Madison Grove Post Acute
Inspection Findings
F-Tag F0689
F 0689 Level of Harm - Actual harm Residents Affected - Few
FORM CMS-2567 (02/99) Previous Versions Obsolete
interview on September 2, 2025, at 10:08 AM, with CNA 3, CNA 3 stated, It was about 1:30 AM. 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.I called for the nurses and we got him back to bed. He was not able to help in the repositioning, he is contracted (a shortening or tightening of muscles, tendons, or other tissues). He is a two-person assist after the fall. Now everyone in subacute is two-person assist. I would always provide care for him on my own. I was made aware he had a fracture.During an interview on August 27, 2025, at 2:10 PM, with the Director of Nursing (DON), the DON stated Resident 1 had a fall on July 29, 2025, with femur (thigh bone) fracture. The DON stated that upon their investigation, CNA 3 did not wait for help. The LVN, stated she was in the middle of medication pass, and said to give a couple minutes. CNA 3 was doing patient care, there was no siderails and the residents fell. The DON further stated, Resident 1 requires a two-person assist, CNA 3 should have waited for help as they have a ‘buddy system.During a
review of the facility's policy and procedure (P&P) titled, Fall and Fall Risk, Managing, undated, the P&P indicated, Based on previous evaluation and current data, the staff will identify interventions related to the residents specific risk and causes to try to prevent the resident from falling and to try to minimize complications from failing.
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Madison Grove Post Acute in Redlands, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in Redlands, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from Madison Grove Post Acute or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.