Covenant Village Care Center
2125 North Olive Avenue, Turlock, CA 95382 · Non profit - Corporation · 50 certified beds · (209) 664-5300 Medicare & Medicaid certified
On the public record, this home looks stronger than most — but visit before you decide.
- a strong health-inspection score (4/5) — the hardest rating to game (though it’s ranked within its own state, not nationally)
- no federal fines or payment denials on record
- a high payroll-based staffing rating (4/5)
- lower-than-typical staff turnover (31% vs 45% nationally) — better care continuity
- it has a citation for its abuse-prevention policies, restraint use, or reporting and investigating of allegations (F0605) — cited below the harm level, meaning inspectors found the process wanting but did not find a resident harmed
- a high number of inspection citations overall (18) — worth reading through, though larger and more-often-surveyed homes tend to accrue more lower-severity tags
One thing this read cannot see: what residents and families actually experience day to day. Public data misses the feel of a place — visit unannounced, ideally at a mealtime or on a weekend, talk to staff and families, and ask your tour questions.
A plain-English summary of the public record below — not a rating, ranking, or recommendation. We take no money from any facility.
| Health inspectionSurveyor-assigned, ranked within your stateInspector-verified | 4 of 5 |
| StaffingFrom payroll records (PBJ) | 4 of 5 |
| Quality measuresSelf-reported by the facility | 4 of 5 |
Location & what’s nearby
Open in Google Maps ↗ · Directions ↗ · Larger map ↗
Nearest of each type, straight-line distance. Hospitals come from the CMS Hospital General Information registry; everything else from Overture Maps (public data). Hospital and park hours are typical — call ahead to confirm.
Quality measures — how residents actually fare
| Overall quality measures | 4 of 5 |
| Long-stay residentspeople who live here | 2 of 5 |
| Short-stay residentsrehab / post-hospital | 5 of 5 |
Quality-measure stars summarize outcomes CMS tracks from the assessments each home submits — avoidable hospitalizations and ER visits, falls with injury, pressure ulcers, unplanned weight loss, and long-term antipsychotic use. Because the underlying data is self-reported, weigh a high score against the independent inspection record. Long-stay = permanent residents; short-stay = rehab and post-hospital stays.
Trend — is this home getting better or worse?
Over 2025-02 to 2026-06, this home’s CMS overall rating fell from 5 to 4 stars. From monthly CMS archive snapshots.
Horizontal axis runs 2025-02 to 2026-06. That is where CMS’s monthly archive ends, so the right-hand edge of each line is that month — not today.
See all quality measures vs. state & national benchmarks
| Measure | This home | State avg | Typical state | vs typical state |
|---|---|---|---|---|
| Long-stay residents whose need for help with daily activities increased | 25.8% | 10.2% | 15.4% | worse |
| Long-stay residents who lose too much weight | 0.8% | 4.0% | 5.4% | better |
| Long-stay residents with a catheter left in their bladder | 0.4% | 0.8% | 0.9% | better |
| Long-stay residents with a urinary tract infection | 2.6% | 1.2% | 2.0% | worse |
| Long-stay residents with depressive symptoms | 1.5% | 7.3% | 6.5% | better |
| Long-stay residents who were physically restrained | 0.0% | 0.4% | 0.1% | better than state‡ — see note marked double-dagger below the table |
| Long-stay residents with falls causing major injury | 3.1% | 1.6% | 3.3% | typical |
| Long-stay residents whose ability to walk worsened | 38.8% | 9.8% | 16.1% | worse |
| Long-stay residents on antianxiety or hypnotic medication | 15.0% | 13.7% | 18.9% | better |
| Long-stay residents given the seasonal flu vaccine | 100.0% | 98.2% | 95.3% | typical |
| Long-stay residents with pressure ulcers | 2.6% | 4.3% | 4.7% | better |
| Long-stay residents with worsening bladder/bowel control | 35.7% | 10.2% | 21.2% | worse than state‡ — see note marked double-dagger below the table |
| Long-stay residents who got an antipsychotic medication§ — see the note below the table | 9.3% | 12.0% | 17.1% | better |
| Short-stay residents who newly got an antipsychotic medication | 0.0% | 1.5% | 1.4% | better |
| Short-stay residents given the seasonal flu vaccine | 98.2% | 93.2% | 79.4% | better |
| Short-stay residents rehospitalized after admission | 19.9% | 23.0% | 22.6% | better |
| Short-stay residents with an outpatient ER visit | 20.3% | 11.2% | 12.0% | worse |
| Long-stay hospitalizations per 1,000 resident days | 1.91 | 2.25 | 1.67 | worse |
| Long-stay outpatient ER visits per 1,000 resident days | 1.64 | 1.57 | 1.80 | typical |
‡ On this measure the state average is at least twice (or half) the typical state — a gap that size is usually how the state codes and reports the measure, not how its homes actually perform. Against a benchmark this state does not sit on, a “vs typical state” verdict would mostly be measuring the state, so we compare this home with its own state instead and show both averages.
