Starfile / California

Madera Post Acute Center

11900 RAMONA BOULEVARD, EL MONTE, CA 91732 · CCN 055141

Inspection history vs California & national averages

Cycle 1 is the most recent standard health inspection. Lower total deficiency counts are better.

Cycle 1 deficiencies by category

Staffing (hours per resident per day)

Fines & penalties

Total fines

$38,341

Number of fines

3

Number of penalties

3

Payment denials

0

Chain

Chain

THE ENSIGN GROUP

Facilities in chain

329

Chain avg overall

3.20 / 5

Inspection citations (64)1 immediate jeopardy2 actual harm

1. EF0692Provide enough food/fluids to maintain a resident's health.2026-01-28 · Health

   Potential for more than minimal harm

2. EF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2026-01-06 · Health · corrected 2026-01-30

   Potential for more than minimal harm

3. EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2026-01-06 · Health · corrected 2026-01-30

   Potential for more than minimal harm

4. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2026-01-06 · Health · corrected 2026-01-30

   Potential for more than minimal harm

5. EF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-08-21 · Health · corrected 2025-09-12

   Potential for more than minimal harm

6. EF0550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.2025-07-10 · Health · corrected 2025-07-30

   Potential for more than minimal harm

7. DF0584Honor 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.2025-07-10 · Health · corrected 2025-07-30

   Potential for more than minimal harm

8. EF0641Ensure each resident receives an accurate assessment.2025-07-10 · Health · corrected 2025-07-30

   Potential for more than minimal harm

9. EF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2025-07-10 · Health · corrected 2025-07-30

   Potential for more than minimal harm

10. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-07-10 · Health · corrected 2025-07-30

    Potential for more than minimal harm

11. KF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2025-07-10 · Health · corrected 2025-07-24

    Immediate jeopardy

12. DF0700Try 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.2025-07-10 · Health · corrected 2025-07-30

    Potential for more than minimal harm

13. BF0732Post nurse staffing information every day.2025-07-10 · Health · corrected 2025-07-30

    Potential for minimal harm

14. DF0810Provide special eating equipment and utensils for residents who need them and appropriate assistance.2025-07-10 · Health · corrected 2025-07-30

    Potential for more than minimal harm

15. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2025-07-10 · Health · corrected 2025-07-25

    Potential for more than minimal harm

16. EF0880Provide and implement an infection prevention and control program.2025-07-10 · Health · corrected 2025-07-30

    Potential for more than minimal harm

17. DF0908Keep all essential equipment working safely.2025-07-10 · Health · corrected 2025-07-30

    Potential for more than minimal harm

18. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-04-07 · Health · corrected 2025-05-01

    Potential for more than minimal harm

19. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2025-03-19 · Health · corrected 2025-04-09

    Potential for more than minimal harm

20. DF0580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.2025-02-05 · Health · corrected 2025-03-03

    Potential for more than minimal harm

21. DF0684Provide appropriate treatment and care according to orders, resident’s preferences and goals.2025-02-05 · Health · corrected 2025-03-03

    Potential for more than minimal harm

22. DF0658Ensure services provided by the nursing facility meet professional standards of quality.2024-12-16 · Health · corrected 2025-01-07

    Potential for more than minimal harm

23. DF0609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.2024-10-10 · Health · corrected 2024-11-01

    Potential for more than minimal harm

24. DF0758Implement 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.2024-10-09 · Health · corrected 2024-10-28

    Potential for more than minimal harm

25. EF0558Reasonably accommodate the needs and preferences of each resident.2024-07-19 · Health · corrected 2024-08-06

    Potential for more than minimal harm

26. DF0578Honor 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.2024-07-19 · Health · corrected 2024-08-07

    Potential for more than minimal harm

27. EF0676Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.2024-07-19 · Health · corrected 2024-08-05

    Potential for more than minimal harm

28. DF0688Provide 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.2024-07-19 · Health · corrected 2024-08-09

    Potential for more than minimal harm

29. EF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2024-07-19 · Health · corrected 2024-08-08

    Potential for more than minimal harm

30. EF0690Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.2024-07-19 · Health · corrected 2024-08-08

    Potential for more than minimal harm

31. EF0693Ensure 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.2024-07-19 · Health · corrected 2024-08-08

    Potential for more than minimal harm

32. DF0695Provide safe and appropriate respiratory care for a resident when needed.2024-07-19 · Health · corrected 2024-08-08

    Potential for more than minimal harm

33. EF0700Try 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.2024-07-19 · Health · corrected 2024-08-12

    Potential for more than minimal harm

34. BF0732Post nurse staffing information every day.2024-07-19 · Health · corrected 2024-08-07

    Potential for minimal harm

35. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2024-07-19 · Health · corrected 2024-08-12

    Potential for more than minimal harm

36. DF0849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.2024-07-19 · Health · corrected 2024-08-08

    Potential for more than minimal harm

37. GF0694Provide for the safe, appropriate administration of IV fluids for a resident when needed.2024-05-17 · Health · corrected 2024-06-14

    Actual harm

38. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2024-05-17 · Health · corrected 2024-06-14

    Potential for more than minimal harm

39. DF0725Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.2024-03-08 · Health · corrected 2024-03-27

    Potential for more than minimal harm

40. DF0919Make sure that a working call system is available in each resident's bathroom and bathing area.2024-03-08 · Health · corrected 2024-03-27

    Potential for more than minimal harm

41. DF0842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.2023-05-23 · Health · corrected 2023-06-09

    Potential for more than minimal harm

42. DF0604Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.2023-05-16 · Health · corrected 2023-06-05

    Potential for more than minimal harm

43. GF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2023-05-16 · Health · corrected 2023-06-05

    Actual harm

44. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2023-05-16 · Health · corrected 2023-06-05

    Potential for more than minimal harm

45. EF0880Provide and implement an infection prevention and control program.2023-04-19 · Health · corrected 2023-05-30

    Potential for more than minimal harm

46. DF0886Perform COVID19 testing on residents and staff.2023-04-19 · Health · corrected 2023-05-30

    Potential for more than minimal harm

47. DF0552Ensure that residents are fully informed and understand their health status, care and treatments.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

48. DF0558Reasonably accommodate the needs and preferences of each resident.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

49. EF0578Honor 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.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

50. DF0583Keep residents' personal and medical records private and confidential.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

51. DF0656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

52. DF0657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

53. DF0685Assist a resident in gaining access to vision and hearing services.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

54. DF0686Provide appropriate pressure ulcer care and prevent new ulcers from developing.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

55. DF0689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

56. DF0691Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

57. DF0697Provide safe, appropriate pain management for a resident who requires such services.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

58. DF0755Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

59. DF0761Ensure 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.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

60. EF0812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

61. DF0825Provide or get specialized rehabilitative services as required for a resident.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

62. DF0849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

63. EF0880Provide and implement an infection prevention and control program.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

64. DF0881Implement a program that monitors antibiotic use.2021-10-21 · Health · corrected 2021-12-01

    Potential for more than minimal harm

Ownership

Other facilities in EL MONTE

Source: CMS Provider Data Catalog, Nursing Home Care Compare files (processed 2026-03-01). Citations show the 3 most recent inspection cycles.