Is your loved one at Madera Post Acute Center?
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Madera Post Acute Center at a glance: owner, beds and ratings
* California separately requires at least 3.5 direct care service hours per patient day, counted under state rules, so the two numbers are not measured the same way.
Records: Cal Health Find ↗ · Medicare Care Compare ↗
Madera Post Acute Center citations and inspection findings
Newest first. State citations come from CDPH; federal deficiencies come from the CMS-2567 inspection report CDPH writes for Medicare. Every row links to the government record.
| Date | Source | Finding | Record |
|---|---|---|---|
| February 20, 2026 | State (CDPH) | Class B citation (Patient Care), penalty $3,000 | Government record (CDPH) ↗ |
| December 29, 2025 | Federal (CMS-2567), Complaint | F609 – Reporting of Alleged Violations, severity E (no actual harm, potential for more than minimal harm, pattern) Abuse | Government record (CDPH) ↗ |
| October 6, 2025 | State (CDPH) | Class B citation (Patient Care), penalty $3,000 | Government record (CDPH) ↗ |
| August 20, 2025 | State (CDPH) | Class B citation (Patient Care), penalty $3,000 | Government record (CDPH) ↗ |
| July 7, 2025 | Federal (CMS-2567), Certification | F689 – Free of Accident Hazards/Supervision/Devices, severity K (immediate jeopardy, a pattern) Falls / supervision › Read what inspectors found ↓ | Government record (CDPH) ↗ |
| May 15, 2025 | State (CDPH) | Administrative Penalty (DHPPD: 12 – 24 Days), penalty $50,000 | Government record (CDPH) ↗ |
| October 8, 2024 | Federal (CMS-2567), Complaint | F609 – Reporting of Alleged Violations, severity D (no actual harm, potential for more than minimal harm, isolated) Abuse | Government record (CDPH) ↗ |
| July 3, 2024 | State (CDPH) | Class A citation (Patient Care), penalty $25,000 Read what inspectors found ↓ | Government record (CDPH) ↗ |
| May 17, 2024 | Federal (CMS-2567), Complaint | F694 – Parenteral/IV Fluids, severity G (actual harm, one or a few residents) Read what inspectors found ↓ | Government record (CDPH) ↗ |
| June 12, 2023 | State (CDPH) | Class A citation (Patient Care), penalty $25,000 Read what inspectors found ↓ | Government record (CDPH) ↗ |
| May 4, 2023 | Federal (CMS-2567), Complaint | F656 – Develop/Implement Comprehensive Care Plan, severity G (actual harm, one or a few residents) Read what inspectors found ↓ | Government record (CDPH) ↗ |
What inspectors found at Madera Post Acute Center
Tap a finding to read the summary. Each one is written from the government report linked under it.
July 2025: F689 (severity K) after three residents who needed supervision while smoking kept cigarettes and lighters
The 2567 report states that during a July 2025 survey, inspectors found three residents (Residents 48, 50 and 64) who required supervision while smoking had cigarettes and lighters in their possession. The facility's own smoking policy did not allow residents to keep lighting materials, tobacco or smoking devices on their person or in the facility. Inspectors found staff did not follow care plans that said to keep these residents' smoking materials at the nurses' station and to watch Resident 64 while smoking on the patio.
The 2567 report states this could let the residents light up and smoke unsupervised inside the building and start a fire affecting all 135 residents, staff and visitors. The state survey agency called an Immediate Jeopardy situation on July 7, 2025, and removed it on July 8 after verifying that the facility had carried out its removal plan.
The 2567 report states the plan included taking the lighters and cigarettes from the three residents and locking them at a nurses' station, reviewing the smoking policy with them and with all other residents, completing smoking evaluations, checking every resident's room (no other smoking materials were found), training staff and adding checks for smoking materials every shift. Inspectors cited F689, on accident hazards and supervision, at severity K, the immediate jeopardy level for a pattern.
July 2024: Class A citation and F694 (severity G) after heavy bleeding from a resident's dialysis catheter
According to the citation, CDPH made an unannounced visit on May 18, 2024 to investigate a complaint about quality of care and treatment. Resident 1, a 40-year-old man with end stage kidney disease and type 2 diabetes, received hemodialysis (filtering of the blood) through a Permacath, a central venous catheter in his right upper chest. He also had an order for heparin, a blood thinner. On May 9, 2024, staff started an IV dextrose (sugar) infusion through the Permacath for low blood sugar.
