Health inspection·March 19, 2025

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure adequate supervision was provided to prevent avoidable accidents when one of four residents (Resident 2)'s left knee noted with pain and fracture of the proximal left tibia (break in the long bone of the left lower leg). This failure resulted in Resident 2 a clinically compromised resident being sent to the hospital for evaluation and treatment. Findings: During an observation on March 19, 2025, at 12:35 PM, Resident 2 was lying in bed awake and did not respond verbally. During an interview on March 19, 2025, at 12:50 PM, with Certified Nursing Assistant (CNA 2), the CNA 2 stated, He (Resident 2) does not talk. He is total dependent with ADLs (activity of daily living). I usually give him bath, clean and change him, and reposition him every two hours. During an interview on March 19, 2025, at 1:00 PM, with Licensed Vocational Nurse (LVN 2), LVN 2 stated, [Resident 2's name] does not talk. I don't know what happened, but I know he was transferred to the hospital due to pain of his legs and he came back with a diagnosis of fracture. During a review of Resident 2' admission Record (general demographics) on March 19, 2025, the document indicated Resident 2 was originally admitted to the facility on [DATE], with diagnoses that included quadriplegia (paralysis that affects all four limbs) and contracture other specified joint (a permanent tightening of muscle and tissues leading to a loss of movement). During an interview on March 19, 2025, at 1:50 PM, with the Director of Nursing, she stated, nursing staff used facial grimacing to assess [Resident's name]'s pain since the resident could not speak. A review of Resident 2's care plan dated June 24, 2024, indicated, Focus . has an ADL self-care performance deficit r/t (related to) activity intolerance, confusion, limited mobility. Goal: The resident will maintain current function . Intervention: The resident is totally dependent on (2) staff for repositioning and turning in bed (every 2 hours) and as necessary . A review of Resident 2's Restorative Nursing Assistant Treatment dated January 1, 2025 - January 31, 2025, indicated, RNA (restorative nursing assistant) program passive range of motion to bilateral lower extremities every day shift 3 time a week as tolerated. (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555350 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555350 B. Wing A. Building (X3) DATE SURVEY COMPLETED 03/19/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Madison Grove Post Acute 1618 Laurel Ave Redlands, CA 92373 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)