Overall Score
CMS Five-Star Quality Rating- Much below average
- Below average
- Average
- Above average
- Much above average
Where it ranks
- CaliforniaAbove only 16% of peers1,154 rated homes · average 3.2★
- Madera CountyAbove only 25% of peers5 rated homes · average 2.8★
- United StatesAbove only 20% of peers14,574 rated homes · average 3.0★
How the rating is built
- Health inspectionsStarting point1★−1.8 vs CA avg
- StaffingCan add or remove a star3★−0.1 vs CA avg
- Quality measuresCan add or remove a star5★+0.9 vs CA avg
CMS starts from the health inspection stars, then adds or subtracts a star for staffing and for quality measures. Stars are assigned relative to other facilities in the same state.
Ratings & measures
Tap a row to see what it meansHealth inspection ratingCMS stars from the last three on-site inspection cycles1★Lowest tier among peersCA avg2.8★U.S. avg2.8★
Stars assigned from the last three standard surveys and every complaint investigation in that window, weighted toward the most recent and the most serious findings. CMS assigns these stars relative to other facilities in the same state.
It carries the most weight in the overall rating and is the only domain based on what trained inspectors saw on site rather than what the facility reported.
Staffing ratingCMS stars from payroll-reported hours and turnover3★Above only 27% of peersCA avg3.1★U.S. avg2.9★
Nurse and aide hours per resident day from payroll records CMS collects every quarter, adjusted for how much care residents need, plus staff turnover and weekend coverage.
More hours and lower turnover are the strongest predictors of fewer falls, pressure sores, and avoidable hospital stays.
Quality measures ratingCMS stars from clinical outcomes and resident assessments5★Above 57% of peersCA avg4.1★U.S. avg3.6★
Clinical outcomes from resident assessments and Medicare claims: falls with injury, pressure ulcers, hospitalizations, antipsychotic use, and more, for both short-stay and long-stay residents.
It shows whether care is working, but part of it comes from the facility’s own assessments, so read it alongside the inspection results.
Total nurse hoursPer resident per day, all nursing staff3.92hrsAbove only 17% of peersCA avg4.51Benchmark4.10
All licensed nurse and aide hours worked, divided by the number of residents, on an average day. Reported from payroll, not self-reported.
Federal research links 4.1 hours a day to fewer avoidable harms. Below about 3 hours, residents wait longer for help with basics like toileting and repositioning.
RN hoursPer resident per day, registered nurses only0.60hrsAbove 65% of peersCA avg0.65Benchmark0.75
Registered nurse hours only. RNs assess residents, manage medications, and catch changes in condition; LPNs and aides deliver most hands-on care.
RN coverage is the staffing measure most tied to fewer hospital transfers and infections, and it is where thinly staffed facilities cut first.
Nursing staff turnoverShare of nursing staff who left within a year · lower is better40%Above only 41% of peersCA avg38%RN turnover48%
The share of nursing staff who left within the past year, from the same payroll data.
High turnover means residents are cared for by people who do not know them, and it is one of the strongest predictors of inspection problems.
Fines in the last three yearsCivil money penalties imposed by CMS · lower is better$386,733Lowest tier among peersCA avg$26,970Fines · denials4 · 3
Civil money penalties CMS imposed after serious or uncorrected deficiencies, and denials of Medicare payment for new admissions.
Penalties follow the worst inspection findings. A recent fine is the clearest sign that inspectors found real harm.
Inspection history
Last three inspection cyclesCitations by monthJul 2018 – Aug 2025
- No actual harm (D–F)
- Actual harm (G–I)
- Immediate jeopardy (J–L)
- $Fine or payment denial
Showing
Click a month or a year to filter the findings below. Arrow keys move between months; Esc clears.
