Below average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of August 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.
Food storage and kitchen sanitation were deficient due to expired food items remaining in storage, debris and dead insects in the dry storage area, pooled water and no backup thermometer in the walk-in cooler, employee soda stored in the cooler, and torn, soiled potholder gloves in use. Additional buildup of food spillage and grease, soiled saucers, and food debris in prep table drawers were also observed.
Walk-In Freezer Ice Buildup Surveyors observed heavy ice buildup and condensation inside the walk-in freezer, including ice on walls, surfaces, and food boxes, with some areas inches thick. The DD said a work order had already been submitted, and the freezer service provider documented a damaged fan, an unusually long defrost period, and staff leaving cooler and freezer doors open for extended periods. The OA later confirmed the ice accumulation was still present and said her attempt to remove it did not fix the problem.
A resident who wore bilateral hand splints did not have an appropriate usable call light within reach. Staff found the call light on the floor under the bed, and the standard push-button call light was not usable for the resident. The DON stated the resident could use a soft touch pad call light but not a push-button call light, and the facility did not have soft touch call lights available at the time.
A resident’s code status was not accurately reflected in the facility’s Code Book after the physician order changed from DNR to Full Code. Staff identified the Code Book as the most reliable source for emergency code status, but it still listed the resident as DNR despite an active Full Code order and updated CPR consent. The resident had vascular dementia and lacked decisional capacity, and the SSD and DON confirmed the Code Book had not been updated.
Unlabeled Tube Feeding Formula and Flush Bag: A resident receiving nutrition via G-tube had Jevity 1.5 and a clear flush bag hanging at the bedside without labels showing the resident’s name, date, time, or infusion rate. The DON stated the facility had no policy for labeling tube feeding formula, and confirmed that tube feedings and water bags should be labeled because feeds are often paused for care, repositioning, and transfers.
Failure to provide ordered oxygen therapy for two residents. One resident with a tracheostomy was observed with the oxygen concentrator turned off, so the resident was not receiving the ordered O2 via tracheal collar, and the tracheal collar and tubing were not dated. Another resident with hypoxia and OSA had O2 via NC in use, but the tubing date did not match the weekly change schedule, and RN confirmed the facility’s tubing-change process was not followed.
A facility failed to maintain controlled-drug records detailed enough to accurately reconcile a Schedule III injectable multi-dose vial when nurses changed shifts. During narcotic count review, an LPN/S found a clear, unscored, unmarked testosterone cypionate vial in the narcotic lock box, and the amount remaining could not be verified by inspection; staff were relying only on the narcotic sign-out sheet for counts. The DON confirmed the vial could not be visually reconciled, and pharmacy reportedly said this was the only packaging available.
A CNA entered a resident’s room to deliver a meal tray without donning PPE even though the resident was on contact isolation precautions and signage was posted outside the room. The CNA said PPE was not needed because no care was being provided, while the unit’s LPN manager and the DON confirmed PPE was required; the DON also noted the resident’s tray with reusable dishware was returned to the kitchen on the cart.
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.
Food Storage and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, and serve food under accepted sanitary conditions because the food service area was not kept clean and sanitary, expired food items remained in storage, and non-resident items were placed in the walk-in cooler. During the initial kitchen tour, the Dietary Director observed a tub of vanilla frosting that had been opened on 03/03/26 with a Use By date of 06/06/26, along with two large bags of vanilla wafers with a Best By date of 04/13/26 in the dry food storage area. The same area contained fallen food crumbs, other debris, soil on the floor, several dead insects, and dried substances smeared on the shelving. Additional observations in the walk-in cooler showed no backup thermometer inside and pooled water on the floor, with three cans of soda belonging to an employee on a shelf in the cooler. On a later observation, three torn and soiled potholder gloves were being used in the kitchen, and the Dietary Director stated he had more and would replace them. Further inspection of the kitchen area revealed buildup of food spillage and grease, soiled saucers stored on the bottom shelf of food prep areas, and food debris inside the storage drawers of the food preparation tables.
