Below average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Riverside Health Care Center during CMS and state inspections, most recent first.
Failure to complete PASARR Level II screening for a resident with qualifying mental health diagnoses. The resident had anxiety disorder, major depressive disorder, bipolar disorder, and schizoaffective disorder, with care planned for mood problems, suicidal ideations, and anxiety. The AC, SSD, and DON all verified that no PASARR Level II assessment was in the chart or conducted despite the resident meeting criteria.
A resident with severe cognitive impairment, multiple mobility limitations, and a stage 4 sacral pressure ulcer was care planned for repositioning every two hours and had a posted turning schedule above the bed. During observation, the resident was found lying on the back instead of the scheduled side position, including while tube feeding was running. Staff interviews confirmed the resident was not repositioned as scheduled, one CNA had not turned the resident that day, and an LPN stated she kept the resident propped up for tube feeding. The MDS coordinator stated the facility did not document turning and repositioning in the EMR.
Failure to Provide Ordered Meal Tray: A resident with severe cognitive impairment, dysphagia, and PEG tube feeding had an active order for a CCD NAS puree diet with thin liquids and a care plan calling for a pleasure tray and staff assistance with meals. Surveyors observed the resident receiving continuous tube feeding while meal trays were passed on the hall, but the resident did not receive a tray; the CNA and LPN stated the resident did not get meal trays because she was tube-fed, while the DON could not provide documentation of refusal and the Dietary Manager stated trays were ordered.
Dirty oxygen concentrator filters remained in use for two residents receiving oxygen therapy. One resident had acute and chronic respiratory failure with hypoxia, COPD, CHF, SOB, and pneumonia, and another had Alzheimer’s disease, cerebral infarction, CHF, and chronic respiratory disease with hypoxia. Observations showed visible dust and debris on the concentrator exterior and filter while oxygen was in progress, and the soiled filters remained unchanged on follow-up observations. Staff stated oxygen equipment was monitored for flow and function, and that an outside company was reportedly responsible for filter maintenance, but the dirty filters were still present.
Failure to perform hand hygiene between meal tray passes. Two CNAs were observed passing lunch trays in a dining hall without sanitizing their hands between residents, despite the facility policy requiring hand hygiene between tray passes. An LPN confirmed the practice was not being followed, and the ADON stated handwashing/hand sanitizing was expected between tray passes.
A resident with right hemiparesis and a history of femur fracture, who required two-person assistance for transfers per care plan and Kardex, was transferred alone by a CNA who did not review the care plan. This resulted in a fall and a displaced spiral fracture of the right femur. Staff interviews confirmed the expectation for two-person transfers and the need to follow the care plan, but the protocol was not followed, leading to actual harm.
A resident with right hemiparesis and a history of falls, who required two-person assistance for transfers, was moved by a CNA without help, resulting in a fall and a fractured femur. The CNA did not review the care plan or EMR and relied on informal knowledge, contrary to facility policy and staff expectations.
The facility failed to ensure legible medication labels and proper disposal of expired medications. Expired glucagon syringes, pneumococcal vaccines, sodium chloride solution, and Ketamine were found in medication carts and storage rooms. Staff interviews revealed a lack of knowledge about auditing and removing expired medications, indicating a failure in medication management processes.
A resident with respiratory issues was found to have medicated inhalers at her bedside without a proper assessment or physician's order for self-administration. Facility staff were inconsistent in their understanding of the protocol, and the Director of Nursing confirmed that an assessment and order were required before medications could be left at the bedside.
The facility failed to include necessary interventions in the care plans for two residents, one with an indwelling urinary catheter and another receiving oxygen therapy. The care plans lacked focus areas for these treatments, despite observations confirming their use and staff acknowledging the oversight.
The facility failed to update care plans for a resident with a new sacral pressure injury and another resident whose oxygen therapy was discontinued. Despite treatment initiation for the pressure injury, the care plan was not revised. Similarly, the care plan for the resident with discontinued oxygen therapy still included the intervention. Staff interviews confirmed these oversights.
The facility failed to ensure proper oxygen administration for three residents, leading to deficiencies in respiratory care. One resident received oxygen without a physician's order, while two others received incorrect oxygen levels compared to their physician's orders. Observations and interviews confirmed these discrepancies, highlighting a lack of adherence to prescribed oxygen therapy protocols.
