Madera Care Center

Inspectors wroteBased on interview and record review, the facility failed to report to the state agency two episodes of alleged or suspected abuse violations when;1. An unknown intruder entered the facility without staff knowledge and interacted with Resident 1, Resident 2, Resident 3, and Resident 4. 2. One resident (Resident 6) struck another resident (Resident 5) across the face with a walker, causing a laceration (cut in the skin) on his left eyebrow. These failures resulted in delayed investigations, potential for delayed protection and continued harm for the five sampled residents (Resident 1, Resident 2, Resident 3, Resident 4, and Resident 5). [...]

Inspectors wroteBased on interview and record review, the facility failed to provide adequate supervision and failed to report an elopement (resident leaving a healthcare facility, hospital, or care setting without authorization, without being discharged , or without notifying staff.) to the State Survey Agency within the required timeframe for one of three residents (Resident 1), when Resident 1 was not reassessed for risk of elopement after repeatedly expressing the desire to leave the facility and return to the river. On 2/8/26, Resident 1 left the facility without staff knowledge or supervision. The State Agency was unaware of the elopement until it was reported by the Ombudsman (a neutral, independent advocate who investigates, and resolves issues between patients/residents and healthcare providers, insurers, and long term care facilities) on 2/26/26. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure there was consistently enough linen (specifically towels and washcloths) available for incontinent residents (those unable to control their bowels and/or bladders) during night shifts. This failure resulted in the facility's incontinent residents, approximately over half of the facility's census of 64, to receive incontinent care with non-linen items such as toilet paper, which has the potential to increase discomfort, decrease cleaning, and increase chance of skin issues. (Linens, such as washcloths, provide better to provide care to incontinent residents with because they can retain moisture better, are gentler on skin, reduce the risk of skin breakdown, clean better, and are more comfortable, especially when pre-moistened with warm water).

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat one of three residents (Resident 1) with dignity and respect when Resident 1 requested assistance from the Certified Nursing Assistant (CNA) to locate the footrest (a stationary hanger and footplate for the user's feet to rest on the wheelchair) to her wheelchair and the CNA told Resident 1 to shut up on 3/31/25. This failure resulted in Resident 1 to experience mental and emotional distress (anger and frustration) on 3/31/25.

Inspectors wroteBased on observation, interview, record review, and facility policy review, the facility failed to ensure staff implemented enhanced barrier precautions (EBP) for 1 (Resident #7) of 1 sampled resident reviewed for dialysis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and assistance to prevent accidents for one of three residents (Resident 1), when Resident 1 required two person assist for transfer but was transferred from wheelchair to bed by Certified Nursing Assistant (CNA) 1 without another person to assist on [DATE]. This failure resulted in Resident 1 falling out of bed and onto the floor on [DATE] and the potential for Resident 1 to be injured.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents (Resident 1) received supplemental oxygen (from a portable tank which delivers oxygen through a tube inserted into the nostrils), as ordered by her physician, when she left the facility to go to a medical appointment. This failure resulted in Resident 1 going approximately 7 hours without her physician-ordered supplemental oxygen, which has the potential to cause respiratory distress such as shortness of breath, elevated heart rate, anxiety, and confusion.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for one of three residents (Resident 1) when Resident 1 was admitted with a stage 3 pressure ulcer (damage to an area of the skin caused by constant pressure on the area for a long time through the skin into deeper tissue and fat but do not reach muscle, tendon, or bone) to the sacral (tailbone) region on 4/17/24 and Resident 1 ' s stage 3 pressure ulcer assessment was not documented (a process used to learn about a patient's condition) until 5/14/24. This failure was not the standard of practice according to the facility ' s policy and procedure titled, Charting and Documentation, and Prevention of Pressure Injuries.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a clean, safe, and sanitary homelike environment for six of 19 sampled residents (Residents 4, 8, 10, 15, 29 and 31) when: 1. There were missing floor tile in Residents 4 and Resident 10's bathroom with darkened areas in the tile grout. 2. There was a missing baseboard from the wall behind Resident 8's bed exposing chipped paint and grime. 3. The floor tile by Resident 15's bed was broken with missing pieces of tile. 4. There were trash and dirt on the floors and dirty (blackened) floor tiles in Resident 29's room. 5. The privacy curtain in Resident 31's room was torn. These failures placed Residents 4, 8, 10, 15, 31 and 29 in an unclean, unsafe, unsanitary and a non-homelike environment which could affect residents' well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered Care Plan (CP-the process by which healthcare professionals and patients discuss, agree, and review an action plan to achieve the goals or behavior change of most importance to the patient) to prevent falls and injuries, for four (4) of fifty-four (54) sampled residents (Resident 4, Resident 28, Resident 250, and Resident 410) when: 1. Resident 4's supervision CP during meals was not implemented. This failure put Resident 4 at an increased risk of choking and aspiration of food. 2. Resident 28's toenail clipping and/or podiatry care was not done and there was no CP to address repeated refusals to bathe or shower. This failure placed Resident 28 at risk for infection and other diabetic (high blood sugar disease) complications. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for the dysphagia advanced (bite-sized foods that are moist) diet for five of 47 sampled residents (Residents 17, 22, 31, 35, and 36) when Residents 17, 22, 31, 35, and 36 received puree broccoli instead of chopped broccoli for lunch. This failure had the potential to result in Residents 17, 22, 31, 35, and 36 having a decrease in satisfaction with their meal because it was not the correct texture of food as prescribed by the physician.

