Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Pruitthealth - Covington during CMS and state inspections, most recent first.
A resident with multiple serious medical conditions experienced a significant downward weight trend over several months, documented by dietary staff who noted varied meal intake and recommended liberalizing the diet, adding double eggs at breakfast, and monitoring weight. Although the MDS was coded to indicate weight loss on a physician-prescribed weight-loss regimen, there was no evidence of an intentional weight-reduction plan in the record. The resident’s care plan contained no goals, interventions, or revisions related to the documented weight loss, despite facility policy requiring nurses, the CMD, and the IDT to update care plans to reflect current needs, and leadership confirmed that no care plan updates were made for the weight decline.
Inaccurate MDS coding for significant weight loss. A resident with encephalopathy, pneumonia, severe sepsis with septic shock, and oropharyngeal cancer had a significant unplanned weight decline, but the quarterly MDS coded weight loss as a physician-prescribed weight-loss regimen. Dietary notes documented trending weight loss and variable intake, and the MDS Coordinator said the coding was based on diuretic use even though the medication had been prescribed long before. The DHS confirmed the coding was inaccurate and that no care plan revisions had been made to address the weight trend.
Failure to Complete Required Smoking Assessment and Supervision: A resident with diagnoses including dementia, CKD, glaucoma, and moderate intellectual disabilities was identified as a smoker and observed using the designated smoking area with a smoking apron. However, the resident’s smoking assessment was overdue, with the DON confirming the last assessment had been completed months earlier and should have been done quarterly. Staff interviews showed the floor nurse was responsible for completing the smoking observation form when due.
A resident with CHF, severe cognitive impairment, and continuous oxygen therapy on admission did not have an oxygen order in the physician orders. Staff observed the resident on oxygen via NC at times, but also without tubing in place during one observation, and interviews confirmed the resident was supposed to wear oxygen continuously. The DON stated that any resident on oxygen should have an order and that nurses are responsible for admission orders.
A resident with multiple medical conditions was found with unauthorized and unsecured medications at the bedside, despite not being assessed for self-administration. The facility's policy requires nurses to observe residents ingesting medications, but the nurse left the medications unattended. The eMAR indicated the medications were administered, but the presence of the medication cup suggested a discrepancy.
The facility failed to maintain a safe, clean, and homelike environment in two rooms. In one room, the bathroom had missing tiles, a sticky and malodorous floor, and spiders. In another room, a roach was observed. The Maintenance Director confirmed the pest issue, noting monthly pest control visits. A policy for a homelike environment was not provided.
A facility failed to comply with regulations regarding the prescription of an opioid medication for a resident with chronic pain and anxiety. The resident was prescribed oxycodone-acetaminophen on a PRN basis without a stop date, contrary to the regulation limiting PRN orders for psychotropic medications to 14 days unless clinically justified. Staff interviews confirmed the resident's long-term use of the medication, highlighting the risk of polypharmacy.
A resident with a history of cognitive impairment and shoulder pain was alleged by their family to have suffered a dislocated shoulder due to staff mishandling. Despite the facility's policy requiring immediate reporting of such allegations, the report to the state survey agency was delayed by six days. Interviews with the DHS and Administrator confirmed the delay and acknowledged the reporting should have occurred within two hours of the allegation.
Failure to Care Plan for Significant Weight Loss
Penalty
Summary
The deficiency involves the facility’s failure to develop and implement a care plan addressing significant weight loss for a resident with multiple serious diagnoses, including encephalopathy, pneumonia, severe sepsis with septic shock, and malignant neoplasm of the oropharynx. Facility policy stated that care plans would be updated by nurses, Case Mix Directors, or other IDT members so that the care plan reflects the resident’s needs at any given moment. Record review showed the resident’s weight decreased from 151.4 pounds to 141.0 pounds over approximately three months, a 6.9% loss. Dietary progress notes documented that the resident’s weight was trending down, with varied meal intake, and that the resident was receiving Ensure twice daily. The dietitian recommended liberalizing the diet by discontinuing no-added-salt restrictions and later recommended double eggs at breakfast, continued weight monitoring per protocol, and follow-up as needed. Despite these documented weight trends and dietary recommendations, review of the resident’s care plan revealed no evidence that the significant weight loss or downward weight trend was addressed through care plan goals, interventions, or revisions. The Quarterly MDS coded the resident as having weight loss on a physician-prescribed weight-loss regimen, but further record review did not identify evidence of any such intentional weight-reduction regimen. The MDS Coordinator confirmed that the MDS was coded "Yes" for physician-prescribed weight-loss regimen based on the resident’s use of diuretics and stated that the IDT is responsible for care plan development and updates. The Director of Health Services confirmed there were no care plan updates related to the resident’s downward weight trend and stated that nursing staff and/or the MDS Coordinator are responsible for updating care plans.
