Safety Report: Madera Care Center
How to read this report. Every nursing home receives some citations. One citation does not mean a facility is unsafe. Look at how serious the findings were, whether the same problems keep coming back, and whether things are getting better or worse. Learn how inspections work.
Official ratings
Medicare's star ratings compare nursing homes within the same state for health inspections. A 5-star facility performed better than most in its state; a 1-star facility performed worse than most.
Stars are calculated by CMS, not by us. We do not create our own safety score.
Serious documented violations
0Immediate jeopardy citations (severity J–L)
0Actual harm citations (severity G–I)
7Requirements cited on more than one inspection
No citations at the “actual harm” or “immediate jeopardy” level in the last three inspection cycles.
Citations by topic
1Abuse, neglect & exploitation
3Infection control
2Medications & pharmacy
2Accidents & supervision
Topics use CMS's own deficiency categories; “accidents & supervision” counts tag F689 (free of accident hazards / adequate supervision). Counts cover the last three inspection cycles, including complaint investigations.
Is it getting better or worse?
Fewer citations in the most recent cycle (3) than in the cycle before (13).
An inspection cycle is roughly one year and includes the standard inspection plus complaint investigations. Counts depend partly on how many complaint investigations occurred, so treat small changes with caution. Red bars include at least one serious citation.
Staffing and rating trends will appear as we collect monthly CMS releases. We have one month so far, so a staffing trend cannot yet be determined.
Repeat findings
These requirements were cited on more than one inspection date in the last three cycles.
| Requirement | Times cited | Inspection dates |
|---|---|---|
| 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. (F584) | 3 | April 16, 2025; February 20, 2024; April 13, 2023 |
| Provide and implement an infection prevention and control program. (F880) | 3 | April 3, 2025; February 20, 2024; April 13, 2023 |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (F689) | 2 | February 27, 2026; February 26, 2025 |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. (F550) | 2 | April 4, 2025; April 13, 2023 |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (F842) | 2 | June 19, 2024; April 13, 2023 |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (F812) | 2 | February 20, 2024; April 13, 2023 |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. (F803) | 2 | February 20, 2024; April 13, 2023 |
Fines and enforcement
| Date | Type | Amount / length |
|---|---|---|
| January 8, 2024 | Fine | $4,938 |
| January 2, 2024 | Fine | $4,587 |
| December 11, 2023 | Fine | $12,703 |
| November 6, 2023 | Fine | $9,527 |
| October 17, 2023 | Fine | $2,787 |
Federal civil money penalties and Medicare/Medicaid payment denials. State-level penalties may not be included.
Complete inspection history
March 19, 2026 — 1 citation · complaint investigation
E
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
No actual harm, but potential for more than minimal harm · Pattern · Freedom from Abuse, Neglect, and Exploitation Deficiencies · F609 · complaint · corrected April 6, 2026
February 27, 2026 — 1 citation · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected March 23, 2026
April 16, 2025 — 1 citation · complaint investigation
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected April 24, 2025
April 4, 2025 — 1 citation · complaint investigation
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · complaint · corrected April 3, 2025
April 3, 2025 — 1 citation
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected April 14, 2025
February 26, 2025 — 1 citation · complaint investigation
D
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F689 · complaint · corrected March 25, 2025
July 3, 2024 — 1 citation · complaint investigation
D
Provide safe and appropriate respiratory care for a resident when needed.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F695 · complaint · corrected July 25, 2024
June 19, 2024 — 1 citation · complaint investigation
D
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F842 · complaint · corrected August 12, 2024
February 20, 2024 — 10 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected March 20, 2024
E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F803 · corrected March 20, 2024
E
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F656 · complaint · corrected March 20, 2024
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · complaint · corrected March 20, 2024
D
Keep all essential equipment working safely.
No actual harm, but potential for more than minimal harm · Isolated · Environmental Deficiencies · F908 · corrected March 20, 2024
D
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Isolated · Infection Control Deficiencies · F880 · corrected March 20, 2024
D
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.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F761 · corrected March 20, 2024
D
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
No actual harm, but potential for more than minimal harm · Isolated · Pharmacy Service Deficiencies · F755 · corrected March 20, 2024
D
Provide appropriate foot care.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F687 · complaint · corrected March 20, 2024
D
Ensure services provided by the nursing facility meet professional standards of quality.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F658 · corrected March 20, 2024
November 9, 2023 — 1 citation · complaint investigation
D
Let each resident or the resident's legal representative access or purchase copies of all the resident's records.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F573 · complaint · corrected November 21, 2023
April 13, 2023 — 19 citations
F
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F812 · corrected August 21, 2023
F
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F802 · corrected June 21, 2023
F
Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.
No actual harm, but potential for more than minimal harm · Widespread · Nutrition and Dietary Deficiencies · F801 · corrected August 21, 2023
E
Provide and implement an infection prevention and control program.
No actual harm, but potential for more than minimal harm · Pattern · Infection Control Deficiencies · F880 · corrected June 21, 2023
E
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
No actual harm, but potential for more than minimal harm · Pattern · Resident Assessment and Care Planning Deficiencies · F842 · corrected June 21, 2023
E
Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F805 · corrected June 20, 2023
E
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F804 · corrected August 21, 2023
E
Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
No actual harm, but potential for more than minimal harm · Pattern · Nutrition and Dietary Deficiencies · F803 · corrected June 21, 2023
E
Post nurse staffing information every day.
No actual harm, but potential for more than minimal harm · Pattern · Nursing and Physician Services Deficiencies · F732 · corrected June 21, 2023
E
Provide enough food/fluids to maintain a resident's health.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F692 · corrected August 21, 2023
E
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
No actual harm, but potential for more than minimal harm · Pattern · Quality of Life and Care Deficiencies · F684 · corrected June 21, 2023
E
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.
No actual harm, but potential for more than minimal harm · Pattern · Resident Rights Deficiencies · F584 · corrected June 21, 2023
D
Dispose of garbage and refuse properly.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F814 · corrected June 21, 2023
D
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
No actual harm, but potential for more than minimal harm · Isolated · Nutrition and Dietary Deficiencies · F806 · corrected June 21, 2023
D
Provide safe, appropriate dialysis care/services for a resident who requires such services.
No actual harm, but potential for more than minimal harm · Isolated · Quality of Life and Care Deficiencies · F698 · corrected August 21, 2023
D
Ensure each resident receives an accurate assessment.
No actual harm, but potential for more than minimal harm · Isolated · Resident Assessment and Care Planning Deficiencies · F641 · corrected June 21, 2023
D
Reasonably accommodate the needs and preferences of each resident.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F558 · corrected June 21, 2023
D
Ensure that residents are fully informed and understand their health status, care and treatments.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F552 · corrected June 21, 2023
D
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
No actual harm, but potential for more than minimal harm · Isolated · Resident Rights Deficiencies · F550 · corrected June 21, 2023
Source: CMS Health Deficiencies dataset (data as of October 1, 2026); full inspection narratives on Medicare Care Compare