Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Madison Grove Post Acute during CMS and state inspections, most recent first.
The facility failed to maintain a clean, pest-free environment in a shared room and bathroom for two residents, both with tracheostomies and significant neurologic or motor impairments. A CNA and an LVN observed and confirmed approximately 50 dead gnats on the shower floor in the shared bathroom. In the adjoining bedroom, an LVN and the Maintenance Supervisor identified a cracked vinyl flooring plank near a sliding door with a missing section and visible evidence of termites. The DON, referencing the facility’s pest control and maintenance policies, acknowledged that resident rooms are expected to be free of gnats and termites and that the building should be kept in good repair and free from hazards.
Surveyors found that eight of nine shower beds in three shower rooms were missing required locking pins on their side rails, and staff had been using plastic bags to support the rails while continuing to use the beds. A CNA reported the pins had been missing for about two weeks, and the Maintenance Director confirmed the missing pins during inspections. The DON reviewed the PVC equipment owner’s manual, which warns that improper use and failure to ensure proper assembly may result in death or injury, and acknowledged that the shower beds were used before repairs, contrary to the manufacturer’s instructions and the facility’s maintenance policy assigning responsibility to the Maintenance Director to keep equipment safe and operable.
A resident who was dependent on staff for all ADLs and required a two-person assist for bed mobility was left with only one CNA during repositioning and a brief change. Despite the care plan and facility policy mandating two-person assistance, the CNA proceeded alone, resulting in the resident falling from bed and sustaining a displaced intertrochanteric fracture of the left hip. Staff interviews confirmed the expectation of two-person assistance, and the DON acknowledged the protocol was not followed.
A resident with quadriplegia, contractures, and total dependence on staff for care and repositioning was found with left leg pain and later diagnosed with a fracture after being sent to the hospital. Despite care plans requiring two staff for repositioning and regular passive range of motion, there was no documentation explaining how the injury occurred, indicating a failure to provide adequate supervision and accident prevention.
A resident with multiple health conditions developed a stage 3 pressure ulcer on the right trochanter due to the facility's failure to prevent it. Despite efforts to reposition the resident and use an air loss mattress, the resident's noncompliance and preference for the right side contributed to the ulcer's development. The care plan did not address the resident's refusal to reposition, and there was no documentation of an interdisciplinary team meeting to address the issue.
A resident in distress, with chronic health conditions, experienced verbal abuse from a respiratory therapist (RT) who clapped loudly and used foul language. The RT's behavior was witnessed by staff, including an LVN who intervened. After leaving the resident's room, the RT damaged facility property in a fit of anger. The facility's abuse prevention policy was not followed, as acknowledged by the ADON.
A resident with multiple health conditions, including knee contractures, sustained an acute distal femur shaft fracture due to inadequate supervision. Despite a care plan to prevent injuries, staff were unaware of how the injury occurred, and no incidents were reported. The facility's policy on safety and supervision was not effectively implemented.
Failure to Maintain Pest-Free, Hazard-Free Resident Room and Bathroom
Penalty
Summary
The facility failed to maintain a safe, clean, and sanitary environment for two residents sharing a room and bathroom. One resident had diagnoses including tracheostomy status, hemiplegia, and hemiparesis affecting the right dominant side, and the other had diagnoses including encephalopathy and tracheostomy status. During an observation with a CNA in the shared bathroom, approximately 50 dead gnats were found on the shower floor and verified by the CNA. A subsequent observation with an LVN in the same bathroom confirmed the presence of approximately 50 dead gnats on the shower floor. Further observation with the LVN and the Maintenance Supervisor in the residents’ shared room revealed evidence of termites on the vinyl flooring near the sliding door. The Maintenance Supervisor identified a cracked vinyl flooring plank with a missing section measuring approximately 2 inches wide and 8 inches long, and stated there was evidence of termites in that area, describing the situation as unacceptable and something that should have been addressed promptly. Review of the facility’s pest control policy indicated the facility maintains an ongoing pest control program to keep the building free of insects and rodents, and the DON acknowledged that residents’ rooms should be free from gnats and termites and that the building should be in good condition and free from hazards, as also reflected in the facility’s maintenance policy.
Failure to Maintain Shower Beds in Safe Working Condition
Penalty
Summary
The facility failed to maintain eight of nine shower beds in safe working condition when surveyors observed that the side rails on these beds were missing required locking pins. During an observation in one shower room, a CNA reported that several locking pins had been missing for approximately two weeks and that plastic bags were being used to support the side rails while awaiting repairs. The CNA confirmed that the shower beds continued to be used in this condition. Subsequent inspections by the Maintenance Director in three separate shower rooms confirmed that a total of eight shower beds had missing locking pins on their side rails. During a telephone interview and record review, the DON reviewed the manufacturer’s owner’s manual for the PVC healthcare equipment, which stated that improper use of the equipment or failure to follow directions and warnings may result in death or injury, and that equipment must be properly assembled before use and after any adjustments, repairs, or service. The DON acknowledged that the shower beds had been used prior to repair, contrary to the manual’s instructions. The facility’s maintenance policy indicated that the building must be maintained in compliance with applicable laws and guidelines and that the Maintenance Director is responsible for maintaining a schedule of maintenance services to ensure the building and equipment are maintained in a safe and operable manner.