Inaccurate MDS Coding for Significant Weight Loss
Penalty
Summary
The facility failed to ensure Minimum Data Set (MDS) assessments were accurately coded to reflect a significant weight loss for one resident, R46, who was reviewed for nutrition. R46 was admitted with diagnoses including encephalopathy, pneumonia, severe sepsis with septic shock, and malignant neoplasm of the oropharynx. Record review showed the resident’s weight declined from 151.4 pounds on 10/01/2025 to 141.0 pounds on 01/02/2026, a loss of 10.4 pounds or 6.9% over approximately three months, which met the criteria for significant weight change. Dietary progress notes dated 01/12/2026 documented that the resident’s weight was trending down, meal intake was varied, and the resident was receiving Ensure 1 carton BID; the note also recommended liberalizing the diet by discontinuing NAS and continuing a regular diet. The quarterly MDS dated [DATE] coded Section K0300 (Weight Loss) as 1, indicating the resident was on a physician-prescribed weight-loss regimen, but the record did not show evidence of an intentional weight-loss regimen. The MDS Coordinator stated the coding was based on the resident receiving diuretic medication, which she considered a prescribed weight-loss regimen, although the medication had been prescribed since 09/2/2022. The DHS confirmed the MDS coding was inaccurate and that no care plan revisions had been made to address the resident’s significant downward weight trend.
Failure to Complete Required Smoking Assessment and Supervision
Penalty
Summary
The facility failed to ensure safe smoking for one resident reviewed for smoking. The facility policy stated that residents who were grandfathered in prior to January 1, 2015, could smoke only in outdoor designated areas, and that residents were to be assessed for smoking risk and supervised as necessary based on the Smoking Observation Form. Review of the resident’s record showed diagnoses including acute respiratory failure, unspecified dementia, chronic kidney disease, glaucoma, and moderate intellectual disabilities. The resident’s most recent MDS showed a BIMS score of 13, indicating no cognitive impairment. The last completed smoking observation form, dated 05/23/2023, indicated the resident smoked and had a past history of smoking. An admission smoking observation form completed after return from the hospital on 09/17/2025 identified the resident as a current every day smoker, and the resident’s baseline and comprehensive care plans contained smoking-related interventions and goals. Observation on 04/07/2026 showed the resident smoking in the designated smoking area with one nursing assistant outside with him, wearing a smoking apron and appearing to smoke safely. On 04/09/2026, the resident was waiting at the back door to go to the designated smoking area when the Maintenance Director provided smoking materials, unlocked the door, and led the resident to the smoking area; the resident was again observed wearing a smoking apron. Interview with the MDS coordinator indicated that nurses on the floor were responsible for completing smoking observation forms when assessments were due. The DON confirmed that the resident had last been assessed for smoking on 09/17/2025 and that the assessment was overdue and should have been completed quarterly; she stated that the nurse assigned to the resident’s hall/unit was expected to complete the smoking observation form when indicated by the MatrixCare system.
Missing Oxygen Order for Resident on Continuous Oxygen
Penalty
Summary
The facility failed to obtain an oxygen order for one resident who was receiving continuous oxygen therapy. Review of the resident’s record showed admission diagnoses including chronic systolic congestive heart failure, urinary tract infection, and type 2 diabetes mellitus with diabetic neuropathy. The admission MDS indicated a BIMS score of 4, showing severe cognitive impairment, and Section O documented continuous oxygen therapy on admission. The care plan addressed shortness of breath and included interventions to administer oxygen as indicated, but the physician orders did not include an oxygen order. Observations showed the resident sitting in a wheelchair with oxygen via nasal cannula, and later receiving oxygen at 3L with no distress noted. On another observation, the resident was sitting outside the room without oxygen tubing in place, with the oxygen tank low and set at 2L; the nurse later checked the tank, exchanged it, and placed the tubing back in the resident’s nose. Staff interviews confirmed the resident wore oxygen continuously, sometimes removed it, and that nurses were responsible for admission orders. The DON stated that anytime a resident is on oxygen, the resident should have an order, and that nurses are responsible for entering orders for new admissions.
