Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Heartland Health Care Center - Greenville East during CMS and state inspections, most recent first.
The facility allowed its DON to continue working and performing typical DON duties, including direct resident care and clinical documentation, after her RN license had been temporarily suspended. During this period, the DON assessed a resident’s erythematous, ulcerated chest rash, contacted a wound provider, obtained and entered medication orders, and managed wound care timing, while also completing a weekly summary and IDT assessment for another resident. Human Resources and current leadership later reported they were unaware of the suspension at the time, resulting in an unlicensed individual functioning in a nursing leadership and care role in violation of regulatory requirements.
The facility failed to maintain effective systems to verify licensure for nursing leadership, allowing the DON to continue in a role that included clinical oversight, supervision of nursing staff, and direct resident care after her RN license was temporarily suspended by the state. Her job description required that she remain in good standing with the Board of Nursing, yet she continued performing typical DON duties during the suspension period. Facility HR reported they were unaware of the suspension at the time, had no interim license‑audit policy beyond checks at hire and renewal, and could not specify the exact duties performed while the DON was unlicensed. The State Agency determined this non‑compliance with administrative requirements constituted Immediate Jeopardy related to potential psychosocial harm.
Surveyors found that food items were improperly stored, with some placed directly on the floor and others not labeled or dated. Dented cans were stored with ready-to-use food, and expired products were present in the refrigerator. The kitchen was observed to be dirty, and staff interviews confirmed awareness of these issues and a lack of proper food safety practices.
Unlicensed DON Provided Nursing Oversight and Direct Care
Penalty
Summary
The deficiency involves the facility’s failure to ensure that nursing services were provided by a licensed nurse when the Director of Nursing (DON1) worked while her nursing license was under temporary suspension. A document from the South Carolina Department of Labor Licensing and Regulation dated June 18, 2025, stated that DON1’s license to practice nursing in the state was temporarily suspended effective immediately, until further order of the Board. Despite this suspension, DON1 continued to work at the facility on June 18, 2025, and June 23, 2025, performing DON duties and providing nursing leadership oversight without a valid nursing license. The facility’s own job description for the Director of Nursing, signed by DON1, specified that the DON must be a registered nurse in good standing with the State Board of Nursing and responsible for overall management of the nursing department, staffing levels, resident safety, and direct resident care as needed. During the period of suspension, DON1 provided direct care and clinical oversight for at least two residents. For one resident (R4), the electronic medical record for June 2025 documented that on June 23, 2025, the resident approached DON1 to assess a large erythematous and ulcerated rash under the right pectoral area. The note indicated that the nurse practitioner and physician were made aware and examined the area, and that DON1 contacted the wound provider and obtained orders for Mycolog II cream twice daily for 14 days, Diflucan 100 mg by mouth daily for 5 days, Keflex 500 mg by mouth twice daily for 10 days, and Interdry application several hours after the cream. The documentation further showed that at 2:33 PM that same day, DON1 entered medication orders for Diflucan and Cephalexin for erythrasma, and later documented extensive interaction with the resident regarding showering and timing of leg wraps, including multiple reminders and an explanation of her need to leave the facility for an appointment. For another resident (R5), the electronic medical record for June 2025 showed that DON1 completed a weekly summary note and signed an interdisciplinary team (IDT) conference assessment on June 18, 2025, the same date her license suspension became effective. These entries indicated that DON1 was performing clinical assessment and documentation functions for this resident while not legally authorized to practice as a nurse. Human Resources staff later stated that they were unaware of the suspension at the time and that DON1, a salaried exempt employee who did not clock in and out, continued to perform typical DON duties during this period. The survey agency determined that the facility’s noncompliance with nursing services requirements, specifically allowing an unlicensed individual to function as the DON and provide direct resident care, constituted Immediate Jeopardy related to 42 CFR §483.35(c)(3) Nursing Services.
Removal Plan
- Notify the Medical Director of the Immediate Jeopardy and complete any additional required external notifications if applicable.
- Initiate a primary source audit of all currently employed licensed nursing staff to confirm active licensure and good standing; print/electronically save verification evidence and place it in personnel files.
- Complete a look-back investigation for all shifts worked by the ex-employee; assess/interview identified residents.
- Provide mandatory re-education to licensed nursing staff on the requirement to immediately notify the Administrator and/or DON of any license investigation, consent order, suspension, restriction, expiration, or other status change.
- Monitor compliance through QAPI; report results monthly for three months and quarterly for three additional quarters; QAPI Committee to re-evaluate need for further monitoring; Human Resource Director responsible for monitoring and follow-up.
- Upload current active nursing licenses for all licensed nursing staff into the facility’s human resources system to centralize and improve access to credential verification.
- Re-educate the Human Resources Director on the licensure certification and registration of personnel policy.
- Implement a process requiring all newly hired employees to sign an attestation that they must inform the Administrator/DON/HR Director of any licensure investigation, consent order, or change in licensure status; failure to report may result in discipline up to termination.
- Initiate an attestation for all currently employed licensed personnel regarding responsibility to report any licensure investigation, consent order, or change in licensure status; failure to report may result in discipline up to termination.
- Complete all attestations for licensed personnel; employees will not work until the attestation is completed.
- Implement a standardized license verification form and a central licensure tracking log with verification and expiration dates.