§ Antipsychotics carry an FDA boxed warning — they raise the risk of death in older people with dementia-related psychosis, and are not approved for that use. So this measure is partly a read on whether a home sedates residents instead of staffing for them. But read a low rate carefully in both directions: CMS excludes residents coded with schizophrenia (and Tourette's or Huntington's) from this measure, and federal auditors have found implausible increases in schizophrenia coding since the measure was published — so a very low rate can reflect recoding rather than less prescribing. Ask the home what share of its residents carry a schizophrenia diagnosis, and how it handles behavioral symptoms without medication.
CMS quality measures, as Care Compare shows them. For most rows lower is better (fewer falls, ulcers, hospitalizations); vaccination rates are the exception. Not every row is risk-adjusted. CMS adjusts some measures for resident mix, but falls with major injury, antipsychotic use, physical restraints and the vaccination rates are unadjusted rates — so a home caring for heavier or more behaviorally complex residents can look worse on them without providing worse care. The “typical state” column is the median of the 50 state averages — not a national average of all homes. We use it because a plain average across homes is pulled badly off course by a few states’ reporting habits (long-stay depressive symptoms is the clearest case: Illinois codes it several times higher than most states, which alone lifted the all-homes figure to about twice what a typical state records). The median of state averages resists that — but it does weigh every state equally, so a large state counts no more than a small one, and it is a benchmark of our construction rather than a CMS-published figure. better/worse means the home differs from that benchmark by more than 10% of it; closer than that reads typical. CMS does not publish how many residents each measure covers, and the counts are often small — a single resident can move a rate by several points — so treat small gaps as noise. These come from data the facility reports, so weigh them against the independent inspection record above.
Short-stay rehab — if you are coming here from a hospital
Arriving from a hospital right now? Read the discharge guide → — your appeal rights, how to slow a rushed discharge, and what to ask about the numbers below.
62.1% of the Medicare patients who left this home got back to the community and stayed there for at least 31 days — CMS rates that better than the national rate. This is CMS’s risk-adjusted rate over 146 Medicare stays in Oct 2022–Sep 2024, and CMS’s own comparison — not ours.
Met the expected recovery: 63.6% of this home’s Medicare short-stay residents left it at or above the ability to care for themselves and move around that CMS predicted for them, across 77 stays in Oct 2024–Sep 2025. The median of the 11,061 homes CMS publishes this for is 56.6%. Read it beside the getting-home figure, not instead of it: unlike the two measures above, CMS makes no better-or-worse call on this one and publishes no confidence interval for it, so this is a comparison and not a verdict — but it is the short-stay measure that separates homes most, and the one to ask about.
Therapy staffing: this home’s payroll records show 0.25 therapist hours per resident per day in 2026Q1 — more than 33% of the 13,892 homes that report any therapy hours at all.
Weekend therapy: weekend therapy hours are 2% of this home’s weekday level — it runs therapy on weekdays, with essentially none at the weekend. The median home that reports therapy runs 13% — weekday-focused therapy is the industry norm, not a shortfall. But recovery does not pause on a Saturday: ask what the weekend actually looks like here.
This section is about rehab stays, not living here. Most of this page — the stars, the quality measures, the inspection record — describes the home the way a permanent resident experiences it. These figures describe the short Medicare stay after a hospital discharge: a hip, a stroke, a bad infection, six weeks and home. They are different residents, different staff, often a different wing. Therapy hours are per resident in the building, not per rehab patient — the count includes every long-stay resident, and they mostly get no therapy at all. So a home with a small rehab wing inside a large nursing population reads low here even if its rehab patients get plenty of therapy, and a mostly-rehab home reads high. Use it to compare homes doing similar work, ask what a rehab resident actually gets in a day, and remember that CMS does not publish therapy minutes per patient — nobody does.
