Palms Care Center
1010 Ventura Avenue, Chowchilla, CA 93610 · Madera County · 65 certified beds · avg 60 residents/day · certified since Jan 1, 1967
Part of chain: AJC HEALTHCARE (14 facilities, chain avg rating 2.2★)
What health inspectors found (on-site government inspections — the most independent evidence available)
Health inspection rating: ★★★★☆4/5 · CMS overall rating: 4/5
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 · Nov 10, 2021 · F-0700
The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly.
Why it matters: Improperly used bed rails can trap or injure residents — in the worst cases, causing serious harm.
Severity (K): A life-threatening or extremely dangerous situation affected several residents. Among the most serious findings an inspection can produce.
Corrected: Mar 4, 2022 (Deficient, Provider has date of correction)
▲ Actual harm, one-off · Jul 30, 2024 · 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 4, 2024 (Deficient, Provider has date of correction)
All citations in the current public record (39)
CMS publishes roughly the last three inspection cycles plus recent complaint investigations. Older surveys drop out of the record as new ones are completed.
| Date | Severity | What the facility was cited for |
|---|---|---|
| Apr 4, 2025 | F · Potential for harm, facility-wide | The facility did not post its nurse staffing information every day. Nursing homes must publicly display how many nurses and aides are on duty each day. |
| Apr 4, 2025 | E · Potential for harm, repeated | The 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. |
| Apr 4, 2025 | E · Potential for harm, repeated | The 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. |
| Apr 4, 2025 | D · Potential for harm, one-off | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 4, 2025 | D · Potential for harm, one-off | The facility did not provide activities that meet residents' needs and interests. Nursing homes must offer meaningful activity programs, not just leave residents idle. |
| Apr 4, 2025 | D · Potential for harm, one-off | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Apr 4, 2025 | D · Potential for harm, one-off | The facility did not protect residents' personal information or did not keep complete, accurate medical records that meet professional standards. |
| Apr 4, 2025 | D · Potential for harm, one-off | The facility did not have a working call system — the button or cord residents use to summon help — in each resident's bathroom and bathing area. |
| Jul 30, 2024 | ▲ G · Actual harm, one-off | The 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 19, 2024 | F · Potential for harm, facility-wide | The facility did not employ enough qualified food and nutrition staff, including a qualified dietician, to properly run its food service. |
| Apr 19, 2024 | F · Potential for harm, facility-wide | The 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 19, 2024 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not make sure residents were fully informed about their own health, care, and treatments in a way they could understand. |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not let a resident help develop and carry out their own plan of care — the written roadmap of the services and support they'll receive, built around their personal goals and preferences. |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not provide a safe, clean, comfortable, and homelike environment, including safe support for residents' daily living needs. |
| Apr 19, 2024 | D · Potential for harm, one-off | The facility did not accurately assess a resident's health and needs. Assessments are the foundation for all the care a resident receives. |
| Apr 19, 2024 | D · Potential for harm, one-off | The 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. |
| Apr 19, 2024 | D · Potential for harm, one-off | The 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 19, 2024 | D · Potential for harm, one-off | The 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. |
| Nov 29, 2023 | E · Potential for harm, repeated | The facility did not keep the environment free of accident hazards, or did not provide enough supervision to prevent accidents like falls. · from a complaint |
| Nov 10, 2021 | ▲ K · Immediate jeopardy, repeated | The facility used bed rails without first trying safer alternatives, or without assessing the resident's safety risk, discussing the risks and benefits with the resident or family, getting consent, and installing the rails correctly. |
| Nov 10, 2021 | F · Potential for harm, facility-wide | The facility did not have enough nursing staff each day to meet every resident's needs, or did not have a licensed nurse in charge on each shift. Adequate staffing is one of the strongest predictors of good care. |
| Nov 10, 2021 | F · Potential for harm, facility-wide | The facility did not make sure its nurses and nurse aides had the skills and training needed to properly care for every resident. |
| Nov 10, 2021 | F · Potential for harm, facility-wide | The facility did not get its food from approved, safe sources, or did not store, prepare, and serve food according to professional food safety standards. |
| Nov 10, 2021 | F · Potential for harm, facility-wide | The facility did not have a policy covering how food brought in by family and visitors is used and stored safely. |
| Nov 10, 2021 | F · Potential for harm, facility-wide | The facility was not managed in a way that uses its money, staff, and resources effectively and efficiently to care for residents. |
| Nov 10, 2021 | F · Potential for harm, facility-wide | The 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. |
| Nov 10, 2021 | F · Potential for harm, facility-wide | The facility did not designate a qualified infection preventionist — a trained person responsible for running the infection prevention and control program. |
| Nov 10, 2021 | F · Potential for harm, facility-wide | The facility did not keep its building and grounds safe, functional, clean, and comfortable for residents, staff, and visitors. |
| Nov 10, 2021 | E · Potential for harm, repeated | The facility provided care that did not meet professional standards of quality — the accepted standards that nurses and other clinicians are expected to follow. |
| Nov 10, 2021 | E · Potential for harm, repeated | The facility's medication error rate was 5 percent or higher — meaning too many doses were given incorrectly, such as the wrong drug, dose, or time. |
| Nov 10, 2021 | E · Potential for harm, repeated | The facility did not keep residents free from significant medication errors — such as giving the wrong drug, the wrong dose, or missing a critical medication. |
| Nov 10, 2021 | D · Potential for harm, one-off | The facility did not keep residents' personal and medical information private and confidential. |
| Nov 10, 2021 | D · Potential for harm, one-off | The 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. |
| Nov 10, 2021 | D · Potential for harm, one-off | The facility did not provide appropriate care related to bladder and bowel needs — including care for residents who use catheters and steps to prevent urinary tract infections. |
| Nov 10, 2021 | D · Potential for harm, one-off | The facility used feeding tubes without a valid medical reason or the resident's agreement, or did not provide proper care to residents who have feeding tubes. |
| Nov 10, 2021 | D · Potential for harm, one-off | The 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. |
| Nov 10, 2021 | D · Potential for harm, one-off | The facility did not have enough support staff to safely and effectively run its food and nutrition service. |
| Nov 10, 2021 | D · Potential for harm, one-off | The facility did not train its staff on dementia care and on recognizing and reporting abuse, neglect, and exploitation. |
Inspection trend by year
Citations from standard inspections stayed about the same across the last two inspection cycles (10 → 8).
