Below average — CMS composite of the measures below.
A standard survey is most likely before around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at River Brook Healthcare Center during CMS and state inspections, most recent first.
Two residents with complex medical conditions, including one with traumatic brain injury and another with ESRD on dialysis and paraplegia, were transferred to other SNFs within 24 hours without 30‑day discharge notices, physician discharge orders, or completed discharge recapitulations. In both cases, the ombudsman was not notified prior to the facility‑initiated transfers, and one resident reported being told the move was temporary for room work, while another was moved following a conflict involving family, law enforcement, and a roommate. The Social Services Director acknowledged not issuing 30‑day notices or contacting the ombudsman before arranging these discharges.
Surveyors found that the facility did not follow its RAI/care planning policy or honor the documented wishes of two residents who wanted to remain in LTC. One resident with multiple conditions, including hypertension, depression, and traumatic brain injury, had a care plan specifying long‑term residency with interventions such as activity participation and Social Services involvement. Another resident with ESRD on dialysis, paraplegia, hypertensive heart and CKD, diabetes, hypertension, and seizures had a care plan stating no desire for discharge, a need for 24‑hour care, and a family unable to provide care, with instructions to involve Social Services if interest in outside resources arose. An LPN MDS Coordinator reported that the Social Services Director is responsible for initiating transfers/discharges but could not explain why the required process was not followed for these residents.
Failure to follow a resident’s fall care plan resulted in injury after a CNA moved the resident to a different room and did not ensure the bed was in the lowest position. The resident had a history of falls, was totally dependent on staff, and had diagnoses including seizures, anxiety disorder, major depressive disorder, and generalized muscle weakness. The fall led to fractured ribs, a head hematoma, and a cut lip.
Failure to Keep Bed in Lowest Position Resulted in Major Injury A resident with seizures, anxiety, MDD, and generalized muscle weakness was dependent on staff for ADLs and identified as a fall risk due to prior falls and poor safety awareness. Her care plan included keeping the bed in the lowest position, but after a CNA moved her to a different room, the bed was not left in the lowest position. The resident fell from bed and sustained a lip laceration, forehead hematoma, and two rib fractures.
A facility failed to properly handle expired and discharged meds in a medication room. A large box of medication packs and vials was observed filled to the top with no lid, no label, and no count. RN AA, the DON, and an LPN stated that expired or discontinued meds were placed in the box without being logged or labeled, and the box remained in the med room until the pharmacist came monthly.
The facility failed to maintain a safe, clean, and comfortable environment when roof damage from a prior hurricane was left unrepaired, with hanging eaves and gutters, roof gaps, and a room that continued to leak after rain. In addition, two resident rooms on 200 Hall had A/C filters clogged with dust, and the facility lacked an environmental management policy; the Maintenance Director and DON confirmed the filters should be monitored by maintenance and housekeeping.
Failure to assess self-administration before leaving medications at the bedside. A resident with cognitive impairment and a BIMS score of 5 was observed with nasal spray, antifungal powder, and zinc oxide cream in a bedside basket. The record had no self-administration assessment, physician order, or care plan showing the resident could self-administer the medications, and staff confirmed the items were in the room without the required documentation.
A resident's medical information was disclosed by an LPN to the resident's family without the resident's permission. The resident, who had a BIMS score of 14 and no POA or representative, reported the disclosure and requested to speak with the Administrator and DON about the complaint. The Administrator confirmed the resident's information should not have been shared without consent.
Missing and jammed privacy curtains were found in multiple resident rooms, and an environmental tour also identified curtain gaps that did not provide full visual privacy during care. The Housekeeper Supervisor confirmed the issues had not been addressed before the survey, and the DON stated staff were expected to check that privacy curtains were in place and noted the concern could be a dignity issue.
