Madison Grove Post Acute
Madison Grove Post Acute in Redlands, CA — inspection on August 27, 2025.
Found 1 citation. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
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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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.