Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Riverside Health Care Center during CMS and state inspections, most recent first.
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 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 | ★★★★★ | 8 | 0 |
| Social Circle Nsg & Rehab Ctr | 9.7 mi | ★★★★★ | 0 | 0 |
| Rockdale Healthcare Center | 10.5 mi | ★★★★★ | 1 | 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 July 2026) and official state health department websites.