Failure to assess Geri-chair use as a restraint for a resident with Alzheimer’s disease, schizoaffective disorder, and dementia with behavioral disturbance. The resident was observed in a reclined, locked Geri-chair and later positioned between a dining table and the wall, which prevented free movement and attempts to rise. An LPN said the chair was being used due to an unsteady gait and several falls, and the DON stated residents should not be reclined in Geri-chairs so movement is restricted.
The facility failed to ensure that the designated Infection Preventionist (IP) had completed the required specialized training in Infection Prevention and Control. The Unit Manager, temporarily filling in as the IP, and the DON were not certified, although they were enrolled in an online certification course. This deficiency placed all 68 residents at risk for potential transmission of infections.
The facility failed to implement enhanced barrier precautions (EBP) for three residents with pressure ulcers. Observations showed the wound care nurse did not wear a gown, and there was no signage indicating EBP. Staff interviews revealed a lack of instruction and ongoing efforts to implement EBP and educate staff.
Failure to Provide Required 30‑Day Discharge Notices and Ombudsman Notification for Two Residents
Penalty
Summary
The facility failed to provide required 30‑day discharge notices, obtain physician discharge orders, complete discharge documentation, and notify the ombudsman for two residents who were transferred or discharged within 24 hours. One resident with hypertension, depression, diffuse traumatic brain injury with loss of consciousness, and traumatic ischemia of muscle was admitted on an unspecified date and later accepted to an out‑of‑county facility. Progress notes documented that the resident and a family member were informed of the discharge and that transport would arrive the next morning, and the resident was transferred via EMS with belongings. However, there was no physician order for discharge, no 30‑day discharge notice, no documented request for transfer to another SNF, no documented behaviors, and no ombudsman notification. The discharge recapitulation form contained only demographic information and the resident’s name, with all other sections left blank. The ombudsman reported not being notified and stated the family was also not notified, and the resident reported being told the move was temporary and related to room work, later learning at the receiving facility that he would not return. The Maintenance Director stated no renovation was done to the room, while the Social Services Director stated she told the resident he would be leaving the next morning due to environmental issues and acknowledged she did not contact the ombudsman. A second resident with end‑stage renal disease on dialysis, paraplegia, hypertensive heart and chronic kidney disease, type 2 diabetes, hypertension, and seizures was also discharged without a 30‑day notice, physician discharge order, or completed discharge recapitulation. Progress notes documented that a family member accused the resident’s roommate of slapping the resident, that the roommate denied the allegation, and that law enforcement was contacted due to family members attempting to fight and verbally threaten the roommate; the roommate was moved to another room. There was no physician order related to the discharge and no evidence of a 30‑day discharge notice. The ombudsman stated the resident wanted to return, was not given a 30‑day notice, and that the facility did not notify the ombudsman prior to discharge, which would have allowed the resident to appeal with assistance. The Social Services Director reported she sent a referral package to another facility after speaking with corporate and the previous administrator, stated that a family member had to be escorted out by law enforcement, and that the resident kept the television on all night and talked loudly on the phone using speaker mode. She acknowledged the resident was not given a 30‑day discharge notice because another facility had been found, the ombudsman was not notified, and the resident was transferred within 24 hours.
Failure to Honor Residents’ Care Plan Goals to Remain in LTC
Penalty
Summary
Surveyors identified that the facility failed to develop and implement care plans that honored two residents’ expressed wishes to remain in the facility. The facility’s policy titled “RAI/Care Planning Management,” revised August 2017, states that a discharge plan will be included in the care plan at admission and that goals will be resident-specific, measurable, and realistic. For one resident with diagnoses including hypertension, depression, diffuse traumatic brain injury with loss of consciousness, and traumatic ischemia of muscle, the admission record and care plan documented that the resident’s plan was to remain a long‑term care resident. The care plan interventions included encouraging and assisting the resident to participate in activities of choice and directing the Social Services Director to visit as needed. Another resident was admitted with end‑stage renal disease on dialysis, paraplegia, hypertensive heart and chronic kidney disease, type 2 diabetes, hypertension, and seizures. This resident’s care plan documented that the resident had voiced no desire to be discharged from long‑term care, required 24‑hour care, and that the family was unable to provide care at that time. The care plan further directed staff to refer to Social Services if the resident voiced or demonstrated interest in seeking outside resources to live elsewhere. During an interview, the LPN MDS Coordinator stated that the Social Services Director is responsible for initiating the transfer/discharge process and acknowledged not knowing why the required process was not followed for these residents, despite their care plans indicating they wished to remain in the facility.
