Madera Rehabilitation & Nursing Center
MADERA REHABILITATION & NURSING CENTER in MADERA, CA — inspection on March 7, 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
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