Aug 14, 2025Cycle 1worst G · actual harm$126,900, payment denial
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected Sep 27, 2025
Jun 10, 2025Cycle 1worst E · no actual harm
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Jun 10, 2025
- F584Honor 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.Resident RightsE · patternCorrected Jun 10, 2025
Apr 15, 2025Cycle 1worst G · actual harm
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 7, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected May 7, 2025
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected May 7, 2025
Mar 7, 2025Cycle 1worst K · immediate jeopardy
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected May 7, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected May 7, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareK · patternCorrected May 7, 2025
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesE · patternCorrected May 7, 2025
- F849Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.AdministrationE · patternCorrected May 7, 2025
- F835Administer the facility in a manner that enables it to use its resources effectively and efficiently.AdministrationF · widespreadCorrected May 7, 2025
- F880Provide and implement an infection prevention and control program.Infection ControlD · isolatedCorrected May 7, 2025
- F865Have a plan that describes the process for conducting QAPI and QAA activities.AdministrationE · patternCorrected May 7, 2025
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsD · isolatedCorrected May 7, 2025
- F584Honor 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.Resident RightsD · isolatedCorrected May 7, 2025
- F609Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 7, 2025
Jan 9, 2025Cycle 2worst G · actual harm$194,145, payment denial
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected May 7, 2025
- F641Ensure each resident receives an accurate assessment.Resident Assessment and Care PlanningD · isolatedCorrected May 7, 2025
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningE · patternCorrected May 7, 2025
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningE · patternCorrected May 7, 2025
- F689Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.Quality of Life and CareG · isolatedCorrected May 7, 2025
Nov 22, 2024Cycle 2worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jan 2, 2025
Jun 21, 2024Cycle 1worst F · no actual harm
- F840Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service.AdministrationD · isolatedCorrected Jul 20, 2024
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected Jul 20, 2024
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalE · patternCorrected Jul 20, 2024
- Notify the resident or the residentâs representative in writing how long the nursing home will hold the residentâs bed in cases of transfer to a hospital or therapeutic leave.Resident RightsE · patternCorrected Jul 20, 2024
- F623Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.Resident RightsE · patternCorrected Jul 20, 2024
- F656Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.Resident Assessment and Care PlanningE · patternCorrected Jul 20, 2024
- F578Honor 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.Resident RightsE · patternCorrected Jul 20, 2024
May 2, 2024Cycle 2worst G · actual harm
- Provide appropriate treatment and care according to orders, residentâs preferences and goals.Quality of Life and CareG · isolatedCorrected Apr 26, 2024
Apr 4, 2024Cycle 2worst G · actual harm
- F580Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.Resident RightsG · isolatedCorrected Apr 26, 2024
- F655Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admittedResident Assessment and Care PlanningE · patternCorrected Apr 26, 2024
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Apr 26, 2024
Mar 8, 2024Cycle 2worst D · no actual harm$52,688
- F657Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.Resident Assessment and Care PlanningD · isolatedCorrected Apr 24, 2024
Nov 15, 2023Cycle 3worst D · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Dec 8, 2023
Mar 21, 2023Cycle 3worst D · no actual harmpayment denial, $13,000
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected May 19, 2023
Mar 9, 2023Cycle 3worst F · no actual harmpayment denial, $13,000
- F880Provide and implement an infection prevention and control program.Infection ControlF · widespreadCorrected May 5, 2023
Apr 26, 2019Cycle 2worst F · no actual harm
- F600Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.Freedom from Abuse, Neglect, and ExploitationD · isolatedCorrected Jun 25, 2019
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Jun 25, 2019
- F677Provide care and assistance to perform activities of daily living for any resident who is unable.Quality of Life and CareD · isolatedCorrected Jun 25, 2019
- F761Ensure 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.Pharmacy ServiceE · patternCorrected Jun 25, 2019
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryF · widespreadCorrected Jun 25, 2019
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryD · isolatedCorrected Jun 25, 2019
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalE · patternCorrected Jun 25, 2019
- F921Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.EnvironmentalE · patternCorrected Jun 25, 2019
