Madison Grove Post Acute

• Star rating

  The CMS staffing star rating changed from 2 of 5 to 3 of 5.

• Star rating

  The CMS overall star rating changed from 1 of 5 to 3 of 5.

• Star rating

  The CMS staffing star rating changed from 1 of 5 to 2 of 5.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0925. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

  CMS lists it as corrected on March 13, 2026.

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CMS lists this as a complaint inspection.

• Citation F0908. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Keep all essential equipment working safely.

  CMS lists it as corrected on March 7, 2026.

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• Star rating

  The CMS health inspection star rating changed from 2 of 5 to 3 of 5.

CMS stopped payment for new admissions from September 27, 2025, for 3 days.

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CMS lists this as a standard inspection.

• Citation F0880. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on September 30, 2025.

  CMS has cited this home for F0880 3 times since 2021.

• Citation F0575. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

  CMS lists it as corrected on September 30, 2025.

• Citation F0761. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

  CMS lists it as corrected on September 30, 2025.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on September 30, 2025.

  CMS has cited this home for F0550 2 times since 2021.

• Citation F0656. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

  CMS lists it as corrected on September 30, 2025.

• Citation F0692. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide enough food/fluids to maintain a resident's health.

  CMS lists it as corrected on September 30, 2025.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on September 30, 2025.

  CMS has cited this home for F0755 2 times since 2021.

• Citation F0759. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure medication error rates are not 5 percent or greater.

  CMS lists it as corrected on September 30, 2025.

• Citation F0921. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on September 30, 2025.

  CMS has cited this home for F0921 2 times since 2021.

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CMS lists this as a standard inspection.

• Citation E0031. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Provide emergency officials' contact information.

  CMS lists it as corrected on November 28, 2025.

  CMS has cited this home for E0031 2 times since 2022.

• Citation K0161. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on November 28, 2025.

  CMS has cited this home for K0161 3 times since 2021.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on November 28, 2025.

  CMS has cited this home for K0363 2 times since 2022.

• Citation K0372. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

  CMS lists it as corrected on November 28, 2025.

• Citation K0741. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on November 24, 2025.

  CMS has cited this home for K0741 2 times since 2022.

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CMS lists this as a complaint inspection.

Severity G is the second-highest of CMS's four levels. It means a resident was harmed.

227 of 1,165 California homes (19%) got a citation at the actual harm level in 2025.

• Citation F0689. Severity G: actual harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on September 27, 2025.

  CMS has cited this home for F0689 3 times since 2024.

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CMS fine of $9,110 on August 27, 2025.

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CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on May 16, 2025.

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• Star rating

  The CMS health inspection star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on September 19, 2024.

  CMS has cited this home for F0686 3 times since 2021.

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CMS lists this as a complaint inspection.

• Citation F0600. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

  CMS lists it as corrected on August 31, 2024.

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• Star rating

  The CMS staffing star rating changed from 2 of 5 to 1 of 5. CMS changed how it scores this rating for many homes at once.

• Star rating

  The CMS quality measures star rating changed from 2 of 5 to 1 of 5.

• Star rating

  The CMS quality measures star rating changed from 1 of 5 to 2 of 5.

CMS lists this as a complaint inspection.

• Citation F0689. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

  CMS lists it as corrected on June 28, 2024.

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• Star rating

  The CMS quality measures star rating changed from not rated by CMS to 1 of 5.

• Name

  CMS lists a new name for this home. It was TERRACINA POST ACUTE.

CMS lists this as a standard inspection.

• Citation F0812. Severity F: potential for more than minimal harm, widespread.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on May 19, 2022.

  CMS has cited this home for F0812 2 times since 2021.

• Citation F0578. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

  CMS lists it as corrected on May 19, 2022.

• Citation F0646. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Notify the appropriate authorities when residents with MD or ID services has a significant change in condition.

  CMS lists it as corrected on May 19, 2022.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on May 19, 2022.

  CMS has cited this home for F0684 2 times since 2021.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on May 19, 2022.

• Citation F0688. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

  CMS lists it as corrected on May 19, 2022.

• Citation F0693. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

  CMS lists it as corrected on May 19, 2022.