See every short-stay measure CMS publishes for this home
| Measure | This home | U.S. median | Period covered | CMS’s call |
|---|---|---|---|---|
| Got home and stayed homeRate of successful return to home or community from a SNF | 62.1%CMS range 56.0–68.4 | 51.5% | Oct 2022–Sep 2024 | better than U.S. |
| Went back to hospitalRate of potentially preventable hospital readmissions 30 days after discharge from a SNF | 10.2%CMS range 7.1–13.8 | 10.7% | Oct 2022–Sep 2024 | no different from U.S. |
| Met the expected recoveryPercentage of residents who are at or above an expected ability to care for themselves and move around at discharge | 63.6% | 56.6% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Self-care at dischargePercentage of residents who are at or above an expected ability to care for themselves at discharge | 57.1% | 52.8% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Moving around at dischargePercentage of residents who are at or above an expected ability to move around at discharge | 55.8% | 50.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication problems followed upPercentage of residents whose medications were reviewed and who received follow-up care when medication issues were identified | 97.5% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Medication list to the next providerPercentage of residents where the SNF provided a current medication list to the next health care setting | not reported — The number of residents or resident stays is too small to report. Call the facility to discuss this quality measure. | — | ||
| Medication list to the familyPercentage of residents where the SNF provided a current medication list to the resident, family, and/or caregiver at final discharge | 100.0% | 98.7% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Falls with major injuryPercentage of SNF residents who experience one or more falls with major injury during their SNF stay | 0.0% | 0.0% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| New or worsened pressure ulcersPercentage of residents with pressure ulcers/pressure injuries that are new or worsened | 0.0% | 1.9% | Oct 2024–Sep 2025 | CMS makes no comparison for this measure |
| Infections that led to hospitalPercentage of infections residents got during their SNF stay that resulted in hospitalization | 8.6%CMS range 4.8–14.7 | 7.1% | Oct 2023–Sep 2024 | no different from U.S. |
| Medicare spending per stayMedicare Spending Per Beneficiary (MSPB) for residents in SNFs | 0.71 | 1.02 | Oct 2022–Sep 2024 | CMS makes no comparison for this measure |
From the CMS Skilled Nursing Facility Quality Reporting Program — Medicare short-stay outcomes, which is a different dataset from the long-stay quality measures above and describes a different set of residents. Where CMS risk-adjusts a measure we show its adjusted rate, and the CMS range beside it is the confidence interval CMS publishes: a home whose range is wide is a home with few stays, where one patient moves the number several points. Read the period column. These measures do not share a window — the claims-based ones (getting home, readmission, spending) lag by a year or more, because a stay has to finish and its claims settle before it can be counted. CMS’s call is CMS’s, not ours: it is the only place anyone tests whether this home differs from the national rate at all, and most homes on most measures do not. Two caveats on it. CMS tests only three of these measures — getting home, readmission, and infections that led to hospital; on the other nine it publishes a rate and no comparison, and rather than compute a verdict CMS declined to make, we say so in the column. And on readmission almost every home in the country lands on “no different”, so that row separates homes far less than getting-home does — which is why met the expected recovery, a measure CMS does not test but which spreads across the whole range, is called out above the table rather than left in this list. The U.S. median column is our own, taken across every home CMS publishes that measure for in this same file; it is not a CMS-published benchmark. Homes CMS gives no rate for are left out of it rather than counted as zero. Medicare spending per stay is a ratio, not a percentage — 1.00 means this home’s Medicare spending for a stay matched the national figure CMS compares it against, and it measures cost to Medicare, not quality of care.
Staffing
How full it usually is: this home is certified for 50 beds and averages 47.0 residents a day — about 94% occupied, or roughly 3 beds typically open. It runs fairly full. This is a CMS average, not live availability — no public source publishes real-time vacancies, and a home can be full the day you call. Confirm with the home, and if you need a Medicaid bed specifically, ask about that separately: a home with open beds may still not have an open Medicaid bed.
Against a benchmark — not a legal minimum. In May 2024 CMS finalized the first federal staffing floor for nursing homes: 3.48 total nurse hours per resident per day, including 0.55 RN hours and 2.45 nurse-aide hours. Its hour requirements never took effect and are no longer on the books. Homes had until 2026 (2027 if rural) to comply, and that deadline never arrived: a federal court vacated the hour requirements in April 2025 (CMS has appealed), Congress then barred enforcement until 2034, and CMS formally repealed them by rule effective February 2026. This home is not required to meet these numbers, and is not violating anything by missing them. We still show the comparison because the figures are CMS’s own published estimate of adequate staffing, which makes them a useful yardstick — but they are our benchmark, not federal law: this home’s total nurse staffing of 4.29 hrs/resident/day is at or above the 3.48-hour benchmark and RN staffing of 0.65 is at or above the 0.55-hour RN benchmark and nurse-aide staffing of 2.62 is at or above the 2.45-hour aide benchmark. What federal law does require today is unchanged: “sufficient” nursing staff for residents’ needs and an RN on duty at least 8 consecutive hours a day, 7 days a week (42 CFR 483.35). Those are judged by inspectors on site, not by these averages, so read this comparison alongside the inspection record rather than as a pass/fail.
Weekend coverage: total nurse staffing is 3.78 hrs/resident/day on weekends vs 4.49 on weekdays — 16% thinner on weekends. RN hours go from 0.73 to 0.46 per resident-day. (Payroll-based daily records; the national median home is 15% thinner on weekends.)
This home’s total nursing-staff turnover of 31% is below the national median of 45%.
Payroll-based (PBJ) staffing hours, as reported for Jan–Mar 2026 (CMS PBJ CY2026Q1) — the most recent quarter CMS has published, so they can lag a change of operator or staffing agency. Higher is generally better. Registered-nurse coverage and weekend staffing are the numbers families most often overlook — an RN on site matters most when something goes wrong, and coverage usually thins on weekends. High turnover means residents rarely see the same caregiver twice. One caveat: these are hours as reported, not adjusted for how sick or heavy-care this home’s residents are. CMS separately publishes a case-mix-adjusted view; we show the reported hours. A home caring for higher-acuity residents needs more hours to deliver the same care, so compare these figures against homes doing similar work, and read them next to the inspection record rather than alone.