Failure to Follow Fall Care Plan
Penalty
Summary
The facility failed to implement the care plan interventions related to falls for one resident with a history of falls, poor safety awareness, chairfast status, total dependence on staff, restlessness and agitation, contractures, muscle weakness, seizures, sacrococcygeal disorders, and spastic mobility. The resident’s care plan included interventions such as bilateral fall mats at the bedside, CNA assistance with proper positioning in bed, use of appropriate wedges, and keeping the bed in the lowest position, with a goal of being free from fall-related injuries through nursing and therapy interventions by the next review date. Record review showed that after a fall, the post-fall evaluation documented that the bed was at an improper height. The DON stated that the resident fell from the bed after a CNA moved the resident to a different room and did not ensure the bed was in the lowest position, resulting in a cut lip, a hematoma to the right side of the head, and fractured ribs. The resident had diagnoses including seizures, anxiety disorder, major depressive disorder, and generalized muscle weakness.
Failure to Keep Bed in Lowest Position Resulted in Resident Fall With Major Injury
Penalty
Summary
The facility failed to ensure one of five residents, R12, was free from falls with major injury. R12 had diagnoses including seizures, anxiety disorder, major depressive disorder, and generalized muscle weakness. The Quarterly MDS indicated the resident was not assessed for BIMS because she rarely or never understood, and Section GG showed she was dependent on staff for dressing, bathing, transfers, and toileting. Her care plan identified her as at risk for falls related to a history of falls and poor safety awareness, and included keeping the bed in the lowest position as an intervention. On 9/19/2025, R12 fell from her bed and sustained a small laceration to her upper lip, a hematoma to the right side of her forehead, redness to the right side of her abdomen, and later hospital findings of two minimally displaced rib fractures involving the right fourth and fifth ribs. The post-fall evaluation documented that the bed was at an improper height. The incident note stated the resident was found on the floor beside the bed, unable to voice pain or describe the fall, and was sent to the ER after the MD was notified. The DON stated that R12 fell after a CNA moved her to a different room and did not ensure the bed was in the lowest position.
Expired and Discharged Medications Left Unlabeled in Medication Room
Penalty
Summary
The facility failed to ensure that expired and discharged medications were disposed of and stored in accordance with its medication policies in one drug storage room. The facility policy titled Medication Administration stated that medication destruction follows pharmacy policy, and the Pharmacy Policy Manual required discontinued or outdated medications to be destroyed by specific methods, including placing medication containers in a sealed, labeled box marked for destruction and securing it in a locked cabinet or room until disposal or pickup. During observation of the medication room, a large box filled to the top with medication packs and vials was seen with no lid, no description of the medications, and no quantity listed. RN AA stated that she empties the box monthly by placing medications into smaller boxes and giving them to the DON, but she does not log or label what is in the boxes. The DON stated that the facility does not log discharged or expired medications anywhere and that the medications sit in the box in the medication room until the pharmacist comes in monthly. LPN BB stated that when medications are expired or discontinued, she removes them from the cart and places them in a box in the medication room without logging them.