Walk-In Freezer Not Maintained in Proper Working Condition
Penalty
Summary
The facility failed to maintain the walk-in freezer in proper working condition, and survey observation found heavy ice buildup and condensation inside the unit. During the initial kitchen tour, the freezer accessed from inside the walk-in cooler had ice buildup along the walls and on food boxes and surfaces, with ice inches thick in some areas. The Dietary Director stated that a work order had already been submitted for repairs and that the freezer was supposed to have been fixed. A review of the freezer service provider’s work summary documented that staff reported ice buildup inside the box, especially around the fans. The service provider found a damaged fan that needed replacement and noted an unusually long defrost period that could cause excess moisture inside the box. The report also stated that staff had been keeping cooler and freezer doors open for extended periods, sometimes exceeding one hour. During a later kitchen observation, the Operations Assistant confirmed the ice accumulation remained and stated that she had tried to remove the buildup, but it did not resolve the problem.
Usable Call Light Not Available for Resident With Hand Splints
Penalty
Summary
The facility failed to ensure that R13 had an appropriate usable call light within reach. On 06/16/26, R13’s call light was observed on the floor under the bed. When the Unit Manager retrieved it, cleaned it, and placed it on the bed, it was identified as a standard push-button call light. The Unit Manager stated R13 wore bilateral hand splints for eight hours daily and did not think R13 could use the push-button call light while wearing them. The Unit Manager also stated R13 previously had a soft touch pad call light that could be activated by bumping the pad, but she did not know why it was no longer available. The DON later stated that R13 was able to move his/her arms and could use a soft touch pad call light, but was not physically able to use a push-button call light. The DON confirmed R13 could not pick up and ring a handheld bell. The DON also stated the facility was in the process of installing a new call light system, that soft touch call lights were not available in the building, and that R13 had been without the soft touch call light until replacement equipment arrived. The OA reported that soft touch call lights had been ordered but had not yet arrived, and the installation company message indicated the order would not ship until 06/18/26.
Code Book Not Updated to Match Resident’s Full Code Status
Penalty
Summary
The facility failed to ensure its Code Book was updated to reflect a resident’s current code status after the physician order changed from DNR to Full Code. The facility policy required staff to document advance directives and provide clear instructions for determining code status during an emergency. Resident 14 had diagnoses including vascular dementia and was determined to lack decisional capacity. The resident’s record contained an earlier physician order for DNR and an advance directive form stating CPR should not be done, followed by an updated consent form stating CPR should be done and a physician order for Full Code. During interview and observation, staff identified the Code Book at the nursing station as the primary and most reliable source for determining code status in an emergency. The Code Book still listed the resident as DNR even though the active physician order was Full Code. The LPN, CNA, SSD, and DON all confirmed that staff relied on the Code Book for emergency code status and that it had not been updated to match the resident’s current order. The SSD stated the paperwork had been lost on her desk and she did not update the Code Book, and the DON stated the Code Book should be updated in a timely manner when the order is received.
Unlabeled Tube Feeding Formula and Flush Bag
Penalty
Summary
The facility failed to ensure appropriate treatment and services for a resident receiving nutrition through a percutaneous endoscopic gastrostomy (G-tube). During observation of the resident’s room, a container of Jevity 1.5 was seen hanging on a pole beside the bed and connected to the resident’s G-tube, infusing at 70 ml per hour with water flushes ordered at 175 ml every four hours. The formula container had the manufacturer’s label, but it did not identify the resident, the date or time it was started, or the infusion rate, and those areas were left blank. A clear bag containing a clear liquid was also hanging on the pole, and it likewise did not identify the contents, the resident, the date, the time, or the rate of infusion. Review of the physician’s orders showed the resident was ordered Jevity 1.5 at 70 ml per hour for 20 hours daily, with residual checks every shift and water flushes every four hours. The DON stated the facility did not have a policy regarding labeling tube feeding formula, and confirmed that bottles of tube feeding formula and water should be labeled with the date and time because feedings are often paused for care, repositioning, and transfers.