Inspection trend
Deficiencies are more than at the previous inspection — worsening. Fewer citations over time suggests a home is fixing problems; a rising count is a warning sign — though two surveys are a short record, and survey teams differ. These counts are from the standard annual health survey only; the full citation list below may also include findings from complaint investigations, so the two won’t always add up.
Inspection deficiencies
State health-inspection citations, most serious first. Each carries an F-code (the federal rule it cites, e.g. F-684 = quality of care) and a letter A–L marking how serious and how widespread the problem was — we translate that grid into the plain tiers shown here. Wording is the official federal description.
Each letter is a CMS scope-severity level; highlighted ones are where this home has citations. A–C = no harm found; D–F = potential for harm; G–I = actual harm; J–L = immediate jeopardy. Within each band the later letter is the more widespread finding (an isolated G is one resident; a widespread I is a pattern), so rightward and downward is worse.
18 citations, most serious first. The 10 most serious are shown; the remaining 8 are one tap away and print in full.
- Potential for harm · Fcited before2025-06-27 · tag F0812 — failed to store, cook, and serve food safely — widespreadProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure proper sanitation of equipment when two of two ice machines for resident use had brown and yellow discoloration in the machines. This failure had the potential to contaminate the ice distributed to residents and the potential for residents to become ill.Findings: During a concurrent observation and interview on 6/23/25 at 2:34 p.m. with Director of Facilities Management (DFM) in the kitchen at the ice machine, DFM removed the front panel of the ice machine and observed brown and yellow staining around the perimeter of the inside of the ice machine. Surveyor conducted a tissue swipe of the areas with brown and yellow staining and brown debris was observed on tissue. Confirmed the brown debris seen on tissue with DFM. DFM stated the debris should not be there. DFM stated the ice machine is deep cleaned once a month. During a concurrent observation and interview on 6/24/25 at 9:50 a.m. with DFM at nurses' station one utility room, the ice machine was inspected. DFM removed front panel of the ice machine…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Fcited before2025-06-27 · tag F0880 — failed to prevent and control infections — widespreadProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to follow proper infection control practices for 1 of 4 sampled residents (Resident 5) when the nurse did not use Enhanced Barrier Precautions (EBP as gown, and gloves), while administering medications and a bolus feeding through a gastrostomy tube (G-tube- a small, soft tube that is inserted through the skin directly into the stomach, and is used to give food, water or medicine).This failure increased the risk of spreading germs amongst all residents in the facility.Findings:During a review of Resident 5's admission Record (AR- a summary of important information regarding a patient which include patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), Resident 5's AR indicated, Resident 5 was admitted to the facility on [DATE] with a diagnosis which included dysphagia (difficulty swallowing), cerebrovascular accident (CVA-a stroke, loss of blood flow to a…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · tag F0605 — failed to not use drugs as a restraint — patternPrevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure that four of four sampled residents (Resident 299, Resident 35, Resident 1, and Resident 18) were free from unnecessary psychotropic (drugs that affect brain activities associated with mental processes and behavior) medications when:1. For Resident 299, Seroquel (an antipsychotic medication that balances certain chemicals in the brain to help the person feel calmer and think clearly), was initiated without an appropriate indication, the facility did not document, implement, or monitor resident specific non-pharmacological interventions (ways to help someone feel better or manage a health problem without using medicine) prior to the initiation and continued used of Seroquel, include objective measurable behavioral goals with timeframes on the care plan for adequate behavioral monitoring, , and adequately monitor, track and document behavioral episodes, and side effect monitoring.These failures placed Resident 299 at risk for…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · tag F0656 — failed to write and follow a full care plan — patternDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review the facility failed to develop and implement a comprehensive person centered Care Plan (a document that outlines a personalized approach to an individual's healthcare and support needs) for two of two sampled (Residents 6 and 20) when:1. Resident 20 had no Care Plan created for the use of their mobility rails (rails on the side of the bed which help a resident turn and move in bed)This failure had the potential to cause Resident 20's use of mobility rails to not receive proper monitoring or support to ensure they were used safely.2. Resident 6 did not have a care plan developed for ordered padded side rails.This failure had the potential to result in harm to Resident 6 if the padded side rails were removed.Findings: 1. During an observation on 6/23/25 at 3:31 p.m. in Resident 20's room, Resident 20 had mobility rails raised on the left and right side of his bed. During a review of Resident 20's Face Sheet (FS- a document that provides resident contact details, a brief medical history, level of functioning, preferences, and wishes),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · tag F0658 — failed to meet professional standards of care — patternEnsure services provided by the nursing facility meet professional standards of quality.