Cycle 1
Health 2024-11-07 · Fire 2024-11-07
3 health deficiencies
Top issue: Environmental (1 deficiency)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Covington, TN
Covington Post Acute
3-star overall rating with 3-star inspections with 3 recent health deficiencies
765 Bert Johnston Avenue, Covington, TN
(901) 475-0027
Overall
3 / 5
CMS overall stars
Health inspections
3 / 5
Survey and complaint cycles
Staffing
2 / 5
RN + nurse staffing
Quality measures
4 / 5
Resident outcomes and process measures
Quick facts
Facility snapshot
Beds
98
Certified beds
Average residents
82
Average occupied residents
Ownership
For-Profit
Publicly displayed owner type
Chain
Links Healthcare Group
Operator or chain grouping
Approved since
1994-06-09
CMS approved date
Coverage
Medicare + Medicaid
Participation flags
Chain footprint
31 facilities
Chain averages 3 overall / 3 health / 3 staffing / 4 quality stars
Changed ownership
No
Within the last 12 months
Family council
Yes
Resident and family council reported
Sprinklers
Yes
Automatic sprinklers in all required areas
Staffing
Hours and turnover
RN hours / resident day
0.53
Registered nurse staffing · state 0.61 · national 0.68
LPN hours / resident day
1.11
Licensed practical nurse staffing · state 1.09 · national 0.87
Aide hours / resident day
1.74
Nurse aide staffing · state 2.15 · national 2.35
Total nurse hours
3.37
All reported nurse hours · state 3.85 · national 3.89
Licensed hours
1.63
RN + LPN hours · state 1.70 · national 1.54
Weekend hours
2.82
Weekend nurse staffing · state 3.34 · national 3.43
Weekend RN hours
0.32
Weekend registered nurse coverage · state 0.40 · national 0.47
Physical therapist
0.04
Reported PT staffing · state 0.08 · national 0.07
Adjusted RN hours
0.44
CMS adjusted RN staffing hours
Adjusted total hours
2.83
CMS adjusted total nurse staffing hours
Case-mix index
1.63
Higher values indicate more complex resident acuity
RN turnover
50%
Annual RN turnover · state 45% · national 45%
Total nurse turnover
31%
Annual nurse turnover · state 49% · national 46%
SNF VBP
Value-based purchasing
Program rank
3,549
Lower is better among SNFs in the FY 2026 VBP program.
Performance score
43.81
Composite VBP score used to determine payment impact.
Payment multiplier
0.9968
Above 1.000 increases Medicare payment; below 1.000 reduces it.
Program components
How the VBP score is built
Readmission
0.74
Baseline 21.80% · Performance 21.21% · Measure score 0.74 · Achievement 0 · Improvement 0.74
Healthcare-associated infections
8.53
Baseline 7.45% · Performance 5.29% · Measure score 8.53 · Achievement 8.53 · Improvement 8.31
Total nurse turnover
7.75
Baseline 33.33% · Performance 32.00% · Measure score 7.75 · Achievement 7.75 · Improvement 1.07
Adjusted total nurse staffing
0.50
Baseline 3.31 hours · Performance 3.22 hours · Measure score 0.50 · Achievement 0.50 · Improvement 0
SNF QRP
Medicare quality reporting measures
| Measure | Facility | National | Note |
|---|---|---|---|
| Potentially preventable 30-day readmission | 13% |
10.72%
2.3 pts worse
|
No Different than the National Rate · Eligible stays 139 · Observed rate 15.83% · Lower 95% interval 9.35% |
| Discharge to community | 50.83% |
50.57%
0.3 pts better
|
No Different than the National Rate · Eligible stays 120 · Observed rate 44.17% · Lower 95% interval 42.92% |
| Medicare spending per beneficiary | 1.05 |
1.02
About the same
|
|
| Drug regimen review with follow-up | 98.98% |
95.27%
3.7 pts better
|
Numerator 97 · Denominator 98 |
| Falls with major injury | 2.04% |
0.77%
1.3 pts worse
|
Numerator 2 · Denominator 98 |
| Discharge self-care score | 55.07% |
53.69%
1.4 pts better
|
Numerator 38 · Denominator 69 |
| Discharge mobility score | 39.13% |
50.94%
11.8 pts worse
|
Numerator 27 · Denominator 69 |
| Pressure ulcers or injuries, new or worsened | 6.12% |
2.29%
3.8 pts worse
|
Numerator 6 · Denominator 98 · Adjusted rate 6.3% |
| Healthcare-associated infections requiring hospitalization | 5.29% |
7.12%
1.8 pts better
|
No Different than the National Rate · Eligible stays 98 · Observed rate 2.04% · Lower 95% interval 3.28% |
| Staff COVID-19 vaccination coverage | 0.77% |
8.2%
7.4 pts worse
|
Numerator 1 · Denominator 130 |
