River Grove Health: Broken Floor Tiles in Room - TN
River Grove Health and Rehabilitation violated its own policy requiring a "safe, clean, comfortable and homelike environment" for Resident #28, who suffers from focal traumatic brain injury, hemiplegia, speech disorders, epilepsy, mood disorder and anxiety, according to a federal inspection completed in August.
The resident scored a 10 on a cognitive assessment, indicating moderate impairment. When inspectors found the damaged flooring on July 28, one tile had been pulled from the floor and was lying beside his bed. Another tile sat loose underneath the bed.
Resident #28 shook his head no when asked if he remembered how long the tiles had been damaged. He shook his head yes when asked if he wanted them repaired.
The tiles remained unfixed the next day. During a second observation on July 29 at 1:00 PM, inspectors found the same missing tile lying to the right of the resident's bed and the same loose tile under his bed.
Two hours later, when inspectors returned with the facility's administrator and maintenance director at 3:00 PM, nothing had changed. The missing tile still lay beside the bed. The loose tile remained under the bed.
Both the administrator and maintenance director confirmed the room failed to meet safety standards. They acknowledged Resident #28's room "was not maintained in a safe, clean, homelike environment."
The facility's own policy, revised in May 2025, requires maintaining conditions that "de-emphasizes the institutional character of the building" and "allows the resident to use personal belongings that support a homelike environment." The policy specifically states housekeeping and maintenance services "will be provided as necessary to maintain and sanitary, orderly and comfortable environment."
The policy also requires considering "the resident's opinion of the living environment" when determining whether conditions are homelike. Resident #28 had clearly indicated he wanted the tiles repaired.
For a resident with traumatic brain injury and epilepsy, loose flooring presents particular dangers. The combination of cognitive impairment, speech difficulties and mobility issues from hemiplegia makes navigating around scattered floor tiles especially hazardous.
The inspection found the facility failed to maintain safe conditions on one of five hallways observed, suggesting the problem may have been isolated to this resident's room. However, the violation occurred despite clear facility policies and after multiple opportunities to address the issue.
Federal regulations require nursing homes to provide environments that feel like home rather than institutions. Missing floor tiles, loose flooring materials and general disrepair directly contradict these requirements, particularly when administrators acknowledge the problems but fail to act.
The facility admitted to the violation during the inspection. Both management officials confirmed they understood the room conditions were unacceptable yet had allowed them to persist for an unknown period.
Resident #28's multiple medical conditions make him particularly vulnerable to environmental hazards. His traumatic brain injury affects cognitive function, while hemiplegia impacts his mobility and balance. Speech disorders prevent him from easily communicating concerns about his living conditions.
The inspection classified the violation as causing "minimal harm or potential for actual harm" affecting "few" residents. However, for Resident #28, the damaged flooring represented a daily safety risk in his own room, where he should feel most secure.
The facility's maintenance director was present during the final inspection observation, indicating management was aware of the specific problem and had assigned responsibility for addressing it. Yet the tiles remained unfixed even after direct administrative attention.
River Grove Health and Rehabilitation must submit a plan of correction explaining how it will prevent similar violations. The facility faces potential federal fines and increased oversight if it fails to demonstrate adequate improvements to its maintenance and housekeeping procedures.
The violation highlights a fundamental failure in basic facility management. Maintaining safe flooring requires minimal resources compared to other nursing home operations, yet administrators allowed a vulnerable resident to live with obvious hazards for days after becoming aware of the problem.
Resident #28 continues to live at the facility while waiting for repairs that should have been completed immediately upon discovery.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for River Grove Health and Rehabilitation from 2025-08-11 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
RIVER GROVE HEALTH AND REHABILITATION in LOUDON, TN was cited for violations during a health inspection on August 11, 2025.
The resident scored a 10 on a cognitive assessment, indicating moderate impairment.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.