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review the facility failed to ensure care and services were provided in accordance with professional standards of quality for three of five sampled residents (Resident 8, Resident 5 and Resident 12) when:1.For Resident 8, there was no documented evidence of the removal of the previously applied medication patches from the residents' back.This failure to track and document patch removal had the potential to result in overmedication and adverse effects.2. Social Service Director (SSD) did not have a system in place to monitor Resident 8 for a follow up dental appointment.This failure had the potential to result in Resident 8's dental care to not be completed.3.Resident 5 did not have a running total of daily fluid intake calculated and documented.This failure had the potential to prevent a clear assessment of hydration status and overall fluid balance.4. Resident 12's potassium lab result was not communicated to the prescriber, and there was no evidence of clinical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · tag F0755 — failed to provide safe pharmacy services — patternProvide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure proper pharmaceutical services were provided to meet the needs of residents when the facility did not have an effective system in place to periodically reconcile all controlled substances in the facility.This failure had the potential for diversion, mismanagement, or unaccounted medication, and the potential not to meet the needs of the residents in the facility.Findings:During an interview on [DATE] at 3:13 p.m. with the Director of Nursing (DON), the DON stated that residents were typically discharged with their medications. DON stated that if a resident was deceased or a medication was discontinued, nursing staff would inform her, and the medications would be stored in a locked box in her office until destruction by both her and the consultant pharmacist. The DON stated she and the nurse would sign the disposition log and date it at the time the medication was handed to her for destruction. The DON stated she does not periodically reconcile…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2025-06-27 · tag F0759 — failed to keep medication error rate low — patternEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the medication error rate was less than five percent when the facility's medication error rate was 8 percent. There were 25 opportunities for errors and two medication errors occurred for two of four sampled residents (Resident 28, and Resident 12) when:1. Resident 28's diclofenac 1% gel (topical pain medication) dose was not correctly measured.2. Resident 12's Refresh Classic 1.4-0.6% eye drops (medication used to treat dry eye disease) were administered incorrectly in both dosage amount and technique. The quantity exceeded the prescribed amount in the left eye and the drops were placed directly in the center of the eye.These failures to follow proper medication administration practices had the potential to result in reduced effectiveness of treatment or harm to Residents 28 and 12.Findings:1. During a concurrent observation and interview on 6/24/25 at 8:34 a.m. with Licensed Vocational Nurse (LVN) 2, during a medication…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2025-06-27 · tag F0761 — failed to label and store drugs safely — patternEnsure 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.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled and stored in accordance with the facility policy and procedures when:1. One bottle of Resident 17's latanoprost (medication used to decrease blood pressure in the eye) was stored in the Station 1 (Whispering [NAME]) medication cart did not have resident-specific label.This had the potential to result in medication administration errors, including administration to the wrong resident, which may adversely affect resident safety.2. Discontinued medications for Resident 17, Resident 28 and Resident 32 were stored in in the active medication section of the Station 1 medication cart.This had the potential to result in the administration of discontinued medications, placing residents at risk for receiving unnecessary or inappropriate treatment.3. A bottle of house stock medication (over the counter medication available for administration to any resident in the facility) in the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2025-06-27 · tag F0552 — isolatedEnsure that residents are fully informed and understand their health status, care and treatments.
What the surveyor found here — an excerpt from the official record, may be distressing
NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' right to be informed and make decisions about their care for one of four sample residents (Resident 1) when the facility did not obtain informed consent prior to increasing Resident 1's Seroquel (an antipsychotic medication that balances certain chemicals in the brain to help the person feel calmer and think clearly) dosage.This failure had the potential to result in Resident 1 receiving psychotropic medication (medication that affects brain activities associated with mental processes and behavior) without proper understanding or consent, compromising their right to participate in medical decision-making.Findings:During a review of Resident 1's admission Record (a summary of important information regarding a patient which includes patient identification, past medical history, insurance status, care providers, family contact information and other pertinent information), the admission Record indicated, Resident 1 was…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2024-06-12 · tag F0756 — failed to review each resident's drug regimen — isolatedEnsure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, document review, and facility policy review, the facility failed to act upon the Pharmacist's recommendation to add a specific duration to as needed psychotropic medication for 2 (Resident #11 and Resident #37) of 5 residents sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Medication Regimen Review and Reporting, dated 01/2024, indicated, 6. Resident-specific MRR [medication regimen review] recommendations and findings are documented and acted upon by nursing care center and/or physician. The policy indicated, 8. The nursing care center follows up on the recommendations to verify that appropriate action has been taken. Recommendations should be acted upon within 30 calendar days or per facility specific protocols. a. For those issues that require physician intervention, the attending physician either accepts and acts upon the report and recommendations or rejects all or some of the report and should document his or her rationale of why the recommendation is rejected in the resident's medical…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
