Madison Grove Post Acute: Fall Causes Femur Fracture - CA
The incident happened at Madison Grove Post Acute on July 29, 2025, at approximately 1:30 AM.
CNA 3, interviewed by inspectors on September 2, 2025, described what happened in her own words. "I wanted to see if Resident 1 was wet. He was, so I placed him on his side, he rolled and I tried to catch him, I ran to the other side, he slid down to the floor."
He could not help. The resident has contractures, a condition in which muscles, tendons, and other tissues shorten and tighten, leaving him unable to assist with his own movement or repositioning. He was entirely dependent on whoever was in that room with him. That night, there was only one person.
CNA 3 called for the nurses. They got him back to bed. Then came the news: he had fractured his femur, the thigh bone.
The Director of Nursing laid out what the investigation found when inspectors interviewed her on August 27, 2025. The resident required a two-person assist. The facility had a buddy system in place specifically for situations like this. CNA 3 had not waited. She had gone to check on him alone, attempted to reposition him alone, and when he began to slide she had no one to help her stop it.
The nurse on duty that night, an LVN, told investigators she had been in the middle of medication pass when CNA 3 came to her. She told CNA 3 to give her a couple of minutes.
CNA 3 did not wait.
"CNA 3 should have waited for help," the DON told inspectors. "They have a buddy system."
Whether CNA 3 understood the urgency of the two-person requirement, or believed she could manage on her own, or simply didn't want to wait, the inspection report does not say. What it does say is that there were no siderails on the bed that night, and that a man with contractures who could not move himself was left in the hands of a single caregiver at 1:30 in the morning.
CNA 3 confirmed she had always provided care for this resident on her own before the fall. "I would always provide care for him on my own," she told inspectors. The two-person requirement, she said, came after. Now, she added, everyone in the subacute unit is a two-person assist.
That change came too late for Resident 1.
Federal inspectors cited the facility under F0689, the tag covering protection from accident hazards and supervision, and classified the violation as causing actual harm. The inspection was triggered by a complaint and completed August 27, 2025.
The facility's own fall prevention policy, reviewed by inspectors, states that staff will identify interventions related to each resident's specific risks and causes to try to prevent falls and minimize complications. The policy carries no date. It did not prevent a contracted, fully dependent resident from being repositioned alone in the dark by a single aide who ran from one side of the bed to the other and still could not catch him.
He fractured his femur on the floor.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Madison Grove Post Acute from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: October 7, 2026 · Our methodology
Madison Grove Post Acute in Redlands, CA was cited for violations during a health inspection on August 27, 2025.
The incident happened at Madison Grove Post Acute on July 29, 2025, at approximately 1:30 AM.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.