Failure to Complete PASARR Level II Screening for a Resident With Mental Health Diagnoses
Penalty
Summary
The facility failed to refer one of 10 residents identified with level two PASARR needs for a level two pre-admission screening and resident review. Review of the facility policy titled Preadmission Screening (PASSAR/PASSR) dated June 2025 stated that a level II PASSR must be completed if an individual has a primary or secondary diagnosis of dementia or related neurocognitive disorder, or a suspicion or diagnosis of serious mental illness, intellectual disability, or both, and that a PASRR level II may only be terminated by a PASSR Level II Evaluator. Resident 7 was admitted with diagnoses including anxiety disorder, major depressive disorder, recurrent moderate mixed obsessional thoughts and acts, bipolar disorder, and schizoaffective disorder. The quarterly MDS showed a BIMS score of 13, indicating intact cognition, with no potential indicators of psychosis in Section E and high-risk medications in Section N with indications noted as antidepressant and antipsychotic. The care plan addressed mood problems related to depression, schizoaffective disorder, suicidal ideations, and anxiety. The AC verified that Resident 7 did not have a PASARR level two screening, and the SSD confirmed the resident had diagnoses that met criteria for a PASARR level two assessment but no level two screening was in the chart. The DON also verified that the resident had qualifying diagnoses and that no PASARR level two assessment had been conducted.
Failure to Reposition a Dependent Resident According to Turning Schedule
Penalty
Summary
The facility failed to ensure that one of six sampled residents, R13, was repositioned according to the resident’s turning schedule and care plan interventions. R13 was admitted with multiple diagnoses including traumatic cerebral hemorrhage, obstructive hydrocephalus, epilepsy, dysphagia, rheumatoid arthritis, osteoarthritis, generalized muscle weakness, muscle wasting/atrophy, lack of coordination, sarcopenia, cognitive communication deficit, and a sacral pressure ulcer stage 4. The resident’s assessments showed severe cognitive impairment with a BIMS score of 2, dependence on staff for multiple activities of daily living, and risk for pressure injuries with pressure-reducing devices and wound care interventions in place. The care plan directed repositioning every two hours and as needed, maintaining body alignment, and keeping skin and linens clean and dry. A turning schedule posted above the bed instructed staff to reposition the resident on a specific two-hour rotation and not to place the resident flat on the back. During observation, R13 was seen lying on the back with the head of the bed elevated, including during a three-hour observation period and again the next morning while tube feeding was in progress. Staff interviews confirmed the resident was not repositioned as scheduled, and one CNA stated she had not repositioned the resident that day and thought the wound nurse would do it during wound care. Additional interviews showed the LPN assigned to the resident acknowledged the resident was lying on the back instead of the scheduled side position and said she wanted the resident to remain propped up for tube feeding. The wound nurse stated any nursing staff member could reposition the resident and that repositioning occurred during wound care, while the MDS coordinator stated the facility did not document turning and repositioning in the EMR and that the turning schedule was used to guide staff. The DON and unit manager both stated they expected dependent residents to be turned and repositioned every two hours, and the DON could not find documentation that the resident had refused care.
Failure to Provide Ordered Meal Tray
Penalty
Summary
The facility failed to follow physician orders related to diet for a resident with significant medical complexity and severe cognitive impairment. The resident had diagnoses including traumatic cerebral hemorrhage, obstructive hydrocephalus, epilepsy, dysphagia following cerebral infarction, dysphagia, rheumatoid arthritis, osteoarthritis, esophageal dyskinesia, cognitive communication deficit, generalized muscle weakness, muscle wasting/atrophy, lack of coordination, sarcopenia, and stage 4 sacral pressure ulcers. The resident’s BIMS score was 2, and the care plan included tube feeding via PEG tube, providing diet as prescribed, offering a pleasure tray, and staff assistance with all meals. Physician orders included a CCD NAS diet with puree texture and thin liquids, along with Jevity 1.5 via PEG tube and related tube-feeding care. During observation, the resident was seen in bed with the head of the bed elevated and tube feeding infusing at 60 mL/hr. When meal trays were being passed on the hall, the resident did not receive a tray. The assigned CNA stated the resident did not receive meal trays because she was tube-fed, and an LPN later stated the resident did not take anything by mouth because she received continuous tube feeding. The DON stated the resident received a pleasure tray and staff assisted with all meals, but she could not provide documentation that the resident had refused meal trays before the survey. The Dietary Manager stated the resident had an active order to receive meal trays and that trays were always sent as ordered.