Show the remaining 8 citations
- Potential for harm · D2024-06-12 · tag F0758 — failed to limit and justify psychotropic drugs — isolatedImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on interview, record review, and facility policy review, the facility failed to indicate the duration of an as needed antianxiety medication for 2 (Resident #11 and Resident #37) of 5 sampled residents reviewed for unnecessary medications. Findings included: A facility policy titled, Psychotropic Medication Use, dated 07/2022, indicated, 12. Psychotropic medications are not prescribed or given on a PRN [pro re nata, as needed] basis unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record. a. PRN orders for psychotropic medications are limited to 14 days. (1) For psychotropic medications that are NOT antipsychotics: If the prescriber or attending physician believes it is appropriate to extend the PRN order beyond 14 days, he or she will document the rationale for extending the use and include the duration for the PRN order. 1. A Face Sheet revealed the facility admitted Resident #37 on 12/28/2022. According to the Face Sheet, the resident had a medical history that included diagnose of right femur fracture, major…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2024-06-12 · tag F0880 — failed to prevent and control infections — isolatedProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, record review, and facility policy review, the facility failed to ensure staff stored respiratory equipment per the facility policy when not in use for 1 (Resident #3) of 1 sampled resident reviewed for respiratory care. The facility also failed to ensure enhanced barrier precautions were utilized during the provision of wound care for 1 (Resident #33) of 12 sampled residents. 1. A facility policy titled, Departmental (Respiratory Therapy) - Prevention of Infection, revised 11/2011, specified, 8. Keep the oxygen cannulae and tubing used PRN [pro re nata, as needed] in a plastic bag when not in use. A Face Sheet revealed the facility admitted Resident #3 on 03/24/2022. According to the Face Sheet, the resident had a medical history that included diagnoses of acute and chronic respiratory failure with hypoxia, and chronic obstructive pulmonary disease (COPD) with exacerbation. A quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 05/23/2024, revealed Resident #3 had a Brief Interview for Mental Status (BIMS) of 15, which…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · E2019-06-14 · tag F0803 — failed to meet residents' dietary needs — patternEnsure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to follow the recipe portion size for five of five sampled residents (Resident 21, Resident 37, Resident 18, Resident 193, Resident 22) when: the Dietary [NAME] (DC) served 2.2 ounces (dry unit of measurement) of braised Swiss steak instead of serving four ounces for one lunch meal. This failure placed Resident 21, Resident 37, Resident 18, Resident 193 and Resident 31 at risk for nutritional inadequacy. Findings: During a concurrent observation and interview with the DC, on 6/12/19, at 11:50 a.m., in the kitchen, the DC served the residents with the lunch of the day. The DC served braised Swiss steak, cheese tortellini with pesto sauce, sliced apples and a cucumber salad with ginger vinaigrette to Resident 18, Resident 21, Resident 22, Resident 37, and Resident 193. The DC did not measure the braised Swiss steak prior to serving. The DC stated the braised Swiss steak weighed four ounces prior to cooking. The DC stated she would weigh the braised Swiss steak and should have weighed the braised Swiss steak prior…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Ecited before2019-06-14 · tag F0880 — failed to prevent and control infections — patternProvide and implement an infection prevention and control program.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to establish and maintain an effective infection prevention and control program to prevent cross contamination (the transfer of germs from one surface to another) when: 1. A used nebulizer mask (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) laid on top of Resident 9's nebulizer machine. The mask was unmarked. 2. An out dated nasal cannula (device used to deliver supplemental oxygen or increased airflow to a patient) laid on top of a concentrator (a medical device used to deliver oxygen which purifies the surrounding air) dated 6/2/19. These failures had the potential for bacteria to grow. 3. Resident 20's indwelling catheter (a flexible plastic tube inserted into the bladder to provide continuous urinary drainage) was kinked at the lower end of the catheter line and catheter urinary bag. This failure had the potential to place the resident at risk for discomfort and could lead to urinary tract infection. 4. Soiled briefs were found on top of a trash can in…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-06-14 · tag F0583 — failed to protect personal privacy — isolatedKeep residents' personal and medical records private and confidential.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to accommodate personal privacy for one of 10 sampled residents (Resident 4) when: Resident 4's privacy curtain was not drawn around his bed while he rested and exposed his undressed body below the waist line. This failure violated Resident 4's right to be treated with dignity and respect. Findings: During an observation on 6/13/19, at 7:54 a.m., in Resident 4's room, Resident 4 laid in bed while asleep, he was undressed from the waist down and was uncovered. Resident 4's brief, naked legs and feet were visible to those who passed by his room. Resident 4's privacy curtain was not drawn around Resident 4 to provide him with privacy. During a concurrent observation and interview with Certified Nursing Assistant (CNA) 1, on 6/13/19, at 8:05 a.m., CNA 1 stated Resident 4 was uncovered and was not provided with privacy. CNA 1 stated anyone who passed by Resident 4's room could see his brief and undressed lower body. CNA 1 stated Resident 4's privacy curtain was not drawn around his bed to provide him with privacy and…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-06-14 · tag F0759 — failed to keep medication error rate low — isolatedEnsure medication error rates are not 5 percent or greater.