River Grove Health and Rehabilitation: Care Plan Failure - TN
That gap, confirmed by two of the facility's own nursing leaders during a federal inspection this summer, is the kind of documentation failure that can leave staff unaware of what a resident actually needs, and leave a resident without the protection they were supposed to have.
The inspection, conducted on August 11, 2025, stemmed from a complaint. Investigators found that River Grove had failed to revise and update the comprehensive care plan for Resident 83 to reflect the required use of off-loading boots to the bilateral heels.
Off-loading boots are used to redistribute pressure away from the heel, typically when a resident is at risk for or already has a pressure wound. When a care plan doesn't document that a resident wears them, nurses and aides working a shift, particularly those who didn't happen to be present when the order was first given, have no formal record telling them the boots are part of that person's daily care.
The MDS Nurse, interviewed at 11:00 a.m. on July 30, 2025, said plainly that the care plan should be revised and updated when new care interventions are ordered for each resident. Then she confirmed that it wasn't done for Resident 83.
Four minutes later, at 11:04 a.m., the Assistant Director of Nursing said the same thing. The facility failed to revise and update Resident 83's comprehensive care plan to reflect the required use of the off-loading boots to the bilateral heels.
Two senior nursing staff members, four minutes apart, confirming the same failure. Neither disputed it.
The violation was cited at the level of minimal harm, meaning inspectors did not find evidence that Resident 83 suffered a measurable injury as a direct result of the missing documentation. That distinction matters, and it also has limits. Minimal harm is a finding about what inspectors could document after the fact. It says less about the risk that existed while the care plan sat incomplete.
Care plans are the central document that coordinates what happens to a nursing home resident each day. They are supposed to capture every significant intervention, every piece of equipment, every condition that shapes how staff interact with that person. When an intervention as specific as bilateral heel off-loading boots is ordered and not recorded, the plan no longer reflects the resident's actual care needs.
River Grove Health and Rehabilitation is a skilled nursing facility in Loudon, Tennessee. The complaint inspection covered four pages of findings. The care plan failure for Resident 83 was among them.
What the inspection report does not say is how long the care plan went without being updated, how many shifts passed before the omission was caught, or whether Resident 83's boots were consistently applied during that time. Those details were not documented in the findings available.
What it does say is that the people responsible for maintaining that documentation, the MDS Nurse whose job centers on assessment and care planning, and the Assistant Director of Nursing who oversees the nursing department, both acknowledged the failure directly when asked.
There was no dispute about what happened. There was no suggestion that the omission was caught internally before inspectors arrived. The record shows it took an outside complaint and a federal inspection to surface it.
Resident 83's heels needed protection. Whether they got it, consistently, on every shift, while the care plan sat silent on the matter, is a question the inspection report leaves open.
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: 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.
Corrections: We strive for accuracy in everything we publish. If you believe any fact in this article is incorrect, please contact us with details, and we will review and correct it promptly.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
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.
The inspection, conducted on August 11, 2025, stemmed from a complaint.
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.