Madera Post Acute Center
11900 Ramona Boulevard · El Monte, CA · 91732 · 6264425721
148 certified beds For profit - Corporation Chain: The Ensign Group
Why this verdict
- Inspectors found immediate jeopardy — danger of serious harm or death — in the most recent cycle (1 citation).
- Inspection record is far worse than the national median (deficiency count and severity).
- Inspection results are getting worse cycle over cycle, not better.
The complete Safety Report — $19
Everything on this page plus the full citation-by-citation history with inspector findings, the complete penalty record, staffing vs benchmarks, side-by-side nearby comparisons, and the printable tour checklist. One PDF, emailed in minutes, yours to keep and share with family.
Red flags
1 immediate-jeopardy citation in the most recent inspection cycle
Immediate jeopardy is the most serious finding an inspector can make: a situation likely to cause serious injury, harm, or death.
If someone you love was harmed at a facility with findings like these, you have options — read this.
Score breakdown
Quality-measure stars are deliberately excluded — they're largely self-reported by facilities. Full method.
CMS ratings & staffing
Overall: 1 of 5 Inspections: 1 of 5 Staffing: 3 of 5 Quality measures: 4 of 5
| Total nurse hours / resident-day | 3.99 | 3.48 min · 4.1 strong |
|---|---|---|
| RN hours / resident-day | 0.37 | 0.55–0.75 |
| Weekend hours / resident-day | 3.42 | ≈ weekday level |
| Nursing turnover / year | 46% | median 45% |
| Fines (3-yr window) | 2 · $29,517 |
Inspection citations (67 in the current record)
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Potential for harm · D April 23, 2026 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Deficient, Provider has no plan of correction · Resident Rights
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Potential for harm · D April 23, 2026 · found via complaint
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Deficient, Provider has no plan of correction · Resident Rights
-
Potential for harm · D April 23, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Deficient, Provider has no plan of correction · Quality of Life and Care
-
Potential for harm · D April 23, 2026 · found via complaint
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Deficient, Provider has no plan of correction · Resident Assessment and Care Planning
-
Potential for harm · D April 8, 2026 · found via complaint
Reasonably accommodate the needs and preferences of each resident.
Corrected May 1, 2026 · Resident Rights
-
Potential for harm · D March 16, 2026 · found via complaint
Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.
Corrected April 2, 2026 · Resident Rights
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Potential for harm · E March 16, 2026 · found via complaint
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected April 2, 2026 · Resident Assessment and Care Planning
-
Potential for harm · D March 16, 2026 · found via complaint
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.
Corrected April 2, 2026 · Pharmacy Service
-
Potential for harm · D March 16, 2026 · found via complaint
Have policies on smoking.
Corrected April 2, 2026 · Environmental
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Potential for harm · E January 28, 2026 · found via complaint
Provide enough food/fluids to maintain a resident's health.
Corrected February 14, 2026 · Quality of Life and Care
-
Potential for harm · E January 6, 2026 · found via complaint
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Corrected January 30, 2026 · Freedom from Abuse, Neglect, and Exploitation
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Potential for harm · E January 6, 2026 · found via complaint
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected January 30, 2026 · Quality of Life and Care
-
Potential for harm · E January 6, 2026 · found via complaint
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected January 30, 2026 · Nutrition and Dietary
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Potential for harm · E August 21, 2025 · found via complaint
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected September 12, 2025 · Quality of Life and Care
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Immediate jeopardy · K July 10, 2025
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Corrected July 24, 2025 · Quality of Life and Care
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Potential for harm · E July 10, 2025
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected July 30, 2025 · Resident Rights
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Potential for harm · D July 10, 2025
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.
Corrected July 30, 2025 · Resident Rights
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Potential for harm · E July 10, 2025
Ensure each resident receives an accurate assessment.
Corrected July 30, 2025 · Resident Assessment and Care Planning
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Potential for harm · E July 10, 2025
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Corrected July 30, 2025 · Resident Assessment and Care Planning
-
Potential for harm · D July 10, 2025
Provide appropriate treatment and care according to orders, resident’s preferences and goals.
Corrected July 30, 2025 · Quality of Life and Care
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Potential for harm · D July 10, 2025
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.
Corrected July 30, 2025 · Quality of Life and Care
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Potential for harm · D July 10, 2025
Provide special eating equipment and utensils for residents who need them and appropriate assistance.
Corrected July 30, 2025 · Nutrition and Dietary
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Potential for harm · E July 10, 2025
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected July 25, 2025 · Nutrition and Dietary
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Potential for harm · E July 10, 2025
Provide and implement an infection prevention and control program.
Corrected July 30, 2025 · Infection Control
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Potential for harm · D July 10, 2025
Keep all essential equipment working safely.
Corrected July 30, 2025 · Environmental
Showing the 25 most recent. The Safety Report includes every citation with full findings.
Federal penalties
| Date | Type | Amount / length |
|---|---|---|
| July 10, 2025 | Fine | $13,319 |
| May 17, 2024 | Fine | $16,198 |
Family & resident reviews — a separate signal, never mixed into the score
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Source: CMS Care Compare (public domain), data as of June 1, 2026 · CCN 055141 · certified since November 1, 1971. The score is a screen, not a verdict on any one resident's experience — read how it's computed, then visit in person.