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure the facility medication error rate did not exceed five percent or greater when: there were 82 medication pass opportunities for error and 10 errors resulted in a medication error rate of 12.2 percent. This failure resulted in the significant medication error for Resident 15. Findings: During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3, on 6/12/19, at 11:39 a.m., during a morning medication pass, LVN 3 prepared medications for Resident 15. LVN 3 prepared and administered the following medications: amitriptline hydrochloride (hcl) (medication used to treat major depression) (mood disorder) 50 milligram (mg) (dry unit of measurement), carbidopa-levodopa (used to treat Parkinson) (disease of the brain causes involuntary body movements) 25-100 mg, duloxetine hcl (medication to treat depression) (mood disorder ) 30 mg capsule, isosorbide mononitrate 10 mg (mediction used to prevent chest pain), losartan potassium 50 mg tablets (medication to lowers blood pressure),…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · D2019-06-14 · tag F0760 — failed to prevent significant medication errors — isolatedEnsure that residents are free from significant medication errors.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview, and record review, the facility failed to ensure Resident 15 was free of a significant medication error when Licensed Vocational Nurse (LVN) 3 did not administer a morning dose of glipizide (medication used to treat high blood sugar). This failure placed Resident 15 at risk for complications from elevated blood sugar. Findings: During an observation and concurrent interview with Licensed Vocational Nurse (LVN) 3, on 6/12/19, at 11:39 a.m., during a morning medication pass, LVN 3 prepared medications for Resident 15. LVN 3 prepared all 9 a.m., medications ordered except for glipizide 5 mg tablet. LVN 3 stated she was not going to administer Resident 15's glipizide because the medication indicated an expiration date of 5/2019. During a concurrent observation and interview with LVN 3, on 6/12/19, at 11:45 a.m., LVN 3 checked Resident 15's blood sugar. Resident 15's blood sugar was 187 and required 2 units of novolin insulin (medication used to help control blood sugar) injection based on a sliding scale (ordered amount of insulin given according to the…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
- Potential for harm · Dcited before2019-06-14 · tag F0812 — failed to store, cook, and serve food safely — isolatedProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
What the surveyor found here — an excerpt from the official record, may be distressing
Based on observation, interview and record review, the facility failed to ensure food was stored, prepared and served in accordance with professional standards for food service safety when: undated, opened bags of spices, hot dog buns, waffles, sugar, mayonnaise, chunk light tuna, chopped onions and an expired 1/4 milk gallon container were stored and available for use in the walk-in freezer, refrigerator and dry food storage areas. These failures to ensure effective dietetic service operations placed residents that received meal from the kitchen at risk for food borne illness and the growth of microorganisms. Findings: During a concurrent observation and interview with the Kitchen Director (KD), on 6/11/19, at 9:07 a.m., in the dry storage area, an undated and unlabeled 40 ounce opened bag of parsley flakes, an opened undated and unlabeled bag of basil leaves, an opened undated and unlabeled 8 ounce bag of white sugar with an expiration date of 5/1/19 were stored and available for use. The KD stated the items should have been dated with open date and used by date by the kitchen…
This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.
“Cited before” means this same F-tag appears on at least one other survey date in the record we hold — counting complaint investigations as well as standard surveys, with no time limit. It is our own read of the data, not CMS’s: CMS uses repeat deficiency as a formal term tied to consecutive standard surveys, and that is a narrower test than this one. A tag marked here may or may not meet it.
- Long-Term Care Ombudsman — a free, confidential advocate for the resident. They act only with the resident’s consent and work to resolve the problem. Find yours at theconsumervoice.org/get_help.
- Adult Protective Services — the state agency that investigates suspected abuse, neglect, or exploitation of a vulnerable adult. Not sure of your state’s APS number? The federal Eldercare Locator will route you: 1-800-677-1116 or eldercare.acl.gov.
- State survey agency — the regulator that licenses and inspects the home. Every state has an official nursing-home complaint line and most take complaints online; the Ombudsman or Eldercare Locator can connect you.
Fines & penalties
No federal fines in the current CMS record.
Part of a chain
This home belongs to COVENANT LIVING — 15 facilities. Here is how its ratings compare with the chain’s average across all its homes: See the whole chain — ratings, flags, fines and finances →
| Rating | This home | Chain avg | |
|---|---|---|---|
| Overall | 4 of 5 | 4.4 | -0.4 vs chain |
| Health inspection | 4 of 5 | 4.1 | ≈ chain avg |
| Staffing | 4 of 5 | 4.3 | -0.3 vs chain |
| Quality measures | 4 of 5 | 3.6 | +0.4 vs chain |
The other 14 homes this chain runs (chain average 4.4★, per CMS)
A home rated well below its chain’s average can signal local problems; a chain with a low average across the board is a bigger pattern worth researching. CMS chain data under-reports private-equity and REIT ownership, so treat this as a floor, not the full picture.
