Below average — CMS composite of the measures below.
A standard survey is most likely before around November 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 Grove Health And Rehabilitation during CMS and state inspections, most recent first.
Improper Food Storage and Unsanitary Kitchen Equipment: An uncovered box of frozen wedges was found open to air in the freezer, with visible discoloration on some pieces, and the CDM confirmed it was available for resident use without proper sealing. In the kitchen, food debris and grease-like buildup were observed on convection oven dials and door handles, a can opener blade had a thick black sticky substance, and several nectar thick beverages in the refrigerator lacked open dates despite label instructions to discard them 7 days after opening.
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.
A facility failed to keep resident personal and medical information private when a shift-to-shift communication sheet listing residents' names and medical conditions was left on top of a medication cart and a medication card label with a resident's name was stored in view on the side of the cart above clean cups. An LPN acknowledged the information should not have been visible, and the DON stated staff were expected to secure and cover confidential information before leaving the cart.
A resident’s admission MDS was inaccurately completed in Section L, Oral/Dental Status, by indicating no dental problems despite poor dentition with multiple missing, broken, and rotted teeth and visible decay/discoloration. The resident had dementia with moderate cognitive impairment on BIMS, no oral pain, and no weight loss, and the remote MDS coordinator stated she coded the section as none of the above because nothing was documented in the record.
A resident with multiple diagnoses, including dysphagia and significant wt loss, had weekly wt monitoring ordered and an ST eval ordered for a possible diet upgrade. The DON discontinued the weekly wts without a physician or NP order, and the ST eval was not completed even though the NP believed it had been done. The NP, Medical Director, and DON all confirmed the orders were not followed as written.
Failure to address significant weight loss: A resident with dementia, dysphagia, DM, and a history of obesity had major unplanned weight loss after being changed to a puree diet. Nursing documented that she disliked the diet and often refused to eat, staff were observed leaving meals in the room without assisting, and the RD did not promptly document interventions to prevent further loss. The record also showed no IDT notes, no lab evaluation of nutritional status, and weekly weights were later stopped despite ongoing decline.
A resident with pneumonia, cerebral infarction, OSA, and dementia had a nebulizer mask left uncovered and open to air on the bedside table during multiple observations. The Wound Care Nurse confirmed the mask should have been stored in a plastic bag, and the DON stated nebulizer masks were to be stored in a plastic bag and labeled with the resident's name.
A resident with multiple diagnoses including DM, dementia, dysphagia, and severe obesity experienced significant unplanned weight loss while on a mechanically altered diet. After ST recommended a puree diet, the resident refused to eat the pureed meals and intake dropped further, with nursing notes and family reporting poor eating. The RD documented the weight loss but did not promptly implement effective nutritional interventions, and the resident continued to lose weight despite later Boost BID and a diet upgrade.
Improperly Contained Trash and Unsanitary Dumpster Area The facility failed to keep garbage and refuse properly contained and failed to maintain the exterior dumpster area in a sanitary, orderly condition. Surveyors observed two alternate trash receptacles with lids propped open, exposing contents to the elements and potential pests, along with broken furniture, wooden pallets, and a blue barrel containing rusted metal, broken planks, and unidentified trash floating in brown, turbid water. The CDM confirmed the trash was not properly contained and the dumpster area was not maintained appropriately.
A facility failed to ensure appropriate PPE was worn for a resident on EBP. The resident had an indwelling urinary catheter and needed assistance with turning. During med pass, an LPN entered the room wearing gloves only, repositioned the resident, and applied a Lidocaine patch while her top touched the resident’s blanket. The LPN confirmed she did not wear a gown, and the DON confirmed gown and gloves were expected for care and repositioning of residents on EBP.
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.
Improper Food Storage and Unsanitary Kitchen Equipment
Penalty
Summary
The facility failed to store frozen food items properly when an uncovered 10-pound box of frozen wedges was observed in the walk-in freezer, leaving the contents open to air. Two of eight wedges had visible discoloration on the surface from direct exposure to the air inside the freezer. The Certified Dietary Manager confirmed the frozen wedges were available for resident use and were not sealed or stored properly. The facility also failed to maintain kitchen equipment in a sanitary condition and failed to discard undated cold food items. In the cooking and meal preparation area, thick brownish-yellow food debris was observed on 4 of 6 temperature dials on the convection ovens, and a thick black grease-like substance was present on the inner perimeter of the lower oven door handles. In the reach-in refrigerator, one 32-ounce container of nectar thick milk, one 46-ounce container of nectar thick water, and one 46-ounce container of nectar thick apple juice were all missing open dates despite label directions to discard them 7 days after opening. The CDM stated the dates could not be verified and confirmed the thickened liquids were available for resident use and should be discarded. The can opener blade was also observed with a thick black sticky substance on the end of the blade, and the CDM confirmed it needed to be cleaned and was not sanitary.
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.
