The nursing home failed to keep the area free of hazards and provide enough supervision to prevent accidents. Cited July 2025 — limited pattern, immediate jeopardy to residents.
View the original federal record
F-Tag 689 — 42 CFR §483.25(d) — S/S: K
Nursing home report
Madera Post Acute Center
EL MONTE, CA · Medicare-certified · 148 beds
Needs attention
For-profitChain member
1 of 5 overall
Madera Post Acute Center in El Monte, CA has an overall rating of 1 out of 5 stars, with a 1-star health inspection rating and 3-star staffing. Reported nurse staffing is 3.99 hours per resident per day, slightly below the federal benchmark of 4.1, and the facility had $29,517 in fines in the last 24 months, including a recent federal penalty.
Facility ratings
Health inspections
Staffing
3.99 hrs/resident/day
Quality measures
Last inspection: March 16, 2026Penalties, last 24 months: $29,517recent federal penalty
Federal guidance recommends at least 4.1 nursing hours per resident each day. This facility reports 3.99.
Staffing detail
- Registered nurses
- 0.37
- Licensed practical nurses
- 1.10
- Nurse aides
- 2.52
- Weekend nursing
- 3.42
Hours per resident per day.
Total staff turnover: 46%
Registered nurse turnover: 33%
Resident outcomes
Each measure compares a year ago with the most recent quarter. Green means the facility moved the right way; red means the wrong way.
Negative outcomes
Lower is better — fewer affected residents. A decrease is good (green); an increase is concerning (red).
Long-stay residents on antipsychotic medication
14.5%10.3%Improving
Residents with a fall causing major injury
1.7%0.8%Improving
Residents with pressure ulcers (bedsores)
4.1%5.2%Worsening
Residents with a urinary tract infection
1.9%0%Improving
Residents who lost too much weight
0%0%No change
Residents who were physically restrained
0%0%No change
Residents needing more help with daily activities
16.7%8.2%Improving
Residents whose ability to walk got worse
18.2%14.7%Improving
Long-stay residents on antianxiety or sleep medication
16.8%13.9%Improving
Short-stay residents newly given an antipsychotic
4%0%Improving
Residents with a long-term catheter
0%0.6%Worsening
Residents with new or worsening incontinence
20%17.8%Improving
Residents with depressive symptoms
4%3%Improving
Positive outcomes
Higher is better — e.g. vaccinations. An increase is good (green); a decrease is concerning (red).
Long-stay residents given the seasonal flu vaccine
—100%—
Long-stay residents given the pneumonia vaccine
100%100%No change
Short-stay residents given the seasonal flu vaccine
—96.7%—
Short-stay residents given the pneumonia vaccine
97.4%99%Improving
What the inspectors found
The home failed to ensure IV fluids were given safely and appropriately when needed. Cited May 2024 — isolated incident, actual harm.
View the original federal record
F-Tag 694 — 42 CFR §483.25 — S/S: G
The nursing home failed to develop and carry out a complete care plan that met each resident’s needs with clear steps and timelines. Cited May 2023 — isolated incident, actual harm.
View the original federal record
F-Tag 656 — 42 CFR §483.21(b)(1) — S/S: G
The home failed to provide enough food and fluids to keep residents healthy. Cited January 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 692 — 42 CFR §483.25(g) — S/S: E
The home failed to promptly report suspected abuse, neglect, or theft and share the investigation results with the proper authorities. Cited January 2026 — limited pattern, potential for harm.
View the original federal record
F-Tag 609 — 42 CFR §483.12 — S/S: E
Recent history
- STAFFING
Reported nurse staffing was below the federal recommendation of 4.1 hours per resident per day.
- INSPECTION
Health inspection found 4 health deficiencies.
See what inspectors found
- INSPECTION
Health inspection found 1 health deficiency.
See what inspectors found
- INSPECTION
Health inspection found 3 health deficiencies.
See what inspectors found
- PENALTY
A federal fine of $13,319 was recorded.
- PENALTY
A federal fine of $16,198 was recorded.
Penalties & enforcement
On record with Medicare: 2 fines · $29,517 in total fines.
- $13,319
Federal fine
Jul 10, 2025
- $16,198
Federal fine
May 17, 2024
Operator & ownership
- Ownership
- For profit - Corporation
- Chain
- Part of THE ENSIGN GROUP · 338 homes · 3.2 stars avg
- Occupancy
- 132.4 residents on an average day (89% of 148 beds)
- Resident voice
- Resident council
- Medicare history
- Certified for 54 years
Things at a nursing home change — inspections, staffing, ownership, news.
Source: Centers for Medicare & Medicaid Services — public records, updated monthly. GoodStanding presents official records with plain-language summaries. Always visit a facility in person.