Dirty oxygen concentrator filters remained in use for two residents
Penalty
Summary
The facility failed to ensure proper maintenance and monitoring of oxygen equipment for two residents receiving oxygen therapy. The facility policy titled Respiratory Therapy Equipment directed staff to wash oxygen concentrator filters weekly, rinse the filters, and squeeze them dry prior to reuse. However, observations showed that the oxygen concentrator exterior and filter used by one resident with diagnoses including acute and chronic respiratory failure with hypoxia, COPD, CHF, SOB, and pneumonia had visible dust and debris accumulation while oxygen therapy remained in progress. The same condition was observed again during follow-up observations, and the filter remained visibly soiled each time. A second resident with diagnoses including Alzheimer’s disease, cerebral infarction, CHF, and chronic respiratory disease with hypoxia had an order for continuous oxygen at 2 liters per minute via nasal cannula, with weekly changes of respiratory supplies and tubing and cleaning of the concentrator filter if present. Observations showed this resident’s oxygen concentrator exterior and filter also had visible dust and debris accumulation while the equipment remained in use, and the filter remained visibly soiled on subsequent observations. Staff interviews indicated that oxygen equipment was monitored for flow rates, cannula placement, and functioning, and that an outside company was reportedly responsible for concentrator filter maintenance; however, the visibly dirty filters remained in use.
Failure to Perform Hand Hygiene Between Meal Tray Passes
Penalty
Summary
Provide and implement an infection prevention and control program. The facility failed to perform appropriate hand hygiene while passing lunch meal trays between residents on one of three units. Review of the facility policy titled, Hand Hygiene, dated February 2026, stated that handwashing/hand hygiene is a means of preventing the spread of infections and that associates must perform appropriate handwashing procedures between passing out meal trays at lunch. During observations on 05/11/2026 at 12:33 PM in the Unit 2 dining hall, two CNAs, PP and QQ, were observed not performing proper hand hygiene between passing out lunch meal trays. In an interview at the same time, an LPN stated that employees who passed out lunch trays were supposed to sanitize their hands before grabbing a new tray and confirmed that CNAs PP and QQ were not performing appropriate hand hygiene between tray passes. CNA QQ stated that she knew to hand-sanitize after each tray pass and acknowledged that she sanitized her hands only before the first tray she passed out. The ADON stated she expected handwashing/hand sanitizing to be done between tray passes.
Failure to Follow Two-Person Transfer Protocol Results in Resident Fall and Injury
Penalty
Summary
A deficiency occurred when a resident with a history of right hemiparesis, weakness, and a prior femur fracture was transferred unassisted by a CNA, despite care plan documentation and the Kardex indicating that two-person assistance was required for all transfers. The resident was dependent on staff for transfers, as documented in the Minimum Data Set (MDS) and care plan, which specifically outlined the need for two staff members to assist with transfers due to the resident's medical conditions and risk of falls. The facility's policy required comprehensive, individualized care plans with measurable objectives and clear assignment of responsibilities, which were in place for this resident. Despite these documented requirements, the CNA transferred the resident alone, resulting in a fall and a closed displaced spiral fracture of the right femur. Interviews with staff confirmed that the expectation was for two-person transfers, and that the Kardex and care plan were to be followed. The CNA admitted to not reviewing the resident's care plan or Kardex, instead relying on informal observations of other staff. The incident demonstrated a failure to provide adequate supervision and to follow established care plans, directly leading to the resident's injury.
Failure to Provide Required Supervision During Resident Transfer Resulting in Injury
Penalty
Summary
A deficiency occurred when a certified nursing assistant (CNA) transferred a resident with significant mobility impairments from bed to wheelchair without the required assistance of a second staff member. The resident had a history of right hemiparesis, episodes of weakness, and was care planned as a two-person transfer due to a previous right femur fracture and moderate cognitive impairment. Despite these documented needs, the CNA performed the transfer alone, resulting in the resident falling and sustaining a closed displaced spiral fracture of the right femur. The CNA admitted to not reviewing the resident's electronic medical record (EMR) or care plan prior to the transfer and relied instead on informal observations of other staff. Interviews with staff and review of facility policy confirmed that the expectation was for two staff to assist with transfers for this resident. The incident was reported after the fall, and the resident was subsequently assessed and sent to the emergency department for further treatment. The facility's policy emphasized minimizing accident hazards and providing adequate supervision, but this was not followed in this instance, directly leading to the resident's injury.
Medication Management Deficiency
Penalty
Summary
The facility failed to ensure that all medication labels were legible and that expired medications were disposed of appropriately. During an audit of a medication cart, two boxes of expired glucagon injection syringes were found, which were confirmed by a Certified Medication Aide (CMA) to be expired. Additionally, in the medication storage rooms on two different halls, expired pneumococcal vaccines, sodium chloride inhalation solution, and a bottle of Ketamine were discovered. A medication bottle in the locked narcotic box had an unreadable label, making it impossible to determine its contents or ownership. Interviews with staff revealed a lack of knowledge and responsibility regarding the auditing and removal of expired medications. A Licensed Practical Nurse (LPN) admitted to not knowing the process for handling expired and discontinued medications, while a unit manager was unaware of who was responsible for auditing medication rooms. The Director of Nursing (DON) stated that night staff usually checks for expired medications and that the pharmacy picks up expired items monthly. However, the presence of expired medications and unreadable labels indicates a failure in the facility's medication management processes.
