR, dated 3/13/25, the OSR indicated, .
Admit to [Name of Hospice Agency] with a primary diagnosis of Alzheimer Disease under the care of [Attending Physician] .
Order Date . 6/22/23 .
During a review of the facility's P&P titled, Hospice Program dated 7/23, the P&P indicated, .
Hospice services are available to residents at the end of life . 5.
Hospice providers who contract with this facility: a. musth have a written agreement with the facility outlining (in detail) the responsibilities of the facility and the hospice agency . 6.
The agreement with the hospice provider will be signed by the facility representative and a representative from the hospice agency before hospice services are furnished to any resident .
055147 03/07/2025
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
During an interview on 3/5/25 at 2:37 p.m. with the ADM, the ADM stated resident falls were discussed between clinical staff in the IDT.
The ADM stated, There is a lot that goes on in this building.
The ADM stated the Director of Nursing was in charge of resident falls and the IDT.
The ADM stated, I am not a nurse, so I am not involved in that part, [the] clinical part of the meeting.
During a review of the facility ' s policy and procedure (P&P) titled Quality Assurance and Performance Improvement (QAPI) Program, dated 2/2020, the P&P indicated, . facility shall develop, implement, and maintain an ongoing, facility-wide, data-driven QAPI program that is focused on indicators of the outcomes of care and quality of life for our residents . objectives of QAPI program are to . provide a means to establish and implement performance improvement projects to correct identified negative or problematic indicators . establish systems through which to monitor and evaluate corrective actions . administrator is responsible for assuring that this facility ' s QAPI program complies with federal, state, and local regulatory agency requirements . QAPI committee reports directly to the administrator . QAPI plan describes the process for identifying and correcting quality deficiencies.
Key components . tracking and measuring performance . identifying and prioritizing quality deficiencies . systematically analyzing underlying causes of systemic quality deficiencies . developing and implementing corrective action or performance improvement activities . committee meets monthly to review reports, evaluate data, and monitor QAPI-related activities and make adjustments .
055147 03/07/2025
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
During a review of the facility's policy and procedure (P&P) titled, Infection Control, dated 10/18, the P&P indicated, . 1.
The facility ' s infection control policies and practices are intended to facilitate maintaining a safe, sanitary and comfortable environment . 4.
All personnel will be trained on our infection control policies and practices .
During a review of the oxygen concentrator manual titled, [Brand X] Oxygen Concentrator User Manual, dated 2021, the manual indicated, .
Frequency of inspection and cleaning of filter may be dependent upon environmental conditions like dust and lint . NOTE- The air filter should be monitored closely in environments with abnormal amounts of dust and lint .
During an interview on 2/12/25 at 4:01 p.m. with the Director of Staff Development (DSD), the DSD stated she was aware the facility had a high number of resident falls.
The DSD stated she held a fall prevention in-service for the staff on 1/28/25 to address the high fall rate.
The DSD stated she did not test the staff ' s competency after the in-service.
During a concurrent interview and record review on 2/12/25 at 4:17 p.m. with the ADM, the ADM stated the QAPI committee included himself, the department heads, the interdisciplinary team (IDT-involves team members from different disciplines working collaboratively, with a common purpose, to set goals, make decisions and share resources and responsibilities for the best interest of the resident), and the medical director.
The ADM stated the QAPI met on a monthly basis to discuss any issues happening within the facility.
The facility ' s document titled Incidents By Incident Type, dated 1/1/25 to 2/12/25 was reviewed.
The document indicated there were 31 falls in 1/2025 and 11 falls between 2/1/25-2/12/25.
The ADM stated he was aware there were issues with the number of resident falls.
The ADM stated the falls were a clinical issue and would fall under the Director of Nursing ' s (DON) responsibility.
The ADM reviewed the QAPI document titled [name of facility] Performance Improvement Plan, the plan indicated, . 1.
Resident Falls . 2. 4 P ' s [pain, position, placement and personal needs] Fall prevention program (May 2023) . 1.
Initiate Safety Committee for Resident Falls which will include Admin [administrator], DON, DOR [Director of Rehabilitation], ACT [activities], RNA [Restorative Nursing Assistant], and DSD [Director of Staff Development] to review and assess resident falls.
Committee will review conditions, medications, interventions, as well as hold weekly meetings to identify whether the interventions that have been implemented are affective [effective] and provide new recommendations to reduce resident falls .1.
Our goal is to reduce falls to 15 or less per month for three months .
There were 31 resident falls in January 2025, the ADM stated he could not answer if the QAPI was effective because he needed to review the month-to-month data.
The ADM was unable to state how the data gathered as part of QAPI was used to decrease resident falls.
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 03/07/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Madera Rehabilitation & Nursing Center 517 South A Street Madera, CA 93638
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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.