| Staff flu vaccination coverage | 61.68% |
42%
19.7 pts better
|
Numerator 132 · Denominator 214 |
| Discharge function score | 56.52% |
56.45%
0.1 pts better
|
Numerator 39 · Denominator 69 |
| Transfer of health information to provider | 100% |
95.95%
4 pts better
|
Numerator 26 · Denominator 26 |
| Transfer of health information to patient | 100% |
96.28%
3.7 pts better
|
Numerator 53 · Denominator 53 |
| Resident COVID-19 vaccinations up to date | 7.02% |
25.2%
18.2 pts worse
|
Numerator 4 · Denominator 57 |
Quality measures
Resident outcomes and process scores
| Measure | Facility | State | National | Note |
|---|---|---|---|---|
| Number of hospitalizations per 1000 long-stay resident days | 0.9 |
1.6
0.7 pts better
|
1.9
1 pts better
|
Long Stay · 20240701-20250630 · Adjusted 0.9 · Observed 1.0 · Expected 1.9 · Used in QM five-star |
| Number of outpatient emergency department visits per 1000 long-stay resident days | 1.0 |
1.6
0.6 pts better
|
1.8
0.8 pts better
|
Long Stay · 20240701-20250630 · Adjusted 1.0 · Observed 1.0 · Expected 1.6 · Used in QM five-star |
| Percentage of long-stay residents assessed and appropriately given the pneumococcal vaccine | 99.2% |
89.9%
9.3 pts better
|
93.4%
5.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 98.3% · Q4 98.5% · 4Q avg 99.2% |
| Percentage of long-stay residents assessed and appropriately given the seasonal influenza vaccine | 100.0% |
94.5%
5.5 pts better
|
95.5%
4.5 pts better
|
Long Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of long-stay residents experiencing one or more falls with major injury | 2.4% |
3.6%
1.2 pts better
|
3.3%
0.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 1.5% · Q2 0.0% · Q3 3.3% · Q4 4.6% · 4Q avg 2.4% · Used in QM five-star |
| Percentage of long-stay residents who have depressive symptoms | 34.3% |
11.8%
22.5 pts worse
|
11.4%
22.9 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 6.7% · Q2 35.5% · Q3 52.6% · Q4 42.9% · 4Q avg 34.3% |
| Percentage of long-stay residents who lose too much weight | 0.0% |
6.2%
6.2 pts better
|
5.4%
5.4 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents who received an antianxiety or hypnotic medication | 16.3% |
32.2%
15.9 pts better
|
19.6%
3.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 16.1% · Q2 15.4% · Q3 18.4% · Q4 15.4% · 4Q avg 16.3% |
| Percentage of long-stay residents who received an antipsychotic medication | 3.8% |
18.1%
14.3 pts better
|
16.7%
12.9 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 7.3% · Q2 5.3% · Q3 2.7% · Q4 0.0% · 4Q avg 3.8% · Used in QM five-star |
| Percentage of long-stay residents who were physically restrained | 0.0% |
0.1%
0.1 pts better
|
0.1%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 0.0% · Q4 0.0% · 4Q avg 0.0% |
| Percentage of long-stay residents whose ability to walk independently worsened | 29.7% |
19.9%
9.8 pts worse
|
16.3%
13.4 pts worse
|
Long Stay · 2024Q4-2025Q3 · 4Q avg 29.7% · Used in QM five-star |
| Percentage of long-stay residents whose need for help with daily activities has increased | 9.6% |
15.3%
5.7 pts better
|
14.9%
5.3 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.0% · Q2 6.2% · Q3 22.2% · Q4 6.8% · 4Q avg 9.6% · Used in QM five-star |
| Percentage of long-stay residents with a catheter inserted and left in their bladder | 1.3% |
0.9%
0.4 pts worse
|
1.0%
0.3 pts worse
|
Long Stay · 2024Q4-2025Q3 · Q1 2.8% · Q2 1.2% · Q3 0.0% · Q4 0.9% · 4Q avg 1.3% · Used in QM five-star |
| Percentage of long-stay residents with a urinary tract infection | 1.6% |
1.9%
0.3 pts better
|
1.7%
0.1 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 1.6% · Q3 5.0% · Q4 0.0% · 4Q avg 1.6% · Used in QM five-star |
| Percentage of long-stay residents with new or worsened bowel or bladder incontinence | 11.0% |
20.2%
9.2 pts better
|
19.8%
8.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 9.8% · Q2 17.8% · Q3 14.6% · Q4 1.6% · 4Q avg 11.0% |
| Percentage of long-stay residents with pressure ulcers | 3.3% |
5.4%
2.1 pts better
|
5.1%
1.8 pts better
|
Long Stay · 2024Q4-2025Q3 · Q1 4.7% · Q2 3.3% · Q3 4.1% · Q4 0.9% · 4Q avg 3.3% · Used in QM five-star |
| Percentage of short-stay residents assessed and appropriately given the pneumococcal vaccine | 100.0% |