| Year | Citations | Serious (G–L) | Worst severity that year |
|---|---|---|---|
| 2021 | 19 | 1 | K ▲ |
| 2023 | 1 | 0 | E |
| 2024 | 11 | 1 | G ▲ |
| 2025 | 8 | 0 | F |
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)
No fines or payment denials in the published 3-year window.
Nurse staffing (from payroll records, adjusted for how much care residents need)
| Measure | This facility | California avg | U.S. avg | Where it stands |
|---|---|---|---|---|
| Total nurse staffing (hours per resident per day) | 3.83 | 4.31 | 3.95 | bottom 29% in California; top 47% in the U.S. |
| Registered Nurse hours | 0.25 | 0.61 | 0.69 | bottom 5% in California; bottom 5% in the U.S. |
| Weekend total nurse staffing | 3.43 | 3.90 | 3.50 | bottom 24% in California; top 46% in the U.S. |
| Weekend RN hours (not acuity-adjusted) | 0.16 | 0.51 | 0.48 | bottom 3% in California; bottom 7% in the U.S. |
| Total nursing staff turnover (%) | 37.3 | 36.7 | 45.8 | bottom 46% in California; top 30% in the U.S. |
| RN turnover (%) | 16.7 | 38.1 | 42.9 | top 13% in California; top 9% 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 4.15, RN 0.27, weekend 3.71. 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: 3/5 · long-stay residents: 4/5 · short-stay residents: 2/5
Who owns this facility
For profit - Limited Liability company
| Owner / manager | Type | Role | Stake | Since |
|---|---|---|---|---|
| Chesley, Aaron | Individual | 5% or Greater Indirect Ownership Interest | — | 02/01/2021 |
| Palms Care Center Holdings LLC | Organization | 5% or Greater Direct Ownership Interest | 100% | 05/17/2019 |
| SWC Ca Opco, LLC | Organization | 5% or Greater Indirect Ownership Interest | — | 02/01/2021 |
| Chesley, Aaron | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2021 |
| Gamett, James | Individual | Corporate Officer | NOT APPLICABLE | 02/01/2021 |
| Hawk, Regan | Individual | W-2 Managing Employee | NOT APPLICABLE | 02/01/2021 |
| Palms Care Center Holdings LLC | Organization | Operational/Managerial Control | NOT APPLICABLE | 05/17/2019 |
Questions to ask on your visit
Generated from this facility's actual citation record — bring them to a tour and ask the administrator directly.
- "What alternatives do you try before using bed rails, and how do you involve families in that decision?"
- "What is your falls rate, and what specific steps do you take to prevent falls and supervise residents at risk?"
- "Where do you post your daily staffing numbers, and can I see today's?"
- "Can you show me an example care plan, and how are families included when it's created and updated?"
- "Who leads your infection prevention program, and how do you make sure staff follow practices like hand hygiene every day?"
- "Can you tell me what this citation involved and what steps you took to bring care back up to standard?"
- "Can I see this month's activities calendar, and what do you offer residents who can't leave their rooms?"
- "Do you have a qualified dietician on staff, and how involved are they in each resident's nutrition plan?"
- "What is your current ratio of nursing staff to residents on day, evening, and weekend shifts?"
- "Can I see the results and plan of correction from your most recent state inspection?"
Nearby facilities (within 20 miles)
| Facility | Distance | City | Overall | Inspection | Flags |
|---|---|---|---|---|---|
| Chowchilla Memorial Healthcare District | 0.1 mi | Chowchilla, CA | ★★★★☆ | 4/5 | |
| Madera Care Center | 15.7 mi | Madera, CA | ★★★★☆ | 4/5 | |
| Merced Behavioral Center | 16.1 mi | Merced, CA | ★★★★★ | 5/5 | |
| Madera Rehabilitation & Nursing Center | 16.5 mi | Madera, CA | ★☆☆☆☆ | 1/5 | |
| Anberry Post Acute | 16.9 mi | Merced, CA | ★★★☆☆ | 3/5 | |
| La Sierra Care Center | 17.4 mi | Merced, CA | ★★★☆☆ | 3/5 | |
| Merced Nursing & Rehabilitation Ctr | 17.4 mi | Merced, CA | ★★★★☆ | 3/5 | |
| Golden Merced Care Center | 17.6 mi | Merced, CA | ★★★☆☆ | 3/5 | |
| Franciscan Post-Acute Care Center | 18.0 mi | Merced, CA | ★★★★☆ | 4/5 |
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Facility data as of CMS processing date 2026-08-01. CCN 055047.