• Citation F0710. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Obtain a doctor's order to admit a resident and ensure the resident is under a doctor's care.

  CMS lists it as corrected on May 19, 2022.

• Citation F0880. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on May 19, 2022.

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CMS lists this as a standard inspection.

• Citation K0363. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Install corridor and hallway doors that block smoke.

  CMS lists it as corrected on May 24, 2022.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on May 24, 2022.

  CMS has cited this home for K0920 2 times since 2021.

• Citation E0031. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide emergency officials' contact information.

  CMS lists it as corrected on May 24, 2022.

• Citation K0161. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on May 24, 2022.

• Citation K0325. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have properly installed hallway dispensers for alcohol-based hand rub.

  CMS lists it as corrected on May 24, 2022.

• Citation K0346. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Follow proper procedures when the fire alarm was out of service for more than 4 hours.

  CMS lists it as corrected on May 24, 2022.

• Citation K0351. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install an approved automatic sprinkler system.

  CMS lists it as corrected on May 24, 2022.

• Citation K0354. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours.

  CMS lists it as corrected on May 24, 2022.

• Citation K0355. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Properly select, install, inspect, or maintain portable fire extinguishes.

  CMS lists it as corrected on May 24, 2022.

• Citation K0374. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Install smoke barrier doors that can resist smoke for at least 20 minutes.

  CMS lists it as corrected on May 24, 2022.

• Citation K0741. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

  CMS lists it as corrected on May 24, 2022.

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CMS lists this as a standard inspection.

• Citation F0640. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

  CMS lists it as corrected on November 30, 2021.

• Citation F0679. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide activities to meet all resident's needs.

  CMS lists it as corrected on November 30, 2021.

• Citation F0812. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

  CMS lists it as corrected on November 30, 2021.

• Citation F0880. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Provide and implement an infection prevention and control program.

  CMS lists it as corrected on November 30, 2021.

• Citation F0921. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

  CMS lists it as corrected on November 30, 2021.

• Citation F0550. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

  CMS lists it as corrected on November 30, 2021.

• Citation F0558. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Reasonably accommodate the needs and preferences of each resident.

  CMS lists it as corrected on November 30, 2021.

• Citation F0584. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

  CMS lists it as corrected on November 30, 2021.

• Citation F0658. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Ensure services provided by the nursing facility meet professional standards of quality.

  CMS lists it as corrected on November 30, 2021.

• Citation F0684. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

  CMS lists it as corrected on November 30, 2021.

• Citation F0686. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate pressure ulcer care and prevent new ulcers from developing.

  CMS lists it as corrected on November 30, 2021.

• Citation F0690. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

  CMS lists it as corrected on November 30, 2021.

• Citation F0695. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide safe and appropriate respiratory care for a resident when needed.

  CMS lists it as corrected on November 30, 2021.

• Citation F0755. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

  CMS lists it as corrected on November 30, 2021.

• Citation F0814. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Dispose of garbage and refuse properly.

  CMS lists it as corrected on November 30, 2021.

• Citation F0865. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have a plan that describes the process for conducting QAPI and QAA activities.

  CMS lists it as corrected on November 30, 2021.

• Citation F0867. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

  CMS lists it as corrected on November 30, 2021.

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CMS lists this as a standard inspection.

• Citation K0753. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Have restrictions on the use of highly flammable decorations.

  CMS lists it as corrected on November 2, 2021.

• Citation K0920. Severity E: potential for more than minimal harm, pattern.

  The rule CMS cited: Ensure proper usage of power strips and extension cords.

  CMS lists it as corrected on November 2, 2021.

• Citation K0161. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Use approved construction type or materials.

  CMS lists it as corrected on November 2, 2021.

• Citation K0700. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Meet requirements for operating features, such as evacuation plans, fire drills, smoking regulations, draperies, decorations and the inspection, testing and maintenance of fire doors.

  CMS lists it as corrected on November 2, 2021.

• Citation K0918. Severity D: potential for more than minimal harm, isolated.

  The rule CMS cited: Have generator or other power source capable of supplying service within 10 seconds.

  CMS lists it as corrected on November 2, 2021.

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