Facility Watch Inspection records for every certified US nursing home

Madera Post Acute Center

11900 Ramona Boulevard
EL Monte, CA 91732
(626) 442-5721

CCN
055141
Certified beds
148
Ownership
For profit - Corporation
Chain
THE Ensign Group

Nurse staffing

4.07
Total nurse staffing hours per resident per day, case-mix adjusted

Registered nurses: 0.37 hours per resident per day

Nursing staff turnover: 46% a year

Derived by CMS from the Payroll-Based Journal and refreshed quarterly.

Inspection history

Inspected April 23, 2026

4 citations · from a complaint investigation · Health
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has no plan of correction
D
F0580 No actual harm with potential for more than minimal harm · Isolated

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
D
F0689 No actual harm with potential for more than minimal harm · Isolated

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
D
F0842 No actual harm with potential for more than minimal harm · Isolated

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

Inspected April 8, 2026

1 citation · from a complaint investigation · Health
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected May 1, 2026

Inspected March 16, 2026

4 citations · from a complaint investigation · Health
D
F0557 No actual harm with potential for more than minimal harm · Isolated

Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions.

Deficient, Provider has date of correction · corrected April 2, 2026
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected April 2, 2026
D
F0926 No actual harm with potential for more than minimal harm · Isolated

Have policies on smoking.

Deficient, Provider has date of correction · corrected April 2, 2026
E
F0656 No actual harm with potential for more than minimal harm · Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected April 2, 2026

Inspected January 28, 2026

1 citation · from a complaint investigation · Health
E
F0692 No actual harm with potential for more than minimal harm · Pattern

Provide enough food/fluids to maintain a resident's health.

Deficient, Provider has date of correction · corrected February 14, 2026

Inspected January 6, 2026

3 citations · from a complaint investigation · Health
E
F0609 No actual harm with potential for more than minimal harm · Pattern

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected January 30, 2026
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected January 30, 2026
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected January 30, 2026

Inspected August 21, 2025

1 citation · from a complaint investigation · Health
E
F0684 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected September 12, 2025

Inspected July 10, 2025

12 citations · Health
B
F0732 No actual harm with potential for minimal harm · Pattern

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected July 30, 2025
D
F0584 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 30, 2025
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected July 30, 2025
D
F0700 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected July 30, 2025
D
F0810 No actual harm with potential for more than minimal harm · Isolated

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Deficient, Provider has date of correction · corrected July 30, 2025
D
F0908 No actual harm with potential for more than minimal harm · Isolated

Keep all essential equipment working safely.

Deficient, Provider has date of correction · corrected July 30, 2025
E
F0550 No actual harm with potential for more than minimal harm · Pattern

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Deficient, Provider has date of correction · corrected July 30, 2025
E
F0641 No actual harm with potential for more than minimal harm · Pattern

Ensure each resident receives an accurate assessment.

Deficient, Provider has date of correction · corrected July 30, 2025
E
F0656 No actual harm with potential for more than minimal harm · Pattern

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected July 30, 2025
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected July 25, 2025
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected July 30, 2025
K
F0689 Immediate jeopardy to resident health or safety · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected July 24, 2025

Inspected April 7, 2025

1 citation · from a complaint investigation · Health
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected May 1, 2025

Inspected March 19, 2025

1 citation · from a complaint investigation · Health
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected April 9, 2025

Inspected February 5, 2025

2 citations · from a complaint investigation · Health
D
F0580 No actual harm with potential for more than minimal harm · Isolated

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 date of correction · corrected March 3, 2025
D
F0684 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Deficient, Provider has date of correction · corrected March 3, 2025

Inspected December 16, 2024

1 citation · from a complaint investigation · Health
D
F0658 No actual harm with potential for more than minimal harm · Isolated

Ensure services provided by the nursing facility meet professional standards of quality.

Deficient, Provider has date of correction · corrected January 7, 2025

Inspected October 10, 2024

1 citation · from a complaint investigation · Health
D
F0609 No actual harm with potential for more than minimal harm · Isolated

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Deficient, Provider has date of correction · corrected November 1, 2024

Inspected October 9, 2024

1 citation · from a complaint investigation · Health
D
F0758 No actual harm with potential for more than minimal harm · Isolated

Implement 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.

Deficient, Provider has date of correction · corrected October 28, 2024

Inspected July 19, 2024

12 citations · Health
B
F0732 No actual harm with potential for minimal harm · Pattern

Post nurse staffing information every day.