Inspectors wroteBased on interview and record review the facility failed to provide needed care according to professional standards of practice for one of four sampled residents (Resident 59) when facility did not notify physician of Resident 59's change of condition (COC) of hyperglycemia (high blood sugar). This failure had the potential to result in Resident 59's development of diabetic ketoacidosis (DKA- complication of diabetes, when the body can't make enough insulin to allow blood sugar into the cells for energy and the body breaks down fat).

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for two of four sampled residents (Resident 361 and Resident 17) when 1. Resident 361's toenails were not cut or trimmed for a year and 3 months. 2. Resident 17's toenails were not cut or trimmed. These failures resulted in Resident 361's and Resident 17's toenails to become long and curled which had the potential to result in Resident 361's and Resident 17's toenails to become painful, ingrown or to break off the nail bed causing infection and limit resident's mobility during activities of daily living (ADL).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drug records to account for the receipt and accurate reconciliation (comparing medication received is being delivered) for controlled medications (medications that may be abused or cause addiction) for one of three sampled residents (Resident 13) when the pharmacy manifest (form that contains information about the type and quantity of medication delivered) was not signed upon delivery of a controlled medication. This failure had the potential for drug diversion (distribution or abuse of a prescription drug or it's use for purpose) of Resident 13's controlled medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were properly stored and labeled in accordance with professional standards when: 1. The facility's medication emergency kit (ekit) containing controlled medications (medications that may be abused or cause addiction) was observed missing a zip tie. 2. Medication for one of three sampled residents (Resident 14) was observed with expired date in Medication Cart two. These failures had the potential for medication diversion (distribution or abuse of a prescription drug or it's use for purpose) from the ekit and the potential for adverse effects (undesired harmful effect) and medication error for Resident 14 when the expired medication was left in the medication cart.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection prevention and control program to prevent the transmission of infections when: 1. Unit Manager-Registered Nurse (UM- RN) did not perform hand hygiene during a dressing change to Resident 28; 2. Three hand sanitizer dispensers in the hallway outside resident rooms did not work; These failures placed residents at risk for cross-contamination (the process by which bacteria or other microorganisms are unintentionally transferred from one substance or object to another, with harmful effect).

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition when a drawer holding clean utensils used for meal service was no longer on the drawer track (the mechanisms that allow drawers to open and close smoothly) and was difficult to open and close. This failure had the potential to result in contamination of the clean utensils because the drawer could not be completely closed and potential in bodily injury to dietary staff.

Inspectors wroteBased on interview and record review the facility failed to provide a copy of the resident's medical record for one of one resident (Resident 1) when Resident 1 requested her medical records on 9/21/23. This failure was not the standard of practice according to the facility's policy and procedure (P&P) titled, Release of Information.

Inspectors wroteBased 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)

Inspectors wroteBased 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 [NAME] did not follow pureed bread recipe for preparing pureed bread during lunch on 4/11/23. [...]

Inspectors wroteBased 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, ventilator in dishwashing area 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a homelike environment for the residents in rooms 17, 3,10, and 26, and those using the dining room when: 1. Resident rooms 17, 3, 10, and 26 were in disrepair. 2. The noise level in the dining room was too loud. These failures resulted in an unhomelike atmosphere.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide effective interventions to meet the needs of residents and in accordance with standards of practice for one of five sampled residents, Resident 41, when Resident was diagnosed with leg varicose veins and nursing staff did not implement every two hour repositioning and range of motion. This failure resulted in Resident 41 acquiring new venous ulcers, delay in wound healing, pain, suffering, and decreased mobility. This failure also had the potential to result in infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive systemic approach, to ensure effective monitoring systems to maintain acceptable parameters of nutritional status for one of five sampled residents (Resident 41). The facility failed to ensure a Registered Dietitian (RD) provided nutritional interventions despite documented meetings acknowledging weight loss. The facility failed to ensure RD effectively monitored nutrition interventions, after an unplanned severe and continuous weight loss of 13.6-pound (lbs.) 8 percent weight loss in five months from 12/6/22-4/2/23. There was no plan of care to address the weight loss and prevent further weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the total number of licensed and unlicensed staff and actual hours worked per shift within two hours of the start of each shift in accordance with the facility policy and procedure when the posting did not represent actual hours worked but projected hours. This failure resulted in residents and visitors not having the benefit of viewing the actual hours and total number of staff providing care per shift and possibly not meeting the needs of the residents