Failure to Assess Resident for Self-Administration of Medications
Penalty
Summary
The facility failed to ensure that a resident, identified as R150, was assessed for self-administration of medications before leaving inhalers at her bedside. The facility's policy requires a written order from the attending physician and approval from the Interdisciplinary Care Plan Team for a resident to self-administer or retain medications in their room. However, R150's electronic health record and care plan did not include any assessments or orders for self-administration of medications. Despite this, R150 had two medicated inhalers left at her bedside, which she stated had been there for a month, and she was told by staff that she could administer them on her own. Interviews with facility staff revealed inconsistencies in the understanding and application of the facility's protocol regarding medications at the bedside. A CNA was unsure if there was an order for the inhalers to be left at the bedside, while an LPN incorrectly believed there was an order for R150 to have the inhalers at her bedside due to her respiratory issues. The Director of Nursing confirmed that a physician's order and an assessment of the resident's ability to self-administer were required before medications could be left at the bedside. The lack of proper assessment and authorization for R150 to self-administer her inhalers represents a failure to adhere to the facility's medication administration policy.
Failure to Include Indwelling Catheter and Oxygen Therapy in Care Plans
Penalty
Summary
The facility failed to develop a comprehensive person-centered care plan for two residents, one with an indwelling urinary catheter and another receiving oxygen therapy. For the resident with the urinary catheter, the Admission Minimum Data Set (MDS) indicated the presence of the catheter, but the comprehensive care plan did not include any focus area or interventions related to it. Observations confirmed the presence of the catheter, and interviews with the Director of Nursing (DON) and the MDS Coordinator revealed that the care plan should have included this information, but it was not updated accordingly. Similarly, the resident receiving oxygen therapy was admitted with diagnoses including pneumonia and cough, and the Admission MDS documented the use of oxygen. However, the care plan lacked any focus area or interventions for oxygen therapy. Observations confirmed the resident was receiving oxygen via a nasal cannula, and interviews with LPNs and the DON verified that the care plan did not address oxygen administration, which should have been included.
Failure to Update Care Plans for Pressure Injury and Discontinued Oxygen Therapy
Penalty
Summary
The facility failed to revise the comprehensive care plan for a resident who developed a new sacral pressure injury. The resident, who was admitted for rehabilitation following hip surgery, returned from the hospital with a newly identified deep tissue injury (DTI) to the sacrum. Despite the initiation of treatment for the DTI, the care plan was not updated to include this new condition. Interviews with the treatment nurse and the Director of Nursing confirmed that the care plan should have been revised to reflect the new skin integrity concerns, but it was not. Additionally, the facility did not update the care plan for another resident whose oxygen treatment had been discontinued. The care plan still included an intervention for oxygen administration, even though the physician's order for oxygen therapy had ended. The LPN and MDS Coordinator acknowledged that the care plan should have been updated to resolve the intervention for oxygen administration, but it remained in the current care plan.
Oxygen Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to ensure proper oxygen administration for three residents, leading to deficiencies in respiratory care. For one resident, there was no physician's order for oxygen therapy, despite the resident receiving oxygen via nasal cannula at 2.5 liters per minute. This resident had severe cognitive impairment, as indicated by a BIMS score of 4. Observations confirmed the absence of a physician's order, which was verified by both an LPN and the Unit Manager. For two other residents, the facility did not administer oxygen as per the physician's orders. One resident, with a BIMS score of 15 indicating little to no cognitive impairment, had a physician's order for oxygen at three liters per minute, but was observed receiving four liters. Another resident, with a BIMS score of 14, was supposed to receive oxygen at three liters per minute but was observed receiving it at two liters. Interviews with the LPN and DON confirmed the discrepancies between the physician's orders and the actual oxygen settings.
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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) |
|---|---|---|---|---|
| Pruitthealth - Covington | 0.8 mi | ★★★★★ | 4 | 0 |
| Westbury Center Of Conyers For Nursing And Healing | 9.1 mi | ★★★★★ | 1 | 0 |
| Social Circle Nsg & Rehab Ctr | 9.7 mi | ★★★★★ | 0 | 0 |
| Rockdale Healthcare Center | 10.5 mi | ★★★★★ | 5 | 0 |
| Pruitthealth - Lithonia, Llc | 15.8 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.