CaliforniaMadera

Madera Rehabilitation & Nursing Center

517 South A Street, Madera, CA 93638 · Madera County · 176 certified beds · avg 168 residents/day · certified since Jan 1, 1967

Part of chain: CAMBRIDGE HEALTHCARE SERVICES (32 facilities, chain avg rating 2.5★)

1/5
Health inspection rating (on-site)
7
Serious findings on record
$373,733
Fines, last 3 years
3.97
Nurse hours/resident/day (adjusted)

What health inspectors found (on-site government inspections — the most independent evidence available)

Health inspection rating: ★☆☆☆☆1/5 · CMS overall rating: 1/5

The health inspection star above is graded on a curve within each state — a set share of each state's facilities gets each star level — so a facility can have few citations and still rate 2–3 stars if others in its state did even better. The overall rating combines that inspection score with staffing and self-reported quality measures.

Most serious findings (actual harm or immediate jeopardy)

▲ Immediate jeopardy, repeated · Mar 7, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.

Corrected: May 7, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Aug 14, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Sep 27, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Aug 14, 2025 · F-0692

The facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.

Why it matters: Malnutrition and dehydration can quickly weaken a resident and lead to serious complications.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Sep 27, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Apr 15, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 7, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · Jan 9, 2025 · F-0689 · triggered by a complaint

The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls.

Why it matters: This is one of the most common citations and directly relates to falls and injuries, which can be devastating for older adults.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: May 7, 2025 (Deficient, Provider has date of correction)

▲ Actual harm, one-off · May 2, 2024 · F-0684 · triggered by a complaint

The facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals.

Why it matters: Care that strays from doctor's orders or ignores the resident's wishes can lead to declining health and avoidable harm.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Apr 26, 2024 (Past Non-Compliance)

▲ Actual harm, one-off · Apr 4, 2024 · F-0580 · triggered by a complaint

The facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away.

Why it matters: A family could learn about a serious injury or decline days later, after the chance to act has passed.

Severity (G): One or a few residents were actually harmed — physically or emotionally — though not put in immediate danger of serious injury or death.

Corrected: Apr 26, 2024 (Deficient, Provider has date of correction)

All citations in the current public record (71)

CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.