- F558Reasonably accommodate the needs and preferences of each resident.Resident RightsE · patternCorrected Jun 25, 2019
- F577Allow residents to easily view the nursing home's survey results and communicate with advocate agencies.Resident RightsF · widespreadCorrected Jun 25, 2019
- F584Honor 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.Resident RightsE · patternCorrected Jun 25, 2019
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsD · isolatedCorrected Jun 25, 2019
Jul 3, 2018Cycle 3worst K · immediate jeopardy
- F912Provide rooms that are at least 80 square feet per resident in multiple rooms and 100 square feet for single resident rooms.EnvironmentalC · widespreadCorrected Sep 14, 2018
- F550Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.Resident RightsE · patternCorrected Sep 14, 2018
- F658Ensure services provided by the nursing facility meet professional standards of quality.Resident Assessment and Care PlanningD · isolatedCorrected Sep 14, 2018
- F726Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.Nursing and Physician ServicesF · widespreadCorrected Sep 14, 2018
- F740Ensure each resident must receive and the facility must provide necessary behavioral health care and services.Quality of Life and CareG · isolatedCorrected Sep 14, 2018
- F760Ensure that residents are free from significant medication errors.Pharmacy ServiceD · isolatedCorrected Sep 14, 2018
- F761Ensure 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.Pharmacy ServiceK · patternCorrected Sep 14, 2018
- F803Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.Nutrition and DietaryF · widespreadCorrected Sep 14, 2018
- F807Ensure each resident receives and the facility provides drinks consistent with resident needs and preferences and sufficient to maintain resident hydration.Nutrition and DietaryE · patternCorrected Sep 14, 2018
- F812Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.Nutrition and DietaryE · patternCorrected Sep 14, 2018
- F813Have a policy regarding use and storage of foods brought to residents by family and other visitors.Nutrition and DietaryF · widespreadCorrected Sep 14, 2018
- F842Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.Resident Assessment and Care PlanningE · patternCorrected Sep 14, 2018
- F880Provide and implement an infection prevention and control program.Infection ControlE · patternCorrected Sep 14, 2018
- F908Keep all essential equipment working safely.EnvironmentalD · isolatedCorrected Sep 14, 2018
- F919Make sure that a working call system is available in each resident's bathroom and bathing area.EnvironmentalE · patternCorrected Sep 14, 2018
Staffing
From quarterly payroll reportsHours per resident per day
- All nursing staffRNs, LPNs and aides combined3.92hrs
- Registered nursesRN hours only0.60hrs
- Licensed practical nursesLPN hours0.70hrs
- Nurse aidesCNA hours2.61hrs
- Weekend nursingAll staff on Saturdays and Sundays3.68hrs
- California average
- Research benchmark (4.10 total, 0.75 RN)
Turnover & capacity
- Nursing staff turnoverShare who left within a year · lower is better40%Above only 41% of peersCA avg 38%
- RN turnoverRegistered nurses only48%Not ranked by CMS
- Administrators who leftIn the past year2Leadership changed
- Occupancy176 certified beds · ~169 residents a day96%Above 88% of peersCA avg 88%
Fines & penalties
Roughly the past three yearsEnforcement summary
- $386,733In fines
- 4Fines
- 3Payment denials
- $26,970CA avg in fines
Actions on record
- Aug 14, 2025Civil money penalty$126,900
- Aug 14, 2025Denial of payment for new admissionsfrom Sep 12, 2025
- Jan 9, 2025Civil money penalty$194,145
- Jan 9, 2025Denial of payment for new admissionsfrom Feb 13, 2025
- Mar 8, 2024Civil money penalty$52,688
- Mar 9, 2023Denial of payment for new admissionsfrom Apr 21, 2023
- Mar 9, 2023Civil money penalty$13,000
Ownership
As filed with CMSStructure
- Ownership type
- For profit - Limited Liability company
- Chain
- Cambridge Healthcare Services32 facilities in the chain2.7★ chain average
- Certification
- Medicare and Medicaid
- Location type
- Urban
- Ownership change
- None in the last 12 months
People and entities on file
- Crescent Facilities Operations LLC
- Bering Properties LLC
- Jenmax Enterprises LLC
- Jk-Csh Jv LLC
- Manhattan Five Partners LLC
- Win Win Enterprises, LLC
- Ira Smedra
- Cambridge Healthcare Services LLC
- Gregory Bretsch
- Julia Bulosan
- Julie Butenko
- Heidi Capela
- Lance Hassell
- Akash Lal
- Linda Lutz
- +4 more
- Jacob Wintner
Person Organization
Sources & notes
Public data, updated quarterlyData sources
- CMS Care Compare · Provider InformationStar ratings, staffing hours, turnover, penalties and flags · processed February 2026.
- CMS Health CitationsEvery deficiency from the last three inspection cycles, with scope, severity and inspection cycle.
- CMS Penalties and Ownership filesCivil money penalties, payment denials, and the owners and managers on file.
Notes
- CMS Certification Number 055147 · 517 SOUTH A STREET, MADERA, CA, 93638.
- Percentiles compare this facility with every rated nursing home in California and Madera County. Turnover and fines are inverted so a high percentile is always good.
- This is an informational summary of public data, not medical, legal, or placement advice. Facilities cannot pay to change it; a facility that believes a record is wrong can dispute it with CMS.









