Madera Care Center

In the surveyor’s words

From the most serious findings on record at Madera Care Center, in the surveyor’s own words.

• Actual harm, isolatedF806Apr 13, 2023

  Based on observation, interview, and record review, the facility failed to ensure resident's food preference were honored for one of 50 sampled residents (Resident 49) when Resident 49 and her family told staff that Resident 49 disliked chopped foods. No food upgrade options were provided for Resident 49, despite informing the staff that she did not want tomatoes soup, yet she still received it on 4/12/23 during dinner. This failure resulted in Resident 49 decreased food intake with an unplanned 1.6-pound weight loss from 1/31/23 until 4/9/23 which further compromised Resident 49's nutritional and medical status. […]

• No harm, potential for more than minimal, widespreadF812Feb 20, 2024

  Based on observation, interview, and record review, the facility failed to serve food in accordance with professional standards for food service safety when: 1. There was a build-up of food crumbs and debris under the dishwasher, this had the potential for microorganism growth and to attract pests. 2. The ceiling had a patch that was not smooth and easily cleanable, this had the potential for build-up of dust and microorganism growth. These failures had the potential for microorganism growth that could be inadvertently transferred to food and to attract pests in the kitchen that prepared food for 47 out of 47 medically compromised residents who received food from the kitchen. Findings: 1. During a concurrent observation and interview on 2/13/24 at 10:47 a.m. […]

• No harm, potential for more than minimal, widespreadF801Apr 13, 2023

  Based on dietetic services observations, interviews, and record reviews, the facility failed to ensure the Registered Dietitian conducted effective oversight of the food and nutrition department in accordance with the facility's executed contract and professional standards of practice. These failures had the potential to result in ineffective and inadequate directing of the day-to-day Food and Nutrition operations to ensure the nutritional needs for 46 of 48 sampled residents were met in a safe and sanitary manner. (Cross reference: F692, F802, F803, F804, F805, F806 and F812) Findings: During the initial kitchen tour on 4/10/23, beginning at 9:32 AM, observations and concurrent interviews were conducted with the Dietary Manager (DM) regarding overall kitchen sanitation and cleanliness. […]

• No harm, potential for more than minimal, widespreadF802Apr 13, 2023

  Based on observations, interviews and record reviews, the facility failed to ensure that dietary staff safely and effectively carried out the functions of food and nutrition services when: 1. One of the dietary staff and the Dietary Manager did not know the right location to check dish machine sanitizer. This failure had the potential to cause foodborne illness for 46 out of 48 sampled residents who received food from the kitchen. 2. One of the dietary staff and the Dietary Manager did not know the proper steps for washing dishes in two-compartment sinks. This failure had the potential to cause foodborne illness for 48 out of 50 sampled residents who received food from the kitchen. 3. The AM Cook did not follow pureed bread recipe for preparing pureed bread during lunch on 4/11/23. […]

• No harm, potential for more than minimal, widespreadF812Apr 13, 2023

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food preparation and storage practices in the kitchen when: 1. There was no air gap (a fixture that provides back-flow prevention. When installed and maintained properly, the air gap works to prevents drain water from backing up into the sink and possibly contaminating the area used for washing food) under the prep sink (sink used to preparation of foods). 2. There was brown, grey and black debris observed several places in the kitchen: exit door to hallway, on the insect lamp, two ventilator's fans inside milk refrigerator, the exit door to the dining hall, in the dry storage room's storage shelves and door, the air conditioning and heating unit next to hand washing sink, the window, fans,… […]