CDPH found that a registered nurse supervisor did not flush the catheter with saline after the infusion, did not document it, and did not clamp and cap the catheter when it was not in use. Inspectors found licensed nurses did not carry out his care plan to monitor the catheter site for infection and bleeding. According to the citation, shortly after midnight on May 10, a nurse found "massive" bleeding from the Permacath, possibly from a ruptured catheter and missing locks. Staff applied pressure, clamped the port and increased his oxygen as his oxygen level dropped. Paramedics took him to an acute care hospital, where he was admitted to the intensive care unit.
The department determined this was a Class A violation and assessed a $25,000 penalty. The federal 2567 report from the same investigation cited F694, the rule on parenteral and IV fluids, at severity G, which means actual harm.
June 2023: Class A citation and F656 (severity G) after a resident who turned off his bed alarm fell and broke his hip
According to the citation, CDPH made an unannounced visit on May 4, 2023 to investigate a fall the facility had reported. Patient 1, an 81-year-old man, had a history of stroke and muscle weakness, used a walker and wheelchair, and had severely impaired cognition. He had been assessed as high risk for falls, had fallen before, and a physician had ordered a bed pad alarm to alert staff if he got out of bed alone because of poor safety awareness.
The department determined the facility did not develop and carry out a care plan to prevent his falls and did not address his known habit of turning off the bed pad alarm. According to the citation, at 4:45 a.m. on April 27, 2023, a nurse found him on the floor next to his bed. He said he had turned off the alarm because he did not want to hear the noise while getting up to get his wheelchair. Later that day he reported 10 out of 10 pain in his right hip, and an X-ray showed a displaced fracture of the right femoral neck (the top of the thigh bone at the hip). He was sent to an acute care hospital that evening, where doctors considered a partial hip replacement.
CDPH found these failures warranted a Class A citation with a $25,000 penalty. The federal 2567 report from the same investigation cited F656, on developing and carrying out a comprehensive care plan, at severity G, which means actual harm.
Complaints against Madera Post Acute Center
| Year | Intakes | Complaints | Facility-reported incidents | Substantiated (at least one allegation) |
|---|---|---|---|---|
| 2023 | 22 | 16 | 6 | 8 |
| 2024 | 28 | 13 | 15 | 14 |
| 2025 | 27 | 25 | 2 | 7 |
| 2026 | 58 | 47 | 11 | 6 |
Cal Health Find lists 135 complaint and facility-reported incident intakes for this facility from 2023 through October 30, 2026. CDPH substantiated at least one allegation in 35 of them. 36 intakes involved an allegation in CDPH’s abuse category, and 8 of those had an abuse allegation substantiated. An intake can contain several allegations; “unsubstantiated” means CDPH did not find enough evidence, not that nothing happened.
Sexual abuse reports at Madera Post Acute Center
Cal Health Find lists 2 intakes for Madera Post Acute Center from 2023 through October 30, 2026 that included an allegation CDPH classified as sexual abuse (1 from complaints and 1 reported by the facility itself). CDPH substantiated a sexual abuse allegation in 0 of them. Federal rules require a nursing home to report an abuse allegation to the state within two hours, so a facility-reported incident means staff raised the allegation, not that it was proven. “Unsubstantiated” means CDPH did not find enough evidence; it does not mean nothing happened.
| Year | Intakes with a sexual abuse allegation | Substantiated |
|---|---|---|
| 2024 | 2 | 0 |
Warning signs include bruising or bleeding in the genital area or inner thighs, a new genital infection, torn or stained underclothing, and a resident who suddenly fears a particular staff member or resists being bathed or changed. If you suspect sexual abuse, call 911 or local police first, ask that the resident not be bathed before a medical exam, and then report it to CDPH and the long-term care ombudsman. Sexual abuse reports at Los Angeles County nursing homes →
Madera Post Acute Center lawsuits and criminal cases
Our search of California Attorney General and Los Angeles County District Attorney announcements, court reports and news coverage for Madera Post Acute Center is not finished yet. This section will be updated when it is; until then, do not read the absence of a case here as a finding that none exists.
What this record means for your family
California uses classes for state citations. Under Health and Safety Code section 1424 ↗, a Class AA citation is a Class A violation that CDPH determined was a direct proximate cause of a resident’s death. A Class A citation means CDPH found an imminent danger, or a substantial probability, that death or serious physical harm would result. Class B covers violations with a direct or immediate relationship to residents’ health, safety or security.
Federal deficiencies carry a letter from A to L. G, H and I mean inspectors found actual harm to residents; J, K and L mean immediate jeopardy, the most serious level. F600 is the federal rule that residents be free from abuse and neglect; F609 and F610 cover reporting and investigating allegations; F689 covers accidents and supervision; F686 covers pressure injuries.