Unauthorized and Unsecured Medications at Bedside
Penalty
Summary
The facility failed to ensure that a resident did not have unauthorized and unsecured medications at the bedside, which created the potential for medication errors and unauthorized access by other residents. The policy titled 'Medication Administration: Guidelines' specifies that residents are allowed to self-administer medications only when authorized by the attending physician. However, the resident in question, who was not cognitively intact and had not been assessed for self-administration, was found with a plastic medication cup containing eight pills on the bedside table. The resident, who had a history of multiple medical conditions including hemiplegia, coronary artery disease, and diabetes, was observed with the medication cup on two separate occasions. The nurse had reportedly left the medications at the bedside, contrary to the facility's policy that requires nurses to observe residents ingesting medications before leaving the room. Interviews with the Registered Nurse and Director of Nursing confirmed that no residents in the facility had been assessed to self-administer medications, and medications should not be left in residents' rooms. Further review of the electronic Medication Administration Record (eMAR) indicated that the medications were documented as administered to the resident by the nurse. However, the Director of Nursing was unable to provide a clear explanation of the eMAR coding initially, which was later clarified by a Licensed Practical Nurse. The coding indicated that the medications were given within the allowed timeframe, but the presence of the medication cup at the bedside suggested otherwise.
Deficiency in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, clean, and homelike environment in two out of 35 rooms, as observed during a survey. In room [ROOM NUMBER], the bathroom had missing tiles on the left side of the toilet, a sticky and malodorous floor, and multiple spiders and spider webs in the corners of the ceiling. A resident in this room mentioned that the spiders had been present for a while. Despite cleaning efforts, the missing tiles were not replaced by the end of the observation period. In room [ROOM NUMBER], a roach was observed crawling on the wall. The Maintenance Director confirmed the presence of the roach and stated that the facility was contracted with a pest control service that visited monthly and provided additional services as needed. However, the Maintenance Director considered the roach sighting an isolated incident. The facility failed to provide a policy for maintaining a homelike environment, instead providing a goods and services agreement.
Non-compliance with PRN Opioid Prescription Regulations
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of psychotropic medications, specifically concerning the prescription of an opioid medication for a resident. The resident, identified as R10, was admitted with diagnoses including generalized anxiety disorder and chronic pain. The Quarterly Minimum Data Set (MDS) assessment indicated that R10 had intact cognition and was taking antipsychotics, hypnotics, and opioids. A review of the physician's orders revealed that R10 was prescribed oxycodone-acetaminophen, an opioid, on an as-needed (PRN) basis without a stop date, which is against the regulation that limits PRN orders for psychotropic medications to 14 days unless clinically justified. Interviews with facility staff, including an LPN and the Director of Health Services, confirmed that R10 had been taking the opioid medication for an extended period due to chronic back pain. The Director of Health Services acknowledged that R10's medication regimen placed him at high risk for polypharmacy and emphasized the need for regular pharmacy and physician consultations to evaluate the necessity of the medication.
Delayed Reporting of Abuse Allegation
Penalty
Summary
The facility failed to report an allegation of abuse to the State Survey Agency within the required two-hour timeframe. The facility's policy mandates that any allegations of abuse, neglect, exploitation, mistreatment, or misappropriation of property should be reported immediately to the Administrator and then to the appropriate state agency within two hours if the allegation involves abuse or results in serious bodily injury. In this case, a resident's family alleged that the resident's dislocated shoulder was caused by facility staff, but the report to the state survey agency was delayed by six days. The resident involved had a history of metabolic encephalopathy, diabetes mellitus with kidney complications, end-stage renal disease, and vascular dementia, among other conditions. The resident had moderate cognitive impairment and functional limitations in their upper and lower extremities. The resident's care plan noted frequent complaints of pain in the left shoulder, which was later diagnosed as a dislocation. Despite the resident's family alleging mishandling by staff on a specific date, the facility did not report the allegation to the state survey agency until several days later. Interviews with the Director of Health Services (DHS) and the Administrator confirmed the delay in reporting. The DHS acknowledged that upon receiving a complaint of staff roughness or an unexplained injury, it should be reported to the Administrator and the state within two hours. The Administrator also confirmed the timeline of events and recognized that the report should have been submitted on the day the allegation was made by the resident's family.
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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 Covington
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Riverside Health Care Center | 0.8 mi | ★★★★★ | 2 | 0 |
| Westbury Center Of Conyers For Nursing And Healing | 9.5 mi | ★★★★★ | 8 | 0 |
| Social Circle Nsg & Rehab Ctr | 10.2 mi | ★★★★★ | 0 | 0 |
| Rockdale Healthcare Center | 10.9 mi | ★★★★★ | 1 | 0 |
| Pruitthealth - Lithonia, Llc | 16 mi | ★★★★★ | 9 | 0 |
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