Failure to Verify DON Licensure Resulting in Unlicensed Nursing Leadership
Penalty
Summary
The deficiency involves the facility’s failure to have systems in place to verify licensure for nursing leadership, specifically the Director of Nursing (DON). The South Carolina Department of Labor, Licensing and Regulation issued an order dated June 18, 2025, temporarily suspending the DON’s nursing license effective immediately. Despite this suspension, the DON continued in her role, which, per her signed job description dated May 15, 2024, included overseeing and supervising the care of all residents, providing direct resident care as needed, managing the entire nursing department and staffing levels, ensuring resident safety, and supervising the ADON and all nursing staff. The job description also required that the DON be in good standing with the State Board of Nursing and maintain all required licensure requirements at all times. Human resources staff reported in interview that the DON was terminated on June 25, 2025, for conduct and unprofessionalism related to sexual harassment, and that they were unaware of the license suspension at the time of termination. HR stated that the DON was a salaried exempt employee who did not clock in and out, and HR could not specify what duties the DON performed while her license was suspended. Another DON, who assumed the DON role on June 25, 2025, stated that the previous DON would have performed typical DON duties and did not believe she was signed off for any patient care during the suspension period, but also indicated that they did not learn of the suspension until June 30, 2025, after conducting an internal audit prompted by information the former DON shared following her termination. During interviews, HR staff acknowledged that the facility did not have a policy for auditing licenses and that, for nurses, licenses were not checked between the two‑year renewal periods unless there was a specific reason to do so. The facility stated that licensure verification was performed at hire, at licensure renewal dates, and annually, but no verification occurred in the seven days between the Board’s temporary suspension order and the DON’s termination. The State Agency determined on February 14, 2026, that the facility’s non‑compliance with federal regulations related to administration could cause psychosocial harm, and Immediate Jeopardy was cited under 42 CFR §483.70, with the IJ determined to have existed as of June 18, 2025, due to the DON continuing to provide clinical oversight, supervise nursing staff, and provide direct resident care while unlicensed.
Removal Plan
- The Director of Nursing notified the Medical Director of the Immediate Jeopardy and will complete any additional required external notifications if applicable.
- The Human Resource Director initiated a primary source audit of all currently employed licensed nursing staff to confirm active licensure and good standing; no issues were identified.
- Verification evidence for all licensed nursing staff was printed or electronically saved and will be placed into appropriate personnel files.
- The Director of Nursing completed a look-back investigation for all shifts worked by the former Director of Nursing; the review found no evidence of resident harm or complaints, and residents were interviewed/assessed with no complaints or negative effects identified.
- Licensed nursing staff received mandatory re-education to immediately notify the Administrator and/or Director of Nursing if their license is under investigation, a licensure-related consent order is entered, or the license becomes suspended, restricted, expires, or changes status for any reason.
- The Human Resource Director will audit nursing licenses monthly for 3 months and then quarterly for 3 quarters; results will be reported to the QAPI Committee monthly for 3 months and quarterly for 3 quarters, with the QAPI Committee re-evaluating the need for further monitoring after these periods; the Human Resource Director will be responsible for monitoring and follow up.
- The Human Resource Director uploaded current, active nursing licenses for all licensed nursing staff into the facility's human resources system to ensure centralized and accessible credential verification.
- The Human Resource Director was re-educated by the Regional President and Assistant Regional Director of Clinical Services on the licensure certification and registration of personnel policy.
- The facility implemented a process requiring all newly hired employees to sign an attestation that they must inform the Administrator, Director of Nursing, or Human Resource Director of any licensure investigation, licensure-related consent order, or change in licensure status; failure to report is grounds for discipline up to and including termination.
- The facility initiated an attestation for all currently employed licensed personnel that they must inform the Administrator, Director of Nursing, or Human Resource Director of any licensure investigation, licensure-related consent order, or change in licensure status; failure to report is grounds for discipline up to and including termination.
- All attestations for licensed personnel will be completed or the employee will not work until the attestation is completed.
- A standardized license verification form and central licensure tracking log with verification and expiration dates will be implemented.
Failure to Store, Prepare, and Serve Food According to Professional Standards
Penalty
Summary
The facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for all residents. During a kitchen tour, surveyors observed a box of cereal and a box of thickened sweet tea stored on the floor, which is against the facility's policy requiring items to be stored at least six inches above the floor. Dented cans of food were found stored with ready-to-use cans, and several food items, including egg salad and pureed fruit, were not labeled or dated. In the walk-in refrigerator, cases of chocolate milk were found with expired dates, and multiple containers of unidentifiable food lacked labels and dates. Pepperoni was partially wrapped and undated, stored on top of raw beef that was also undated and not in a container. The kitchen's shelving, vent hoods, ceiling vents, and floor were observed to be dirty throughout. Interviews with staff revealed that the Account Manager agreed with the surveyors' observations and acknowledged the lack of labeling and dating, stating that they would discard all unlabeled containers. The Dietary Manager, who had recently started, described the kitchen as being in disarray upon arrival. The Administrator reported that the person previously running the kitchen was not a Certified Dietary Manager as believed and that the kitchen had been identified as problematic shortly after their own start at the facility.
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What surveyors actually found near you
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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
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Greenville
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| The Arboretum At The Woodlands | 3.3 mi | ★★★★★ | 0 | 0 |
| Greenville Post Acute | 3.3 mi | ★★★★★ | 2 | 0 |
| West Village Post Acute | 3.7 mi | ★★★★★ | 7 | 0 |
| Magnolia Manor - Greenville | 4.2 mi | ★★★★★ | 0 | 0 |
| Presbyterian Home Of Sc - Foothills | 8.1 mi | ★★★★★ | 6 | 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.