DateSeverityWhat the facility was cited for
Feb 24, 2026E · Potential for harm, repeatedThe facility did not keep all essential equipment working safely — things like heating and cooling systems, kitchen equipment, and medical devices. · from a complaint
Feb 11, 2026E · Potential for harm, repeatedThe facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. · from a complaint
Feb 11, 2026E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Aug 14, 2025▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Aug 14, 2025▲ G · Actual harm, one-offThe facility did not provide enough food and fluids to keep residents healthy, such as preventing unplanned weight loss or dehydration.
Aug 14, 2025F · Potential for harm, facility-wideThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Aug 14, 2025F · Potential for harm, facility-wideThe facility did not serve food and drinks that were appetizing, attractive, and at a safe and pleasant temperature.
Aug 14, 2025F · Potential for harm, facility-wideThe facility did not make sure special medical diets — like low-sodium or diabetic diets — were properly ordered by the resident's doctor or managed by a qualified dietitian as state law allows.
Aug 14, 2025F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Aug 14, 2025F · Potential for harm, facility-wideThe facility did not conduct and document a facility-wide assessment of what staff, supplies, and resources it needs to care for its residents properly — during everyday operations, nights, weekends, and emergencies.
Aug 14, 2025E · Potential for harm, repeatedThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Aug 14, 2025E · Potential for harm, repeatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Aug 14, 2025E · Potential for harm, repeatedThe facility did not provide pharmacy services that meet each resident's needs, or did not employ or contract with a licensed pharmacist.
Aug 14, 2025E · Potential for harm, repeatedThe facility did not provide special eating equipment and utensils — like adaptive cups or easy-grip silverware — for residents who need them, along with appropriate help at meals.
Aug 14, 2025D · Potential for harm, one-offThe facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand.
Aug 14, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives.
Aug 14, 2025D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Aug 14, 2025D · Potential for harm, one-offThe facility did not have a licensed pharmacist review each resident's complete medication regimen and medical chart every month, or did not follow its own rules for reporting medication problems.
Aug 14, 2025D · Potential for harm, one-offThe facility did not keep residents' medications free from unnecessary drugs. Residents should only take medicines they truly need, at the right dose, for a clear reason.
Aug 14, 2025D · Potential for harm, one-offThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Aug 14, 2025D · Potential for harm, one-offThe facility did not prepare and serve food in a form that meets each resident's individual needs — for example, chopped, pureed, or softened food for residents with chewing or swallowing problems.
Aug 14, 2025D · Potential for harm, one-offThe facility did not have a policy covering how food brought in by family and visitors is used and stored safely.
Aug 14, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Aug 14, 2025B · Minimal risk, repeatedThe facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
Jun 10, 2025E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Jun 10, 2025E · Potential for harm, repeatedThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Apr 15, 2025▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Apr 15, 2025E · Potential for harm, repeatedThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Apr 15, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 7, 2025▲ K · Immediate jeopardy, repeatedThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Mar 7, 2025F · Potential for harm, facility-wideThe facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. · from a complaint
Mar 7, 2025E · Potential for harm, repeatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines. · from a complaint
Mar 7, 2025E · Potential for harm, repeatedThe facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. · from a complaint
Mar 7, 2025E · Potential for harm, repeatedThe facility did not arrange hospice services for a resident who needed them, or help the resident move to a facility that could arrange hospice. Hospice provides comfort-focused care for people nearing the end of life. · from a complaint
Mar 7, 2025E · Potential for harm, repeatedThe facility did not have a written plan describing how it runs its quality improvement program — the ongoing process of finding problems in care and fixing them. · from a complaint
Mar 7, 2025D · Potential for harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Mar 7, 2025D · Potential for harm, one-offThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. · from a complaint
Mar 7, 2025D · Potential for harm, one-offThe facility did not report suspected abuse, neglect, or theft to the proper authorities quickly enough, or did not report the results of its investigation. · from a complaint
Mar 7, 2025D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Mar 7, 2025D · Potential for harm, one-offThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Jan 9, 2025▲ G · Actual harm, one-offThe facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint
Jan 9, 2025F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide. · from a complaint
Jan 9, 2025E · Potential for harm, repeatedThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Jan 9, 2025E · Potential for harm, repeatedThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Jan 9, 2025D · Potential for harm, one-offThe facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. · from a complaint
Nov 22, 2024D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Jun 21, 2024F · Potential for harm, facility-wideThe facility did not have or follow an effective program to prevent and control infections — such as proper hand washing, cleaning, and isolation practices. This is the most commonly cited deficiency nationwide.
Jun 21, 2024E · Potential for harm, repeatedThe facility did not honor residents' rights to request, refuse, or stop treatment, to decline participation in medical research, or to make an advance directive — a written statement of their wishes for future medical care.
Jun 21, 2024E · Potential for harm, repeatedThe facility did not give residents (and their representatives and the ombudsman, a state advocate for residents) proper advance notice before a transfer or discharge, including information about their right to appeal.
Jun 21, 2024E · Potential for harm, repeatedThe facility did not give the resident or their representative written notice of how long it would hold the resident's bed during a hospital stay or approved leave.
Jun 21, 2024E · Potential for harm, repeatedThe facility did not develop or follow a complete care plan for each resident — the written roadmap covering all of a resident's needs, with measurable goals and timelines.
Jun 21, 2024E · Potential for harm, repeatedThe facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
Jun 21, 2024D · Potential for harm, one-offThe facility did not bring in qualified outside professionals to provide a required service when it didn't have a qualified professional on staff.
May 2, 2024▲ G · Actual harm, one-offThe facility did not provide treatment and care that follows the doctor's orders and matches the resident's own preferences and goals. · from a complaint
Apr 4, 2024▲ G · Actual harm, one-offThe facility did not immediately notify the resident, their doctor, and a family member when something significant happened — such as an injury, a decline in health, or a room change. Families and doctors are entitled to know right away. · from a complaint
Apr 4, 2024E · Potential for harm, repeatedThe facility did not create and follow a basic care plan covering a new resident's most immediate needs within 48 hours of admission. The first days are when a new resident is most vulnerable. · from a complaint
Apr 4, 2024D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. · from a complaint
Mar 8, 2024D · Potential for harm, one-offThe facility did not develop a resident's complete plan of care within 7 days of the full assessment, or the plan wasn't prepared, reviewed, and updated by a team of health professionals as required. · from a complaint
Nov 15, 2023D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors. · from a complaint
Apr 26, 2019F · Potential for harm, facility-wideThe facility did not make its inspection results easy for residents to see, or made it hard for residents to contact advocacy agencies like the ombudsman.
Apr 26, 2019F · Potential for harm, facility-wideThe facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards.
Apr 26, 2019E · Potential for harm, repeatedThe facility did not make reasonable adjustments to fit each resident's individual needs and preferences — things like call buttons within reach, preferred wake-up times, or accessible room setups.
Apr 26, 2019E · Potential for harm, repeatedThe facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs.
Apr 26, 2019E · Potential for harm, repeatedThe facility did not label drugs according to professional standards or did not store them in locked compartments, with controlled drugs (medications with a high risk of misuse) kept under a separate lock.
Apr 26, 2019E · Potential for harm, repeatedThe facility had resident rooms smaller than required — at least 80 square feet per person in shared rooms and 100 square feet in single rooms.
Apr 26, 2019E · Potential for harm, repeatedThe facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors.
Apr 26, 2019D · Potential for harm, one-offThe facility did not treat residents with dignity and respect, or did not honor their rights to make their own decisions and communicate freely. This is one of the most fundamental resident rights.
Apr 26, 2019D · Potential for harm, one-offThe facility did not protect residents from abuse or neglect. This covers physical, mental, and sexual abuse, physical punishment, and neglect, by anyone — staff, other residents, or visitors.
Apr 26, 2019D · Potential for harm, one-offThe facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow.
Apr 26, 2019D · Potential for harm, one-offThe facility did not provide the help residents need with basic daily activities — like bathing, dressing, eating, and using the bathroom — for residents who cannot do these things on their own.
Apr 26, 2019D · Potential for harm, one-offThe facility did not have a policy covering how food brought in by family and visitors is used and stored safely.

