Not rated by CMS — ratings are suppressed for new or low-volume facilities.
A standard survey is most likely before around November 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 River Grove Health And Rehabilitation during CMS and state inspections, most recent first.
A resident with moderate cognitive impairment and multiple medical conditions was found to be living in a room with a missing and a loose floor tile, which remained unaddressed over multiple days. Facility leadership confirmed the room was not maintained in a safe, clean, and homelike manner, as required by policy.
The facility did not update the care plans for three residents after changes in their conditions or care needs were identified. One resident's increased dependency for personal hygiene, another's significant weight loss, and a third's new order for off-loading boots were not reflected in their respective care plans, despite staff and assessment findings indicating the need for updates.
The facility failed to maintain food safety and sanitation standards, as observed by unsealed food items, improper storage of cleaning products near food, unsanitary cooking equipment, and expired food available for resident consumption. The CDM confirmed these issues, and the administrator acknowledged the expectation for proper kitchen maintenance.
A resident with severe cognitive impairment and physical limitations was not treated with dignity during meal assistance. A CNA stood over the resident while feeding, contrary to facility policy requiring staff to be seated at eye level. The CNA acknowledged the error, and the DON confirmed the expectation to maintain resident dignity.
The facility failed to accurately complete MDS assessments for three residents, leading to deficiencies. A resident was inaccurately documented as not receiving hospice services despite having a hospice plan of care. Another resident's dialysis treatment was not accurately reflected in the MDS assessment. Additionally, a resident was documented as receiving hospice care even though services had been discontinued. These discrepancies were confirmed by staff interviews.
The facility failed to develop a comprehensive care plan for a resident receiving hospice services and did not involve another resident with severe cognitive impairment or their representative in the care planning process. The MDS Coordinator confirmed the absence of hospice services in the care plan, and the Social Service Assistant and RLSW acknowledged the lack of documentation for the resident's care conference involvement.
A resident with Cerebral Palsy, Epilepsy, and Autistic Disorder was prescribed Jevity 1.2 at 45 ml/hr with a 25 ml/hr water flush via PEG tube. However, observations revealed the feeding was administered at 60 ml/hr and the water flush at 45 ml/hr, contrary to the physician's orders. This discrepancy was confirmed by nursing staff, although it was noted that the incorrect rates did not cause complications.
The facility failed to securely store an oxygen tank for a resident with COPD and did not have a physician's order for oxygen administration for another resident with pneumonia. Observations revealed an unsecured oxygen tank in a resident's room and another resident receiving oxygen without a documented order, contrary to facility policies.
The facility failed to remove expired medications from a medication cart, as observed during a survey. An LPN confirmed the presence of expired Ferrous Gluconate tablets, which were still available for resident use, despite the facility's policy requiring the disposal of expired drugs. The DON acknowledged that expired medications should have been discarded.
Failure to Maintain Safe and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment for one resident on one of five hallways observed. Facility policy requires that all resident environments, including resident rooms, be kept safe, clean, comfortable, and homelike, with housekeeping and maintenance services provided as necessary. During multiple observations and interviews, it was found that a resident's room had one missing floor tile lying to the right side of the bed and one loose tile under the bed. These conditions were observed on consecutive days, and the resident indicated a desire to have the tiles repaired. The resident involved had a history of unspecified focal traumatic brain injury, hemiplegia, dysarthria, anarthria, epilepsy, mood disorder with depressive features, and anxiety. A recent assessment indicated moderate cognitive impairment. Both the Administrator and Maintenance Director confirmed during an observation that the room was not maintained in a safe, clean, and homelike condition, as required by facility policy.
Failure to Revise Comprehensive Care Plans After Changes in Resident Status
Penalty
Summary
The facility failed to revise the comprehensive care plans for three residents following changes in their conditions or care needs, as required by facility policy and federal regulations. For one resident with diagnoses including metabolic encephalopathy, COPD, diabetes, and depression, the quarterly MDS assessment indicated a change in personal hygiene needs from requiring supervision/touch assistance to being dependent on staff. However, the care plan was not updated to reflect this increased dependency, and the MDS Coordinator confirmed the care plan remained outdated. Another resident with multiple diagnoses, including pneumonia, diabetes, severe obesity, dementia, and dysphagia, experienced significant weight loss as identified in a quarterly MDS assessment. Despite this, the resident's care plan was not revised to address the actual weight loss, and this was confirmed by both the DON and the Regional Director of Clinical Reimbursement. The care plan continued to reference risk factors without incorporating the new information about the resident's weight loss. A third resident, with diabetes, hemiplegia, and an acquired absence of toes, was ordered to use off-loading boots while in bed to prevent skin breakdown. Observations and interviews confirmed the resident consistently wore the boots, but the care plan was not updated to include this intervention. Facility staff, including the MDS Nurse and ADON, acknowledged that the care plan should have been revised to reflect the new physician order and the resident's current care needs.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to adhere to its food safety and foodborne illness prevention policy, resulting in several deficiencies. During an inspection, it was observed that multiple food items, including bottles of lemon pepper seasoning, paprika, basil leaves, chili powder, celery seed, and 17-Seasoning, were not sealed properly and left open to air. Additionally, a sanitizing cleaner solution was improperly stored near spice containers, which was against the facility's policy. The Certified Dietary Manager (CDM) acknowledged these issues, confirming that the sanitizing cleaner should not have been placed near the spice containers. Further observations revealed unsanitary conditions in the kitchen's clean dish storage area, where muffin pans and baking sheet pans were found with substances caked on them. Additionally, expired sandwiches were found in the E-F hall refrigerator, which were available for resident consumption. The CDM confirmed that the cooking equipment was not maintained in a sanitary condition and that the expired sandwiches should not have been available. The facility's administrator stated that the expectation was for the kitchen to be maintained in a sanitary condition, with food items sealed properly and expired items discarded.