Resident Health Information Left Visible on Medication Cart
Penalty
Summary
Keep residents' personal and medical records private and confidential was not maintained when a written shift-to-shift communication sheet listing residents' names and various medical conditions was observed on top of Station 2 Cart 1. The facility policy stated that confidential information must be safeguarded from unauthorized disclosure and that paper notes or reminders with resident personal or medical information shall not be left unattended or viewable by unauthorized persons. During observation on the 200 hall, a medication card label with a resident's name was also seen stored above clean plastic drinking cups on the side of the same medication cart. The residents' personal and confidential medical information was visible and left unattended by an LPN. When interviewed, the LPN stated she should have ensured the resident's personal and medical information was not visible before leaving the medication cart. The DON stated staff were expected to ensure residents' personal and confidential information was secured and covered prior to leaving the medication cart.
MDS Oral/Dental Status Was Inaccurately Coded
Penalty
Summary
The facility failed to accurately complete the MDS assessment for one resident by incorrectly coding Section L, Oral/Dental Status, on the admission MDS. The CMS MDS RAI User’s Manual states that obvious or likely cavity or broken natural teeth should be coded when present, but the resident’s admission MDS indicated no broken or missing teeth and no dental problems. The resident had diagnoses including abdominal aortic aneurysm, acute kidney failure, and dementia, and scored a 10 on the BIMS, indicating moderate cognitive impairment. The resident also had no weight loss or oral pain documented in the record. During observations, the resident was noted to have poor dentition with multiple missing upper and lower teeth and areas of decay/discoloration on remaining teeth, while denying chewing difficulty or mouth pain. The resident stated the teeth had been missing and in poor condition before admission and had been that way for a long time. The MDS nurse, DON, and Social Worker later confirmed the resident had multiple missing, broken, and rotted teeth, and the remote MDS Coordinator stated she completed Section L without onsite assessment and marked none of the above because nothing was documented in the record.
Failure to Follow Weight Monitoring and ST Orders
Penalty
Summary
The facility failed to follow physician and NP orders for Resident #72, who had diagnoses including pneumonia, cerebral infarction, diabetes mellitus, severe morbid obesity, dementia, chronic pain syndrome, dysphagia, psychosis, and adjustment disorder with anxiety. The record showed significant weight loss, and the RD documented that weekly weights were to be monitored until the resident stabilized. Although an order was entered for weekly weights, the resident’s weights were not obtained consistently, including one refusal, and the weekly weight monitoring was later discontinued by the DON even though the resident had not been ordered to stop by the physician or NP. The NP stated she expected the resident to remain on weekly weights and was not aware they had been discontinued. The record also showed an NP order for an ST evaluation for possible diet upgrade, but the evaluation was not performed. ST staff stated the resident had recently been discharged from ST services and did not recommend a diet upgrade, while the NP stated she believed the evaluation had been completed and did not learn it had not been done until after the surveyor identified it. The Medical Director stated increased weight monitoring should have been implemented when the resident showed significant weight loss and confirmed physician orders should be followed. The DON stated she discontinued weekly weights because the resident no longer flagged for significant weight loss, but later acknowledged the weights should not have been discontinued and that she had not discussed it with the physician.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to implement appropriate interventions to prevent weight loss for one resident who had diagnoses including pneumonia, cerebral infarction, diabetes mellitus, severe morbid obesity, dementia, dysphagia, psychosis, and adjustment disorder with anxiety. The resident’s care plan identified her as at risk for altered nutritional status related to diabetes, a mechanically altered diet, and a therapeutic diet. Her POST form indicated long-term artificial nutrition by tube, and her record showed a substantial decline in weight over time, including a 13.15% loss in one month and continued loss thereafter. The resident was initially on a mechanical soft, consistent carbohydrate diet, but after speech therapy evaluated her for difficulty taking medications and decreased oral intake, she was changed to a puree diet. After that change, nursing documented that she disliked the puree food and was eating less. The resident repeatedly refused the puree diet, and staff observed multiple meals where the tray was left in the room without staff returning to assist her with eating. During several observations, she ate 0% of meals or only a few bites. Her husband also reported that she had not been eating since the diet change. The registered dietitian documented the significant weight loss but did not document recommendations to prevent further loss until much later, when Boost was added and weekly weights were ordered. The record showed no interdisciplinary team meeting notes addressing the weight loss, no lab work to evaluate nutritional status, and weekly weights were later discontinued even though the resident continued to lose weight. Speech therapy was not re-evaluated as ordered for possible diet upgrade, and staff later documented that the resident and her husband requested a diet change because she preferred quality of life over the puree diet. The resident’s weight continued to decline to 246.8 pounds, reflecting a 21.05% loss from 5/2/2025 to 7/31/2025 and a 23.73% loss over 6 months.