Inspection trend by year

Citations from standard inspections increased between the last two inspection cycles (7 → 21).

YearCitationsSerious (G–L)Worst severity that year
2019120F
202310D
2024132G ▲
2025425K ▲
202630E

Counts reflect the current CMS public record (~3 inspection cycles plus complaint investigations); years with no surveys show no row. Inspection frequency varies, so compare severity as well as counts.

Fines and enforcement (last 3 years)

3 fines totaling $373,733, plus 2 Medicare payment denial periods.

DateTypeAmount / length
Aug 14, 2025Fine$126,900
Aug 14, 2025Payment Denial15 days from Sep 12, 2025
Jan 9, 2025Fine$194,145
Jan 9, 2025Payment Denial83 days from Feb 13, 2025
Mar 8, 2024Fine$52,688

Nurse staffing (from payroll records, adjusted for how much care residents need)

MeasureThis facilityCalifornia avgU.S. avgWhere it stands
Total nurse staffing (hours per resident per day)3.974.313.95bottom 39% in California; top 41% in the U.S.
Registered Nurse hours0.550.610.69top 38% in California; bottom 46% in the U.S.
Weekend total nurse staffing3.693.903.50bottom 46% in California; top 34% in the U.S.
Weekend RN hours (not acuity-adjusted)0.540.510.48top 27% in California; top 29% in the U.S.
Total nursing staff turnover (%)45.536.745.8bottom 24% in California; bottom 49% in the U.S.
RN turnover (%)58.138.142.9bottom 17% in California; bottom 24% in the U.S.