Roof Damage and Dirty A/C Filters
Penalty
Summary
The facility failed to maintain a safe, clean, and comfortable environment by not initiating roof repairs after known hurricane-related damage from 2024. Review of a roof replacement proposal showed estimates prepared on 6/2/2025, but observations on 9/26/2025 and 9/27/2025 found eaves and gutters hanging down from the roof near rooms on the A Hall and 100 Hall, with detached gutters and eaves scattered on the ground and gaps in the roof that allowed access to vermin. An LPN reported that one room on the 100 Hall had been leaking after hard rain for about two months, and that maintenance had placed a piece of wood over the area, but the room still leaked when it rained. The Maintenance Director stated the roof area had been damaged in June or July 2025 after several days of rain and that corporate was aware of the damage and had obtained an estimate for repairs, while the Administrator stated the roof damage occurred after the last hurricane in November 2024 and that there was no indication of when the roof would be repaired. The facility also failed to maintain air conditioning units in residents’ rooms on 200 Hall. During a tour, two rooms in B Hall were observed with air conditioning filters clogged with dust and not replaced. The facility did not have a policy for environmental management. The Maintenance Director confirmed that air conditioning filters should be checked weekly by maintenance and housekeeping, and the DON stated that maintenance is responsible for ensuring the filters are monitored by both housekeeping and maintenance.
Failure to Assess Self-Administration Before Leaving Medications at Bedside
Penalty
Summary
The facility failed to assess one of four sampled residents, R50, for the ability to self-administer medications before leaving medications at the bedside. The facility policy titled Medication Administration stated that self-administration is assessed at each care plan review and that the licensed nurse assists the resident in maintaining medications in a secure area. R50 was admitted with diagnoses including atherosclerotic heart disease of native artery without angina pectoris, chronic kidney disease stage 3A, and generalized anxiety disorder, and her annual MDS showed cognitive impairment with a BIMS score of five. During observation, R50 was found in bed with a small white plastic basket on the bedside table containing Equate nasal spray, Remedy Antifungal powder, and a silicone cream with zinc oxide. R50 stated she used the nasal spray herself, sometimes daily, and that aides sometimes applied the antifungal powder and zinc cream. The MAR showed an order for zinc barrier cream once per shift, but there was no order for the nasal spray or antifungal powder. Staff interviews confirmed the medications were in the resident’s room, and the record contained no self-administration assessment, physician’s order, or care plan showing R50 was able to self-administer the medications observed in her possession.
Confidentiality Breach Involving Resident Medical Information
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained for one resident, R64. R64 stated that she made a complaint after LPN DD exposed her medical care to her sister without her permission. She reported that her nurse told her about her medical care against her wishes, and when she learned of the disclosure, she asked the social worker to bring the Administrator and DON to her so she could complain about LPN DD. The social worker stated that R64 requested contact with the Administrator and DON to make a complaint about LPN DD, but the issue was not disclosed to her. The DON stated she had been told not to place LPN DD on the 200 hall with R64, but was not told why. The Administrator confirmed that R64 did not have a POA or representative, had a BIMS score of 14, and her information should not have been exposed to anyone without her consent. He also confirmed that LPN DD spoke with the resident's family about her care when she left the facility to pick up the resident's supplies from her sister's house.
Missing and Jammed Privacy Curtains in Resident Rooms
Penalty
Summary
The facility failed to ensure that privacy curtains provided full visual privacy in four of 20 sampled resident rooms, including room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]. During observations on Hall 200, Bed B in two rooms was missing privacy curtains and Bed A's privacy curtain was jammed, and in two other rooms Bed B was missing privacy curtains. An environmental tour with the Housekeeping Director and Regional Nurse also found resident privacy curtains with a width space/gap that did not ensure full visual privacy coverage during patient care, including Rooms 3, room [ROOM NUMBER], and room [ROOM NUMBER]. The Housekeeper Supervisor, employed since 9/15/2025, confirmed the missing and jammed curtains and stated the privacy curtains had not been addressed prior to the survey. The DON stated her expectation was for all staff to check privacy curtains and ensure they were in place, noted this could be a dignity issue, and reported being unaware of the missing and jammed curtains due to poorly damaged hooks.
