Madison Grove Post Acute

In the surveyor’s words

From the most serious findings on record at Madison Grove Post Acute, in the surveyor’s own words.

• Immediate jeopardy, patternF550Oct 10, 2022

  Based on observations, interviews, and record reviews, the facility failed to ensure resident ' s rights were honored for Justice Involved Residents (residents in custody) when six of six residents (Residents 1,2,3,4, 5 and 6) were denied the same rights and privileges to move freely about the facility and participate in activities of their choosing due to the criminal justice system making their decisions, instead of the facility following federal regulations related to resident rights This failure resulted in Residents 1, 2, 3, 4, 5 and 6 to be shackled by one ankle to the bed frame except for therapy, toileting or showering and denied the right to move around their room, participate in activities which had the potential for severe psychosocial (having to do with the mental, emotional,… […]

• Immediate jeopardy, patternF604Oct 10, 2022

  Based on observation, interview, and record review, the facility failed to ensure their policy and procedure for physical restraints was followed for Justice involved residents (JIR; residents under the care of law enforcement, in custody, held involuntarily through operation of law enforcement authorities) when six of six residents (Residents 1, 2, 3, 4, 5, and 6) were denied the right to be treated with respect and dignity including the right to be free from any physical restraint imposed for the purpose of discipline and not required to treat the resident ' s medical condition. […]

• Immediate jeopardy, isolatedF689Jun 14, 2021

  Based on observation, interview, and record review, the facility failed to provide monitoring and supervision for one of twelve residents (Resident 1) who was disoriented (having lost one's sense of direction) with wandering behaviors eloped (a dependent resident leaving the facility without observation or knowledge of departure) from the facility through an unlocked gate without staff's knowledge. This failure resulted in Resident 1 suffering from head trauma and serious lacerations to his face and head according to hospital records. […]

• Actual harm, isolatedF689Aug 27, 2025

  Based on interview and record review, the facility failed to ensure adequate supervision for one of three sampled residents (Resident1) when Resident 1, who requires a two-person assist, fell out of bed while one Certified Nursing Assistant (CNA) was repositioning the resident and providing a brief change.This failure resulted in Resident 1 sustaining intertrochanteric (thigh bone) fracture of left hip.Findings:During review of Residents 1's admission Record (general demographics information), the document indicated Resident 1 was admitted to the facility on [DATE], with diagnoses which included type 2 diabetes (body has trouble controlling blood sugar), hypertension (high blood pressure), dependance on respirator (difficult to breathe on own, machine dependent). […]

• No harm, potential for more than minimal, widespreadF880Sep 17, 2025

  Based on observation, interviews and record review the facility failed to maintain infection control practices for four of two hundred and twenty-nine residents when: 1. Resident 40's nebulizer (a machine that turns liquid medicine into a mist to be inhaled) . An attached oxygen tubing (a plastic tube that delivers oxygen or misted medicine to the resident) has not been changed since September 1, 2025, (thirteen days past due). 2. For Resident 48, in an Enhanced Barrier Precaution (EBP - an infection control strategy used to reduce the spread of multi-drug-resistant organisms [MDROs] and prevent transmission to other residents and healthcare workers), Restorative Nursing Assistance (RNA 1) did not remove the gloves while providing care and reached out to her pocket and pulled out a walkie… […]