Hours are per resident per day, case-mix adjusted by CMS so facilities caring for sicker residents can be compared fairly (same basis as the CMS staffing star). "Top X%" means better than most facilities: more staffing hours, or lower turnover. Raw (unadjusted) reported hours: total 3.82, RN 0.53, weekend 3.55. Staffing rating: 3/5.

Self-reported quality measures

Note: these ratings are based on data the facility reports about itself to CMS. They are not independently verified by inspectors, and can look better than inspection findings. Give more weight to the inspection results above.

Quality measures rating: 4/5 · long-stay residents: 5/5 · short-stay residents: 3/5

Who owns this facility

For profit - Limited Liability company

Owner / managerTypeRoleStakeSince
Bering Properties LLCOrganization5% or Greater Indirect Ownership Interest6%10/10/2013
BH AllianceOrganizationIndirect Ownership InterestNOT APPLICABLE11/01/2006
Crescent Facilities Operations LLCOrganization5% or Greater Direct Ownership Interest100%12/19/2006
Jenmax Enterprises LLCOrganization5% or Greater Indirect Ownership Interest23%02/01/2007
JK-CSH JV LLCOrganization5% or Greater Indirect Ownership Interest12%11/01/2006
Manhattan Five Partners LLCOrganization5% or Greater Indirect Ownership Interest7%11/01/2006
The Jacob Wintner TrustOrganizationIndirect Ownership InterestNOT APPLICABLE11/01/2006
The Wintner Living Trust Dated 7/08/1992OrganizationIndirect Ownership InterestNOT APPLICABLE02/01/2007
Win Win Enterprises, LLCOrganization5% or Greater Indirect Ownership Interest35%02/01/2007
517 S. a Street LLCOrganizationADP of the SNFNOT APPLICABLE12/15/2006
Bretsch, GregoryIndividualManaging Control - Governing BodyNOT APPLICABLE02/25/2019
Bretsch, GregoryIndividualOperational/Managerial ControlNOT APPLICABLE02/25/2019
Bretsch, GregoryIndividualADP of the SNFNOT APPLICABLE02/25/2019
Bulosan, JuliaIndividualOperational/Managerial ControlNOT APPLICABLE05/27/2025
Bulosan, JuliaIndividualADP of the SNFNOT APPLICABLE05/27/2025
Butenko, JulieIndividualOperational/Managerial ControlNOT APPLICABLE07/24/2023
Butenko, JulieIndividualADP of the SNFNOT APPLICABLE07/24/2023
Cambridge Healthcare Services LLCOrganizationOperational/Managerial ControlNOT APPLICABLE04/01/2014
Cambridge Healthcare Services LLCOrganizationADP of the SNFNOT APPLICABLE07/24/2025
Capela, HeidiIndividualOperational/Managerial ControlNOT APPLICABLE04/03/2023

Questions to ask on your visit

Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.

Nearby facilities (within 20 miles)

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Palms Care Center16.5 miChowchilla, CA★★★★☆4/5
Foundation Skilled Nursing17.4 miFresno, CA★☆☆☆☆1/5
North Point Healthcare & Wellness Centre LP17.7 miFresno, CA★★★★★5/5
The Terraces at San Joaquin Gardens Village17.9 miFresno, CA★★★★★3/5
Horizon Health & Subacute Center19.1 miFresno, CA★★☆☆☆2/5
Willow Creek Healthcare Center19.4 miClovis, CA★★★☆☆2/5
Community Subacute and Transitional Care Center19.6 miFresno, CA★★★★★5/5
Keystone Post-Acute19.7 miFresno, CA★★☆☆☆2/5
Oakwood Gardens Care Center19.9 miFresno, CA★★★★★4/5
Covenant Post Acute19.9 miFresno, CA★★★☆☆2/5

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Facility data as of CMS processing date 2026-08-01. CCN 055147.