Inspectors wroteBased on dietary production observation, interviews and record reviews, the facility failed to ensure the pureed bread recipe was followed by an A.M. [NAME] for lunch on 4/11/23. This failure result in twelve out of twelve sampled residents (Residents' 3, 4, 18, 21, 22, 24, 25, 28, 34, 152, 155, 352) who on pureed bread received less nutritive value and unappetizing pureed bread. This failure had potential result in negatively impact the residents' nutritional status and further compromising residents' medical status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its policy on Food: Quality and Palatability to provide appetizing food at appropriate temperatures according to residents' preferences for ten of 46 sampled residents (Residents' 6, 20, 23, 33, 39, 45, 48, 49,155, 353). This failure had the potential risk to decrease nutritional intake and affect the residents' nutritional status and further compromising residents' medical status.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the appropriate food and beverage textures were provided as evidence by: 1. Three of six sampled residents (Residents'11, 30, 42 ) received Dysphagia Mechanically Altered diet (a diet with food texture need to chop up or ground into small piece for residents who have limited chewing and swallowing ability) received 3-inch-long green bean salad for lunch on 4/10/23. 2. Resident 25 was ordered with honey thick consistency, was served unmixed regular consistency coffee with lumpy thickeners during lunch on 4/10/23. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete, accurately documented and readily accessible for three of six sampled residents (Residents' 22, 32 and 103) when: 1. Resident 22's copy of Physician Orders for Life-Sustaining Treatment (POLST) form (a legal document that specifies the type of care a resident's treatment and services would like in an emergency life threatening medical situation) was signed and dated thirteen months by the Medical Doctor (MD) after it was prepared and readily available as part of Resident 22's current medical records. 2. Resident 32's copy of POLST was incomplete and readily available as part of Resident 32's current medical record. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement and maintain an effective infection control and prevention program to provide a safe, sanitary and comfortable environment to help prevent infections for seven of 50 sampled residents (Residents 6, 22, 41, 31, 33, 49, 353, ) when: 1. Bedpans were observed placed on the top of the two toilets (that are shared with three other residents). One bedpan was observed in Resident 31 restroom, and one bedpan was observed in Resident 33's restrooms. Resident 31's toilet seat contained a brown substance. 2. Resident 49 had concerns of smell and cleanliness of her restroom. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were treated with respect and dignity and in an environment that promotes and enhances quality of life for three out of 11 sampled residents (Residents' 25, 28 and 156) when: 1. Residents' 25 and 28 were not given coffee as requested and watched other residents in the dining room drink coffee. 2. Resident 156 waited for her lunch tray while watching other residents on the same table ate. These failures violated Residents' 25, 28 and 156 the right to be offered a dignified dining experience.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a physician Informed Consent (a process in which residents are given important information of the possible risk and benefits of the use of psychoactive medications) for the use of psychotropic medications (medication capable of affecting mind, emotions, and behavior) for one of three sampled residents (Resident 20) was obtained when Resident 20 was administered three psychotropic medications without an informed consent. These failures resulted for Resident 20 to be administered with psychotropic medications and not fully informed of the risk and benefits and did not have the knowledge to make an informed decision which could place Resident 20 at risk for negative side effects as he was not informed of the side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of eight sampled residents (Resident 13) had their adaptive equipment when Resident 13 was put in the wrong wheelchair. This failure had the potential to result in Resident 13 experiencing an avoidable accident and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Minimum Data Set assessment (MDS-assessment of physical and psychological functions and needs) accurately reflected resident's health and functional status for one of three sampled residents (Resident 20) when Resident 20's smoking habits was inaccurately coded on the MDS assessment. This failure had the potential to result in Resident 20's care needs not met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are receiving dialysis (the process of removing waste products and excess fluid from the body when the kidneys are not able to adequately filter the blood) treatment received services consistent with professional standards of practice for Resident 42 when Resident 42 had a water pitcher on the bedside table within Resident 42's reach for three consecutive days and in charge nurse did not monitor and record daily fluid intake. This failure placed Resident 42's care needs to go unmet and had the potential to result in fluid overload.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly when trash was found outside on the floor surrounding the dumpster. And the lid of the dumpster was not close properly. This failure had the potential to attract pests and rodents.