79.6%
20.4 pts better
|
81.7%
18.3 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 100.0% · Q2 100.0% · Q3 100.0% · Q4 100.0% · 4Q avg 100.0% |
| Percentage of short-stay residents who had an outpatient emergency department visit | 11.8% |
11.2%
0.6 pts worse
|
12.0%
0.2 pts better
|
Short Stay · 20240701-20250630 · Adjusted 11.8% · Observed 10.7% · Expected 10.1% · Used in QM five-star |
| Percentage of short-stay residents who newly received an antipsychotic medication | 0.6% |
1.6%
1 pts better
|
1.6%
1 pts better
|
Short Stay · 2024Q4-2025Q3 · Q1 0.0% · Q2 0.0% · Q3 1.1% · Q4 1.1% · 4Q avg 0.6% · Used in QM five-star |
| Percentage of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine | 100.0% |
79.8%
20.2 pts better
|
79.7%
20.3 pts better
|
Short Stay · 2024Q3-2025Q2 · 4Q avg 100.0% |
| Percentage of short-stay residents who were rehospitalized after a nursing home admission | 25.6% |
22.2%
3.4 pts worse
|
23.9%
1.7 pts worse
|
Short Stay · 20240701-20250630 · Adjusted 25.6% · Observed 22.6% · Expected 21.1% · Used in QM five-star |
Survey summary
Recent inspection cycles
Cycle 2
Health 2021-07-15 · Fire 2021-07-15
5 health deficiencies
Top issue: Resident Rights (2 deficiencies)
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Cycle 3
Health 2019-06-12 · Fire 2019-06-12
0 health deficiencies
No concentrated health issue counts in this cycle.
0 fire-safety deficiencies
No concentrated fire-safety issue counts in this cycle.
Inspection history
Recent health citations
E · Potential for more than minimal harm
2024-11-07
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2024-12-02
E · Potential for more than minimal harm
2024-11-07
F921 · Environmental Deficiencies
Health
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Corrected 2024-12-02
D · Potential for more than minimal harm
2024-11-07
F880 · Infection Control Deficiencies
Health
Provide and implement an infection prevention and control program.
Corrected 2024-12-02
F · Potential for more than minimal harm
2021-07-15
F812 · Nutrition and Dietary Deficiencies
Health
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Corrected 2021-07-29
E · Potential for more than minimal harm
2021-07-15
F657 · Resident Assessment and Care Planning Deficiencies
Health
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-15
F550 · Resident Rights Deficiencies
Health
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-15
F582 · Resident Rights Deficiencies
Health
Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.
Corrected 2021-07-29
D · Potential for more than minimal harm
2021-07-15
F761 · Pharmacy Service Deficiencies
Health
Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.
Corrected 2021-07-29
Penalties and ownership
What sits behind the stars
Ownership
Links Healthcare Group LLC
5% Or Greater Direct Ownership Interest · Organization
Rodriguez, Curtis
5% Or Greater Indirect Ownership Interest · Individual
Tilford, Toby
5% Or Greater Indirect Ownership Interest · Individual
765 Bert Johnston Avenue Tn LLC
5% Or Greater Mortgage Interest · Organization
Links Healthcare Group LLC
Operational/Managerial Control · Organization
Moore, Renita
Operational/Managerial Control · Individual
Moughrabieh, Mohamad
Operational/Managerial Control · Individual
Rodriguez, Curtis
Operational/Managerial Control · Individual
Rodriguez, Curtis
Corporate Officer · Individual
Tilford, Toby
Operational/Managerial Control · Individual
Tilford, Toby
Corporate Officer · Individual
Nearby options
Other facilities in reach
#1
Magnolia Creek Nursing And Rehabilitation
Covington, TN
1-star overall rating with 1-star inspections with $41,399 in total fines with 11 recent health deficiencies
#2
Ripley Healthcare And Rehab Center
Ripley, TN
2-star overall rating with 2-star inspections with $66,472 in total fines with 6 recent health deficiencies with 1 fire-safety deficiencies in the latest cycle
#3
Lauderdale Community Living Center
Ripley, TN
1-star overall rating with 1-star inspections with $42,195 in total fines with 16 recent health deficiencies with 15 fire-safety deficiencies in the latest cycle
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