Warning signs worth asking about: unexplained bruises or fractures, new bed sores, sudden weight loss or dehydration, a resident who becomes fearful or withdrawn around certain staff, and calls that go unanswered.
What to do now
- If someone is in danger, call 911.
- File a complaint with CDPH about Madera Post Acute Center: CDPH complaint form ↗
- Contact the long-term care ombudsman, the state-funded advocate for nursing home residents: California Long-Term Care Ombudsman ↗
- Ask the facility in writing for a copy of the resident’s chart, and write down dates, names of staff on shift, and photos of any injury.
- Talk to a Los Angeles nursing home abuse lawyer →
Free nursing home case review
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Questions families ask
Has Madera Post Acute Center been cited by the State of California?
Cal Health Find lists 5 state citations for Madera Post Acute Center since 2023, including 0 Class AA and 2 Class A. Each one is listed in the timeline above with a link to the CDPH record.
How many complaints have been filed against Madera Post Acute Center?
From 2023 through October 30, 2026, Cal Health Find lists 135 complaint and facility-reported incident intakes, and CDPH substantiated at least one allegation in 35 of them.
Does Medicare flag Madera Post Acute Center for abuse?
As of our data date, Medicare Care Compare does not show its abuse icon for Madera Post Acute Center. The icon is only one signal; read the citations above.
Have there been sexual abuse reports at Madera Post Acute Center?
Cal Health Find lists 2 complaint or facility-reported incident intakes at Madera Post Acute Center since 2023 that included an allegation CDPH classified as sexual abuse, and CDPH substantiated 0. The section above breaks them down by year.
Where can I read reviews and complaints about Madera Post Acute Center?
Online reviews are opinions. The official record is the state and federal inspection file: this page summarizes it and links each citation, complaint outcome and inspection report on Cal Health Find and Medicare Care Compare, so you can read the source yourself.
How many beds does Madera Post Acute Center have?
Madera Post Acute Center is licensed by CDPH for 148 beds and has a CMS overall rating of 1 out of 5 stars.
Who owns or operates Madera Post Acute Center?
CDPH lists the licensee as GLIMMER HEALTHCARE, INC.. CMS lists the facility under the chain or affiliated entity The Ensign Group.
My parent was hurt at Madera Post Acute Center. What should I do?
Get medical care first, then report it to CDPH and the long-term care ombudsman, ask for the chart in writing and keep notes and photos. For a free, confidential review of a possible case, call Beverly Law at (310) 552-6959.
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If your loved one was hurt at Madera Post Acute Center, talk to a California elder abuse attorney. Free, confidential, English or Spanish. You pay no fees and no costs unless we win.
Other nursing homes near Madera Post Acute Center
| Facility | City | Distance | CMS stars | Class AA/A | Federal G–L |
|---|---|---|---|---|---|
| Penn Mar Healthcare Center | El Monte | 0.2 mi | 2/5 | 0 | 1 |
| Eastland Subacute and Rehabilitation Center | El Monte | 0.5 mi | 2/5 | 2 | 1 |
| Fidelity Health Care | El Monte | 1.2 mi | 5/5 | 0 | 0 |
| The Gardens of El Monte | El Monte | 1.4 mi | 2/5 | 1 | 1 |
| Mayflower Care Center | El Monte | 1.4 mi | 4/5 | 1 | 1 |
| Santa Fe Lodge | El Monte | 1.4 mi | 2/5 | 1 | 3 |
Methodology and sources
We pulled this facility’s complaints, state enforcement actions and survey deficiencies from Cal Health Find for 2023 through October 30, 2026, downloaded the CDPH citation notices and CMS-2567 reports behind every Class AA or A citation and every federal deficiency at level G or higher, and wrote the summaries above from those documents. Facility details come from the CDPH licensing file and the CMS Provider Data Catalog. Residents are described only as the government documents describe them. See the methodology page to report an error; we review correction requests within five business days.
Sources
Important: This page reports findings from public records of the California Department of Public Health and the Centers for Medicare & Medicaid Services. A citation or deficiency is a regulatory finding by a government agency; it is not a court judgment and not proof of civil or criminal liability. Criminal defendants are presumed innocent unless proven guilty. Lawsuit allegations are claims, not findings. This page is general information, not legal advice, and reading it does not create an attorney-client relationship with Beverly Law. Attorney advertising. Prior results do not guarantee a similar outcome. Data as of: October 30, 2026. Methodology and corrections.
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