Failure to Provide Required Two-Person Assist Results in Resident Fall and Hip Fracture
Penalty
Summary
A deficiency occurred when a resident, who was dependent on staff for all activities of daily living and required a two-person assist for bed mobility and personal care, was left unsupervised by only one Certified Nursing Assistant (CNA) during repositioning and a brief change. The resident, who had significant medical conditions including type 2 diabetes, hypertension, dependence on a respirator, confusion, limited mobility, and contractures, was unable to assist in their own care. Despite the care plan and facility policy requiring two staff members for such assistance, the CNA proceeded alone, resulting in the resident sliding from the bed, striking their head, and sustaining a displaced intertrochanteric fracture of the left hip. Interviews with staff confirmed that the standard practice in the subacute unit was to use a two-person assist for residents with similar needs, and a buddy system was in place to ensure adequate supervision. The CNA involved admitted to providing care alone and not waiting for assistance, even though the resident was known to be a two-person assist. The Director of Nursing acknowledged that the CNA did not follow protocol, and the facility's policy emphasized the need for interventions based on residents' specific risks to prevent falls. The failure to provide adequate supervision and follow established protocols directly led to the resident's fall and injury.
Failure to Prevent Avoidable Accident Resulting in Resident Fracture
Penalty
Summary
The facility failed to provide adequate supervision and prevent avoidable accidents for a resident with quadriplegia and contractures, who was totally dependent on staff for all activities of daily living and repositioning. The resident, who was nonverbal and assessed for pain through facial grimacing, was found to have pain in the left lower leg and was subsequently diagnosed with a fracture of the proximal left tibia and a possible fibular neck fracture after being transferred to the hospital. Staff interviews indicated that the resident required two staff members for repositioning every two hours, and passive range of motion was to be performed three times a week as tolerated. Record reviews showed that the resident's care plan identified total dependence for repositioning and turning in bed, but there was no documentation or explanation regarding how the injury occurred. The facility's policy stated a commitment to maintaining an environment free from accident hazards and providing supervision to prevent accidents. Despite these policies and care plans, the resident sustained a significant injury resulting in hospitalization, indicating a failure to ensure adequate supervision and accident prevention for a clinically compromised, nonverbal resident.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to prevent the development of a stage 3 pressure ulcer on the right trochanter of a resident, who was clinically compromised with conditions including esophageal cancer, a tracheostomy, diabetes type II, and hypertension. Upon admission, the resident had a stage 4 pressure ulcer on the right knee. Despite the facility's efforts to reposition the resident and use an air loss mattress, the resident developed a stage 3 pressure ulcer on the right trochanter. The resident was noted to be noncompliant and favored the right side, which contributed to the development of the ulcer. The facility's care plan for the resident, initiated in August, did not address the resident's refusal to reposition, and there was no documentation of an interdisciplinary team meeting in June to address the wound and repositioning refusals. The facility's policy on wound care and prevention of pressure ulcers was reviewed, indicating procedures for care, services, and documentation related to pressure and non-pressure related wounds. However, the lack of a care plan addressing the resident's specific needs and refusals contributed to the deficiency.
Verbal Abuse Incident by Respiratory Therapist
Penalty
Summary
The facility failed to protect a resident's right to be free from verbal abuse, as evidenced by an incident involving a respiratory therapist (RT 1) who was verbally abusive towards a resident in distress. The resident, who had been admitted with diagnoses including hypertensive heart disease, chronic kidney disease, and chronic respiratory failure, was experiencing a medical emergency when the incident occurred. During this time, RT 1 was observed clapping loudly in the resident's face and using foul language, threatening to "beat" and "fuck up" the resident. This behavior was witnessed by other staff members, including a licensed vocational nurse (LVN 1), who intervened and instructed RT 1 to stop. Following the incident in the resident's room, RT 1 exhibited further aggressive behavior outside the room. RT 1 was seen in the charting room, where he expressed frustration and anger, stating he was "done with this shit" and "going to lose my job." He proceeded to physically damage facility property by kicking a chair into a desktop computer, breaking the computer over his knee, and throwing it against the wall. RT 1 continued his destructive behavior by kicking a wall, creating a hole, and tearing a kiosk off the wall before leaving the facility in a vehicle. The facility's policy on abuse, neglect, exploitation, and misappropriation prevention was not followed, as acknowledged by the Assistant Director of Nursing (ADON). The policy clearly states that residents have the right to be free from all forms of abuse, including verbal abuse, and that the facility is committed to protecting residents from such incidents. Despite this policy, the actions of RT 1 violated the resident's rights and demonstrated a failure in the facility's commitment to preventing abuse.
Inadequate Supervision Leads to Resident's Fracture
Penalty
Summary
The facility failed to provide adequate supervision to prevent avoidable accidents, resulting in a resident sustaining an acute distal femur shaft fracture. The resident, who had a history of traumatic brain injury, respiratory failure, asthma, seizures, hypertension, and gastrostomy status, was observed with swelling of the left thigh and knee. The care plan indicated the resident had bilateral knee contractures, with a goal to remain free of injuries related to these contractures. However, during a physical assessment, staff noted abnormal movement and swelling in the resident's left thigh and knee, with a popping sensation felt around the joint. Despite the facility's policy emphasizing resident safety and supervision, staff were unsure of how the injury occurred, and no incidents or accidents were reported. The Registered Nurse Supervisor stated that staff are expected to check on residents every two hours and as needed, but the lack of documentation or awareness of the incident suggests a lapse in supervision. The radiology report confirmed the fracture, highlighting the failure to prevent the accident and ensure the resident's safety.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Redlands
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Redlands Healthcare Center | 0.1 mi | — | 6 | 0 |
| Redlands Comm Hosp D/p Snf | 0.1 mi | — | 8 | 0 |
| Brookside Healthcare Center | 0.7 mi | — | 0 | 0 |
| Plymouth Village | 1.8 mi | — | 0 | 0 |
| Asistencia Villa Healthcare Center | 1.9 mi | — | 18 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.