River Grove Health and Rehab: Floor Tile Safety Failure - TN
The resident, identified in inspection records only as Resident #28, was admitted to River Grove with a traumatic brain injury, paralysis on one side of his body, epilepsy, a mood disorder with depressive features, and anxiety. He has dysarthria, meaning his speech is slurred and distorted. He also has anarthria, meaning that despite being cognitively aware, he cannot articulate speech at all. When inspectors asked him questions during their visit on July 28, 2025, he answered by shaking his head.
One tile had been pulled from the floor and was lying to the right side of his bed. A second tile, under the bed, was loose.
Did he remember how long the tiles had been that way? He shook his head no.
Did he want them repaired? He shook his head yes.
The next day, July 29, an inspector returned at 1:00 in the afternoon. The tile was still pulled from the floor. Still lying beside the bed. The loose tile was still under it.
Two hours later, at 3:00 that same afternoon, the facility's administrator and maintenance director walked into the room alongside the inspector. The tile was still there. The loose one was still under the bed. Both the administrator and the maintenance director confirmed, according to the inspection report, that the room was not being maintained in a safe, clean, or homelike environment.
That confirmation came on the second consecutive day inspectors had documented the same condition in the same room.
River Grove's own policy, revised as recently as May 2025, states that the facility will provide a safe, clean, comfortable, and homelike environment for residents. The policy specifies that "homelike" means de-emphasizing the institutional character of the building, allowing residents to use personal belongings that support a homelike feel, and taking the resident's own opinion of their living environment into account. It also states that housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable space.
Resident #28's room, by the account of the facility's own leadership, did not meet that standard.
A quarterly cognitive assessment dated in the inspection record showed Resident #28 scored a 10 on the Brief Interview for Mental Status, placing him in the range of moderate cognitive impairment. He understands what is happening around him. He understood what the inspector was asking. He communicated clearly, with the only tools available to him, that he wanted the problem fixed.
The inspection, conducted August 11, 2025, was triggered by a complaint. CMS classified the floor tile deficiency as causing minimal harm or potential for actual harm. For a resident with hemiplegia and epilepsy, a dislodged floor tile beside his bed represents a different kind of risk than it might for a fully ambulatory person, though the inspection record does not detail a specific injury.
What the record does detail is a man who shook his head yes, and a facility that had at least two days to act before its own administrators stood in the room and acknowledged what they were looking at.
The tile was still on the floor when they got there.
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.
Download the official CMS inspection PDF from Medicare.gov
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
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Last verified: November 3, 2026 · Our methodology
RIVER GROVE HEALTH AND REHABILITATION in LOUDON, TN was cited for violations during a health inspection on August 11, 2025.
He has dysarthria, meaning his speech is slurred and distorted.
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.