Nebulizer Mask Left Uncovered in Resident Room
Penalty
Summary
Provide safe and appropriate respiratory care for a resident when needed was not met when Resident #72's nebulizer mask was left uncovered and open to air in the resident's room. Resident #72 was admitted with diagnoses including pneumonia, cerebral infarction, obstructive sleep apnea, and dementia, and the quarterly MDS showed a BIMS score of 8, indicating moderate cognitive impairment. A physician's order dated 1/29/2025 included Ipratropium-Albuterol solution for nebulizer treatment, and the MAR showed the resident received an inhalation treatment on 7/28/2025 during the 7:00 PM-11:00 PM medication administration. During observations on 7/28/2025 at 11:30 AM, 7/29/2025 at 7:45 AM, and 7/29/2025 at 2:00 PM, the nebulizer mask was observed laying on the bedside table, uncovered and open to air. During an observation and interview on 7/29/2025 at 3:00 PM, the Wound Care Nurse again observed the mask uncovered and confirmed it should have been stored in a plastic bag. During an interview on 7/29/2025 at 3:05 PM, the DON confirmed nebulizer masks were to be stored in a plastic bag and labeled with the resident's name.
Failure to Address Significant Weight Loss
Penalty
Summary
The facility failed to ensure adequate dietary services were provided to prevent significant weight loss for one resident who had diagnoses including pneumonia, cerebral infarction, diabetes mellitus, severe morbid obesity, dementia, chronic pain syndrome, dysphagia, psychosis, and adjustment disorder with anxiety. The resident’s care plan identified her as at risk for altered nutritional status related to diabetes mellitus and a mechanically altered/therapeutic diet. Her weight declined from 323.6 pounds to 271.5 pounds in about one month, and the record documented a 13.15% weight loss. The registered dietitian noted the significant weight loss and attributed it to fluid shifts, with no further nutritional interventions documented at that time. Speech therapy later evaluated the resident because of difficulty taking medications and decreased oral intake and recommended a puree diet, which was then ordered by the physician. After the diet change, nursing notes documented that the resident’s meal intake decreased because she did not like the puree diet and that she refused to eat pureed food. The resident’s husband stated she had not been eating since the diet was changed. The resident continued to lose weight, with documented weights showing further decline to 258 pounds and then 246.8 pounds, totaling 21.05% weight loss from the earlier baseline and 23.73% over six months. The record showed delayed and limited dietary intervention after the significant weight loss was identified. The dietitian did not document ongoing monitoring or recommendations to prevent further weight loss until later, when Boost glucose control twice daily was ordered and the diet was eventually upgraded to mechanical soft with chopped meats after the resident and her husband agreed. The medical record also showed no laboratory tests were performed to evaluate nutritional status during the period of continued weight loss. Interviews with the RD, DON, NP, and Medical Director confirmed the resident’s weight loss was significant and unplanned, that the Boost twice daily was not enough to sustain her weight, and that the resident’s weight loss had not been adequately addressed when first identified.
Improperly Contained Trash and Unsanitary Dumpster Area
Penalty
Summary
The facility failed to ensure garbage and refuse were properly contained and failed to maintain the outside dumpster area in a sanitary and orderly condition. Review of the facility policy titled, "Dispose of Garbage and Refuse," dated 10/2019, stated that all garbage and refuse are to be collected and disposed of in a safe and efficient manner, that the Director coordinates to ensure the area surrounding the exterior dumpster area is maintained free of rubbish and other debris, and that lids are provided for all containers. During an observation of the outside dumpster area with the Certified Dietary Manager, there were 4 dumpsters for waste disposal and 2 alternate trash receptacles to the right of the main dumpster area with lids propped open, exposing their contents to the elements and potential pests. The area adjacent to dumpster A contained a broken bedside table, broken wooden shelf, broken office desk, and broken wooden table. The area adjacent to dumpster D contained a broken over-the-bed table, multiple broken wooden pallets, and one blue barrel with rusted metal, broken wooden planks, and unidentified trash items floating in approximately 12 inches of brown, turbid water. The Certified Dietary Manager confirmed the trash receptacles were not properly contained and the dumpster area was not maintained in a sanitary or orderly condition.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility failed to ensure appropriate PPE was worn for a resident on Enhanced Barrier Precautions (EBP). Review of the facility policy titled, Enhanced Barrier Precautions, dated 1/2025, stated that EBP is an infection control intervention designed to reduce transmission of multidrug-resistant organisms and includes targeted gown and glove use during high-contact resident care activities. The policy also stated EBP would be used for residents with indwelling medical devices, including urinary catheters, even if the resident was not known to be infected or colonized with a MDRO. Resident #96 was admitted with diagnoses including congestive heart failure, urinary tract infection, and hypertension. The resident had an indwelling urinary catheter and required moderate to partial assistance with rolling from left to right. During observation, the resident’s room door displayed EBP signage and PPE was readily available. While medication was being administered, an LPN entered the room wearing gloves, leaned over the resident, assisted the resident to turn onto the right side, and applied a Lidocaine patch to the left hamstring. The LPN’s top touched the resident’s blanket during repositioning and while applying the patch. The LPN confirmed she did not wear a gown in addition to gloves while repositioning the resident and stated she should have worn a gown when applying the patch. The DON confirmed staff were expected to wear appropriate PPE, including gown and gloves, when providing care and/or repositioning residents on EBP.
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 83 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 | ★★★★★ | 18 | 0 |
| Renaissance Terrace | 19.5 mi | ★★★★★ | 2 | 0 |
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