Madera Post Acute Center

In the surveyor’s words

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

• Immediate jeopardy, patternF689Jul 10, 2025

  Based on observation, interview, and record review, the facility failed to ensure three of seven sampled residents (Residents 48, 50, and 64) who required supervision while smoking (breathing in smoke from cigarettes [tobacco wrapped in paper]) had an environment free of accident hazards (risk) by failing to:1. Implement the facility's Policy and Procedure (P&P) titled, Smoking Policy, which indicated no lighting materials (e.g. matches, lighters), tobacco products, or smoking devices (e.g. tobacco cigarettes, cigars) will be allowed to be kept in the possession of the residents, either on their person or in the facility. 2. Ensure Residents 48, 50, and 64 were not in possession of smoking materials (cigarettes and lighters). 3. […]

• Actual harm, isolatedF694May 17, 2024

  Based on interview and record review, the facility failed to implement its policies and procedures (P&P) titled, IV (an intravenous [within a vein] line is a soft, flexible tube placed inside a vein, usually in the hand or arm) Administration (send directly into the vein), and Central Venous (a thin, flexible tube that is inserted into a vein, usually below the right collarbone [a bone at the base of the front of the neck] and Midline Catheter (a catheter inserted in the upper arm with the tip located just below the axilla [armpit]) Care, and follow the manufacturer's instructions for care of the central venous catheter (CVC - an indwelling device inserted into a large, central vein to administer fluid, medication, and/or treatment) for one of one sampled resident (Resident 1) by failing… […]

• Actual harm, isolatedF656May 16, 2023

  Based on interview and record review, the facility failed to develop and implement a resident-centered comprehensive care plan to prevent a fall (unintentionally coming to rest on the ground) for one of two sampled residents (Resident 1), who was assessed as high risk for fall and had a history of falls, by failing to: Develop and implement a plan of care to address Resident 1's behavior of turning off the bed pad alarm (a device with a sensor and monitor to alert staff when a resident attempts to leave the bed), in accordance with the facility's Policy and Procedure titled Comprehensive Resident Centered Care Plan and Fall Management System. This deficient practice resulted in Resident 1's fall on 4/27/2023 at 4:45 am and Resident 1 sustained a right hip fracture (break in the bone). […]

• Actual harm, isolatedF580Aug 29, 2022

  Based on observation, interview and record review, the facility failed to notify the physician for one of two sampled residents (Resident 1) who had a change in condition (COC, a sudden clinically important deviation from a patient's baseline in physical, cognitive, behavioral, or functional domains), that started on 6/17/2022. On 6/17/2022, Resident 1 complained of right hip pain. The facility's nursing staff did not inform Resident 1's attending physician (Physician 1) of Resident 1's pain until 6/20/2022 (three days later) at 10:39 am. Resident 1's X-ray (a test that produces images of the body structures) of the right hip result dated 6/21/2022, indicated a right hip fracture (broken bone). […]

• No harm, potential for more than minimal, patternF558Aug 3, 2026

  Based on observation, interview, and record review, the facility failed to ensure reasonable accommodation was provided to three of three sampled residents (Residents 11, 86 and 96) by failing to: a & b. Ensure call lights were within reach for Residents 11 and 86.c. Ensure Resident 96 had footrests on the wheelchair to place both feet on. These failures had the potential for Residents 11, 86 and 96 not to receive necessary care or receive delayed services affecting the residents' quality of life. Findings: a. […]