Failure to Assess Geri-Chair Use as a Restraint
Penalty
Summary
The facility failed to assess the use of a Geri-chair as a potential restraint device for one sampled resident, R49. The facility policy titled Restraint Policy stated that restraint use should be limited to circumstances in which the resident’s medical symptoms warrant the least restrictive restraint, and listed physical restraint options including chairs that prevent rising. R49’s EMR showed diagnoses including Alzheimer’s disease, schizoaffective disorder, and dementia with behavioral disturbance. The quarterly MDS indicated no BIMS score, no ROM impairment, and that the resident was independent in moving side to side, transfers, and walking 150 feet once standing. The care plan identified fall risk related to confusion, gait and balance problems, incontinence, poor communication/comprehension, psychoactive drug use, unaware of safety needs, and vision/hearing problems, with interventions including appropriate footwear when ambulating or mobilizing in a wheelchair; there was no indication that the resident used a Geri-chair for mobility. During observations, R49 was seen sitting in a reclined Geri-chair in the day room and was attempting to get out of the chair but was unable to ambulate because the chair was reclined and locked. On another observation, R49 was seated in a Geri-chair at a dining room table positioned directly in front of the resident and against the wall, and the resident was observed attempting to rise but was unable to due to the chair’s position between the table and the wall. At another time, the resident remained in the Geri-chair with the dining table in front and the wall on the other side, which prevented free ambulation. An LPN stated that R49 was using the Geri-chair because of an unsteady gait and several falls, and that hospice had ordered the chair. The DON stated that residents in Geri-chairs should not be reclined back so that movement is restricted and that staff are expected to ensure residents are in the least restrictive and safest environment.
Infection Preventionist Lacks Required Certification
Penalty
Summary
The facility failed to ensure that the designated Infection Preventionist (IP) had completed specialized training in Infection Prevention and Control, as required by the job description. This deficiency was identified during a review of records and staff interviews. The job description for the Infection Control Preventionist, dated 2020, specified a requirement for certification in Infection Control Preventionist training. However, during an interview, the Unit Manager, who had been working at the facility for about a week and was temporarily filling in as the IP, confirmed that she did not have the necessary IP certification. Additionally, the Administrator acknowledged that both the Unit Manager and the Director of Nursing (DON) were not certified as IPs, although they were enrolled in an online IP certification course. This lack of certification placed all 68 residents at risk for the potential transmission of infections and communicable diseases.
Failure to Implement Enhanced Barrier Precautions for Residents with Pressure Ulcers
Penalty
Summary
The facility failed to implement enhanced barrier precautions (EBP) for three residents with pressure ulcers, as observed during wound care treatments. The undated document titled 'Implementation of Personal Protective Equipment (PPE) Use In Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs)' outlines that EBP should be used for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. This includes the use of gowns and gloves during high-contact resident care activities. However, during observations, the wound care nurse did not wear a gown, and there was no signage indicating the need for EBP on the residents' doors. Interviews with staff revealed a lack of instruction and implementation regarding EBP. The wound nurse stated she had not been instructed to use EBP unless a resident had a specific condition like ESBL. Additionally, a registered nurse mentioned that they had received an email about EBP a week prior and were in the process of implementing it and educating the staff. This indicates a gap in communication and training regarding the proper use of PPE and EBP for residents with pressure ulcers.
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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 7 citations issued within 25 miles in the last 12 months — 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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Homerville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Sgmc Health Villa | 20.1 mi | ★★★★★ | 0 | 0 |
| Baptist Village, Inc. | 23.4 mi | ★★★★★ | 7 | 0 |
| Waycross Health And Rehabilitation | 26.5 mi | ★★★★★ | 3 | 0 |
| Harborview Satilla | 26.7 mi | ★★★★★ | 21 | 0 |
| Berrien Oaks Nursing And Rehab Center | 31.3 mi | ★★★★★ | 4 | 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 July 2026) and official state health department websites.