Inspection citations
19’24
17’25
30’26
66 shown
| Date | Severity | What inspectors found | Visit |
|---|---|---|---|
| Aug 3, 2026 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Aug 3, 2026 | E · potential | Ensure each resident receives an accurate assessment. | Routine |
| Aug 3, 2026 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Aug 3, 2026 | E · potential | Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Routine |
| Aug 3, 2026 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Aug 3, 2026 | D · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Aug 3, 2026 | D · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Aug 3, 2026 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Aug 3, 2026 | D · potential | Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Routine |
| Aug 3, 2026 | D · potential | Have a policy regarding use and storage of foods brought to residents by family and other visitors. | Routine |
| Aug 3, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Routine |
| Aug 3, 2026 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Aug 3, 2026 | E · potential | Implement a program that monitors antibiotic use. | Routine |
| Aug 3, 2026 | E · potential | Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Routine |
| May 15, 2026 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| May 15, 2026 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| May 15, 2026 | E · potential | Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Complaint |
| Apr 23, 2026 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Apr 23, 2026 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Apr 23, 2026 | D · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Apr 23, 2026 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Apr 8, 2026 | D · potential | Reasonably accommodate the needs and preferences of each resident. | Complaint |
| Mar 16, 2026 | D · potential | Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Complaint |
| Mar 16, 2026 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Complaint |
| Mar 16, 2026 | D · potential | Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Complaint |
| Mar 16, 2026 | D · potential | Have policies on smoking. | Complaint |
| Jan 28, 2026 | E · potential | Provide enough food/fluids to maintain a resident's health. | Complaint |
| Jan 6, 2026 | E · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Jan 6, 2026 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Complaint |
| Jan 6, 2026 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Complaint |
| Aug 21, 2025 | E · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Jul 10, 2025 | E · potential | Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Routine |
| Jul 10, 2025 | D · potential | Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Routine |
| Jul 10, 2025 | E · potential | Ensure each resident receives an accurate assessment. | Routine |
| Jul 10, 2025 | E · potential | Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Routine |
| Jul 10, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Routine |
| Jul 10, 2025 | K · harm | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jul 10, 2025 | D · potential | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Routine |
| Jul 10, 2025 | B · minimal | Post nurse staffing information every day. | Routine |
| Jul 10, 2025 | D · potential | Provide special eating equipment and utensils for residents who need them and appropriate assistance. | Routine |
| Jul 10, 2025 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jul 10, 2025 | E · potential | Provide and implement an infection prevention and control program. | Routine |
| Jul 10, 2025 | D · potential | Keep all essential equipment working safely. | Routine |
| Apr 7, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Mar 19, 2025 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Feb 5, 2025 | D · potential | Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Complaint |
| Feb 5, 2025 | D · potential | Provide appropriate treatment and care according to orders, resident’s preferences and goals. | Complaint |
| Dec 16, 2024 | D · potential | Ensure services provided by the nursing facility meet professional standards of quality. | Complaint |
| Oct 10, 2024 | D · potential | Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Complaint |
| Oct 9, 2024 | D · potential | Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Complaint |
| Jul 19, 2024 | E · potential | Reasonably accommodate the needs and preferences of each resident. | Routine |
| Jul 19, 2024 | D · potential | Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Routine |
| Jul 19, 2024 | E · potential | Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Routine |
| Jul 19, 2024 | D · potential | Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Routine |
| Jul 19, 2024 | E · potential | Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Routine |
| Jul 19, 2024 | E · potential | Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Routine |
| Jul 19, 2024 | E · potential | Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Routine |
| Jul 19, 2024 | D · potential | Provide safe and appropriate respiratory care for a resident when needed. | Routine |
| Jul 19, 2024 | E · potential | Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Routine |
| Jul 19, 2024 | B · minimal | Post nurse staffing information every day. | Routine |
| Jul 19, 2024 | E · potential | Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Routine |
| Jul 19, 2024 | D · potential | Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. | Routine |
| May 17, 2024 | G · harm | Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Complaint |
| May 17, 2024 | D · potential | Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Complaint |
| Mar 8, 2024 | D · potential | Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Complaint |
| Mar 8, 2024 | D · potential | Make sure that a working call system is available in each resident's bathroom and bathing area. | Complaint |
Medicare's severity letters: A–C minimal harm, D–F potential for more than minimal harm, G–L actual harm or immediate danger. Source: CMS health deficiencies file, processed October 1, 2026.
Questions to ask on a visit
Madera Post Acute Center
11900 Ramona Boulevard, El Monte, CA 91732 · (626) 442-5721
Visit date: ____________ Spoke with: ______________________
Record on file
- Certification
- Medicare and Medi-Cal certified skilled nursing facility
- Medicare number (CCN)
- 055141
- Certified beds
- 148
- Legal owner
- Glimmer Healthcare INC
- Part of
- The Ensign Group
Full profile on Medicare's Care Compare. Source: CMS, processed October 1, 2026.
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