Failure to Maintain Resident Dignity During Meal Assistance
Penalty
Summary
The facility failed to maintain a resident's dignity during meal assistance, as observed in the case of a resident with severe cognitive impairment and physical limitations. The resident, who required extensive assistance with eating due to conditions such as traumatic brain injury and hemiplegia, was fed by a CNA who stood over the resident rather than sitting at eye level, as per facility policy. This action was contrary to the facility's policy on resident rights, which emphasizes treating residents with respect and dignity. During the observation, the CNA removed the bedside table from the resident's reach and left the room to obtain additional silverware, further compromising the resident's dignity. The CNA acknowledged the failure to adhere to the expected practice of sitting at eye level while feeding the resident. The Director of Nursing confirmed that the expectation was for staff to be seated at eye level with residents during feeding to maintain their dignity.
Inaccurate MDS Assessments for Residents
Penalty
Summary
The facility failed to accurately complete the Minimum Data Set (MDS) assessments for three residents, leading to deficiencies in the assessment process. Resident #16, who was admitted with multiple diagnoses including dementia and chronic kidney disease, was inaccurately documented as not receiving hospice services on a quarterly MDS assessment, despite having a physician's order for hospice and a hospice plan of care. This discrepancy was confirmed by the MDS Coordinator during an interview. Resident #8, diagnosed with diabetes and end-stage renal disease, was inaccurately documented on the MDS assessment regarding dialysis treatment. Although the resident required dialysis three times a week, as confirmed by both the resident and the MDS Coordinator, the MDS assessment did not accurately reflect this. Similarly, Resident #20, who had a history of diabetes and chronic kidney disease, was inaccurately documented as receiving hospice care on the MDS assessment, even though hospice services had been discontinued months prior. This was confirmed by both the resident and the Director of Nursing.
Failure to Develop Comprehensive Care Plans and Involve Residents
Penalty
Summary
The facility failed to develop a comprehensive care plan to address hospice services for a resident with multiple diagnoses, including Dementia, Muscle Weakness, Chronic Kidney Disease, Myocardial Infarction, Congestive Heart Failure, and Cerebrovascular Accident. Despite a physician's order indicating hospice services, the care plan for this resident did not reflect these services. This deficiency was confirmed during an interview with the MDS Coordinator, who acknowledged that the comprehensive care plan had not been updated to include hospice services. Additionally, the facility did not involve a resident with severe cognitive impairment or their representative in the care planning process. The resident's representative reported not being invited or participating in the initial care plan conference. The facility's Social Service Assistant and Regional Licensed Social Worker confirmed that there was no documentation to verify that the resident or their representative had been invited or attended the initial care conference, despite the facility's policy requiring family involvement in care planning.
Failure to Follow Physician's Orders for Tube Feeding
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of tube feeding and water flush rates for a resident diagnosed with Cerebral Palsy, Epilepsy, and Autistic Disorder. The resident was prescribed Jevity 1.2 to be administered at a rate of 45 ml/hour for 22 hours per day, with a water flush of 25 ml/hour via a PEG tube. However, during an observation, it was noted that the Jevity 1.2 was infusing at 60 ml/hour and the water flush at 45 ml/hour, which was inconsistent with the physician's orders. The discrepancy was confirmed by a registered nurse who acknowledged that the feeding was previously administered at the correct rate. Despite the deviation from the prescribed rates, a nurse practitioner stated that the short-term infusion at the incorrect rates did not result in any complications for the resident. The Director of Nursing also confirmed the facility's failure to follow the physician's orders regarding the tube feeding and water flush rates.
Oxygen Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper storage of an oxygen tank for a resident and did not obtain a physician's order for oxygen administration for another resident. Resident #38, who was admitted with diagnoses including Chronic Obstructive Pulmonary Disease and Atherosclerotic Heart Disease, was observed multiple times with an unsecured oxygen tank in their room. The facility's policy on oxygen safety requires that oxygen cylinders be stored securely to prevent damage, but the tank was found leaning against the wall and not in use during several observations. Additionally, Resident #386, admitted with conditions such as Pneumonia and Chronic Kidney Disease, was receiving oxygen therapy without a physician's order. Despite the comprehensive care plan indicating the need for oxygen administration as ordered, the resident's medical records did not contain an order for oxygen use. Observations confirmed that the resident was receiving oxygen at 2 liters per minute via nasal cannula, and the Assistant Director of Nursing acknowledged the absence of a physician's order, which was against the facility's policy.
Expired Medications Found in Medication Cart
Penalty
Summary
The facility failed to ensure that expired medications were not available for resident use, as observed in one of the four medication carts. During an observation and interview with an LPN, a box of Ferrous Gluconate, containing 87 tablets with an expiration date of January 2024, was found in the unit 2 hall medication cart. The LPN confirmed that the medication was expired and still available for resident use. The facility's policy, titled 'Destruction of Unused Drugs' and revised in April 2024, mandates that all expired drugs should be disposed of. However, during an interview, the DON confirmed that expired medications were supposed to be removed from the medication cart and discarded, indicating a lapse in adherence to the facility's policy.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 55 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Loudon
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Wood Village | 11.3 mi | — | 0 | 0 |
| Waters Of Sweetwater A Rehabilitation & Nursing | 13.3 mi | — | 0 | 0 |
| Nhc Healthcare, Farragut | 14.5 mi | — | 3 | 0 |
| Monroe Health And Rehabilitation Center | 15.5 mi | — | 2 | 0 |
| Renaissance Terrace | 19.5 mi | — | 2 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for River Grove Health And Rehabilitation.
100% money-back within 48 hours.
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.