Deficient, Provider has date of correction · corrected August 7, 2024
D
F0578 No actual harm with potential for more than minimal harm · Isolated

Honor 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.

Deficient, Provider has date of correction · corrected August 7, 2024
D
F0688 No actual harm with potential for more than minimal harm · Isolated

Provide 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.

Deficient, Provider has date of correction · corrected August 9, 2024
D
F0695 No actual harm with potential for more than minimal harm · Isolated

Provide safe and appropriate respiratory care for a resident when needed.

Deficient, Provider has date of correction · corrected August 8, 2024
D
F0849 No actual harm with potential for more than minimal harm · Isolated

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Deficient, Provider has date of correction · corrected August 8, 2024
E
F0558 No actual harm with potential for more than minimal harm · Pattern

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected August 6, 2024
E
F0676 No actual harm with potential for more than minimal harm · Pattern

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Deficient, Provider has date of correction · corrected August 5, 2024
E
F0689 No actual harm with potential for more than minimal harm · Pattern

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected August 8, 2024
E
F0690 No actual harm with potential for more than minimal harm · Pattern

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Deficient, Provider has date of correction · corrected August 8, 2024
E
F0693 No actual harm with potential for more than minimal harm · Pattern

Ensure 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.

Deficient, Provider has date of correction · corrected August 8, 2024
E
F0700 No actual harm with potential for more than minimal harm · Pattern

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.

Deficient, Provider has date of correction · corrected August 12, 2024
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected August 12, 2024

Inspected May 17, 2024

2 citations · from a complaint investigation · Health
D
F0842 No actual harm with potential for more than minimal harm · Isolated

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Deficient, Provider has date of correction · corrected June 14, 2024
G
F0694 Actual harm · Isolated

Provide for the safe, appropriate administration of IV fluids for a resident when needed.

Deficient, Provider has date of correction · corrected June 14, 2024

Inspected March 8, 2024

2 citations · from a complaint investigation · Health
D
F0725 No actual harm with potential for more than minimal harm · Isolated

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Deficient, Provider has date of correction · corrected March 27, 2024
D
F0919 No actual harm with potential for more than minimal harm · Isolated

Make sure that a working call system is available in each resident's bathroom and bathing area.

Deficient, Provider has date of correction · corrected March 27, 2024

Inspected October 21, 2021

18 citations · Health
D
F0552 No actual harm with potential for more than minimal harm · Isolated

Ensure that residents are fully informed and understand their health status, care and treatments.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0558 No actual harm with potential for more than minimal harm · Isolated

Reasonably accommodate the needs and preferences of each resident.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0583 No actual harm with potential for more than minimal harm · Isolated

Keep residents' personal and medical records private and confidential.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0656 No actual harm with potential for more than minimal harm · Isolated

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0657 No actual harm with potential for more than minimal harm · Isolated

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0685 No actual harm with potential for more than minimal harm · Isolated

Assist a resident in gaining access to vision and hearing services.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0686 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0689 No actual harm with potential for more than minimal harm · Isolated

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0691 No actual harm with potential for more than minimal harm · Isolated

Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0697 No actual harm with potential for more than minimal harm · Isolated

Provide safe, appropriate pain management for a resident who requires such services.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0755 No actual harm with potential for more than minimal harm · Isolated

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0761 No actual harm with potential for more than minimal harm · Isolated

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.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0825 No actual harm with potential for more than minimal harm · Isolated

Provide or get specialized rehabilitative services as required for a resident.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0849 No actual harm with potential for more than minimal harm · Isolated

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Deficient, Provider has date of correction · corrected December 1, 2021
D
F0881 No actual harm with potential for more than minimal harm · Isolated

Implement a program that monitors antibiotic use.

Deficient, Provider has date of correction · corrected December 1, 2021
E
F0578 No actual harm with potential for more than minimal harm · Pattern

Honor 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.

Deficient, Provider has date of correction · corrected December 1, 2021
E
F0812 No actual harm with potential for more than minimal harm · Pattern

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Deficient, Provider has date of correction · corrected December 1, 2021
E
F0880 No actual harm with potential for more than minimal harm · Pattern

Provide and implement an infection prevention and control program.

Deficient, Provider has date of correction · corrected December 1, 2021

Penalties

DateTypeAmount
July 10, 2025Fine$13,319
May 17, 2024Fine$16,198

Ownership transfers

EffectiveSellerBuyer
02/01/2023Ramona Care, Inc.Glimmer Healthcare INC

From the CMS Skilled Nursing Facility Change of Ownership dataset. A sale does not by itself say anything about care quality.