Who owns this facility
| Owner / manager | Type | Role | Share | Since |
|---|---|---|---|---|
| COVENANT LIVING COMMUNITIES & SERVICES | Organization | 5% OR GREATER DIRECT OWNERSHIP INTEREST; OPERATIONAL/MANAGERIAL CONTROL | 100% | since 12/23/1975 |
| CUNLIFFE, TERRI | Individual | W-2 MANAGING EMPLOYEE; CORPORATE OFFICER | — | since 03/19/2009 |
| AAGAARD, JON | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| CHRISTENSEN, PAMELA | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| EASTBURG, MARK | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| ERICKSON, DAVID | Individual | CORPORATE DIRECTOR | — | since 01/31/2008 |
| ESPINOSA, MARC | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| HODGKINSON, DONALD | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| MANLOVE, MATT | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| OXENDALE, ROGER | Individual | CORPORATE DIRECTOR | — | since 07/01/2017 |
| STANTE, MARLENE | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| VINING, ANNE | Individual | CORPORATE DIRECTOR | — | since 07/01/2013 |
| HOLT, JODY | Individual | CORPORATE OFFICER | — | since 06/02/2017 |
CMS files one row per role, so the 15 rows in the source record cover these 13 parties — each is shown once here with every role it holds. Nothing is omitted.
1 organizational owner listed — a facility can be part of a larger chain. CMS ownership data is known to under-report private-equity and REIT ties; treat as a starting point.
Follow the money — this home’s finances
Where a nursing home’s revenue comes from and where it goes — including money paid to companies under the same ownership. Most consumer sites never show this; we reproduce it straight from the Medicare cost report.
This home reported $914K paid to related parties — landlords or management companies under common ownership — equal to about 12% of its total expenses. Money routed to affiliated companies can leave a home’s own books looking lean while owners still profit; it is the mechanism regulators watch most closely in private-equity and REIT deals. A reported operating loss is common in this industry and is not by itself a sign of trouble — but paired with large related-party payments it can mean profit is being taken elsewhere in the ownership structure.
Source: CMS Healthcare Provider Cost Reporting Information System (HCRIS), Medicare cost report Form CMS-2540 · fiscal year 2023. Facilities self-file these reports; figures are unaudited and a year or two behind. A home with no Medicare cost report on file shows no figures here.
Cost & finances
Straight from this home’s Medicare cost report (CMS, FY2023). These are its operating economics — what it costs to run per resident-day and what it collects on average across Medicare, Medicaid, and private pay — not a private-pay quote. Your out-of-pocket cost depends on payer and room type, so ask the facility directly; a higher operating cost can reflect richer staffing or a sicker population. The cost-of-care planner shows regional benchmarks by care type.
What families pay in CA
This is a Medicare- and Medicaid-certified nursing home, so it can accept Medicaid for long-term care — like nearly all U.S. nursing homes. The private-pay figures below are what families without Medicaid pay; once a resident qualifies for Medicaid, out-of-pocket cost for covered nursing-home care is typically close to $0 (almost all of their income goes to the home as their share of the cost; they keep a small personal needs allowance — for clothing, haircuts, a phone — and Medicaid pays the rest). The amount of that allowance is set by each state. Confirm Medicaid-bed availability with the home, and see the California Medicaid page.
Median private-pay cost, CareScout (Genworth) 2025 Cost of Care Survey — a regional midpoint, not any single community’s rate. Private rooms and higher care levels cost more; ask for a current quote. Project your own in the cost-of-care planner.
Every figure above is reproduced from the CMS Provider Data Catalog (a public record), from the CMS extract processed 2026-08-01 — CMS provider number 555749. CMS refreshes its data monthly, and the star rating rests on the last standard inspection — dated 2025-06-27, which can lag current conditions. Staffing hours are CMS PBJ CY2026Q1 (Jan–Mar 2026). Check this record against the government’s own page for it: this home on Medicare Care Compare ↗ — the authoritative source, and the place to confirm anything here before you act on it. How we present it →
Not a government site. Eldercare Lens is not affiliated with, endorsed by, or authorized by the Centers for Medicare & Medicaid Services (CMS), Medicare, or any government agency. The star ratings, citations, and inspection wording on this page are reproduced from the public CMS record; the plain-English summaries, tiers, and comparisons around them are ours. We do not speak for CMS, and CMS has not reviewed this page. For the official record, go to Medicare Care Compare. How we’re funded →
Are you this operator? If the record here is out of date, or misses what you have since fixed, tell us and we will look: hello@eldercarelens.com. We reproduce the public CMS record and cannot change what it says — corrections to the underlying data go through CMS and your state survey agency — but we will correct anything we have got wrong about it, and we will say so on the page.