Failure to Provide Ordered Oxygen Therapy
Penalty
Summary
The facility failed to ensure that residents who required oxygen received respiratory care in accordance with physician orders and professional standards of practice for two residents sampled for oxygen therapy. Review of facility policies showed the oxygen administration policy did not address oxygen delivered via a tracheostomy mask, and the respiratory policy also did not address tracheostomy oxygen administration or instruct staff to ensure oxygen concentrators were on and operating correctly. For one resident with a tracheostomy, the resident was observed wearing an oxygen mask/tracheal collar over the tracheostomy site, but the tracheal collar and tubing were not dated, and the oxygen concentrator was found in the off position so the resident was not receiving the ordered oxygen. The Unit Manager confirmed the concentrator was off, turned it on, and set it to 5 liters per minute; the resident’s oxygen saturation was documented as 93%. For a second resident with diagnoses including acute respiratory failure with hypoxia and obstructive sleep apnea, the physician ordered oxygen at 3 liters per nasal cannula continuously and tubing changes every Sunday night. During observation, the resident was using oxygen in the dining room, and the tubing was dated 06/08/26. RN4 stated the tubing should have been dated 06/14/26 based on the weekly change schedule and confirmed the policy and procedure for changing oxygen tubing had not been followed. The DON later stated oxygen tubing was changed every Sunday night on 3rd shift and as needed.
Inaccurate Reconciliation of Controlled Injectable Medication
Penalty
Summary
The facility failed to establish a system of records for the disposition of an injectable multi-dose vial of testosterone cypionate, a Schedule III controlled drug, in enough detail to allow an accurate reconciliation when responsibility for controlled drugs was passed from one nurse to another. During reconciliation of narcotics on the 600 Unit medication storage cart, a 10 mL multidose vial of testosterone cypionate injection for a resident was found in the narcotic lock box with the count sheet documenting 7 mL remaining. The vial was clear glass, unscored, and unmarked, with no way to visually determine how much medication remained in the bottle. The medication was ordered as 0.75 mL IM every 7 days, and the narcotic sign-out sheet showed four doses had been administered over the prior four weeks. An LPN/S conducting the reconciliation stated he could not tell how much was left in the bottle and that shift counts were based only on what was recorded on the narcotic sign-out sheet. The DON later confirmed the count could not be verified by looking at the vial and stated pharmacy would need to be contacted to request a container that would allow the remaining amount to be verified during shift-change reconciliation. The DON also stated she could not determine by inspection how much medication remained in the vial, and the LPN/S reported that pharmacy said the clear, unscored, unmarked vial was the only way the medication was packaged.
Failure to Use PPE When Delivering Meal Tray to Resident on Contact Isolation
Penalty
Summary
Facility staff failed to implement infection control procedures when delivering a meal tray to a resident on contact isolation precautions. The facility’s policy for isolation precautions required that when a resident is placed on transmission-based precautions, appropriate notification be posted and staff follow the required PPE and hand hygiene procedures. The clinical record showed that the resident had a physician’s order placing them on contact isolation precautions through 07/24/26, and signage and equipment were posted outside the room door. During an observation, a CNA entered the resident’s room to deliver the lunch meal tray without donning any PPE. The CNA stated PPE was not required because she was not going to provide care. The unit’s Nurse Manager confirmed that PPE was required because the resident was on contact isolation precautions. The DON also acknowledged that staff should don PPE before entering and doff PPE before exiting rooms for residents on contact isolation precautions, and confirmed that the resident’s meal tray with reusable dishware was placed back onto the cart to be returned to the kitchen, which was identified as an infection control concern.
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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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.
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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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